Scottish Government

2. PROGRESS IN 2008

2.1 The Forum published its first report in December 2007. Below are the recommendations ⁵ made at that time and the Government response ⁶ to those recommendations. The recommendations and Government response are not new, they are taken from the previously published documents (see footnotes). These are given in order to report on progress since the publication of our 2007 report.

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 consider allocating funding specifically for initiatives aimed at reducing drug-related deaths.

Scottish Government Response

2.2 The Drug Misuse Programme budget includes funding allocated specifically to tackle drug-related deaths. Some of this funding is being used to take forward key recommendations from the Forum including establishing a database to collect and analyse information on drug deaths.

2.3 Substantial resources are already being ploughed into tackling the problem of drug misuse in Scotland. The drug misuse budget within the Justice portfolio is £29.5m/£32.0m/£32.8m for the period 2008-9 to 2010-11. This represents a 14% increase in spending overall by 2010-11. It may not be a question of allocating new resources but of using existing funds and targeting them in a more effective way that produces better outcomes for all.

2.4 In addition, local partners fund initiatives aimed at raising awareness of the dangers of overdose such as information campaigns. We are also funding the Scottish Drugs Forum ( SDF) to deliver critical incident training, produce a training manual and to train key workers to deliver the overdose awareness training within their own services.

Progress

2.5 Just over £191,000 has been specifically spent in 2008-9 on work around drug-related deaths. Drug addiction costs society £2.6 billion ⁷ per year but the human cost saved - the cost of people recovering their lives from addiction - is incalculable and beyond price.

2.6 A good example of how Government funding has been used is the SDF manual, Overdose Prevention and Intervention - A Training Resource. The manual was produced as an aid to training for workers in contact with groups such as, amongst others, those in supported accommodation, in needle exchanges, in drug services and in prisons. In addition, SDF provide training to user groups, family groups and others. Further information on training for families, drug users, their friends and key workers can be obtained by contacting Scottish Drugs Forum, 91 Mitchell Street, Glasgow G1 3LN or by telephoning 0141 221 1175.

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.

Scottish Government Response

2.7 The Scottish Prison Service ( SPS) have either actioned or are currently working to the recommendations within the Forum's report. They deliver Harm Reduction Awareness Sessions ( HRAS) to all eligible admissions to custody (including remands) within 5 days of admission. As from 1 August 2007, pre-release sessions are offered to those in custody 31 days or more (including remands). The HRAS is being revised and updated in partnership with the Scottish Drugs Forum to include overdose awareness and basic life support. Alerting vulnerable drug users to the dangers of lower tolerance, such as those being released from prison, may help prevent some of the deaths.

2.8 Overdose awareness is a part of the Harm Reduction Awareness Session delivered on admission to all prisoners as well as at the pre-release session for those in custody for 31 days or more.

2.9 SPS are committed to consistency in prescribing practices in relation to substance misuse. All doctors working in prison settings will be undergoing Royal College of General Practitioners ( RCGP) training on substance misuse. This will ensure there is a level of consistency in prescribing practice. Doctors now have a consistent approach to continuous professional development both in terms of relevant training, supervision and support. Doctors now also have access to training courses run by Scottish Training on Drugs and Alcohol ( STRADA) on substance misuse and dual diagnosis.

2.10 Current SPS policy around prescribing recommends that a move away from detoxification and towards stabilisation and maintenance happens as a matter of priority.

2.11 SPS routinely conducts Critical Incident Group Reviews in respect of drug-related deaths soon after release. This process enables 'lessons learned' to be identified in relation to systems, processes and practice and recommendations for improvement are put in place. The drug death analysis reports and relevant information are shared with key stakeholders including the National Forum, Scottish Government and ADATs.

Progress

There should be more support and overdose awareness training for short term prisoners, i.e. those on remand or serving sentences below 31 days.

