Chapter 3: Promoting Recovery
Chapter 2 looked at some of the ways in which we can address the factors associated with drug use - and this Government is committed to the principle that prevention is better than cure. However, any programme of action to reduce the social and economic costs of drug use has to address, as a priority, the situation of those already suffering from problem drug use.
As we saw in Chapter 1, the provision of interventions for those suffering from problem drug use has, in recent years focussed on harm reduction, primarily through substitute prescribing. Building on recent work by the Scottish Advisory Committee on Drug Misuse, this Chapter proposes a new approach to tackling problem drug use, based firmly on the concept of recovery.
This Chapter sets out:
- the conclusions of two key reports into treatment and rehabilitation: 'Reducing Harm, Promoting Recovery', and 'Essential Care';
- based on these reports, a description of what we mean by 'recovery' in this context;
- the implications of a recovery approach for service providers and practitioners;
- some specific aspects of service provision by practitioners which can have a particular impact on the prospects for recovery; and
- specific action to address what are clearly the most serious harms associated with problem drug use: blood-borne viruses, and drug-related death.
Chapter 6, Making it Work, describes how we intend to work with partners to turn the principle of recovery into reality.
REDUCING HARM, PROMOTING RECOVERY AND ESSENTIAL CARE
77. Two reports published in the last year have examined our approach to tackling problem drug use.
Reducing Harm, Promoting Recovery
This comprehensive review of the place of methadone in drug treatment in Scotland was carried out between June 2006 and May 2007, by an expert group operating under the auspices of the Scottish Advisory Committee on Drug Misuse ( SACDM). Their report was published in July 2007.30
The report concluded that methadone has a key role to play in treating opiate dependency. It is effective in bringing stability to many people's lives, improving health and reducing re-offending. The numbers of people - mainly opiate users - in contact with and accessing services has increased since its introduction.
However, the report identified three areas where its use could be improved:
- more information is needed about how successful provision of methadone has been at achieving outcomes;
- the quality, consistency and delivery of methadone could be improved at a local level; and
- methadone, or indeed other substitute prescribing, is not the whole answer: a wider range of services is required.
The Essential Care report, prepared by a sub-group of the SACDM, was published on 26 March 2008. This built on earlier work, including the Review of the Place of Methadone in Drug Treatment.
The report highlighted a number of important principles for reform of service delivery, including:
- recovery should become the focus of care;
- assessment and recovery plans should address the totality of people's lives; and
- people with substance use problems have aspirations, and should have access to the same services as anyone else.
The report also set out comprehensively the range of services to which people with problem drug use need access, in order to remove obstacles to recovery.
78. The Government considers the recommendations of these reports to be critical to our future success in tackling problem drug use.
What do we mean by recovery?
79. For too long, debate in Scotland has centred on whether the primary aim of treatment for people who use drugs should be harm reduction, or abstinence. We fundamentally disagree with the terms of this debate. We do agree with the United Nations Office on Drugs and Crime, which said in a recent report that "harm reduction is often made an unnecessarily controversial issue, as if there were a contradiction between treatment and prevention on the one hand, and reducing the adverse health and social consequences of drug use on the other. This is a false dichotomy. They are complementary."31
80. Any new strategy to tackle drugs in Scotland must move beyond this artificial distinction. In the Government's view, 'recovery' should be made the explicit aim of services for problem drug users in Scotland.
81. What do we mean by recovery? We mean a process through which an individual is enabled to move on from their problem drug use, towards a drug-free life as an active and contributing member of society. Furthermore, it incorporates the principle that recovery is most effective when service users' needs and aspirations are placed at the centre of their care and treatment. In short, an aspirational, person-centred process.
82. In practice, recovery will mean different things at different times to each individual person with problem drug use. Above all, people aspiring to milestones in recovery must have the confidence that they can achieve their personal goals. For an individual, 'the road to recovery' might mean developing the skills to prevent relapse into further illegal drug taking, rebuilding broken relationships or forging new ones, actively engaging in meaningful activities and taking steps to build a home and provide for themselves and their families. Milestones could be as simple as gaining weight, re-establishing relationships with friends, or building self-esteem. What is key is that recovery is sustained.
