Harm Reduction

A drug-related death is often preceded by a non- or near-fatal overdose (NFO). Both “non” and “near” are used clinically and in the literature. Many of those with lived and living experience, however, prefer the term “near-fatal overdose”. The acronym NFO used throughout this report therefore means “near-fatal overdose”.

We considered the importance of having clear and consistent pathways for people who have experienced an NFO. Being able to intervene quickly and effectively presents an opportunity to offer a range of options and perhaps eliminate risks of future overdoses. Options include harm-reduction advice and information, through to immediate access to treatment. The individual’s needs should determine the nature of the response.

Significant benefits will come from everyone knowing these pathways. Professionals will be able to consistently offer timely, effective support. Families and peers will know they are not alone. Identifying pathways of support to ensure people get the support they need when they need it will help to save and improve lives.

Every ADP has developed an NFO pathway. Implementation and experience, however, remain inconsistent across the country.

What needs to change

People with lived and living experience often talk about a “postcode lottery” in terms of access to services. Accessing care following an NFO is no exception. Services often need to differentiate to address local needs, but a minimum standard should be expected in every area.

Currently, the SAS will often, though not always, attend an NFO. SAS shares NFO data daily with each health board (through a seven-day rolling report). It is then up to each health board to decide if and when to intervene.

In practice, this means responses vary. Some health boards do not follow-up every individual passed to them. Instead, they make their own risk assessments, which may include consideration of time, resources and capacity.

Services need to do all they can to maintain engagement and keep people involved so they can access the support they need.

Someone who has experienced an NFO can choose not to receive medical support or to discharge themselves from hospital before it is medically recommended. Early or unplanned discharge can be a time of increased risk. Services therefore should be designed to minimise unplanned discharges.

We believe every area should have an NFO pathway that adheres to the following standard operating procedure.

In the hours after an NFO:

• emergency care should be available to support every person who experiences an NFO;
• if this is declined by the person, the minimum intervention should be a telephone consultation during the first 24 hours after the NFO;
• emergency treatment and support must be available out of hours and should include appropriate aftercare;
• where a person has well-established contact with a service or GP, they should be notified about the NFO and be requested to make contact with the person within the first 24 hours of receiving the data, or sooner if possible;
• harm-reduction advice and information should form part of this pathway and should be offered as soon as possible;
• as a minimum, take-home naloxone (THN) should always be offered to a person who has experienced or witnessed an NFO; and
• in line with MAT Standard 1, the option to start MAT should be offered to all those who have experienced an NFO who are not already in treatment.

In the days after an NFO:

• a multi-agency team should review each case and agree appropriate actions;
• these teams may wish to cover multiple localities, dependent on local need –
• this should be agreed locally;
• as a minimum, the team should meet daily on weekdays;
• care of individual patients will not remain with the team but will transfer to the service or agency taking forward the agreed aftercare actions;
• all relevant services and agencies should be able to participate in the NFO response team, with identified link personnel that include peer support workers and assertive outreach services; and
• the responsible GP should be notified (through a short discharge summary) of any overdose unless the person declines permission.

Local areas should consider how a peer or family member present at an NFO incident can anonymously refer someone into the NFO pathway. Individuals would continue to have the right to refuse treatment following such a referral. People who have witnessed an NFO or are supporting the individual who has experience an NFO should be proactively offered or referred for support.

Action 37. Within the next year, the Scottish Government, chief officers and ADPs should ensure that every local area has an effective NFO pathway that follows the outlined procedure. Any person flagged as having an NFO by an emergency responder, service or professional should be referred to the pathway

An NFO should be seen as an emergency medical event and every NFO should trigger an emergency response pathway. Currently, many drug services do not operate in evenings or at weekends. If we are to prevent deaths and reduce harm, ensuring parity with other health conditions, we must provide emergency care 24/7 with out-of-hours referral points for people to access if needed.

What needs to change

Emergency treatment and aftercare following an NFO should feed directly into a longer-term recovery or aftercare pathway. Referrals should be made and support provided, just as would be the case if any other emergency medical event identified a longer-term health condition.

The ability to access out-of-hours support should not be contingent on a person having an NFO. Support should be available to anyone in crisis.

We have heard from our Family Reference Group that families would benefit from a referral pathway that can be contacted out of hours. Through our Drug Law Reform consultation and wider policy engagements, we have heard that a 24/7 phone line would help to support individuals access the support they need, when they need it.