2.12 All prisoners whether remand or convicted and regardless of sentence length, attend the HRAS within five days of admission. This session currently includes a brief introduction to overdose awareness, Blood Borne Virus ( BBV) risks and how to access services within the local establishment. A revised and updated session in conjunction with SDF was piloted successfully in HMP Barlinnie at the beginning of 2009 and will replace the current session across the prison estate. The new session will have a greater focus on overdose and the most appropriate ways of dealing with one.

2.13 SPS is an active member of the Glasgow 'Preventing Risk of Overdose in the Vulnerable' group and takes part in all their seasonal campaigns. The Glasgow campaign was aimed at those at risk in Glasgow, however, SPS made their materials available to all prisoners throughout Scotland.

SPS consider revising access criteria for pre-release to prisoners serving 31 days or more.

2.14 Pre-release sessions continue to be offered to all prisoners, both remand and convicted, who will be in custody for 31 days or more. The session will also be revised to incorporate a new film made by an ex-prisoner about overdose and include basic first-aid training for prisoners.

There is consistent policy, implementation and practice regarding delivery of overdose awareness sessions, prescribing practice and detoxification across the prison service nationally.

2.15 Delivery of services continues to remain consistent across all SPS establishments. There are standards and assurance processes in place to ensure consistency and the first intake of SPS doctors and nurses to the RCGP, part 2 Certificate in the Management of Substance Misuse are nearing completion of their training. SPS and the RCGP have also developed a new two-day module on Management of Substance Misuse in Secure Environments. This course is aimed at a range of new and existing staff within SPS.

2.16 Prescribing within SPS is consistent with Drug Misuse and Dependence: UK Guidelines on Clinical Management.

Additional initiatives:

• Scottish Ministers have agreed to NHS provision of health care for prisoners. The process or transferring services from SPS provision to NHS provision is expected to take three to five years.
• HMP Edinburgh has recently concluded an Integrated Addiction Process pilot which involves automatic access to addiction support services for those prisoners on substitute prescribing to provide more than just a prescription. Evaluation of this pilot continues.
• SPS collates drug-related death statistics which results in a case file analysis for all ex-prisoner deaths within two months of liberation (previously this was within six months).
• N-ALIVE is a randomised control trial of the provision of naloxone (the heroin antidote) to 'at-risk' prisoners leaving custody. The trial is being funded by the Medical Research Council ( MRC) and is subject to a decision on additional funding being secured to employ staff within the prison service. If successful in securing the additional funding, the trial will take place in prisons across England and Wales as well in Scotland. The trial is expected to run a maximum of seven years.

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 and Lanarkshire into other areas. This recommendation is made with the understanding that any pilot is rigorously evaluated to prove effectiveness.

Scottish Government Response

2.17 It will be sometime before the real impact of naloxone provision can be determined. We will be looking at the evaluation of the pilot studies which have taken place within Glasgow and Lanarkshire with interest.

2.18 Local planners should consider the findings from the evaluations and decide if naloxone is an intervention they would wish to adopt in their area to prevent fatalities. Before any roll-out of the programme a thorough training programme would have to be in place which covered the use of naloxone and overdose awareness, such as the training programme devised for the Glasgow pilot. Naloxone should not be distributed without such a training programme being in place first.

2.19 Rigorous follow-up procedures should be in place to test the effectiveness of naloxone in reducing drug-related deaths.

Progress

2.20 Following two successful pilots in Glasgow and Lanarkshire both areas are now extending their naloxone provision. In addition, other areas across Scotland are now considering naloxone introduction.

2.21 For example, Fife will employ an overdose co-ordinator, initially for one year, who will start preparing an overarching strategy and implementation programme on all aspects of overdose including naloxone implementation.

2.22 In Highland, they have studied the results of the Glasgow and Lanarkshire trials and would like to carry out a similar trial. This follows a number of drug-related deaths in the area, which may well have been reduced if there had been some basic overdose training for users, or naloxone had been available.

2.23 Dumfries and Galloway is also considering a pilot and other areas are intending to discuss the need for naloxone provision at meetings in 2009.

