Drugs deaths: National Mission Clinical Advisory Group minutes: September 2024

Attendees and apologies

In person 

• John Harden, Co-Chair – Deputy National Clinical Director 
• Adrian MacKenzie, MAT Standards Clinical Lead, Healthcare Improvement Scotland 
• Duncan Hill, Specialist Pharmacist in Substance Misuse, NHS Lanarkshire 
• Duncan McCormick, Consultant in Public Health Medicine at Public Health Scotland 
• Isabel Traynor, Consultant Clinical Psychologist/Head of NHS Fife Addictions Psychological Therapies Service (APTS) and Lead Psychologists in Addiction Services Scotland (LPASS) representative 
• Kirsty Nelson, Parish Nurse, Queen's Nurse 
• Roy Robertson, Professor of Addiction Medicine at the University of Edinburgh and Retired General Practitioner 
• Alpana Mair, Head of Effective Prescribing and Therapeutics Division

Virtually   

• Chanpreet Blayney, Consultant Psychiatrist at Health Improvement Scotland 
• Darren Fullarton, Associate Nurse Director at NHS Ayrshire and Arran and is the Lead Nurse with North Ayrshire Health and Social Care Partnership 
• John Mooney, Consultant in Public Health Medicine at Public Health Scotland 
• Mandy Ramsay, Head of Clinical and Care Governance, Turning Point Scotland 
• Dr Ryan McHenry, Clinical Research Fellow and Registrar in Emergency, Pre-Hospital and Retrieval Medicine 
• Saket Priyadarshi, Associate Medical Director and Senior Medical Officer, Glasgow Alcohol and Drugs Recovery Services 
• Darren Fullarton, Associate Nurse Director at NHS Ayrshire and Arran and is the Lead Nurse with North Ayrshire Health and Social Care Partnership 
• Kira Watson, Scottish Ambulance Service 
• Tara Shivaji, Consultant in Public Health Medicine at Public Health Scotland  

Apologies     

• Marion Bain, Co-Chair – Deputy Chief Medical Officer 
• Dr Trina Ritchie, Lead Clinician, Greater Glasgow and Clyde Alcohol and Drug Recovery Services 
• Professor David Lowe, Clinical Director Health Innovation (Scot Gov) and Consultant Emergency Medicine NHS GGC 
• Hazel Torrance, Head of Forensic Toxicology, Police Scotland 
• Julie McAdam, Lead Pathologist, University of Glasgow 
• Sarah Donaldson, Specialist Pharmacist in Substance Use 
• Steven Short, Programme Lead, Out-of-Hospital Cardiac Arrest, Scottish Ambulance Service 
• Susanna Galea-Singer, Clinical Lead and Consultant Psychiatrist/Chair of the Education Committee/Co-Chair Faculty of Addictions Psychiatry  

In attendance 

• Rachael Sinclair, Scottish Government 
• Chris McEwan, Scottish Government 
• Issy Houston, Scottish Government 
• Morris Fraser, Unit Head, Delivery & Support Unit, Scottish Government 
• Chloe Poole, Scottish Government 
• Georgie Alford, Scottish Government 
• Paul Sutherland, Scottish Government 
• Anniek Sluiman, Analyst, Scottish Government  
• Iain Wilson, Clinical Lead (GP) for Effective Prescribing and Therapeutics

Items and actions

Welcome and introduction 

The Chair welcomed members and attendees to the fifth meeting of the National Mission Clinical Advisory Group.  

Board governance 

The minute of the fifth meeting on 19 June 2024 was approved. 

Members were advised that previous meeting minutes have now been published online on the Scottish Government website. 