The Covid-19 pandemic has demonstrated that NHS24 can be used to good effect in providing information and referrals for specific health issues. We believe that a similar process could be established to support people with substance use and their loved ones.

We heard that people with opioid substitution treatment (OST) prescriptions are specifically excluded from access to out-of-hours GP services. This makes it very difficult for dispensing pharmacies to deal with prescription queries or amendments over weekends and holiday periods.

Pharmacists are restricted in the amendments they can make, even if the prescriber’s intentions are clear. Group exclusion of this kind does not occur for other out-of-hours controlled drug prescriptions and should be changed.

Action 38. The Scottish Government and ADPs should ensure that out-of-hours emergency support for point-of-need care and management of prescriptions is available in every local area. This should provide a place of safety in which individuals can be stabilised and supported to access follow-up support where necessary.

Action 39. The Scottish Government and NHS 24 should extend the existing phone service to provide a dedicated resource for supporting individuals with their substance use and helping them to access treatment and services in their area. This phone line should be available for individuals and their family members.

Supervised drug consumption facilities (SDCFs, also referred to as safer drug consumption rooms or drug consumption rooms) are used in some countries. Evidence shows they have a positive impact on drug deaths and harms. SDCFs can save lives when used in conjunction with other harm-reduction and treatment measures.

What needs to change

Introducing SDCFs in Scotland would provide a supervised space for people who use drugs to take them safely. While in the facility, they could access harm-reduction interventions, including reducing the risk of transmission of blood-borne viruses (BBVs) and related bacterial infections, and be supported into treatment pathways.

Many reports have supported the introduction of SDCFs. We have called for their introduction and recommend that the UK Government should consider a legislative framework to support their introduction. In this report, we focus on how SDCFs could and should operate in Scotland if introduced.

We welcome the announcement on 23 June 2022 from the Minister for Drugs Policy that a proposal for a SCDF in Glasgow has been developed (30). This demonstrates that progress has been made in line with our previous recommendation for the Scottish Government to explore all options within the existing legal framework to support the delivery of SDCFs.

Action 40. The UK Government should implement legislative changes to support the introduction of Supervised Drug Consumption Facilities. In the interim, the Scottish Government should continue its efforts with stakeholders to support their implementation within the existing legal framework.

Once the legal barriers have been overcome, some key issues have to be considered before a SDCF can be established.

• A public health needs analysis should be undertaken by local areas, supported by their director of public health. This should be used to determine the location, model, level of demand and staffing need. It should include consultation with people with lived and living experience, community groups, families, local businesses and local police.
• We believe that SDCFs should take an integrated or specialist approach within a fixed site. Where local need requires it, mobile service provision should be in place to provide flexibility and targeting.
• Clear pathways from SDCFs into services are needed to ensure immediate access when an individual chooses this kind of support.
• Aftercare can also be provided in relation to wider harm-reduction services. These include BBV testing and access to naloxone, recovery communities and services.
• Staff need to be adequately trained, with a system of ongoing support (including debriefs) available.
• As with all our recommendations and actions, expanding services needs increased capacity in the current workforce.
• Engagement and information-sharing should provide an opportunity to enhance public understanding and support for services.
• Consideration should be given to enabling local community members to visit services when they are not in use. This may help to challenge misperceptions and increase understanding of SDCFs’ purposes.
• A trial period will be needed to establish effectiveness and any changes required to best meet the needs of people who inject drugs.

Action 41. SDCFs should be available nationally but be locally commissioned to meet the specific needs of the population, in line with the public health needs assessment. They should be sustainably funded, operated by appropriately trained multi-disciplinary teams and incorporate appropriate aftercare.

Action 42. Clear engagement with local communities and all relevant stakeholders, including sharing the evidence base for SDCFs, should be taken forward prior to implementation in a local area.

Naloxone is an opioid antagonist, which means it can quickly and safely (although only temporarily) reverse the effects of an opioid-related overdose.

Naloxone works. It is a key part of the emergency response to prevent drug-related deaths.

The evidence is clear that wider distribution and training in how and when to administer naloxone saves lives. Expanding the distribution of naloxone would increase its coverage, meaning it is more likely to be available in the event of an opioid overdose.

Expansion would also spread awareness of harm-reduction advice through THN programmes. Pathways could help guide people into appropriate treatment and support.

