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Reducing harm and promoting recovery: a report on methadone treatment for substance misuse in Scotland: SACDM Methadone Project Group


Section 1: Background discussion and evidence

1.1 Introduction and context

This paper has been prepared by the SACDM methadone Project group - a group of clinicians and academics working in the substance msisue filed in Scotland. It forms the third element of a comprehensive Scottish review into the use of methadone as a treatment for opiate dependency. This review has been commissioned to inform the debate on how to ensure that methadone prescribing in Scotland is delivered to the highest quality and achieves the best possible outcomes.

The paper therefore reflects considerable debate by a diverse group of professionals an forms a consensus regarding the strengths and weaknesses of methadone treatment in Scotland, clarifying what current services can and cannot achieve and what additional service elements and processes are required to maximise effectiveness. It concludes with recommendations to ministers outlining key actions for Scottish treatment services, local commissioners and the Scottish Executive. The paper was considered by SACDM in May 2007 and members' comments incorporated into this report.

Detailed consideration of social care elements of the treatment and rehabilitation of substance misuse is beyond the scope of this paper. However, it is acknowledged that medical treatment (including methadone replacement prescribing) should, whenever possible, be delivered as part of a comprehensive and integrated process of care, delivered by statutory (Health and Social Work) and voluntary sector partners, to clear standards and reflecting local strategic plans and governance arrangements. An overview of the key elements required to deliver optimal care is contained in Section 5 - "What should services be like?". A Glossary of terms is included in Appendix 6.

1.2 Methadone treatment in Scotland - history and evidence base

Replacement prescribing with Methadone forms the main plank of medical treatment for opiate dependency in the UK, reflecting a comprehensive and evolving evidence base which consistently demonstrates the effectiveness of methadone in delivering positive outcomes in a complex and demanding population.

1.2.1 History

Drug Dependency Units were established in the UK in 1968, providing Methadone treatment for the small number of known heroin users. In the 1980s, a rapid rise in heroin availability overwhelmed services. Treatment services were reconfigured and began delivering a largely drug-free approach with minimal medical support. The arrival of HIV in Scotland changed this. The McClelland report of 1986 1 advocated urgent reappraisal of services, establishing pilot needle exchanges and methadone substitute prescribing clinics as a matter of urgency - introducing strong support for "harm reduction" approaches which would be formally accepted as the basis of treatment strategies in Scotland from 1994 2. In the 1990s, as methadone prescribing expanded, its benefits in the Criminal Justice arena were recognised and Criminal Justice services incorporating methadone programmes were developed 3. In the 2000s, concern has returned to Blood Borne Virus infection with clear associations between Hepatitis C and injecting drug use maintaining pressure to increase availability of methadone prescribing to reduce drug-related harm 4.

1.2.2 Guidance and good practice

Replacement prescribing to such large numbers of drug users is therefore a relatively new phenomenon and guidance to prescribers has evolved considerably over some 20yrs, reflecting the developing confidence in the harm reduction approach and positive evidence base. In 1984, the first UK national treatment guideline 5 included methadone as a short-term treatment to be followed by detoxification. In the 1991 guideline 6 methadone replacement prescribing was seen as a more long-term treatment and there was a clear expectation that all doctors should consider methadone when assessing opiate dependent individuals. The 1999 "Orange Guidelines" 7 continued to promote this view, outlining improved standards regarding quality of assessment, treatment initiation and delivery as well as training and governance requirements for doctors at different levels in the care system. An evolving evidence-base identified optimal doses and promoted safe prescribing through improved clinical processes. An updated Orange Guideline will be available in 2007. This will state clearly that replacement prescribing should continue as the main medical approach for opiate dependency. It will also exploit the vastly improved evidence base to consider alternative medical treatments to methadone (eg Buprenorphine), psychological interventions along with assessment, care planning and delivery processes which aim to promote better outcomes and facilitate patient progress and recovery whenever possible. Robust clinical governance standards will outline training needs and appropriate quality standards for those delivering services 8.

1.2.3 Effectiveness - the evidence base

Evidence from many international studies has established that, properly prescribed and adequately supported, methadone prescribing achieves harm reduction outcomes in opiate dependent patients. It is associated with reduced deaths, improved lifestyles and less criminal behaviour. A recent NICE Guideline has confirmed that methadone is the most cost effective medical intervention available 9. The evidence base supplied by the key UK prospective study - NTORS10 - shows that all treatment modalities are effective. This work shows that users access many different treatments during their journey, making it hard to clarify what factors are most influential at promoting recovery and rehabilitation in any particular case. However, the international research evidence clearly shows that replacement prescribing with methadone is consistently associated with positive outcomes.

