Annex A Summary of Recommendations
The following recommendations highlighted in the body of this report have been determined by members of the National Forum and its sub-groups. They focus on key areas where there have been gaps in service provision or interventions to reduce drug-related deaths.
Recommendation 1: Funding
There is a need for a dedicated fund to encourage new responses to reduce drug-related deaths in Scotland. It is therefore recommended that the Scottish Government considers allocating funding specifically for initiatives aimed at reducing drug-related deaths.
Recommendation 2: Prisoners
The number of deaths amongst prisoners on release and gaps in services offered to people on short term sentences continue to cause concern. It was felt important to recognise the dangers faced by this group and it is therefore recommended that:
- There should be more support and overdose awareness training for short-term prisoners, i.e. those on remand or serving sentences below 31 days.
- SPS consider revising access criteria for pre-release to prisoners serving 31 days or more.
- There is consistent policy implementation and practice regarding delivery of overdose awareness sessions, prescribing practice and detoxification across the prison service nationally.
Recommendation 3: Providing Naloxone in Order to Save Life
With take-home naloxone being more widely used across the world to save lives, e.g. in Berlin, San Francisco and Chicago, consideration should be given in Scotland to extending take-home naloxone provision beyond Glasgow into other areas. This recommendation is made with the understanding that any pilot is rigorously evaluated to prove effectiveness.
Recommendation 4: Research
The Forum believe that in addition to accurate data collection there is a need to continue to investigate the circumstances and settings of drug-related deaths and how such factors contribute to them.
The Forum also recommend that research should be commissioned into other treatments that may assist addicts to become drug free, e.g. the use of naltrexone highlighted in this report and the effects of the introduction of Subutex and Suboxone in drug treatment.
Recommendation 5: Suicide Prevention
Approximately 23% of all drug-related deaths in Scotland are intentional self-poisoning or where the intent is undetermined. Prevention of suicide amongst drug users should therefore become a key priority as part of the drive to reduce drug-related deaths in Scotland. It is therefore recommended that:
- Suicide prevention be incorporated within the ethos of reducing drug-related harm and becomes a key priority for the attention of ADATs, drug agencies and related services.
- Action to prevent suicide should include prioritising suicide prevention training for front-line agencies and developing greater awareness of heightened risk factors for drug users, particularly in relation to intentional overdose.
- ADATs take a lead role in utilising the linkages to local Choose Life (suicide prevention) networks to access training and other resources and promote greater understanding of mental health problems (such as depression and bi-polar disorder) as likely determinants of suicide.
Recommendation 6: Treatment and Support
The revised Clinical Guidelines on the Treatment of Drug Misusers (Orange Guidelines), published in September 2007 should be properly implemented by practitioners. The guidelines make it clear that, if properly implemented, the treatments outlined in the document will reduce drug-related deaths. The document also highlights areas which are not effective or can be dangerous such as rapid detoxification, long waiting lists and under-medicating patients. In addition, there are examples of those treatments which need further research before they can be recommended or discarded.
Services should comply with the National Quality Standards for Substance Misuse Services11 to improve the consistency and quality of substance misuse service provision in Scotland.
Specialist services need to monitor waiting times and retention rates. The Drug Outcome Research in Scotland ( DORIS) study highlighted a wide variation in retention rates across Scotland. Services need to do more to retain people in treatment, particularly those who have a history of previous overdose.
Recommendation 7: Young People in Care and Leaving Care
There should be continuing practical 'wraparound' support for young people whilst in and leaving care including harm reduction and overdose awareness training. There should also be easy access to essential services that are specifically tailored to young people's requirements and where assessment of risk can be carefully undertaken.
Recommendation 8: Piloting Innovative Projects
There is a particular need to look at those who are known to be at high risk of overdose. If they are not given intensive support they may be more likely to die. These are typically males in their thirties and forties with a long history of substance misuse, marginalised from their families and society, often homeless and in poor general health.
Consideration should be given to identifying and piloting methods used in other countries that have been shown to have an impact on drug-related deaths with this target group, e.g. piloting a safe injecting clinic such as those established in Australia, Canada and Switzerland. If a scheme is evaluated and has proved to be effective we should think about trying it in Scotland. The JRF report should be considered carefully by service commissioners.
In Canada, for example, the results of an evaluation of an injection clinic called Insite, in the Downtown East Side area of Vancouver, showed that in the 500 overdoses that had occurred at the site over a two year period, none had resulted in a fatality. If these overdoses had happened elsewhere the outcome may have been very different.
Recommendation 9: Data Collection
Drawing from the SACDMWorking Group on Drug-related Deaths, Report and Recommendations (2005) and after discussions with ADATs, the GROS, SCDEA and ISD, the following recommendations emerged. A new system for data collection should be constructed as follows:
- ADATS should be asked to gather data in a systematic format on each death after being notified of these by the police or SCDEA.
- That data should be standardised and compiled by ISD in a suitable electronic format which will allow analysis and reporting.
- The national dataset will be augmented by adding information from other ISD files, in particular each case will be matched with information from reports from treatment agencies ( SMR25) and mortality statistics concerning hospital admissions ( SMR01 and SMR04) as well as GROS cause of death information.
- An expert group should supervise these exercises and will provide accurate clinical interpretations in order to correctly brief Scottish Government Ministers, the National Forum, the media and the public.
Recommendation 10: National Campaigns
There is a need for targeted national information campaigns. Up-to-date information should be disseminated to those most at risk. For example, dangerous combinations of drugs and alcohol, in particular methadone and alcohol and cocaine and alcohol, need to be highlighted to drug users.
The Forum recommends that the Scottish Government review and update materials available on overdose and consider using information technology to highlight issues. For example, a dedicated drug deaths website to provide up-to-date information on available materials and where to get help would be very useful.