83. Recovery as an achievable goal is a concept pioneered in recent years with great success in the field of mental health. The Scottish Recovery Network has been raising awareness of the fact that people can and do recover from even the most serious and long-term mental ill-health. 32
84. The strength of the recovery principle is that it can bring about a shift in thinking - a change in attitude both by service providers and by the individual with the drug problem. There is no right or wrong way to recover. Recovery is about helping an individual achieve their full potential - with the ultimate goal being what is important to the individual, rather than the means by which it is achieved.
85. The Government's vision for how drug treatment services in Scotland should be delivered is, therefore, based on the following three principles:
- first, recovery should be made the explicit aim of all services providing treatment and rehabilitation for people with problem drug use;
- secondly, a range of appropriate treatment and rehabilitation services must be available at a local level - since different people with different circumstances inevitably need different routes to recovery; and
- thirdly, treatment services must integrate effectively with a wider range of generic services to fully address the needs of people with problem drug use, not just their addiction.
86. Turning these principles into reality will require a concerted effort by Government, by local service commissioners, by practitioners and by a range of other partners. It will require significant culture change on the part of some service providers, to develop an approach which raises expectations considerably higher than may currently be the case. Nevertheless, we believe that a culture which engenders hope and progress will be welcomed by front-line workers who have high aspirations for their clients.
87. The Government will set in train a number of actions to achieve a shared understanding of how to promote and support recovery, including the following:
- we will establish and support a Drug Recovery Network, along the lines of the Scottish Recovery Network;
- build the capacity of advocacy services, to help service users choose the treatment that is right for them; and
- ensure that the principles of recovery are reflected in training and workforce development programmes.
Wider action to embed recovery in the reform of delivery arrangements is described in Chapter 6.
88. The next sections draw on the Essential Care report to discuss in more detail some specific issues associated with a move to a recovery approach:
- the need to extend and integrate the range of services supporting recovery;
- the key roles of General Practice and pharmacy;
- approaches to person-centred care;
- the need to consider services' response to changing patterns of drug use and the development of new treatment approaches; and
- the importance of carers and families.
EXTENDING AND INTEGRATING THE RANGE OF SERVICES
89. Different people have different routes to recovery. The Government wants to ensure that the appropriate range of services is in place locally and regionally to support recovery.
90. It is for local partners to ensure that the range of services required to promote recovery is available in their area, based on the specific needs and circumstances of that area. There are already many good examples of services which are making a major contribution to recovery from problem drug use. The challenge is to ensure that an appropriate range of services is available across Scotland.
Case Study - LEAP
The Lothians and Edinburgh Abstinence Programme ( LEAP) has extended the range of treatment and rehabilitation available to people with problem drug use. LEAP is a 3-month day programme for people with substance misuse problems, based within NHS Lothian but drawing on a wide range of expertise and delivery of care from both the statutory and voluntary sector partners. By working closely with other agencies, especially the City of Edinburgh Council which provides settled and safe accommodation for clients, LEAP is able to provide a comprehensive package of care which addresses both addiction and wider problems. LEAP delivers a recovery orientated programme in the community by adapting activities and techniques often used in residential rehabilitation.
Patients follow an intensive programme which includes medication and also therapeutic care to address the underlying issues of drug use. The programme links up with vocational training and education providers to help equip clients with skills and qualifications to move on with their lives once the programme has finished, with two years aftercare planned and built in to the programme for every client. Supported housing is provided where required. There is an emphasis on self-help as an integral aspect of the whole process, sustaining clients as they make progress towards their own recovery.