1.2.4 Care processes - responding to need and maximising outcomes

The 2007 Guidelines update reflects the complex nature of drug misusers attending services and clearly describes the processes of assessment and care planning within which any replacement prescribing should be placed 8.

When assessed, many drug misusers are chaotic with complex needs. They are more likely to suffer mental illness than the general population and also experience considerable social instability. Though alternative medical options to replacement prescribing - such as detoxification - may be available (or even requested) at this stage, the nature of the presenting problems may make these abstinence-based approaches more hazardous or less likely to deliver a reduction in drug-related harm. Methadone prescribing offers an approach proven to deliver successful harm reduction outcomes even in the most intransigent of cases as well as forming an important link between the drug misuser and service which has the potential to lead to change. It is for this reason that in most areas, methadone is seen as the appropriate initial treatment approach, offered to reduce the risks associated with drug misuse as well as to attract and retain vulnerable patients in services, giving an opportunity to engage the misuser in a therapeutic process which may lead to recovery.

Once established on methadone, progress from maintenance to detoxification and abstinence will depend on the misuser's circumstances and resources as well as the quality and range of services available. Achieving abstinence may be difficult for many and in cases where abstinence is an unlikely outcome in the medium term, life on methadone may not only be tolerable but positive, facilitating improvements in many areas of health, psychology and social functioning. Effective services retain users on methadone with the aim of addressing concurrent physical, psychological or social issues, ultimately intending to increase the likelihood of success should detoxification be seen as a realistic option in the future. Indeed research shows that treatment retention is strongly associated with positive outcomes.

In summary, replacement prescribing with methadone remains the main plank of medical treatment for opiate dependency in the UK. Harm reduction approaches, incorporating methadone treatment, have evolved rapidly in the face of blood-borne virus infection. It has also been seen to be effective in the Criminal Justice arena by reducing the need for imprisonment. Methadone is more cost effective than any other medical treatment for dependency, though other effective interventions should be part of any comprehensive programme, improving patient choice. Outcomes improve if delivered with associated counselling interventions and these should also be standard. The challenge with methadone is to optimise delivery of harm reduction whilst ensuring that progress to recovery is encouraged, facilitating a way out of methadone treatment whenever appropriate.

1.3 Areas of Concern around Methadone

Despite the very strong evidence that it is a treatment that can deliver significant benefits in the management of opiate dependent individuals, aspects of methadone prescribing raise concerns in society and are also debated amongst clinicians in the field. Popular concern has been raised that some misusers on methadone appear to be no different from untreated misusers - continuing to use illicit drugs freely, involved in ongoing criminal activity, struggling with social hardship and family breakdown and failing to achieve meaningful employment. Some suggest that methadone is the only treatment offered to the majority of substance misusers - when alternatives, which may meet their needs better, are unavailable locally. If valid, such limitations may be underpinned by a philosophical debate regarding the relative merits of harm reduction versus abstinence-orientated treatments - a debate which can affect the ability of methadone prescribing services to offer robust programmes which facilitate progress and recovery. There is also considerable variation in how methadone services function across the country. In Scotland while hard outcome and activity data is generally unavailable, published local research suggests that delivery of methadone treatment may be less successful than elsewhere with poorer harm-reduction outcomes and less progress towards a drug-free lifestyle 11. These concerns are discussed below.

1.3.1 Prescribing Philosophy

Concern has been raised that in some areas in Scotland methadone is prescribed not as an aid to recovery but as a de facto lifelong prescription with some doctors and services actively resisting detoxification or progress to a drug-free lifestyle. Such rigid philosophies would not truly reflect the evidence base which acknowledges that patients are individuals and require personalised programmes of care, delivered by skilled staff to achieve the best outcomes. In Scotland, this inconsistency of approach may mean that, for some, methadone has become a long term (even lifelong) treatment when more comprehensive services or treatment approaches may offer more misusers the opportunity to progress to a drug-free lifestyle.