2.24 Several police custody suites throughout Scotland now have naloxone available to staff who are trained in its use. In addition, police custody suites have started to integrate NHS staff, nurses and doctors into their structures to care for those in police custody and this is seen as a positive step for the safety and care of custodies in the longer term.

Recommendation 4: Research

The Forum believes 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 recommends 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.

Scottish Government Response

2.25 The Scottish Advisory Committee on Drug Misuse ( SACDM) Evidence Sub-Group will consider a range of research topics and deliver a more systematic and co-ordinated approach for feeding the evidence base into national and local policy making and practice and for identifying gaps.

2.26 Dissemination of the evidence will be key to ensuring that the research and good practice that flows from the evidence group is used to its best advantage. Improving the evidence base on reducing drug-related deaths will undoubtedly form part of the group's remit.

Progress

2.27 Two research projects were funded during 2008. The first, mentioned earlier in this report, looked at Reducing Drug User's Risk of Overdose⁸. It examined how to increase the number of those who witnessed a drug overdose calling for help quickly and considered measures that could be effective in preventing death from overdose while help is on its way. The key findings of the report published on 3 November 2008 were:

• The presence of overdose witnesses attempting resuscitation techniques plays a crucial role in preventing overdose deaths. There is a need to provide likely witnesses (peers, family and friends) with information and training on prevention strategies including the need to remain with the casualty.
• Overdose witnesses are willing to intervene although barriers may exist to calling emergency services promptly. The perception and fear of repercussion, especially if children are present, is a key barrier. Drug users, peers and family members need a clear understanding of current policy on police attendance at overdose events.
• Those users who present at hospital with opiate overdose may have unmet health and social care needs. There is a need to develop integrated care pathways for the management of opiate overdose.
• Overdose awareness training should be made available to emergency service staff, clinical staff and service professionals including prevention and management of overdose and harm reduction principles.
• Given the current limited opportunity for reducing the risk of overdose for users who are not ready to engage in structured treatment modalities, patients admitted to hospital following an opiate overdose should be routinely provided with written information on overdose prevention and details of local drug and harm reduction services.
• The Scottish Government and NHS Boards should develop an information system that accurately collects and collates information on fatal and non-fatal overdose to inform local service planning processes. This should include information on overdose related calls, ambulance attendances and A&E activity.
• The progressive disease burden of heroin use increases susceptibility to overdose as users get older. Regular health screening of problem drug users may be beneficial, including targeting high risk users such as harmful dependent drinkers and/or users who experience moderate to severe depression and suicidal ideation.

2.28 The second piece of research, Senior Drug Dependents and Care Structures ( SDDCare), which has been commissioned by the EU and partly funded by the Scottish Government, is covered in the Government response to recommendation 8 of the 2007 report. Funding will continue into 2009-10. The final report is expected in 2011. Findings from this report and the one from Figure 8 will feed into the Forum's deliberations in the future.

2.29 Glasgow Addiction Service is commissioning research into drug deaths which occur after injecting in public places (10% of cases where this happens are in the Glasgow City area).

2.30 The Scottish Government National Drug Evidence Group agree that drug-related deaths are a high priority area which must be investigated as part of the evidence review programme currently being commissioned to support their work.

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 Alcohol and Drug Action Teams ( 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.

Scottish Government Response

2.31 Some local Choose Life areas report engagement with Alcohol and Drugs Action Teams ( ADATs) and substance misuse agencies about suicide prevention - there was a pan-Ayrshire conference in Suicide Prevention Week last year - and there is some work being done with Scottish Training on Drugs and Alcohol ( STRADA) to see how Choose Life can incorporate ASIST (suicide prevention) training into their programmes (or at least promoting the training to substance misuse networks) and tailoring such courses to drug/alcohol related situations. Other local work includes providing suicide prevention training to frontline staff who are most likely to come into contact with substance misusers who may be suicidal - especially at the more chaotic end of the scale.

