Scottish Government

7. Targeting those at Greatest Risk

RECOMMENDATION 7

The Executive supports this recommendation.

274 (86%) of those who died as a result of a drug-related incident in 2003 were known to the Scottish Criminal Records Office. It is not unreasonable to conclude that many of those vulnerable to drug-related death are at some point in contact with the police service. Any review of services should take this into account, and seek to use contact with the police as an opportunity to engage with potential clients. Facilities could be introduced in police custody suites for other services to access clients.

Those at greatest risk and with complex needs i.e. co-morbidity

The Executive's vision for mental health and wellbeing in Scotland is to improve the mental health and well-being of everyone living in Scotland and to improve the quality of life and social inclusion of people who experience mental health problems. A number of initiatives aimed at realising this are being taken forward. Some of this work is designed to support people who have mental health problems and are substance misusers.

'Choose Life', the Executive's National Strategy and Action Plan to Prevent Suicide in Scotland was launched in December 2002, with guidance on implementation for local authorities and their Community Planning Partners issued in July 2003. 27% of drug-related deaths in 2003 (that were studied in this report) were recorded as suicide (including deaths of undetermined intent). People who misuse substances are therefore identified as one of seven priority groups for action under 'Choose Life'. Implementation of local suicide prevention action plans by Community Planning Partnerships includes action to establish and improve links with local drug action work. For example, local 'Choose Life' funds have been used to extend the existing outreach service offered by the Shetland Community Drugs Team and the service offered by the Alcohol Advice Centre in Lerwick. Extension of these key services will provide greater access for those affected by substance misuse (particularly young men) in a rural and isolated area.

The Executive also funds the 'Breathing Space' telephone advice line for people experiencing low mood or depression. 'Breathing Space' is free and confidential and is aimed particularly, although not exclusively, at young men who are experiencing mental health or emotional difficulties. It provides a listening ear and signposting to relevant support agencies in the caller's own locality. 'Breathing Space', which was rolled out nationally in 2004, is available on 0800 83 85 87 from 6 p.m. to 2 a.m. every evening and is therefore a source of support for vulnerable people at a time when many other services are closed. The service handles calls on a wide range of issues, including some from people with substance misuse problems.

Mental Health First Aid is a training course being rolled out across Scotland as part of the Executive's action to raise public awareness about mental health issues. The aim of the course is to improve awareness and understanding of mental health and mental illness amongst the public. It has proved successful with members of the general public and different professional groups including teachers, front line public sector workers and health workers. It also teaches people how to put someone in the recovery position following overdose.

TAKING ACTION

The Executive is working with colleagues on the 'Choose Life' National Implementation Support Team, with the aim of reducing the number of substance misusers who commit suicide.

• For example, with Executive funding, ASIST (Applied Suicide Intervention Skills Training) is being rolled out across Scotland to a wide range of frontline workers and local people. This two-day suicide prevention first aid skills workshop prepares people to intervene competently with a person at risk of suicide. As the cornerstone of suicide prevention training, it is relevant to professionals, carers and volunteers involved with drug and alcohol issues.
• The Executive plans to strengthen links between the substance misuse and mental health agendas and take forward the recommendations of Mind the Gaps ⁵ and A Fuller Life ⁶. As a first step we plan to set up a Cross-Departmental Advisory Group who will be tasked with delivering the objectives of these documents.

Prisoners

It is recognised that prisoners with addiction difficulties are particularly vulnerable on their release from custody. The Scottish Executive is already working in partnership with the SPS, local authority social work services and the voluntary sector to deal with the problem of drug-related deaths amongst ex-prisoners.

Voluntary Throughcare ⁷, often referred to as Phase 2 of the Enhanced Throughcare Strategy ⁸, is about providing services and support to ex-prisoners in order to help them effectively resettle within their communities.

A key new component of Phase 2 is the Throughcare Addiction Service ( TAS). This service seeks to engage prisoners at least six weeks prior to release from custody, motivate them to address addiction and associated problems, and then link them into community-based resources upon release. The Service will continue to work with the prisoner for at least six weeks post release. TAS will have close working links with the SPS and community health and addiction resources. Together they will provide the continuity of care required to help prisoners successfully address their addiction problems. TAS, which will be managed by local authorities or by one of their contracted service providers, is a
developing service. Local authorities only began taking referrals in August 2005 after the SPS's Transitional Care service provider's contract ended in July 2005.

The Scottish Executive and its partners on the Tripartite Group (the SPS and local authorities) recognised that, as a developing service, it was appropriate to target priority groups for TAS from the outset. This has been done in order to avoid overburdening existing resources and service providers.

The Tripartite Group concluded that there would be severe logistical problems in trying to provide a service to all those prisoners serving less than 31 days in custody, on the basis that a person sentenced to 28 days in custody would actually spend only 14 days in prison. This would create substantial practical problems and strains on service providers. However, in recognition of the concerns expressed about the exclusion of those serving less than 31 days, two priority groups were identified within this group of prisoners: young offenders and female prisoners. Both these groups are therefore eligible for TAS after a full addictions assessment has been completed.

All prisoners who are not subject to statutory supervision on release can request a voluntary social work service up to one year after their date of release from custody. Those men serving less than 31 days therefore have a right to request such a service from the local authority.

The SPS is committed to improving prisoners' health and works closely with key stakeholders to reduce drug-related deaths for prisoners on release.