1.3.2 Scale of its Use - impression of excessive use of methadone in Scotland

There is a perception that methadone has become the default treatment for drug misuse problems in Scotland today. The national prevalence study in 2003 estimated a Scottish prevalence of 51,582 opiate or benzodiazepine misusers 12. The Scottish Executive estimates that 18,017 (34.9%) were receiving methadone in 2003, though, no definitive audit of drug users in treatment has ever been carried out in Scotland. The prevalence study also reviewed drug treatment databases in every council area in Scotland and identified a total of 18,037 individuals in treatment. Approximately half of all drug misusers are thought to be in contact with services in England 13. If the proportions were similar in Scotland, these figures suggest that a very high proportion (~70%) of all Scottish drug misusers in treatment are prescribed methadone. This supports the view that methadone is the main treatment available in Scotland and that few substance misusers are accessing any alternative. This may reflect appropriate treatment decisions - and therefore be a success in terms of engagement - but alternatively may be a result of limited availability of alternative treatment options.

1.3.3 Variation in delivery Lack of data on exiting methadone - impression that few become drug free

There is a lack of robust information on the number of drug users who successfully come off methadone once prescribed though some (unpublished) research has found as many as 11% free of all drug 5 years after commencing methadone treatment 14. This may reflect the difficulty in measuring such change. It can however lead to the impression that, while methadone services have successfully increased the numbers of drug misusers in treatment, in line with Scottish Executive objectives, in some areas insufficient attention (or resources) has been given to getting people to the stage where they can contemplate life without drugs. If this is the case, some Scottish methadone treatment services become a one-way road which brings people in but does not deliver progress to recovery or offer this option when the misuser is ready to progress. Variation in prescribing practice - dosage prescribed and duration

There is anxiety that there is no clear and consistent practice in relation to methadone prescribing in Scotland with variation in practice regarding methadone prescribing standards. Whilst there are published guidelines on the most appropriate dosage range there are indications that there are doctors who are consistently prescribing well below or in excess of them despite concern from fellow clinicians in the field that this is inappropriate. There is also wide variation in the duration of methadone prescribing with some areas in Scotland favouring relatively short periods and others opting for long term maintenance prescribing. Finally, there are key treatment environments in which appropriate treatment may be harder to access - examples include the criminal justice services (prisons and police surgeons) or general hospitals. Leakage and Supervision - different standards of work/delivery

The level of leakage of methadone and nature of supervision of methadone consumption varies enormously across Scotland ( ISD). There have been cases where leakage has been linked with methadone-related death. This can create public and political anxiety as to how well controlled and safe methadone prescribing actually is. Clinically there continues to be a debate regarding the relative benefits of supervision (increased community safety) or "take home" (promotes a return to normal life and responsibilities, facilitates employment etc) reflected in differing local policies.

1.3.4 Effectiveness of methadone treatment in Scotland Achieving Abstinence from illicit drugs - failure to demonstrate objective progress

The Drug Outcome Research in Scotland ( DORIS) study has found that compared to England (as evidenced in results from the National Treatment Outcome Research Study - NTORS) fewer drug users in Scotland achieve abstinence nearly three years after starting treatment 11. In NTORS ~35% of drug users receiving residential rehabilitation were abstinent (apart from prescribed methadone) for at least 90 days at their two year follow up interview compared to 25% of those treated in the community. In DORIS, 33% receiving residential rehabilitation were drug free for the 90 day period nearly 3 years into their treatment compared to only 11% of those treated in the community. Only 6.6% of drug users in the methadone arm of the DORIS study were totally drug free (ie had progressed off methadone - though still using Cannabis) after nearly three years in treatment. Another (unpublished) study, however, found that 11% of those on methadone were free of all drugs at five years, while 77% were free of illicit drugs 14. These research studies do vary in some aspects of methodology and require careful interpretation. However, the differences described may reflect real variation in practice across the country - including philosophy, delivery of care or lack of services (eg employability services) supporting the route out of methadone - and thus merit further investigation. Impact on criminal activity

There is clear evidence that methadone has assisted in reducing the frequency of offending by substance misusers and this has been supported by some Scottish research 14. However, some Scottish research has shown that approximately 80% of those on prescribed methadone are still committing crimes 15. Topping Up

There is concern that a substantial number of drug users are topping up their methadone prescription with illegally obtained additional drugs. Within the DORIS study 70% of those on methadone reported supplementing their prescribed drugs. There are indications that this may reflect sub-optimal dosing of prescribed methadone or other limitations in some local methadone programmes. Safety of children

There is concern across the UK that the process around methadone prescribing practice could be failing to reduce risks to children. There has been a drive to increase services' concerns around risks to children 16,17 but recent Scottish research shows that little valid information is known by treatment services about child care responsibilities of substance misusers 18. There have been a number of cases in Scotland where children have been able to access or been administered methadone prescribed to their parents or siblings. This implies that, in some cases, take home methadone is being provided without adequate risk assessment or assurances regarding safe storage.

