Treatment – drug and alcohol services

MAT employs medication such as opioids with psychological and social support in the treatment and care of people with problem drug use. Evidence shows that MAT is protective against the risk of death.

We identified supporting MAT as an initial priority for our work. As explained in Chapter 1, our MAT subgroup worked with partners and experts to develop the MAT standards. The standards have been accepted by the Scottish Government and form a cornerstone of the National Mission.

The standards are aligned with the United Nations Availability, Accessibility, Acceptability and Quality Framework. They are underpinned by criteria that outline the steps to be taken by each NHS board, ADP and health and social care partnership to ensure their full implementation (10).

What needs to change

In May 2021, the Minister for Drugs Policy made a commitment to have the MAT standards embedded across Scotland by April 2022.

We advised when the MAT standards were published that they represent long-term transformational change and would not be delivered overnight.

We understand that the Minister’s commitment is about prioritising delivery at local level and identifying the funding and coordination support local areas will require. Fully implementing the standards within this timeframe has nevertheless proven challenging.

More than a year on from the publication of the MAT standards, a report by Public Health Scotland shows significant failings in their implementation (33).

Only 17% of the standards of care assessed had been fully implemented, with almost 60% of ADPs failing to demonstrate any progress at all towards delivering on MAT Standard 1.

The report also identifies major problems in monitoring of the standards, with inadequate information provided for assessment. Worryingly, it also highlights that only 27% of ADPs were able to provide sufficient documented policies, guidelines, and standard operating procedures to support implementation.

We support the conclusions and recommendations made by Public Health Scotland in its report and call on the Scottish Government to implement them rapidly.

We also support the measures announced by the Minister for Drugs Policy on 23 June 2022 (30). These include using the powers of the Public Bodies (Joint Working) (Scotland) Act 2014 to compel local partners to:

• implement the standards;
• introduce quarterly reporting, with monthly reports for poor-performing ADPs; and
• placing responsibility for these measures directly on chief executives and chief officers.

Deficiencies in monitoring highlighted by the Public Health Scotland report should be addressed, with appropriate accountability and governance for delivery established. We agree that chief officers should be held to account for adoption of the standards. We also believe regular reviews should determine if the experience of people with lived, living and family experience corresponds to the standards.

We ardently believe that full implementation of the standards will provide the best chance of continued engagement with services for many people with problem drug use and reduce the likelihood of fatal overdose. The standards will provide a national platform to increase coverage and enhance the quality of services, allowing people to access the treatment that is right for them at the time they ask for it.

Implementation cannot take until 2025. It must come sooner. We have stated that three years is a reasonable timeframe for implementation and we remain committed to the timescale of full implementation by May 2024.

Action 62. Over the next two years, the Scottish Government, chief officers and ADPs should ensure that all the MAT standards are fully implemented, embedded and mainstreamed, with standards 1–5 implemented in the next year.

Implementation should be monitored with appropriate accountability and governance for delivery. Chief officers should be held to account for their adoption and regular reviews should be conducted to determine if the experience of people with lived, living and family experience is in line with the standards set out.

Implementation of the MAT standards can be supported by innovative approaches like TeleMAT, to which we provided funding. TeleMAT has developed specific guidelines for services on delivering MAT via a telemedicine platform, making MAT more accessible.

Other potential innovations to enhance the implementation and delivery of MAT should be encouraged and supported through funding pathways.

The standards currently focus on OST. Scotland, however, is seeing increases in poly-drug use, and use of benzodiazepines and cocaine. The current MAT standards will not benefit everyone with problem drug use while their focus remains on OST.

Overarching treatment and recovery guidance, with defined and measurable standards, should be developed and implemented. The guidance should cover all types of drugs and the full spectrum of treatment and recovery support. The aim should be to ensure safe, effective, acceptable, accessible and person-centred treatment is available to everyone with problem substance use. The guidance should be co-produced with people with lived and living experience, families and people working in the sector. It should incorporate guidance from the Residential Rehabilitation Development Working Group (RRDWG) on residential services.

Crucially, it should build on the work of the Human Rights Bill and the National Collaborative to embed the highest attainable standard of physical and mental health in treatment and recovery services.

The guidance must not dilute the current MAT standards. Instead, it should expand the principles of access, choice and support that underpin them.

Action 63. The Scottish Government and Healthcare Improvement Scotland should develop and implement overarching treatment and recovery guidance and standards for alcohol and drug services.