2.32 The recommendations in the National Forum report are designed to enlist greater ADAT engagement in the area of suicide prevention and highlight suicide prevention as a cross cutting area particularly in the reduction of drug-related deaths - intentional self-harm and undetermined deaths are included as part of the overall suicide deaths by the General Register of Suicides. Viewing suicide prevention as part of the ethos of reducing drug-related harm is perhaps a helpful way to illustrate this. It also underlines that substance misuse staff are key gatekeepers for drug users who are at increased risk of suicide.

2.33 The recommendation in the report about mental health simply highlights the needs for continued and expanded understanding, training, policy and service developments around dual diagnosis whereby substance misuse staff have a working knowledge of mental health issues and vice-versa for mental health staff. Prevention of suicide is only part of this - but the ability to work with and respond appropriately to presenting mental health issues by substance misusers can only have a positive impact in preventing suicide - particularly in response to crisis.

2.34 Choose Life anticipate that suicide prevention becomes part of local substance misuse strategies thereby mainstreaming suicide prevention across key policy areas. This may also enhance take-up of suicide prevention from the menu of local Single Outcome Agreements ( SOAs). Meantime, Choose Life will be working to ensure the capacity for training and other supports are in place to facilitate take-up of suicide prevention activity across the substance misuse sector.

Progress

2.35 Capacity building with ADATs through provision of suicide prevention and awareness training has continued to develop over the past year. Growing links between ADATs and Choose Life groups recognise that substance misuse staff are key gatekeepers for drug users who are at risk of suicide. Suicide prevention training skills training appears an increasing priority for many ADATs, with the National Confidential Inquiry into Suicide and Homicide: Lessons for Mental Health Care in Scotland⁹ (University of Manchester, 2008) providing further evidence of substance misuse as a key determinant of suicide in Scotland.

2.36 ADATs and Choose Life groups have joint memberships and are increasingly linked to wider mental health improvement and well-being structures. For example, the Choose Life co-ordinator in Shetland is also the Alcohol and Drug Development Officer and sits on both the ADAT and the strategic Mental Health Partnership group.

2.37 A consistent approach to joined-up working is required across Scotland and should be encouraged by all ADATs. This will be supported by considerable investment in suicide prevention training at national as well as local level. Scotland now has 400+ trainers to support both local training efforts. Access to 'training for trainers' courses for addictions staff will be encouraged, in order to disseminate suicide prevention training into all substance misuse service training.

2.38 In Glasgow they have developed clearer service pathways for individuals with mild to moderate mental health problems whom they believe to be at a significant risk of self-harm, suicide and non-accidental drug-related deaths.

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 Services 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.

Scottish Government Response

2.39 The Drug Misuse and Dependence: UK Guidelines on Clinical Management - sometimes known as 'the Orange Book' - are based on current evidence and professional consensus on how to provide drug treatment for the majority of patients, in most instances. They emphasise the need for both pharmacological and psychosocial treatments for people with problem drug use, with individual care plans and co-ordination of care across professional groups, including health and social care. The Government strongly supports these Guidelines as the basis on which clinicians and other professionals should consider the treatment of patients with drug misuse problems.

2.40 Scotland's Chief Medical Officer ( CMO), Dr Harry Burns, has made it clear that he expects NHS Boards to discuss with local service providers how the guidelines will be implemented by practitioners at local level. There is a clear expectation that the guidelines will be adopted as good practice by treatment providers as a means to achieve optimal outcomes for drug users and their families.

2.41 We developed National Quality Standards for Substance Misuse Services to highlight the necessity of addressing all client's needs through partnership working and having clear exit strategies.

2.42 The Government accepts that long waits for treatment are unacceptable. Access to effective treatment and rehabilitation is critical to the long-term goal of recovery from drug misuse, and it is clear that services need to improve. The Government have already written to ADATs pointing out the importance of improving access to treatment and the need to make progress in this area.

2.43 The Government are determined to have the right structures in place to tackle drug misuse effectively. As part of their new drugs strategy, they are reforming local structures to improve the range, access to and quality of drug services delivered locally and to hold local partners more strongly accountable to the Government.