In summary, concern around Scottish methadone treatment focuses on: Prescribing philosophy - some service philosophies may not balance harm reduction and recovery-based approaches; Limited treatment options - basic national data is unavailable. Estimates suggest that the majority of those in treatment for substance misuse in Scotland are on methadone. This may be at the cost of other treatment programmes in some areas; Variation in practice - there is variation in delivery of methadone across Scotland, particularly dose, duration and availability of supervision; Effectiveness of service - when compared to UK, Scottish research suggests that Scottish methadone treatment may be less successful at achieving positive outcomes in some areas; Safety of children - there continue to be rare, but tragic, examples of children consuming their parent/sibling's methadone despite clear guidance and advice regarding professional responsibilities and risk assessment.

1.4. Current Scottish services - description and performance

Other elements of the review process have gathered information on what treatment services are currently available in Scotland. The information collected is presented in the report "Review of Methadone in Drug Treatment: Prescribing Information and Practice" and findings from a consultation of service users, carers and frontline workers.

Methadone Project Group survey of service providers

For the purpose of this report, The SACDM methadone project group asked all Scottish drug treatment services to supply any data from local audit or research activity which could give an assessment of the nature of delivery or effectiveness of methadone services. This was very much a pragmatic approach to inform discussions in a very tight timeframe. A list of responses received is included in Appendix 4.

Most Scottish services did not return any material though some information was returned by services from five NHS Board areas. Some service leads contacted the group less formally, describing their attempts to demonstrate outcomes and the challenges they faced. Those who responded largely sent information on process though some were able to describe harm reduction outcomes in a few specific services. It is likely that those responding represent those services where staff are actively considering these quality issues and who also have dedicated resources committed to aspects of clinical governance. Often these will be services specifically commissioned for a purpose - eg DTTO - where resources to support evaluation are included in commissioning. Findings of the survey are described below. This section ends with a description of services where aspects of delivery could be seen as examples of good practice. The full text regarding these is contained in Appendix 5.

1.4.1 Information on effectiveness - activity and outcomes

Some services supplied activity data. The health department report suggests that services in many areas in Scotland now collect data associated with the monitoring of the new GP contract. However little information was supplied. These data are generally not collected in any uniform way and for the majority it is not clear to what use these data are put. Lothian's annual report comprehensively describes their NES and its performance. Others supplied examples of their prescribing policies, care processes or paperwork. Regarding outcomes or effectiveness there was little hard evidence available from any service and no recent published work. There were two audits of a reasonable standard supplied (200 and 30 patients respectively). The group was also made aware of at least four other substantial audit projects in Scotland of service users addressing, process, outcomes and users' perceptions of their care. In all these cases data had been collected but the project was awaiting either data entry into a database system or analysis. Resources/priorities are delaying services' ability to report on these data.

1.4.2 Care processes

Some respondents sent examples of their assessment protocols. For most areas there was little evidence put forward to show what use might be being made of any assessment information as part of a care planning process in treatment services.

1.4.3 Examples of good practice

The survey identified that in some areas in Scotland, aspects of service delivery could be evidenced as being examples of good practice. Services that responded were actively addressing at least one area of quality practice in terms of: Policies and procedures; standards and audit; process of care delivery; information systems; outcome measurement.

(i) Policies, procedures and clinical governance

All services should work to clear policies and procedures which describe in detail the processes undertaken when considering the delivery of treatment. It is essential that, in the area of substance misuse, where prescribing may be delivered by doctors of differing experience and training in diverse settings all prescribers are encouraged to work consistently. Finally, all NHS systems have clear clinical governance and accountability processes. Substance misuse services must ensure they are included in this process. Group members are aware that some services have led the way in such developments while other services do not prioritise this activity.

Tayside substance misuse services ( TSMS) has developed a comprehensive package comprising - prescribing protocol; associated standards and audit tools; paperwork relating to treatment agreements; information sharing, prescribing, tolerance testing and review of progress. The protocol is due for review this year and as a member of the East Central Scotland Addiction Services Managed Care Network (with NHS Fife and Forth Valley services) TSMS will be undertaking this process with its MCN partners to improve efficiency and consistency. NHS Grampian and its ADAT partners have convened a multidisciplinary group, the Clinical Effectiveness and Reference Group for Addictions ( CERGA), with membership drawn from Public Health, General Practice, the specialist Substance Misuse Services, Pharmacy and the University of Aberdeen. The remit is to inform the service of clinically effective approaches, and ensure development is informed by the most up to date research. A formal agreement with the University secures academic time to provide constant updates on the research evidence.