Heroin-assisted treatment (HAT) is an evidence-based alternative to conventional MAT for people seeking support for street heroin use. It is targeted at people whose addiction persists even after receiving conventional treatment and care services.

HAT has been offered at relatively low threshold and at high capacity in some parts of Europe for decades. It nevertheless remains a controversial and poorly resourced treatment in the UK. At the time of writing (June 2022), only one HAT service operates in Scotland, in NHS Greater Glasgow and Clyde.

Despite the high costs associated with implementing this treatment, a robust clinical evidence base supports its use. Rights, Respect and Recovery found strong evidence that HAT is more effective at retaining people in treatment than other forms of OST.

Benefits for individuals, families and the wider community in prescribing HAT as part of a comprehensive OST programme include:

• improved physical health for individuals through interaction with nursing staff;
• reducing the risk of spread of BBVs such as HIV through supervised injection technique and use of sterile equipment; and
• avoiding individuals having contact with the illegal drugs market, which is likely to benefit Police Scotland and the criminal justice system.

What needs to change

The Scottish Government should explore how it can promote accessibility of HAT by, for example, issuing staff training guidance, identifying suitable premises and making extra funding available for staffing and other costs.

They could be supported in this effort by the UK Government devolving responsibility for licensing of HAT premises to the Scottish Parliament. This would allow single-office co-ordination of premises and prescriber licensing.

Action 64. The Scottish Government should support and promote a national roll-out of HAT.

Primary care settings offer a key environment in which direct care and treatment can be offered to people who use drugs. Treatment services offered by, for example, GPs, dentists, community nurses, pharmacists and pharmacy technicians can also help to address issues around access to drug treatment services in rural areas and reduce stigma.

What needs to change

The groups of people who use drugs in Scotland include older people. Older drug users may have missed opportunities to address their drug use in the past and now live with underlying conditions. They may therefore benefit from treatment services delivered by general practice teams to enable wider health problems to be addressed.

We are aware that primary care practitioners may not have the specialist training of those working in drug services. Close links between primary care settings and specialist drug services are therefore essential.

Current approaches to treating people presenting with various issues such as mental and physical health difficulties, dental health issues and problem use of drugs and/or alcohol tend to be sequential rather than holistic. All presenting conditions should be treated holistically, as one condition can be a contributory factor in another.

The co-existence of problem drug use with mental health issues is well recognised. Perhaps less well acknowledged are the significant physical health problems people with problem drug use experience. These require treatment and support. An action plan to improve the provision of physical healthcare to people who use drugs should be an integral part of local integrated care systems (6).

Action 65. A whole-systems approach should be adopted nationally and locally to meeting the requirements of the MAT standards for treatment and support for those who wish, and are appropriate for accessing, care in a primary care setting. This should include shared care protocols and contractual arrangements for primary care provision that must be effectively implemented and appropriately resourced. Local and national adjustments to the GP contract may be required.

Action 66. Drug treatment services should facilitate transfers to and from primary care at all stages of the person’s journey, depending on their needs and wishes.

Action 67. Referrals to primary care (such as GP, pharmacy, optician and dental services) should be backed by a plan for disengaging from the service. Appropriate aftercare should be in place, with the option for a barrier-free return to specialist care if needed.

People who inject drugs may contract BBVs, bacterial infections and injection site wounds, and are at increased risk of overdose. The WAND (Wound management, Assessment of injecting risk, Naloxone supply and Dry blood-spot test for BBV) model has been piloted in NHS Greater Glasgow and Clyde. WAND has proved effective in engaging with people who inject drugs and who are not in contact with traditional services. We believe this success could be replicated in other parts of the country.

WAND should also be expanded for use in primary care settings as well as in drug treatment services.

Action 68. WAND should be expanded throughout Scotland, reflecting the requirement of MAT Standard 4.

Scotland has a widespread pharmacy network that includes rural communities.

Pharmacists and pharmacy staff are often the people who have the most contact with individuals who are receiving MAT. They are in a strong position to detect if a person has missed doses of their substitution treatment, putting them at risk of disengagement from treatment and overdose.

Supervision of OST is not currently a core component of the national pharmacy contract. It is subject to local negotiations, with pharmacies being able to opt in or out.

Almost all community pharmacy teams in Scotland deliver support to people who use drugs and those in treatment, on behalf of the NHS. Consistency in the types of support available is lacking, however.