Case Study - Glasgow Addiction Services - Employability and Recovery
Getting people back to work, into educational opportunities or training is now at the core of what Glasgow Addiction Services ( GAS) do. GAS has:
- changed the culture and approach to the issue of unemployment within the service. Employment, education, access to training and voluntary work are now not viewed as end point goals for individuals, but as key intermediate goals. They are seen as things that will promote longer term stability, and give additional focus for interventions working towards recovery;
- supported people to remain in employment and training by forging stronger working relationships with training providers, colleges and employers. This helps ensure that if people relapse or struggle to comply with course or employment requirements, then they can immediately be routed back into Community Addiction Teams ( CATs) for a review of care and treatment;
- ensured that employability forms part of their core initial assessment work with service users. GAS has trained all staff in relation to employability and its role in recovery; and
- enhanced the local infrastructure of employment and training by ensuring the expansion of the role of community based rehabilitation in the service network. Structured day care/community rehabilitation services across Glasgow have formed alliances with education and training establishments to ensure smoother, more supported access into courses. Examples of good work in this area are South East Alternatives, Community Rehabilitation Services who offer and host courses in conjunction with the Nautical College, and New Horizons who do likewise with John Wheatley College.
Over the last 3 years, 4700 people have been helped to access training, education, employment or pre-employment support.
91. In developing local services, partners must also ensure that what is available covers the full range of drug use problems encountered locally - not just opiate dependency. In some cases this may involve redesign of existing services through re-branding and up-skilling of employees to address changing patterns of drug use, such as the increase in cocaine and poly-drug use.
92. The different patterns of drug use across Scotland make it likely that the range of services required or prioritised will vary from area to area. However, it is essential that equity of provision across Scotland is assured. The findings of the Essential Care report suggest we would expect the following treatments to be available in each part of Scotland:
- community rehabilitation, delivering packages of support on family, social and financial issues as well as preparing individuals for education, training and employment;
- prescribing substitute drugs, such as methadone and buprenorphine, as recommended in the UK Guidelines on Clinical Management, to reduce high-risk poly-drug use and injecting behaviour;
- detoxification and relapse prevention programmes, using evidence-based approaches, usually supported by substitute drugs, including naltrexone, which can offer a gateway to longer term care programmes;
- residential rehabilitation, lasting from between three months and one year and typically involving intensive psychosocial support;
- harm reduction services which provide needle exchange, sterile paraphernalia and advice to reduce blood-borne virus such as HIV and Hepatitis C (such services will be supported by new national guidelines for services providing injecting equipment which will be developed as part of the Hepatitis C Phase II Action Plan); and
- crisis services which offer improved and timely access with increased out-of-hours availability and/or short-stay accommodation for people in need of respite care.
93. The aim of all treatments should be to promote recovery, but they inevitably do this through different routes: some aim to stabilise the drug user and improve their health, some aim for reduction in drug use, some aim for abstinence. They differ in intensity and in duration, which is reflected in their relative cost.
94. Specific treatment types have been championed as more effective than others; but all treatment types can be successful in the right circumstances. However, some factors are emerging as being more likely to lead to success than the choice of a particular type of treatment. 33
95. These are:
- rapid access to intensive ongoing support focussing on the multiple needs of the individual;
- retaining people in treatment for at least three months;
- client characteristics such as the severity of the problem and their motivation;
- the responsiveness of services to clients' thinking, motivation and behaviour;
- a shared belief that people can recover on the part of the problem drug users as well as those involved in their recovery; and
- treatments which are followed up with structured aftercare, including action planning.
96. The Essential Care report also identifies a need for better integration of services, to ensure that barriers to recovery such as mental health, homelessness and unemployment are addressed in conjunction with medical treatment. It complements the Government's Closing the Gaps - Making a Difference34 report which provides updated guidance on the care and support for people with co-occurring substance misuse and mental health problems. Essential services, including services addressing an individual's physical, psychological and social functioning should be available in every area.
97. The report also recommends effective access to psychological care at all levels, especially as progress is often hampered by psychological distress such as anxiety, depression and personality disorders. This is essential to help people recover. It also mirrors the current challenge within prisons.