(ii) Standards and audit (including numbers in treatment)

With clear procedures in place, local service managers and commissioners must ensure that clinicians are adhering to this system of quality care. Doctors often work eclectically but at the very least, should be prepared to justify why their practice falls outside the norm. Managers and commissioners should be prepared and empowered to challenge inconsistency. Contracts and clinical governance processes are key levers.

Lothian National Enhanced Service ( NES) is supported by a rigorous governance process which encourages GPs to treat substance misusers in a consistent manner. A monitoring group oversees practice regarding - prescribing within minimum standards; Hepatitis B screening and immunisation and "best practice" factors - eg around hepatitis C and HIV. GPs contact with patients is monitored and they are encouraged to assess progress using the Christo inventory annually. Six monthly audits are carried out. Underperforming practices are identified and offered additional support which is usually associated with improvements in standards. NHS Grampian has a detailed service specification for a locally enhanced GP service ( LES). Data is routinely abstracted on numbers in treatment, numbers discharged and reasons for discharge. The University of Aberdeen is being commissioned to undertake a detailed review of the quantity and quality of services being delivered under the LES.

(iii) Process of care delivery

There is clear evidence that treatment effectiveness can be enhanced if methadone is delivered as an element of a coherent care pathway involving wraparound services addressing psychosocial aspects of care. For services which developed in a harm reduction environment it can be a challenge to reorganise to address both harm reduction and recovery needs. This requires a robust process of leadership and commitment - and usually substantial investment from commissioners.

Glasgow Addiction Services has undertaken significant redesign and expansion over recent years to offer a more comprehensive range of approaches delivered in a highly integrated service design. The stated aim is to deliver more assertive services. They have increased access to psychosocial support services - with over 90% of all methadone-prescribed people in receipt of such input - and have improved access to other social interventions around homelessness, training and work opportunities. Tayside Substance Misuse Service has redesigned its methadone prescribing service to address a range of performance issues. Key features of the new service are an increased capacity, agreed standards of accessibility, a clear care pathway for those requiring medical treatments - with associated standards - and a new service design with two discreet service elements - one offering assessment, initiation onto methadone/alternatives and stability; the other (a partnership between NHS and Voluntary sector) offering more rehabilitative services with the aim of moving misusers on into recovery. In Lothian, locality clinics were set up to support GP practices in the management of drug misuse. These clinics bring together GPs, CPNs from the specialist drug service and non-stat drug workers within one integrated team, to provide a comprehensive medical and psychosocial/counselling service to newly presenting or chaotic drug users. The clinics take referrals from primary or secondary care, the criminal justice system including SPS and the non-stat sector. These clients are offered intensive assessment, support and care over a 3 month period. The aim is to achieve harm reduction, stability and cessation of illicit use, with methadone treatment often being central to this. Clients are then discharged back to the care of their own GP, with on going support and key working from the non-stat drug agency as needed.

This service actively fosters strong working relationships with the non-stat sector, promoting skill sharing, cross referring and joint working.

(iv) Information systems

Methadone prescribing may involve many professionals each of whom needs to be linked into a care planning and delivery process to ensure safe delivery of care. There is always the potential for prescribing to be duplicated or errors to occur. If misusers cross service interfaces (eg primary/specialist care or community/prison) this can become a serious risk. Misusers may also have difficulties ensuring care is continued in a timely fashion. Recent concerns around child safety increase the need for robust, real-time systems to allow information sharing.

In NHS Tayside the Dundee LHCC has supported the development of a real time Intranet-based methadone prescribing database. This system aims to give those with access rights (specialist services; GPs; pharmacists - potentially SPS/Police surgeons) access to live prescribing and dispensing information as well as a messaging system to raise alerts etc. NHS Grampian has developed a computerised database which captures information and outcomes generated by the Single Shared Assessment and Review system across 23 dimensions of drug/alcohol use and health and psycho social issues. The database is currently being piloted in Aberdeen City and full roll out is anticipated over the next year.