Progress

2.44 Following the CMO's commitment to follow-up with local areas on the expectation that they would all adopt the UK Guidelines as good practice, an audit on compliance has been carried out to ensure that this has happened at local level. From this we are able to confirm that all areas of Scotland are operating within the UK Guidelines. Some examples of responses are:

• Borders - Community Addiction Team ( CAT) are using the clinical guidelines in their daily practice and have updated their operational policy document to take account of them. They are providing the vast majority of substitute prescriptions for the Borders and are adhering to best practice as recommended in the guidelines. They also set up a monthly education meeting for the team and clinical governance issues are to the forefront.
• Forth Valley - the newly developed Forth Valley Substance Use Strategy has used the guidelines as the basis for best practice in the clinical management of illegal substance misuse. In addition, in discussion with local services they confirmed that within their Community Alcohol and Drug Service their treatments comply with the UK Guidelines. The local MAT and BAT (methadone and buprenorphine assisted treatment) guidelines are based on the UK Guidelines.
• Lanarkshire - alcohol and drugs services in NHS Lanarkshire are provided within the framework of the revised 2007 UK Guidelines (Orange Book). Their prescribers, including psychiatrists, GPs with Special Interest ( GPwSI), and pharmacist prescribers, adhere to the guidelines in relation to pharmacological interventions. Similarly, staff within the various addiction teams work to an operational policy that reflects the essential elements of treatment provision inherent in the guidelines. Within the Clinical Leadership Group for Addictions, their Clinical Governance sub-group has been developing policies, protocols, and guidelines for best practice. This includes not only pharmacological interventions, but extends to the wider, essential-care services such as psychosocial interventions.
• Shetland - has been working with their local providers on the national guidelines for some time, in fact they piloted them with their local Community Drug and Alcohol service along with the National Quality Standards and performance reporting last year. Though they only have community services in Shetland and commission any residential services off island, so there are limited applications for the guidelines in some areas, they continue to work with local providers on the national standards and their local ADAT continue to monitor local services compliance.
• Tayside - the clinical lead for substance misuse services, who was also the lead for Scotland on the UK Guidelines development group, has confirmed that local practice standards are in line with those contained in that document. The East Central Scotland Addiction Services Managed Care Network also produced a detailed response to the consultation on the guidelines, involving all key clinical staff.

2.45 For the first time the Scottish Government has adopted a national Health, Efficiency, Access and Treatment ( HEAT) target that will offer those with drug problems faster access to a range of appropriate drug services to support their recovery. During 2009-10 the Government will work with NHS Boards and other partners to improve the quality of data and set targets. A clear target for shortening the length of time those with drug problems have to wait will be set in 2010-11. In Grampian they are building a new wraparound treatment centre in Aberdeen. Although it will take time to develop, this initiative should go some way to easing waiting times in the Aberdeen area and across Grampian as a whole.

2.46 The joint Scottish Advisory Committee on Drug Misuse ( SACDM) and Scottish Ministerial Advisory Committee on Alcohol Problems ( SMACAP) Delivery Reform Group was established to develop proposals around the future of alcohol and drug delivery arrangements. The Group recently concluded its work and submitted its report to Ministers. The Scottish Government, CoSLA and NHS Scotland considered the report in advance of issuing a joint statement on 20 April 2009, that set out an agreed national delivery framework, the aim of which is to promote consistently effective arrangements across Scotland and ultimately ensure better outcomes for service users.

2.47 This framework outlines a set of arrangements which encompasses not only community planning partners but also makes clear the role and responsibility of the Scottish Government. As well as providing record levels of resource there are a number of ways in which Scottish Government will be supporting the framework's delivery and developing an environment that ensures effective investment decisions are made. Scottish Government will:

• strengthen efforts to promote the use of the National Quality Standards for Substance Misuse Services published in 2006, which clearly outline national minimum standards that should apply to the quality of services across the country;
• work with partners to develop or update frameworks outlining essential services on alcohol and drugs; and
• examine the scope for extending the HEAT target for access to drugs services to cover alcohol services too, providing the same minimum standards for access across the country.