98. The integration of treatment with activities which allow individuals to move towards employment is especially important. There is good evidence that work is beneficial to health and well-being and employment can aid the process of recovery from drug use. 35 Indeed, the evidence suggests a relationship between unemployment and health, and a strong association between unemployment and poor mental health. 36
99. People with problem drug use are not experiencing those economic or health benefits. Data from the NHS Information Services Division ( ISD) in 2007 showed that only about 15% of treatment-seeking drug users are currently in employment or training. 37 At present, support is focussed on the early stages of recovery, with few opportunities to 'move on' into education, training and employment. Action to improve employability must become more aspirational, with treatment and care services providing ongoing support.
100. Scotland's Employability Framework, Workforce Plus, is central to meeting this challenge. This framework looks to devolved policies and services such as health and social care, training and skills development and regeneration to make a significant contribution to individuals' employment prospects. A large number of Community Planning Partnerships are using the framework set out in Workforce Plus to make sure that different local agencies are working together and are clear about their roles and responsibilities in helping people get back to work, including people with problem drug use, who have greater support needs.
101. Employability is an extremely complex and important issue with regards to offender learning. Developing the skills required to be able to enter the labour market and successfully hold down a job is thought to be one of the most effective ways to combat re-offending and thus create stronger and safer communities. Skills for Scotland, the Government's skills strategy, commits to producing an offender learning and skills strategy, with the aim of providing a more streamlined and improved learning service to offenders, which will be developed by establishing a reference group to look at offender learning as a whole.
102. The Workforce Plus approach is consistent with the broader approach to integrating services emphasised in the Essential Care report. It highlighted the need for promoting recovery from problem drug use to be considered explicitly within other national plans and strategies, rather than being considered in isolation. The report stressed that this should include areas such as health care, housing, education, training and employment, legal advice, money issues, and children and families issues. The challenge for Government and local partners is to develop a joined-up approach which ensures that national and local plans of action across all relevant areas take full account of the need to promote recovery from problem drug use.
THE ROLE OF GENERAL PRACTICE
103. General Practitioners ( GPs) clearly have a key role to play in promoting recovery from problem drug use. In addition to dealing with the general health issues of drug users, including medical conditions which stem from the drug use, GPs can provide specialist care of drug users under the National Enhanced Service specification for patients suffering from drug use: including co-ordination of care, substitute prescribing and procedures such as Hepatitis testing and immunisation, as well as referring on and liaising with appropriate support services.
104. There is potential under these contracts to demonstrate the progress people make in recovering from their problem drug use. The Government expects the following of all NHS Boards, in commissioning and monitoring their locally negotiated Enhanced Service contracts with GPs and/or other providers:
- that Health Boards ensure an appropriate level of service capacity, given local needs;
- that Health Boards work with local authorities and other partners to provide co-ordinated and holistic care; and
- that services build on the current provision for data collection and ongoing evaluation of the outcome of treatment for this client group.
105. Work by GPs (and other clinical services) in dealing with drug use should be underpinned by the recently updated UK Guidelines on Clinical Management 38 - sometimes known as the 'Orange Guidelines.'
Drug Misuse and Dependence: UK Guidelines on Clinical Management
The 'Orange Guidelines' provide guidance on the treatment of drug use in the UK and 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 drug users, with individual care plans and co-ordination of care across professional groups, including health and social care.
They focus on care of the individual drug user, but also acknowledge the importance of considering the impact of their drug use on others, especially dependent children and on communities. The Guidelines are consistent with a recovery approach in its discussion of treatment goals.
The Government strongly supports these Guidelines as the basis on which clinicians and other professionals should consider the treatment of patients with drug use problems. It considers them to be a key driver in further building evidence-based practice in primary and secondary care, both as an authoritative guide and as a pragmatic tool.