( v) Outcome measurements

Some criticism of methadone services reflect an inability to demonstrate consistency of practice and achievement of the key outcomes despite substantial investment. Services and their commissioners must deliver systems which can show effectiveness. This requires local systems to be more innovative and consider links with those in the NHS managing population data (eg in public health) or local academic institutions.

Lothian DTTO shows how a simple process of data collection can be effectively delivered in a clinical setting to supply useful information on effectiveness. NHS Ayrshire Addiction Service routinely completes Christo inventories to assess progress. As was reported by many services - resource limitations allowed them only to supply a brief report, pulling out broad themes from their data. Lothian low threshold service aims to attract people into services, reduce harm and help these individuals (many of whom do not engage with other more traditional services) to move onto core services or even detoxify. Their robust data shows objective improvements in drug use, risk taking and impact of drug use in the lives of those attending these services.

Glasgow and Lothian services supplied research papers which aimed to demonstrate impact of methadone treatment on outcomes. These reports show that links between NHS services and academic institutions may offer an opportunity to commit resources to more rigorous objective assessment of outcome. NHS Tayside services have formal links with the University of Dundee and are exploiting these links to support the development of substantial data systems which will ultimately supply prospective data on outcome. These links are actively supported and funded by the Tayside NHS Board and its associated structures. NHS Grampian has also exploited such relationships.

1.4.4 National information

Scottish information reflects that available elsewhere in the UK. There are a number of processes which as part of routine data collection gather information on service activity. Examples include the SMR25, waiting times database and DAAT Corporate Action Plans. All have significant limitations and interpretation of these data requires caution. None were established with the objective of measuring outcomes (harm reduction or abstinence) or recovery rates, instead focussing on entry to services and numbers in treatment. Plans to expand the Substance Misuse Database to allow identification of substance misusers' data - and therefore linking to follow-up data - are developing. New contractual arrangements (eg NES) offer further opportunities to improve outcome measurement.

Some data are available but require careful interpretation. The prevalence of problematic drug use in England is approximately 60% that of Scotland, while ring-fenced funding for drug treatment allocated by central government in England is comparatively generous. In 2007/08 funding allocated in a pooled budget from the Department of Health and the Home Office in support of community based treatment in England is £373.3 million, targeting an estimated problematic drug using population of 327,466 [2004/05 figures]. The May 2007 NTA Board meeting performance report shows that pooled funding in England has risen to £385m, total funding is £640m and total numbers in treatment are 206,285. Comparable Scotland figures are £23.7 million allocated in 2007/08 to target an estimated 52,581 problematic drug users [2003 figure]. Estimates of numbers in treatment in Scotland are unreliable. The 2003 Prevalence Study estimated 18,037 in treatment from service returns 12.

In summary, a few Scottish services supplied helpful information on various aspects of their methadone treatment programme and notable examples of good practice were recovered in the areas of accessibility, treatment processes, quality and standards and outcome measurement. The information generally available however, is limited, inconsistent and cannot be generalised. Despite Enhanced Service contracts with GPs even basic activity data would appear to be hard to retrieve in most areas and is not comparable across Scotland. Some services had carried out audit work - sometimes with large databases containing clinical data - but many reported being unable to analyse their data due to prioritisation and resource issues. Links with academic institutions appear to be helpful. National statistics are extremely limited, focussing on accessibility and making no attempt to assess outcomes or recovery. As in the rest of the UK, in Scotland no definitive statistics are available regarding the numbers of misusers on methadone prescriptions. There may be a significant difference in funding available in England and Scotland.

1.5 Child protection and substance misuse

Our collective responsibility to care for and protect children is embedded in the report of the national audit and review of child protection, 'It's Everyone's Job to Make Sure I'm Alright' 19. Other reports, 'Getting Our Priorities Right' 16 and 'Hidden Harm' 17, highlight the particular issues that confront children affected by substance misuse. This large area of un-met need had hitherto been largely unidentified.

In response NHS boards have developed local inter-agency guidelines to enhance and standardize practice across a range of agencies. This welcome development has obvious resource implications for service providers and many services are now labouring under increased workloads due to this intensive additional work. Prioritising this activity impacts on the capacity of services to respond to other service user needs. This can be seen, in particular, in General Practices in disadvantaged areas, where anecdotally Health Visitors are now routinely able to offer little more than a child protection service. Substance misuse services constantly face challenges in terms of capacity and their ability to deliver of a full range of treatment options. Child protection issues have added considerable pressures to these struggling services with little identified resource allocated to support delivery. A well co-ordinated response from integrated health and social care agencies is required and should be a key action in all ADAT areas. Specific areas for action may include: redistribution of Health Visitors in line with Hall 4 recommendations; augmenting the provision of day nursery places; addressing the paucity of statutory services for the over 5's. The issue of poor inter-service communication needs to be addressed - an essential element being the development of appropriate integrated or linked IT systems, to facilitate data sharing.