2.48 Scottish Government will also recruit a group of national co-ordinators with a background in delivery to help local partners and partnerships meet the challenges presented in this new framework.

2.49 This team will make an important contribution to improving the quality, range and standards of service planning, commissioning and information exchange across the country.

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.

Scottish Government Response

2.50 Local authorities have a duty to ensure that all looked after children and young people have a care plan. This care plan should fully reflect all health care needs and in drawing up the plan the authority should ensure that the child is provided with adequate health care.

2.51 The publication Looked After Children and Young People: We Can and Must Do Better¹⁰, recognised that life outcomes for looked after children and young people need to be improved. A key theme of this Action Plan centres around being emotionally, mentally and physically healthy and this theme has action points aimed at ensuring looked after children and young people have access to a range of appropriate services designed to meet their emotional, mental and physical needs.

Progress

2.52 In September 2008, Scottish Government published These Are Our Bairns - guidance for community planning partnerships on how to be a good corporate parent¹¹. 'Corporate parenting' refers to the collective responsibility that councils and their partner agencies have under the Children (Scotland) Act 1995 for looked after children and young people and care leavers. This guidance, combined with other resources emanating from the actions contained in Looked After Children and Young People: We Can and Must Do Better, such as multi-agency training materials, emphasises the need for all services and individuals working with and for 'Looked After' children and young people and care leavers to work together in a child-centred way. The guidance demonstrates how we can ensure that young people in care receive the support and guidance that they need to live full and healthy lives and that support should continue when they leave care, just as young people in conventional families continue to receive the support they need from their parents.

2.53 The Council as a 'corporate parent' must work with members of the extended 'corporate family', such as health and voluntary sector services, to make sure that all the young person's needs are identified and met in an appropriate way which reflects their individual needs and circumstances. Every young person leaving care should be prepared for independence through the Pathways Planning ¹² process and the assessment of their individual needs should include an assessment of their need for drug-related services, with an appropriate plan to meet those needs. Not all care leavers will need those services, although we acknowledge that these young people are more likely than their peers, who have not been in care, to need them.

2.54 Advice to health boards supplementing the messages in These Are Our Bairns is due to be issued shortly. That advice describes health services' responsibilities and sets out actions which will help them to be able to identify 'Looked After' children and young people and care leavers and to take their needs into account when designing and delivering services. This applies to specialist services such as substance misuse, sexual health and mental health as well as universal health services. Following consultation, the Looked After Children (Scotland) Regulations 2008 are being reviewed. The revised regulations will underscore the statutory duties of agencies such as health boards to identify and meet all aspects of a young person's needs.

2.55 The 'corporate family' approach sets specific services such as health within the context of a more holistic, integrated approach to improving outcomes for 'Looked After' children and young people and care leavers, and the guidance reflects the Scottish Government's commitment to early intervention and prevention, i.e. by giving a child the best possible start in life, with as much family support as is required, fewer children will find themselves at risk of involvement in risk-taking behaviour such as drugs misuse. For those who do find themselves in that situation work to improve the 'corporate parenting' experience aims to reduce the likelihood of young people continuing or escalating their risk-taking behaviour by making sure they have the opportunities, skills and support to live healthy, happy and responsible lives.

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, for example, 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 here. The Joseph Rowntree Foundation ( JRF) report should be considered carefully by service commissioners in Scotland.

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.

Scottish Government Response

2.56 The Scottish Government accepts that there is a need to look at innovative projects that help people to get drug free for good. We have already commissioned research to look at services who are producing better outcomes for homeless substance misusers. Research looks at the links between homelessness and substance misuse to identify the models of service available for people who are homeless and have problem drug or alcohol use. The research is expected to report in the summer of 2008 and findings will be widely disseminated to service commissioners.