Pharmacy support can include one, some or all of the following:

• advice and signposting to services;
• regular personalised care planning;
• IEP (usually one pharmacy per locality);
• naloxone stocking (in case of an emergency in/around the pharmacy);
• naloxone supply and training (in case of emergencies in future);
• BBV interventions (testing and treatment);
• public health interventions; and
• long-acting buprenorphine injections (in pilot schemes).

What needs to change

Pharmacy payments in some NHS board areas are no longer linked to the number of supervisions provided. We believe this is a positive change. It means that pharmacy payments are linked to provision of individual pharmaceutical care (per capita) and not to the number of supervisions. This will enable pharmacists to provide individualised care packages for each patient.

Action 69. The Scottish Government should support a move from pharmacy payments being based on number of supervisions to a per capita system.

Services should be consistent across the country. Areas of pharmacy provision nationally should be agreed with the directors of pharmacy for each NHS board.

Action 70. A nationally agreed specification should be developed with directors of pharmacy and Community Pharmacy Scotland. This should set out what should be expected of each pharmacy in Scotland.

The Misuse of Drugs Regulations 2001 were introduced before there was any widespread OST instalment dispensing, computer-generated prescriptions, pharmacist and nurse prescribers or electronic transfer of prescriptions.

The regulations lack flexibility. This has an impact on patient care and poses an additional burden on prescribers.

Responding to difficulties with missed collection of doses and planned and emergency pharmacy closures, specific Home Office-approved wording was added to prescriptions. This was intended to give pharmacists a degree of flexibility in dispensing.

What needs to change

Pharmacists must be satisfied that the prescriber’s intentions are clear and can only make the supply if the approved Home Office wording has been added to the prescription in advance. This prevents pharmacists from working to meet the immediate needs of the patient and restricts their ability to exercise professional judgement.

Prescription forms can often become illegible due to the amount of additional information required. Pharmacists cannot dispense prescriptions that are not fully compliant with the regulations, even when the prescriber’s intentions are clear and unambiguous.

Pharmacists cannot accept clarifications by phone or an electronic amendment. The time taken to rectify or clarify prescriptions can cause delays lasting days, by which time the patient may have decided to seek drugs elsewhere.

Action 71. The UK Government should conduct a review of the regulations on prescriptions by the end of this year. The review should take account of the changes made since the initial regulations were implemented in 2001.

Residential services are highly intensive interventions. They cover three main types of intervention: crisis and stabilisation, detoxification and rehabilitation.

Crisis and stabilisation services have a harm-reduction focus. They offer a place of safety in which drug use can be stabilised and provide treatments and appropriate supports to better manage an individual’s usage.

Detoxification services focus on safely managing withdrawal symptoms when someone stops taking drugs.

Residential rehabilitation services usually have an abstinence focus and are generally longer term.

The services might interact – for instance, someone may access detoxification prior to entering rehabilitation – but are not necessarily linear. It may not be appropriate or desirable for an individual to move from one service to another.

As we have suggested previously, Scotland’s unique drug challenge includes particularly high use of street benzodiazepines. This is known to be a significant contributing factor in drug deaths. People can face severe medical risks when withdrawing from these drugs and it can be challenging to stabilise a person’s use.

Our benzodiazepine short-term working group highlighted the need for residential facilities to provide a place of immediate safety for those at very high risk of overdose due to their extremely chaotic drug use and life circumstances. This led to our recommendation to the Scottish Government to develop residential crisis and stabilisation services.

The RRDWG was set up specifically to advise Scottish Ministers on residential rehabilitation. It has considered and published a range of evidence, guidance and recommendations. This includes a suite of publications about pathways into, through and out of residential rehabilitation (34) and a good practice guide (35).

Our remit was to provide evidence to reduce the number of drug-related deaths. We therefore focused primarily on crisis and stabilisation services and how they sit within the wider context of residential services.

There is an often-quoted debate on the relative merits of abstinence-based rehabilitation and harm-reduction measures. We believe it is not a case of either/or. Individuals should be able to access whatever support they need, when they need it. That means access to rehabilitation if and when the person is ready to take this step and it is clinically appropriate.

What needs to change

Access to residential services is inconsistent across Scotland. Crisis and stabilisation services are particularly few in number.

Our expectation is that wherever an individual lives in Scotland, they can access detox, crisis and stabilisation or residential rehabilitation at the point of need. It is not necessary or appropriate for every locality to provide a suite of residential services; indeed, a nationally commissioned regional model might be more suitable.