In summary, there is now clear guidance for professionals regarding their obligations in terms of child protection - especially in families affected by substance misuse. This guidance and associated standards has been supported by development of child protection services but has created considerable pressure on treatment services with no associated increase in capacity. This phenomenon impacts on prioritization of services which some areas are struggling to manage. There is a need for action to increase services' capacity to manage these pressures.

1.6 What should services be like?

Medical interventions for substance misuse should be part of a coherent integrated range of services - both medical and psychosocial - which meet the changing needs of substance misusers through their journey to recovery. Harm reduction is the initial goal. The pace of progress will depend on individual circumstances. Assessment; care planning and monitoring of progress are key elements in the delivery of effective methadone prescribing 10. The National Treatment Agency ( NTA) has published advice on models of service delivery and audits of services focusing on consistency of practice 20,21. The SACDM integrated care subgroup is addressing coordination and integration of care 22.

1.6.1 Medical interventions Replacement prescribing

Replacement prescribing should be readily available and delivered to a high standard in all areas. Methadone remains the first line treatment. Buprenorphine may be considered for some patients and other suitable products should be assessed for specific user groups as they are introduced and evaluated. Treatment is delivered through Primary or Secondary Care services based on local agreements. Services should exploit the opportunities presented by Non Medical Prescribing ( NMP) to improve patient access. Supervised self administration ( SSA) is critical and should be commissioned to best meet local need. SSA allows pharmacists to provide additional support and services 23. Detoxification and abstinence/relapse-prevention services

Access to community or residential structured detoxification programmes should be available 24. These should be followed by structured relapse-prevention programmes including naltrexone prescribing where appropriate 25. Such programmes are not without risk and must be targeted to appropriate individuals and incorporate risk assessment. They must be delivered as part of a comprehensive programme including skilled counselling and practical support. Medical/Psychiatric care

Services should offer access to medical/psychiatric assessment and care as required.

1.6.2 Non-medical interventions Care planning, practical support, counselling, and psychological interventions

Medical interventions should be delivered as part of an agreed care plan. All aspects may be delivered by the GP in an uncomplicated progressing case - but may still require a keyworker. Support to deal with housing/family issues or social pressures requires skilled social care staff. Counselling improves outcomes but requires skills, governance and supervision to maximise effectiveness 26. Psychological/ psychotherapeutic interventions should be targeted in most cases and require highly skilled staff working in structured settings. More behaviourally orientated approaches may form the basis of service delivery systems and positively influence outcomes 27,28. Structured, intensive day care and community based rehabilitation services

Programmes should offer access to services offering structured rehabilitative work in a non-residential setting. These services focus on reduction of reliance on prescribed medication and professional support, promoting stability, recovery and progress towards abstinence. Employment/educational/training opportunities are key elements, having potential to improve the impact of prescribing interventions. Residential Rehabilitation

Residential rehabilitation incorporates a diverse range of facilities which offer a long term approach to address substance misuse. There is huge variation in what is available in terms of philosophy, quality, demonstration of valid outcomes and cost. These facilities generally cater for people at the detoxification stage who are actively contemplating a drug-free lifestyle. Services must ensure that referral to such a facility is an appropriate option for the individual. Evidence is sparse regarding effectiveness though it is clear that such interventions bring benefit to suitable candidates 11. Increased use would bring significant financial pressures on existing local funding systems and would require planning. A Scottish Executive report has shown rehabilitation facilities to have a high drop out rate (40% at 3 months) and identified that success relates to ability to meet individual need and availability of aftercare 29. An audit of Scottish specialist doctors referring to such facilities showed that there was huge variation in practice across the country. NHS Boards had different systems for commissioning places and different budgets in place. Few doctors had knowledge of effectiveness of the facilities to which they referred. Referral seemed to reflect mainly patient choice 30. Comprehensive assessment will promote effective use of residential rehabilitation which should be available as a planned and integrated intervention, usually for those who have constructively utilitised all available community strategies to achieve abstinence without success or who do not meet the criteria for community services and have identified residential rehabilitation as a viable option in their circumstances. A National commissioning strategy may help - residential care needs to be available across Scotland and not just based in the central belt. It also needs to be cost effective - but also financially attractive to the voluntary and independent sector to deliver. In-patient services

Recent National Treatment Agency ( NTA) and Specialist Clinical Addiction Network ( SCAN) reviews considered the place of specialist NHS in-patient facilities in the management of substance misusers 31,32. Though evidence is sparse, there are areas of care which are optimised by having access to such facilities. These include: management of complex cases; detoxification; rapid induction onto replacement prescribing programmes; assessment and management of physical health problems.