Mainstreaming the availability of naloxone would help to reduce harmful stigma around problematic substance use and ensure it is seen in parity with other health conditions.

Our aim is for Scotland to have the most extensive naloxone network anywhere in the world. Our ambition is that anyone who may come into contact with a person experiencing an opiate-based overdose should have access to, and have been trained on how to use, naloxone.

We have worked extensively on widening access and have played a critical role in supporting changes to regulations around who can supply naloxone.

What needs to change

There are two main naloxone products licensed in the UK: Prenoxad® (injectable version) and Nyxoid® (intranasal version).

These cost £18 (five doses) and £26 (two doses) respectively.

Prenoxad® is the most common form of naloxone supplied in Scotland. Nyxoid®, although more expensive, appears to be the preferred formulation for some people due to ease of use. The perceived benefits of the intranasal products are linked to their accessibility, usability and safety for people who cannot administer injections or where needles act as potential triggers.

Administration via the nasal passage is less invasive and allows operation by people who are unable to give injections. The Electronic Medicines Compendium advises, however, that intranasal absorption may be less effective. This is particularly so if the nasal route is blocked with blood or mucus or damaged as a result of nasal drug use (31).

Anyone, or any service, who wishes to carry or hold stocks of naloxone should be able to access the product to meet their needs.

Action 43. The Scottish Government should work with NHS naloxone leads and pharmaceutical companies to ensure sufficient supplies are available to meet anticipated demand.

Under current regulations, naloxone is a prescription-only medicine (POM). Amendments to the legislation have extended prescribing rights to wider groups. This includes staff engaged in drug treatment services and, in Scotland (using the Lord Advocate’s Statement of Prosecution Policy), registered non-drug treatment services.

Obtaining supplies of a POM nevertheless can be problematic.

The Covid-19 pandemic caused disruption to drug treatment services. In June 2020, the Lord Advocate published a Statement of Prosecution Policy. This enabled a time-limited measure to allow individuals other than drug treatment service workers to distribute naloxone to those at risk of overdose.

Provision of appropriate instruction on the use of naloxone and basic life-support training was a requirement of this policy.

Since the publication of the statement by the Lord Advocate, demand for naloxone has increased significantly. Many of the projects we supported have reported a large number of naloxone uses, well above the expected number.

Public support has been overwhelmingly positive in response to these projects. Indeed, members of the public are looking to carry naloxone themselves.

Action 44. The UK Government should permanently reclassify naloxone from a POM to a Pharmacy or General Sales List medicine.

Action 45. In the absence of a full reclassification of naloxone, the Scottish Government should work closely with the UK Government to ensure that the changes planned reflect the breadth of the Lord Advocate’s Statement of Prosecution Policy in Scotland.

Action 46. The Scottish Government should also engage with the Lord Advocate in relation to extending the time that the current Statement of Prosecution Policy is in place.

Substance use is a health matter. Responsibility for naloxone expansion therefore should sit with the NHS and health boards.

Local naloxone leads do positive work in coordinating naloxone distribution in their areas. This often is not a core part of their role, but is done in addition to their regular work. National oversight is lacking, however. There is a crucial need for national coordination, including ensuring consistent and regular supplies to frontline and emergency services.

Part of this will involve ensuring kits are rotated, meaning those nearing their use-by date are with the people who are most likely to use them. This will need cross-agency working and national coordination to be effective.

Action 47. The NHS should establish a National Naloxone Coordinator post in NHS National Services Scotland to nationally manage the provision of naloxone. This role should be regularly reviewed to ensure it is effective and still needed. The roles of naloxone leads in health boards should be formalised.

Emergency services are often the first responders to an overdose incident. Ensuring this workforce has access to naloxone has been a core part of our strategy.

Police Scotland’s test of change, which we supported, showed high levels of police officers carrying naloxone voluntarily after training. Following the pilot, Police Scotland are now undertaking a national roll-out, with frontline officers to be trained in naloxone use.

SAS also undertook a test of change to roll out the distribution of THN. Clinicians were trained to administer naloxone and provide THN to patients, peers and family members.

The Scottish Fire and Rescue Service recently started training staff in naloxone use.

Its members will join SAS and Police Scotland in carrying the life-saving medication. The importance of emergency and front-line services having access to naloxone is clear. Consideration should therefore be given to expanding training across the public sector to include GPs, care workers and those who work in pharmacies.