THE ROLE OF PHARMACY
106. The Government believes there is scope for improving the quality, consistency and delivery of methadone treatment programmes. While the dispensing and supervision of methadone is a locally negotiated service, almost 80% of all community pharmacies in Scotland provide it. 39 Pharmacists have the highest number of contacts with people with problem drug use, often seeing them and their families on a daily basis. As well as providing access to treatment, pharmacists offer a wide range of other services, such as the treatment of minor ailments on the NHS, healthy lifestyle advice and sign-posting other service providers. There are also a growing number of pharmacists who have qualified as prescribers in their own right, and have extended their role in supporting patients with drug problems. This can involve taking on caseloads of patients and, for example, adjusting doses of methadone, as well as prescribing other treatments for related conditions. This offers NHS Boards another point of access for treatment and support, as part of their local network of services.
107. Local services, including pharmacies, need to be accessible and flexible to promote recovery and support individuals' needs. NHS Boards should ensure that there is enough flexibility to people in recovery, and that obstacles to people wanting to return to work or education, for example, are minimised. The Government proposes that Boards should review local service arrangements (in and out of normal working hours), and take any appropriate actions to ensure that they offer flexible access to service provision. Boards and individual pharmacies should also consider new technologies that assist with access, as and when they are approved as safe for use in Scotland.
Pharmacy access: an illustration of best practice
A drug user has recently started on a methadone treatment programme with a view to initially stabilising him and then reducing his dosage. His treatment plan and prescription indicate that his methadone should be consumed under the supervision of a pharmacist. As a result he attends a community pharmacy close to where he lives on a daily basis. This initial supervision period is invaluable in helping support him at the early stage of his recovery by providing him with access to a health care professional on a daily basis for support when he is more vulnerable to relapse. Support includes advising on and treating the side effects of methadone, advice on oral health and nutrition and monitoring progress.
He is currently unemployed but is keen to return to work; he is a painter by trade. However, he is concerned that because his methadone is supervised he will not be able to go back to work full-time. He raises his concerns with his pharmacist who in turn contacts his GP and the local specialist misuse service. They all agree, based on the feedback from the pharmacist who has had the daily contact with him, that he is stable and ready to consider returning to work.
As a result the GP relaxes the supervision requirements on his prescription. If he had only recently started his treatment programme or was not considered stable at the time of the request then the professionals may have chosen to keep him on a supervised regime for a longer period. Under these circumstances they may have considered advising him to attend a community pharmacy that is open later in the evening for his supervision.
108. The Government believes that the ideal model for offering appropriate personalised support to enable people to recover from problem drug use is to develop an individual care plan. Such an agreement should be based on a holistic assessment of their needs, and should detail the agreed outcomes (goals) of the recovery plan, and should be subject to regular review to allow the support needed to be adjusted to reflect progress made towards recovery, in accordance with the National Quality Standards for Substance Misuse Services. 40 It should cover both treatment and rehabilitation services, as well as addressing issues such as training or employment needs. The relevant actions in the plan can then be shared with the appropriate service providers, to ensure an integrated approach to delivering the plan, as well as forming the basis for a more proactive engagement of the individual in their own recovery. There is already some experience in this approach in Scotland in the form of 'treatment agreements' addressing immediate addiction needs; an example of such an agreement is at Annex B.
RESPONDING TO CHANGE
109. Service provision also needs to respond to changing patterns of drug use, and to the development of new technologies.
110. A significant example of the former is the recent rise in the use of psychostimulants. This issue has recently been considered by a group drawn from SACDM and a report is due to be published in the summer. As with the Essential Care report, it advocates a person-centred approach, irrespective of which drug(s) a person uses. It says that, due to the historical focus on opiates, current services are not equipped to deal with the rise in cocaine and poly-drug use. There are also specific barriers to treatment experienced by people with psychostimulant problems. Services need to be redesigned to remove these barriers and explore new opportunities such as internet based or self-help services which would be accompanied by education and information to reduce demand.
111. We also know that drug treatment approaches are constantly evolving and improving, with new approaches being tested out in the UK and internationally. Decisions on the introduction of any new approaches should be taken on the basis of a robust evidence base of effectiveness.