Access to specialist in-patient provision adds to the range of services available. They must be delivered as part of a care continuum and admissions followed up by throughcare - via community based structured day services. In much of Scotland, where dedicated beds have been decommissioned, development of these facilities would present significant cost-pressures which could easily cause an imbalance of services. Local commissioners would require to carefully assess the potential impact of such developments on their core services.

1.6.3 Optimising systems of care

Delivery of optimised medical and non-medical interventions requires clearly defined processes of care delivered by integrated services - ie involving NHS a social care agencies working in a person-centred needs-led way. This process includes initial assessment of need (through single shared assessment) 22 care planning/review - and identification of individual 'key workers/care managers' 20,21. Governance arrangements must be in place - including adequate training and supervision of staff, quality assurance, standards and audit to ensure quality and consistency of practice.

In summary - though long term methadone prescribing is often an appropriate intervention, especially during initial stages of treatment, services cannot simply deliver harm reduction and retention on a methadone prescription. Services must become more aspirational and challenge commissioners to develop services which genuinely aim to promote recovery and help to rebuild lives. This implies that alongside the delivery of key harm reduction outcomes, services offer a continuum of care through recovery, managed by a robust care planning process to ensure that those in treatment receiving optimal care matched to their needs. Services must demonstrate achievement of a continuum of outcomes - reductions in illicit use and associated risks; improved social functioning (including genuine training/ employment opportunities); reduced criminality; improved health; abstinence; improved public health outcomes and community safety. This requires well governed integrated services - incorporating medical and social care services in both statutory and voluntary sectors - delivered by appropriately trained, skilled and compassionate staff.

1.7 Summary: Challenges for the methadone programme in Scotland

Harm reduction approaches - incorporating replacement prescribing - appropriately form the basis of treatment programmes for substance misuse in the UK and the developed world. This is supported by a comprehensive international evidence base which underpins clinical guidance for prescribers. In the UK, Methadone is the most cost-effective treatment available. Methadone prescribing is more effective if delivered as part of a process of planned care, especially if psychological interventions are included. Other medical treatments - focussed on achieving a drug-free state - are also supported by evidence. However, drug misusers carry a high risk of premature death and all interventions should be targeted to ensure they will best meet need and will not paradoxically increase risks. As these individual needs change review of progress and re-setting of goals ensures the best match of service user to treatment and is likely to deliver the best outcomes. Such approaches are in keeping with national guidance.

In response to the threat of blood-borne virus infection, Scotland's strategic approach to substance misuse has embodied harm reduction since 1994. The Scottish Executive has invested considerably in service developments for substance misusers and has set clear objectives to ensure rapid access to treatment - specifically measuring numbers in treatment and waiting times. Services have responded to this challenge. However, there has, to date, been little focus on the next stage - progressing those who are suitable towards a more active recovery process. Concerns about lack of availability of alternative medical treatments, consistency of practice, child safety and the ability of services to deliver specific outcomes has stimulated a debate, focussing on how to constructively appraise methadone prescribing services across Scotland and deliver improved outcomes in keeping with national strategic objectives.

It is clear that there are examples of good practice in Scottish treatment services. However, most services struggle to demonstrate the extent of their activity and few collect usable outcome data which could show effectiveness. It is also clear that there are inconsistencies across Scotland regarding what services are commissioned, how they are governed and how they deliver methadone services as part of a locally integrated system of care which can address harm reduction and recovery needs.

In the next section, we will address what can be seen as gaps in provision of Scottish treatment services and will identify actions for services, local commissioners and the Scottish Executive which will aim to address them. These gaps and associated responses can be considered in terms of:

  • Improving accountability and performance management
  • Quality of information available - the ability to demonstrate effectiveness of treatment services in Scotland
  • Effectiveness of services - nature and consistency of practice across Scotland
  • Integration of services - including availability of alternative medical treatments and care pathways
  • Improved commissioning - lack of an effective and credible national and local strategic process/operational delivery system.