TAKING ACTION

• The Throughcare Addiction Service was implemented in August 2005.
• The Executive has invested £2.8 million in voluntary Throughcare services. £0.4m from this budget has been targeted specifically at three (criminal justice) drug hotspot areas because they have significantly high numbers of known problem drug users: Glasgow, the Lothian and Borders Criminal Justice Consortium and the Northern Criminal Justice Partnership.
• Young prisoners and female prisoners serving sentences of less than 31 days are eligible for a Throughcare Addiction Service. Those male prisoners serving sentences under 31 days have the opportunity to request a voluntary Throughcare service whilst in custody, in preparation for release, or up to a year after release from custody .
• The SPS plan to recruit an additional 27 addiction nurses for SPS establishments, increasing the complement to 42 nurses. This increased capacity will allow the SPS to deal with mental health and primary care needs to a higher standard and increase their knowledge base on blood-borne viruses.
• The SPS Addictions Advisor will communicate with the DAT Association regarding membership on ADATs to ensure the appropriate level of representation by the SPS at local level.
• Introduction of Health Care Standard 10 (November 2005) will ensure a shift from predominantly detoxification prescribing to methadone or buprenorphine maintenance treatment in order to better meet the needs of prisoners.
• The SPS will continue to liaise with key stakeholders in Scotland (for example the Golden Lion Group ⁹) regarding prescribing patterns both in prison and in the community.
• The SPS will ensure that prisoners on methadone who are released on a Friday are given their daily prescription dose prior to discharge.
• Measures are being taken by ADATs to improve access to services for prisoners released on Fridays, e.g. in Tayside and Greater Glasgow specific arrangements have been made to ensure continuity of GP prescribing.
• The SPS will continue to liaise with key stakeholders in Scotland, including the Scottish Network of Clinical Specialists, regarding integrated approaches to addiction management both in prison and in the community.
• The SPS will continue to work with ADATs to ensure that prisoners who are at high risk of drug-related death receive appropriate care packages on release.
• A Memorandum of Understanding to formalise existing arrangements for information sharing on drug-related deaths has recently been agreed and signed off by the SPS Director of Rehabilitation and Care and the Director of the SDEA.
• The SPS have introduced a package of addictions and harm reduction booklets and information cards which were recently updated (November 2005), taking account of recommendations on the dangers of oral drug use.
• The Executive will provide the SPS with their First Aid DVD which will be used nationally in the SPS pre-release programme. The SPS were consulted during the production process of the DVD to ensure its suitability for prisoners.

The Homeless

The Executive is committed to improving the links between drug treatment and housing services, in particular in addressing the Homelessness Task Force recommendations. It is hoped the delivery of integrated care which, with its requirement for a wide range of service providers to work together, will deal effectively with the multiple problems faced by drug misusers. Integrating Service Delivery is one of the five key strands of the Action Plan ¹⁰ published in October 2004 following the Executive's Review of Drug Treatment and Rehabilitation Services.

TAKING ACTION

• The Executive has set up an Advisory Group with the aim of improving links between drug, alcohol and housing services. The group held its first meeting in November 2005.
• Every ADAT is operating within the partnership context of a local Homelessness Strategy and a Health and Homelessness Action Plan in which support to housing providers is central.
• Some ADATs have established specialist services and partnerships addressing the needs of people living in hostels and transitory accommodation, e.g. a specialist Homeless Addiction Team has been operating for some years in Glasgow, and other areas such as Fife are expanding services to homeless people.

Services for the Over-Thirties

A high proportion of deaths occur in the population of drug users over thirty years old; there were approximately 200 deaths in 2003 and 2004. There are no specific services that we are aware of currently available for this age group. User Groups may be best placed to advise and look at identifying needs for this group.

TAKING ACTION

• The Executive will encourage ADATs to look at whether service provision is adequate and reaching those over thirty years of age, and to work with User Groups to identify needs.

RECOMMENDATION 8

The Executive supports this recommendation.

The SDEA is responsible for collating trend information from all Scottish police forces for inclusion in their Drug Trends Bulletin, which is distributed nationwide to the law enforcement community and partner agencies, including ADATs. Further, the SDEA has agreed a written protocol with the Scottish forces in relation to information sharing on the emergence of new drugs or methods, which may be worthy of national dissemination by way of Special Alerts or Health Alerts.

ACPOS considers it important to identify the scale of the market for prescription-only drugs in order to devise control strategies. Members of ACPOS Drugs Sub-Committee agreed that forces should make local enquiries with health partners to establish the position with regard to prescribing practices and measures to prevent over-prescribing. Intelligence should also be reviewed in relation to the availability of counterfeit drugs.

The issue of prescribed drugs being used as cutting agents has also been discussed at ACPOS level, and work is ongoing with the Scottish Police Forensic Laboratories to conduct analysis to establish the extent of this practice.

The National Hi-Tech Crime Unit recently developed an intelligence-led operation into the illegal sale of prescription-only drugs over the Internet.

TAKING ACTION

• The Drug Trends Bulletin will continue to be produced by the SDEA (three per year). The SDEA will continue to produce Special Alerts and Health Alerts based on information received from Scottish police forces.
• ACPOS Drugs Sub-Committee has been tasked with making enquiries with local health partners regarding prescribing practices, and with reviewing intelligence relating to the availability of counterfeit drugs.
• ACPOS Drugs Sub-Committee is considering strategies to deal with the diversion/supply of prescription drugs.
• Work is ongoing with the Scottish Police Forensic Laboratories regarding the testing of samples of illicit drugs for evidence of prescribed drugs being used as cutting agents.
• The National Hi-Tech Crime Unit remains capable of responding to intelligence regarding the illegal sale of prescription only drugs over the Internet.
• Within the development of integrated care services as part of Joint Future, and together with the existing Critical Incidents Groups, ADATs are improving and monitoring prescribing protocols.