THE ROLE OF CARERS AND FAMILIES
112. Moving to a recovery approach also highlights the role that carers and families can play. In line with the National Quality Standards for Substance Misuse published in 2006, 41 if the client wishes, the care they receive should involve family members or other representatives. Services should also be designed with the needs of the family in mind and provide support for them where appropriate.
113. Families play an important role in the treatment, care and support for those using drugs. Families can contribute to the assessment process and provide support, from attending appointments to helping loved ones turn their lives around. However, the level of intensive commitment can come at a heavy price for the family. Ongoing support for families is vital.
114. The Scottish Government supports the work of the Scottish Network for Families Affected by Drugs ( SNFAD). The Network supports local Family Support Groups and individual families through a dedicated helpline, information and training and representation both locally and nationally on issues which affect
115. This chapter concludes by discussing action to address two particularly significant aspects of the harms caused by problem drug use: action to tackle blood-borne viruses; and action to prevent drug-related deaths.
Action to tackle blood-borne viruses
116. The Hepatitis C Phase II Action Plan was published on 19 May 2008, World Hepatitis Day. The Plan sets out a range of actions for Health Boards and others around the themes of treatment, testing, care and support; prevention; monitoring and surveillance; and governance and co-ordination. The Action Plan will be supported by over £45m over the next three years and the intention is to impact significantly on the prevalence of Hepatitis C in Scotland. The vast majority of individuals suffering from Hepatitis C are current or former injecting drug users and as there will be significant funding directed towards care and support, and explicit links into other social care services such as addictions and mental health, the Phase II Hepatitis C Action Plan should improve access to local health and social care services for injecting drug users.
Action to prevent drug-related deaths
117. As noted in Chapter 1, deaths in Scotland due to the use of drugs are currently at their highest level ever - (421 in 2006). Early indications are that the final figure for 2007 will be similarly high. Alongside the wider effort to promote recovery from problem drug use, specific action to prevent drug-related deaths must be developed further.
118. Research over a number of years has identified a 'typical' drug death in Scotland as a male, in his thirties, who died in a home environment and where there was a window of opportunity for someone to intervene. 42 Nearly half of the 317 deaths examined in the National Investigation into Drug Related Deaths in 2003 occurred when other people were present, and demonstrated a clear reluctance in those present to call for help. Most involved poly-drug misuse, that is, the use of more than one drug. Further investigation 43 has shown that the picture of the 'typical' drug death has not changed since the 2003 report.
119. It is possible to identify people who are more likely to die as a result of their drug use, and to try and engage with them. Offering a range of services including increased general health care, the provision of routine function tests (for example, liver function), and alerting drug users to the dangers of lower tolerance, may help prevent some of these deaths.
120. However, this group of people do not make up the total number of drug deaths. Services should therefore be vigilant in identifying others who may be at risk, for example, those people who have had a significant life event, such as bereavement, and who may be more likely to commit suicide. It is worth noting that GPs, who are most likely to be the first contact in cases of bereavement, had seen 77% of drug users in the six months prior to their death in the 2003 investigation. It is possible, therefore, that GPs could play a greater role in recognising where there may be a potential fatality.
121. Giving people the confidence to know when to intervene, what to look for and do may help bring about a reversal in the trend. Adequate training and the provision of relevant information to staff and service users, family and friends, may also bring about improvements over time.
122. The Government was grateful for the first annual report published by the National Forum on Drug-Related Deaths in December 2007. We are publishing our response to the report alongside this strategy. Among the many helpful proposals from the report, the Government accepts the need for more systematic data collection, the need for dedicated funding, and for up-to-date, focused national information campaigns.
123. The Chapter has focussed on the need for a move to a model of services to tackle problem drug use in Scotland based firmly on the concept of recovery. Building on the SACDM reports, the Government will continue to promote and make the case for the adoption of this approach across Scotland, and will build it into the reform of delivery arrangements described in Chapter 6.