Consideration should be given to stabilisation units having “crisis beds.” These would be used by people treated by SAS who either do not require ongoing hospital care or refuse to attend hospital, but who agree they would benefit from being transferred to a place of safety. The emergency response from SAS would thereby be part of a continuous care pathway.

All aspects of residential services should be seen as vital parts of the system. Each provides critical support for different stages of recovery.

We recognise the role of residential rehabilitation in a recovery system of care. We also understand the Scottish Government’s commitment to improve access to residential rehabilitation. We recommend, however, that the Scottish Government considers all Tier 4 residential care services as a whole.

Action 72. The Scottish Government should expand the current commitment on residential rehabilitation to consider crisis and stabilisation, detoxification and residential rehabilitation. Appropriate funding should be provided to ensure that all are available everywhere in Scotland at the point of need.

Action 73. The Scottish Government should work to ensure national coverage of crisis and stabilisation services that include crisis beds to provide a place of safety. This should be available out of hours and have links to SAS to enable SAS personnel to take an individual directly to the service.

People who use drugs, their families and clinicians need to have clarity on how someone accesses residential care. Currently, entry criteria appear inconsistent and pathways into care lack transparency.

One of the RRDWG’s approaches to improving residential rehabilitation is “Improving pathways into and from rehabilitation services, in particular for those with multiple complex needs”. The RRDWG published a good practice guide on this in November 2021 (35).

If treatment in the community is not working or is not suitable, and it is clinically appropriate, the pathway into residential services should be set out and clear to all.

Self-referral needs to be considered as a core element of these pathways. Ensuring that treatment is truly person-centred and residential treatment is the right route for the individual at that time, based on their needs and future aspirations, is also crucial.

Leaving a service can be a time of high risk of overdose or drug-related death. Aftercare is therefore crucial to ensure that people remain stable in their drug use or recovery. Aftercare cannot be dependent on a person remaining abstinent.

We have heard that while some services provide harm-reduction advice and support when someone leaves care, this is not universal. There may be concerns among workers that doing so will give the impression the person is not trusted to remain abstinent.

Providing harm-reduction information and THN may nevertheless assist someone who returns to drug use. It may also help the person leaving care to support others in their peer group who may still use drugs.

The Taskforce supports the recommendation of the RRDWG that:

All residential services must have appropriate pathways into their services and appropriate aftercare to support people leaving care including access to harm reduction, provision of naloxone and referrals to relevant services to ensure a holistic ongoing care package.

Many residential rehabilitation services have positive links with local recovery communities. These communities play a crucial role in providing ongoing support and engagement with people in recovery. Reintegration into a local community can be a challenge after leaving residential care, and support is vital.

Three factors have been highlighted as being core in determining the success of recovery – jobs, housing and social connection.

Recovery communities can (and do) provide the social interaction, networks and friendships highlighted as one of the biggest factors in successful recovery. The visibility of recovery communities and of recovery in general provides hope for individuals. It demonstrates to people who use drugs and the workforce that recovery is possible.

Dame Carol Black’s Review of Drugs (6) recommends that local areas should be

supported to ensure that “thriving communities of recovery are linked to every drug treatment system.” It goes on to call for standards to be developed to “raise the quality and improve the governance of the recovery sector”.

We support the drive behind this recommendation. The Scottish Government should also look to support the thriving recovery communities across Scotland.

Action 74. The Scottish Government should ensure recovery communities are funded to provide their vital service and are encouraged to develop peer-led services.

Latest available data for 2018/19 show that of 1,017 voluntary tests carried out at prison entry as part of an addiction prevalence monitoring study, 71% of people tested positive for illegal drugs (including illicit use of prescribed drugs) (36). While statistics are not available specifically for those on remand, it can be assumed that rates would be similar.

Before and the Covid-19 pandemic, 15.9% of the male prison population and 19.6% of female were on remand (February 2020). By April 2021, the proportions had increased to 23.9% of the male population and 25.6% of the female (37).

Clearly, the pandemic has had a significant impact. Even without this, however, over 15% of the prison population was on remand. When a person is using drugs or wishes to end their drug use, residential services may prove a more effective intervention than remand.

Action 75. The Scottish Government should look at opportunities for expanded residential and specialised care services to be used as an alternative to remand or custody, where appropriate.