Action 48. The National Naloxone Coordinator should ensure that all front-facing public services staff are trained and have access to naloxone.

Expanding access across the public sector does not necessarily mean every individual needs to carry naloxone. Rather, it is about ensuring it is available in all locations in or near where a person may have an opioid overdose.

Action 49. GPs should be encouraged to supply naloxone on GP10 prescriptions and through direct distribution of naloxone packs, possibly obtained on a stock order to hold in the practice.

Action 50. An awareness campaign should be launched for GPs and practice staff around naloxone to enable them to provide information to patients on its use.

Action 51. All community pharmacies should hold naloxone for administration in an emergency and should be able to supply THN to people who use drugs, families and anyone likely to witness an opioid overdose.

One potential solution here would be to include naloxone in first-aid kits and to develop “naloxboxes”. These are similar to the defibrillator boxes already available within communities.

Action 52. The National Naloxone Coordinator should ensure that naloxone training is incorporated into all standard first-aid and resuscitation training, and consideration should be given to supplying “naloxboxes”. Training should be provided for all students in professions where people may reasonably be expected to come into contact with a person experiencing an overdose.

Training on naloxone has had a positive impact across a range of settings. We have learned, however, that some employers are not allowing staff to administer it due to concerns about liability.

It may be beneficial to have clarity for all services on their right to carry and administer naloxone for the purposes of saving a life.

Action 53. Clarity must be provided on the legal right to carry and administer naloxone.

The minimum annual level of distribution for naloxone nationally should be nine times more THN kits than opiate-related deaths. Evidence shows, however, that countries should be aiming to issue 20 times as many THN kits as opiate-related deaths. Given the level of opioid-related deaths in Scotland, we should be distributing this higher number.

Monitoring of the availability of naloxone would include ongoing assessment of:

• the cumulative total of naloxone in circulation;
• expiry dates;
• the range of people who have access to naloxone;
• how often it has been used to prevent a drug-related death; and
• to what extent those who have been provided with naloxone actually carry it and therefore have it available when needed.

Action 54. The NHS Naloxone Coordinator and Public Health Scotland should undertake a rapid review of the monitoring and evaluation of naloxone. The review should lead to changes to more effectively assess the amount of naloxone in circulation, its use and the effectiveness of current initiatives to increase distribution.

Having naloxone available at the scene of every opiate overdose is a clear priority.

Wider public awareness of naloxone and the ability to administer it are important, but peers are the people most likely to be in a position to need to use naloxone. Training and supporting those who use drugs to access and, crucially, carry naloxone is a vital part of the strategy.

With support from the Scottish Drugs Forum, SFAD launched their naloxone “click and deliver” THN service in 2020. This allowed anyone who wanted to have access to THN to undertake online training and have it delivered to their door.

Action 55. People should continue to be able to access THN through a “click and deliver” service that is accessible to all. ADPs, as well as services that do not offer THN, should direct people who use drugs, peers and family members to this service. The Scottish Government should ensure that the service is adequately funded to meet increasing demand.

Action 56. The Scottish Government should expand the THN programme, ensuring in particular that it is available where required for all leavers from police and prison custody and on release from hospital.

We welcome the steps taken by the Scottish Government and the Scottish Drugs Forum with taxi drivers in Glasgow to support the “How to Save a Life” campaign. The campaign promotes the carriage of naloxone and trains taxi drivers in its use. We would like to see this work continued, with distribution widened as far as possible.

Action 57. As part of the roll-out of naloxone provision, the Scottish Government should look to extend its availability wherever possible, including through the support of relevant public-facing services such as taxi and bus companies.

These measures are in no way a replacement for the SAS attending an NFO and aftercare being provided, especially given the temporary nature of a naloxone administration. The purpose of these steps is primarily to provide a quicker intervention that will reverse the effects of an overdose until professional support can arrive.

As outlined in MAT Standard 3, assertive outreach means that all people at high risk of drug-related harm are proactively identified and offered support. The aim is to proactively identify and reach out to individuals who are vulnerable, and offer them support when they are ready to seek help.

Assertive outreach teams do not give up on someone if they do not initially engage with the team, or if they start to disengage with the service. Instead, they look to support people to maintain contact with a range of services, including the justice system, but also housing and mental health services.