Presentation: NRS drug deaths statistics for 2023, published in August (10 mins) 

Rachael Sinclair delivered a presentation on NRS Drug Deaths Statistics for 2023 

Points to note 

• 1,172 drug deaths registered in 2023.  
• Up 12% (121 deaths) on previous year (2022: 1,051 deaths). Most of the increase was in males (up 16%). 
• Second lowest number of drug misuse deaths since 2017.  
• General profile of drug misuse deaths broadly in line with previous years – but note trends in substances implicated (increase in cocaine, methadone and gabapentin/pregabalin) and regional detail. 
• People in the most deprived areas were over 15 times as likely to die from drugs than people in the least deprived areas. 
• Opiates remain the most commonly implicated drugs but deaths involving cocaine are increasing and reached their highest ever level. 
• Street benzodiazepines appear to be driving the increase in benzodiazepine deaths; changes in street benzo market evident. 
• The proportion of drug deaths involving gabapentin and/or pregabalin has risen over recent years. 
• In 2022, the rate of drug poisoning deaths in Scotland was more than double the rates of other UK countries. 

Presentation- RADAR update  

Presentation by Tara Shivaji of Public Health Scotland providing RADAR update. 

Points to note 

• The RADAR Quarterly report is due to be published in October. =
• The last RADAR report published in July showed that: 
• Naloxone administration rates increased 5%  
• Emergency Department attendance increased 2%. 
• Suspected drug deaths increased by 9%. 
• Increased reporting of injecting wounds and new drugs/ xylazine are associated with soft tissue injuries. 
• Xylazine wounds caused by injecting practice damage is linked to necrotic skin. 
• Cocaine is increasing in presence in injecting drug harms. 

Discussion: NRS Statistics and RADAR 

John Harden opened the discussion to the floor  

Points to note 

• On soft tissue damage, it was stated that we do not track amputation rates. Little is known about the social or environmental conditions that could also be attributed to it. 
• There was interest raised in the rise of deaths where cocaine was implicated, and it was noted that it would be valuable to hear a pathologist stake on rise in numbers to better understand how cocaine has contribution to deaths. Though it is likely to be related to cardiovascular event, there may be something else happening with cocaine in the system.  
• Public Health Scotland confirmed they are writing a paper on cocaine and how it is contributing to deaths.  
• Attendees agreed the focus on naloxone and MAT standards remains important as the majority of patients are polydrug users. It was suggested that it would be beneficial to have a session on recording deaths and establish a toxicology and pathology interface to allow a trade on data and this could help form questions on polydrug use. 
• It was noted that it would be of interest to get a pathologist’s view on cocaine-implicated deaths, as cocaine use is often alongside use of heroin and benzos.  
• The group discussed how deaths are recorded and listed on the death certificate, questioning whether there may be another primary cause of death. The inclusions and exclusions in the statistics were confirmed – most deaths are acute intoxication and primarily caused by drugs. The process is for the pathologist to submit their findings to the procurator fiscal who will make the final confirmation. 
• It was suggested there may be wide range of prescribed drug deaths that are not included in the figures, and it might be beneficial to look at case studies where deaths are due to prescribed meds. 
• The group discussed the data on gabapentin noting that it is likely that most deaths are due to diverted prescription drugs rather than from illicit supplies.  
• It was confirmed that quality prescribing guidance for gabapentin is due to be published and the group asked for a gabapentin case study to be brought once the guidelines are published.  
• The group discussed how effective current harm reduction strategies and health practices are in addressing wound care and infection prevention. They questioned whether we should be looking at what improvements can be made in terms of guidance, training, and resources to enhance overall detection and prevention of complications and comprehensive care. 

Presentation: national specification 

Presentation by Chris McEwan of Scottish Government on National Specification 

Points to note 

• The National Specification and proposed Overarching Guidance to follow are part of our response to the recommendations made in the Drug Deaths Taskforce report  
• The purpose of the National Specification is to provide clarity on the range of support options which should be available in local areas.  
• This will help local services to set out future strategic plans to deliver on their commitment to reduce harms, alcohol, and drug deaths and to improve the lives of those impacted by alcohol and drugs within a ROSC as per the definition in the Quality Principles.  
• This will help improve lives and reduce deaths by developing treatment and recovery services, help services to deliver on their duty to provide the highest quality of healthcare and be inclusive of the voices and experiences of people, and their families, in recovery.      