2.57 We are also part funding a Scottish Drugs Forum European project that will explore and monitor the situation of senior drug dependents in different age brackets and by gender (starting at age 35 up to 70 and older) in partner countries in Europe (Scotland, Germany, Austria and Poland). The Senior Drug Dependents and Care Structures ( SDDCare) project will, via re-analysing existing data sets on a European level, on a national level and at community level (of the partner cities), look at the older users mental and physical health status (including chronic infectious diseases such as HCV-infections, HIV etc.), their life circumstances and their social networks, their accommodations and their needs of care and treatment. The project is expected to report in 2011.

2.58 We are also already funding a number of innovative pilot projects. One of those is FV-Tox in Forth Valley. The overall aim of FV-TOX is to provide a structured, standardised, evidence-based care package to help clients dependent on opiates who seek to become abstinent. The programme gives people support through the effects of detoxification, encourages lifestyle and behaviour change and aims to improve their health and well-being, their family relationships and access to employment and training.

2.59 The Government however, does not support the need for drug consumption rooms. There are legal and ethical issues around their introduction that cannot be resolved easily. The Misuse of Drugs Act 1971 makes it an offence to allow the use of drugs on premises. We have no plans to introduce consumption rooms in Scotland.

Progress

2.60 SDF is taking forward the SDDCare research that is referred to earlier under recommendation 4. Scottish Government are closely monitoring progress and are represented on the European Governmental Advisory Board. A second meeting of the group was held in January 2009. Progress continues to be made on data collection and the legal framework of the participating countries. The next stage of the project will be to undertake a survey of workers and older drug users. SDF will survey workers who have specific knowledge or understanding of the needs of older drug users. These surveys across the four partner countries will be used to inform the development of guidelines for good practice. In addition, a Scottish conference on older drug users is to be held with a European conference next June in Frankfurt at the conclusion of the project.

2.61 In Forth Valley, FV-TOX, a front line detoxification service, was funded by the Scottish Government in September 2006. It was one of five projects funded across Scotland to deliver a 'different model of treatment' from what was previously available. The aim of the service is to work with individuals addicted to opiates at an earlier stage and offer something different. The ethos of the service is that by providing a structured programme with an intense level of support, individuals could address their addiction. An independent evaluation of the service has been carried out and the report will be published in the near future. In light of a positive evaluation the service will continue to be delivered as part of a range of options for treatment in Forth Valley.

Recommendation 9: Data Collection

Drawing from the SACDM report and recommendations (2005), and after discussions with ADATs, the GROS, the SCDEA and NHS Services Scotland, 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 Ministers, the National Forum, the media and the public.

Scottish Government Response

2.62 We have taken forward this recommendation as a matter of urgency and fully agree that this work should be taken forward. Discussions have already taken place with NHS Scotland, Information Services Division ( ISD) and ADATs to develop a standard national database for the collection of detailed information on drug-related deaths.

2.63 The database will cross link with existing ISD datasets to give a picture of the drug user's life prior to death which, following analysis, will assist in identifying interventions that may prevent deaths in the future. ISD will provide the analysis to the National Forum and local ADATs to help future planning.

2.64 As mentioned in the introduction a sub-group of the Forum has also redesigned the form used by pathologists to gather information for GROS, which they use to produce annual National Statistics on drug deaths in Scotland.

2.65 We also recognise the need to look closer at those people who are classed as 'near misses', i.e. those who go into overdose but recover or are brought round by the intervention of others. The Forum report pointed out opportunities for intervention at A&E departments and by ambulance crews. We will work with the Forum to look at addressing ways of utilising these points of contact to their best advantage.

Progress

2.66 The Scottish Government launched a national drug-related deaths database on 1 January 2009. The Forum worked closely with the Scottish Government, ADATs and NHS Scotland, ISD to develop the database which will look at the circumstances of each individual death to help us understand why people are dying, rather than simply counting numbers, so that local partners can put in place interventions to help prevent deaths in the future.