Beyond the focus in the MAT standards, we have chosen to focus on the assertive outreach provided by navigators and peer support workers.

Navigators primarily guide people who use drugs through the complex systems with which they interact. Navigators work with individuals, helping them to connect with statutory and third-sector services that will support them to stabilise their lives and move forward. Similarities with advocacy exist, but navigators provide more involved, proactive support to individuals.

Peer support workers are people with lived experience who are employed to support those who use drugs. Through shared understanding and experiences, peer support workers are able to offer practical and motivational support to people accessing services. The trusting relationship they build helps individuals to remain engaged with services. While navigators may also be peers, not all peer support workers will follow a navigator model.

Demand for these services is high. We therefore funded some navigator and peer support projects in different settings. These particularly looked at how the model works for people when they interact with the criminal justice system, on release from prison and in various community settings.

What needs to change

We identified very positive examples of navigators and peer support workers making a difference to people’s lives.

Currently, however, provision of navigator services across Scotland is patchy. Coverage in the central belt is good, but rural areas are less well catered for.

The expansion of navigator services nationally, supported by a comprehensive framework, standards and guidance, may help to remove the “postcode lottery” many individuals now face when seeking access to a navigator.

Community-based services that link to the hospital navigator service are necessary. Knowledge of local areas is imperative for navigators.

Navigators need access to peer support within services, training and a programme of continuous development. This will help to ensure the people they work with can expect a consistent standard of care.

Action 58. Healthcare Improvement Scotland and the Scottish Government should work with navigator services to develop standards and guidance to which services must adhere. People should be guaranteed a consistent standard of care and support that encompasses all areas, including mental health, violence and drug use.

A coordinated approach to commissioning navigators would provide a gateway to assistance for people when they are at a “reachable, teachable moment” and looking to access support and treatment. It would also consolidate the plethora of services that have been established in recent years due to the success of the model.

Action 59. The Scottish Government should ensure that a navigator framework is set up and consolidated, allowing local knowledge to link with national funding.

Peer support should be clearly defined. The role of peer workers should be appropriately valued, including through funding for the service and remuneration for workers commensurate with their skills and experience. As is the case with other skilled workers, peer support workers should be facilitated to develop and progress in their careers.

Action 60. The Scottish Government should commission the development of standards and guidance for all services that use peer support, ensuring workers are paid, developed and have career progression opportunities.

People who take street drugs may not know what they contain or what strength they are. Scotland has seen a rise in the use of “street benzos” (benzodiazepines), which can be mass produced and are relatively inexpensive.

Licensed drug-checking services allow people to anonymously submit samples of psychoactive drugs for testing. On completion of testing, they are advised on the content and potency of the submitted drugs so they can make more informed decisions about use.

This process can play a vital role in harm reduction, not just for the person deciding whether to use the drug, but also through providing wider public health information about the drugs in circulation in an area.

Concerns have been raised about drug checking encouraging drug use. Some argue that it enables drug dealers to check the purity of the drugs they plan to sell and use the information they receive to boost sales. We feel these concerns focus more on the illegality of drug selling than the welfare of people who use drugs. Research highlights that communicating drug-test results to customers could act as a risk-reduction measure.

What needs to change

Drug checking is a core part of public health surveillance. Licensed facilities should be available widely across Scotland and be easily accessible at short notice.

Services could be provided where people who use drugs live, particularly in all major urban centres. A postal system similar to the Welsh Emerging Drugs & Identification of Novel Substances Project (WEDINOS) service (32) should also be in place. This would be particularly helpful for rural populations and people who are dissuaded from attending services in-person due to the threat of stigma.

Drug use is likely to take place at events such as music festivals. Evidence tells us that having licensed drug-checking services at such events allows engagement with young adults who may not be in touch with other health services. It also enables rapid identification of substances of concern, meaning people who use drugs can make an informed choice about use.

The minimum standard of safety at festivals requires festival organisers to have a police presence to gain their licence. We would also like to see event organisers providing licensed drug-checking facilities as standard at festivals and other major events where there is likely to be significant drug use.

A research project into licensed drug-checking facilities is due to report in January 2023. We understand that applications will soon be made to the Home Office to establish pilot facilities. It will be important to fully consider the evaluation of these pilots to support wider national expansion.

Action 61. The Scottish Government should support the provision of licensed drug-checking facilities nationally, ensuring they are available within existing services, at key events and through a postal system.