Discussion- National Specification 

John Harden opened the discussion to the floor  

Questions put to the group.

• From a clinical perspective, is anything missing on the National Specification?  
• What advice could you provide on the direction of the National Specification and subsequent Guidance?  

Points to note 

• The group discussed how the National Specification relates to the MAT Standards. It was noted that it is influenced by MAT and will incorporate MAT into longer term Overarching Guidance, outlining highest standard of care.  
• It was noted that we need to be clear on what is meant by ‘regular review’ of a person care. There should be clarity if this will include pharmacological interventions, and the journey beyond pharma for the person receiving care needs to be clear. 
• The group asked what measures and tools will be available to support treatment.  
• It was stated that most MAT standards are not pharmacological and more about wraparound care and psychological guidance. 
• It was confirmed that people with lived and living experience will be involved in the development of the National Specification (through SDF, SRC and the Health and Social Care Alliance).  
• There are rapid changes of in trends meaning services can only deliver on what is being seen on ground. 
• Members proposed that there is a need for more MAT quality standards first and then a more structured specification required second, but learning from MAT is important in implementing and planning resources.  
• It was noted that it would require investment to deliver National Specification.  
• It was noted that harm reduction is not mentioned within the National Specification, and neither is retention, which are two key elements of MAT standards.  
• It was noted that the NHS in England regularly develops specifications, and they are useful resources for explaining what can be expected from a service. Some factors were discussed as missing from the Specification, including, expectations of accessibility, geographical issues, equality and planning, workforce staffing ratios.  
• It was noted that in support of the National Specification might be useful to develop a national needs assessment – this would drive consistency in terms of access to the ‘right’ treatment at the right time for the individual.  
• It was also noted that it would be good to see the National Specification for Drugs and Alcohol and the National Specification for Community Pharmacy progress in parallel.  

Presentation on Charter of Rights 

Presentation by Issy Houston of Scottish Government on the Charter of Rights to the group. 

Points to note 

• The Draft Outline Charter of Rights summarises the key rights and how they apply to people affected by substance use.  
• These are drawn from the existing UK Human Rights Act and from international human rights law which will be put into law via the forthcoming Scottish Human Rights Bill. 
• The National Collaborative will analyse the results of a public consultation process on this Draft Outline and then launch the finalised Charter of Rights in December of 2024. 
• A key part of its implementation will be raising public awareness – particularly of those people affected by substance use and most at risk - and building capacity of those bodies with duties of implementing the rights. 

Discussion: Charter of Right 

John Harden opened the discussion to the floor focusing on two questions. 

Questions put to the group

• What do you think of the Charter? 
• What might you be able to do within your leadership role to apply the Charter? 
• Would the CAG be willing to endorse the Charter? 

Points to note.

• Members stated that they found the charter useful and balanced and were already building it into their existing work - specifically the guidance on responding to drug harm clusters and work to improve drug death reviews.  
• Members agreed that they would support the proposed Charter as and see the benefits towards tackling stigma, system failures or professional misunderstanding. It was suggested that endorsement and support should be sought from Chief Medical Officer, CNO and Royal Colleges. 
• The group discussed how the Charter would be implemented, what training might be required and how it will be shared across the whole system. It was highlighted that there is a need for increased levels of cooperation and collaboration between services. 
• It was agreed that there should be an embedded evaluation element or contemporary assessment which will involve using data to monitor progress and finding evidence that human rights are/are not being met.  
• It was noted that information sharing is still an issue between statutory services and third sector organisations, and a sharing agreement required. It was acknowledged that this remains a problem across the whole health sector.  

AOB and close 

Update/ Brief roundup of meeting and note of dates for next meeting 

Subsequent meeting as follows:  

Wednesday 11th December 2024 1 pm – 3 pm*