2.67 The database has already been piloted successfully in Lanarkshire, Ayrshire and Arran and Dumfries and Galloway and this has been particularly helpful in resolving operational barriers in relation to the data collection.

2.68 The database will gather personal details about the drug user including information on their drug taking history; where they were living and who with (including children); whether they were known to services or were on waiting lists; what drugs were found at the scene of their death and in their toxicology; whether they were on methadone or other drugs and whether the drugs were prescribed to them or not.

2.69 The database will be hosted by ISD. Information is being collected locally by ADATs or another nominated person at a local level on an Excel spreadsheet and submitted to ISD. ISD will analyse the data on a regular basis to give a national picture and local ADATs will be able to receive reports to help them identify any trends or patterns in their area.

2.70 Once the database has been up and running for a while it will be cross-referenced with other ISD data sources such as those on Hospital Discharges ( SMR01), Psychiatric Discharges ( SMR04) and the Scottish Drug Misuse Database ( SMR25a). This will be a unique opportunity to look at all hospital, psychiatric and treatment incidents prior to death.

New Data Collected by the Scottish Ambulance Service on Non-fatal Overdoses

2.71 Up until September 2007 the Scottish Ambulance Service ( SAS) used entirely paper Patient Report Forms ( PRFs), which numbered around quarter of a million per year for Glasgow and Lanarkshire Division alone.

2.72 Upon examination it was discovered what appeared to be repetitive non-fatal near misses involving possible controlled substances.

2.73 It was felt a new electronic PRF (e PRF) would be able to generate reports so that individual areas/Divisions could take appropriate action in relation to those patients who may only surface on the 'drug support radar' systems once they had died.

2.74 In the autumn of 2008 the SAS started to download the report screen onto the e PRF to allow crews to record, for example, where they had attended a suspected heroin overdose, where the patient after successful resuscitation had refused to go to hospital. This is important because if no criminality takes place, i.e. the crew are not assaulted or threatened, then they do not routinely request the police. It is also important as many of these 999 calls are not communicated initially as a potential overdose, but as a collapse commonly.

2.75 The text from the bulletin advising crews of the update is as follows:

Substances Report - this is an option on the PRF Review screen. It should be used whenever a particular substance (alcohol and recreational drugs) has been taken in sufficient quantity/timescale to cause physiological changes to vital signs, and may be/become a factor in the on-going treatment of the patient. It is not intended (and will not be used) as an indicator of illegality or drug abuse. It is a clinical tool only.

2.76 At the moment the reports are not in sufficient quantity to run. This is something the SAS are currently working on.

2.77 The intention is to be able to identify where a person was a risk to themselves and be able to, with permission, pass their details onto an agency who could offer help and support to save their life.

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.

Scottish Government Response

2.78 There is material already available on drug overdose which centres around recognising the signs of overdose and what to do in the event of it happening. However, the Government accepts there is a need to develop more targeted material and will work with the Forum in identifying ways of doing that.

2.79 Future work may focus on the dangers of drug taking and alcohol consumption, poly-drug misuse, drug injecting or the development of material for 'older drug users', who make up the majority of the population of drug deaths, to highlight the dangers they face and the need for general health care within this group.

2.80 A new national drug misuse interactive website ( http://www.scotland.gov.uk/topics/justice/law/drugs-strategy ) has been developed which has a dedicated area that focuses on drug deaths. We will use this area to highlight dangers like those mentioned above, to champion innovative practices, report on new research and keep others up-to-date with any developments.

2.81 We will continue to produce the newsletter 'Drug Death Matters' as another means of raising awareness of issues and for reporting the excellent work of the Forum.

Progress

2.82 The Government has been working with SDF and other key interests to develop new awareness raising materials on drug overdose. These include a pocket-sized wallet with information on the risks and signs of overdose and what to do in an emergency and a booklet which goes into the issues in more detail. They will be issued to drug services, families, libraries, police drug awareness officers and homeless services across Scotland by summer 2009. Further copies can be obtained by calling 0131 244 5051.