Drugs deaths: National Mission Clinical Advisory Group minutes - December 2023

Attendees and apologies

Attendees
Marion Bain, Co-Chair – Deputy Chief Medical Officer
Adrian MacKenzie, MAT Standards Clinical Lead, Healthcare Improvement Scotland
Chanpreet Blayney, Consultant Psychiatrist at NHS Greater Glasgow and Clyde
Duncan Hill, Specialist Pharmacist in Substance Misuse, NHS Lanarkshire
Duncan McCormick, Consultant in Public Health Medicine at Public Health Scotland
Hazel Torrance, Head of Forensic Toxicology Service, Scottish Police Authority
Isabel Traynor, Consultant Clinical Psychologist/Head of NHS Fife Addictions Psychological Therapies Service (APTS) and Lead Psychologists in Addiction Services Scotland (LPASS) representative
Dr John Paul Loughery, Vice President Royal College Emergency Medication
Mandy Ramsay, Head of Clinical and Care Governance, Turning Point Scotland
Saket Priyadarshi, Associate Medical Director and Senior Medical Officer - Glasgow Alcohol and Drugs Recovery Services
Susanna Galea-Singer, Clinical Lead and Consultant Psychiatrist / Chair of the Education Committee / Co-Chair Faculty of Addictions Psychiatry
Tara Shivaji, Consultant in Public Health Medicine, Public Health Scotland
Kirsty Nelson, Parish Nurse, Queen's Nurse
Mandy Ramsay, Head of Clinical and Care Governance, Turning Point Scotland
Mark Richards, Associate Chief Nursing Officer and Executive Nurse Director

Apologies    
John Harden, Co-Chair – Deputy National Clinical Director
Professor David Lowe, Clinical Director Health Innovation (Scot Gov) and Consultant Emergency Medicine NHS GGC
Roy Robertson, Professor of Addiction Medicine at the University of Edinburgh and Retired General Practitioner
Sarah Donaldson, Specialist Pharmacist in Substance Use, NHS Tayside
Trina Ritchie, Lead Clinician, Greater Glasgow and Clyde Alcohol and Drug Recovery Services
Tracey Clusker, Nurse Consultant, Public Health Scotland/ NHS Lothian
Darren Fullarton, Associate Nurse Director and is the Lead Nurse with North Ayrshire Health and Social Care Partnership
Sarah Donaldson, Specialist Pharmacist in Substance Use

Also in attendance
Alpana Mair, Scottish Government
Elinor Dickie, Public Health Scotland
Morris Fraser, Scottish Government
Maggie Page, Scottish Government
Deanna Francis, Scottish Government
Mark Richards, Scottish Government
Stuart Law, Scottish Government
Paul Sutherland, Scottish Government

Items and actions

Welcome and Introduction

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

Board Governance

The minute of the second meeting on 12 September 2023 was approved.

Members were advised that a membership list as well as previous meeting minutes have now been published online on the Scottish Government website.

Presentation: Prescription, treatment and harm reduction for people with who use benzodiazepines illicitly.

Alpana Mair (Head of Effective Prescribing and Therapeutics Division, Scottish Government) delivered a presentation to provide an outline of the forthcoming guidance for appropriate use of antidepressants, and benzodiazepines (meeting paper 3.1 and 3.2)

Public Health Scotland delivered a presentation to give a summary of the DDTF work and interim guidance on benzodiazepine prescribing and a summary of the challenges around MAT and substitute prescribing for benzos.

Q&A and discussion

Led by Dr Tara Shivaji, Head of the Drugs Team, Public Health Scotland delivered the key questions for the Clinical Advisory Group:

1. What are the relative contributions of substitute prescribing, mediation review, psychological therapy?
2. What additional guidance or advice is needed to enable people to prescribe Benzo safely to people who are taking illicit street drugs? (within the context of a clinical pathway that includes medication review etc and takes into account the polypharmacy - comprising street and prescribed drugs) 
3. How do we change practice and get further endorsement for the approach?

 
The following outlines the key themes of the discussion regarding the questions put to the group 
What are the relative contributions of substitute prescribing, medication review, psychological therapy?

• They must always address the issue of dependency
• Three points should be considered

1.     Not prescribing is harmful
2.     Prescribing without addressing the anxieties the psychological needs, and also being trauma informed, is harmful.
3. Long term prescribing can be harmful

• At the outset, a period of stabilization must be established, where psychological interventions can be initiated and then the detox started so that the patient is appropriately supported through the process 
• Generating the goals with the patients is important. The period of stabilization and initiation of detox needs to be driven by the patients.
• Work is needed with the patient to complete a multidisciplinary assessment and a formulation together and then deciding on an agreed period of stabilization and detox.
• Cognitive impairment needs to be recognised and appropriately considered. 
• Testing what types of psychological interventions could be required would be useful.
• Support is needed around the individual as well as the possible prescription.  It needs to be recognised that doing a medicine review isn't necessarily about stopping prescriptions. It's also about considering what needs to happen in order to ensure safety for the individual.

What additional guidance or advice is needed to enable people to prescribe Benzo safely to people who are taking illicit street drugs?  (within the context of a clinical pathway that includes medication review etc and takes into account the polypharmacy - comprising street and prescribed drugs) 

 

• Clinicians would really welcome any guidance as there has been very limited evidence out there to make a basis on for a long time.
• We must have more proactive research through drug checking. As it stands new information comes to practitioners months down the line after new drugs have become available and used in the streets. This usually comes through forensic toxicology rather than through drug checking and in real time. 
• We must address the major differences in prescribing practices within services across the country and find a solution on how to do this in the absence of available evidence based data. 
• One size doesn't fit all, key in this is considering individual differences and why people are using and where they are in terms of their motivation to stop, and what other supports are needed.

How do we change practice and get further endorsement for the approach?

 

• We must establish who will lead on the prescribing. Will there be GP’s or should we establish a statute, whilst tying in the 3rd sector?
• Many clinicians are waiting for clarity and a clear evidence base before implementing changes.
• There are opportunities around using tests of change and their findings and also communicating and joining up best practice while we further develop our evidence base.
• Clinicians are also concerned about the extra level of work and numbers of patients that this may bring as they are already under significant pressures.

Focus of next meeting

For March 2024:  Two items under consideration which will be confirmed prior to the next meeting: 

Laboratory and infrastructure challenges: Looking at proactive drug checking and postmortem testing 

Heroin Assisted Treatment: Evaluation of the Glasgow project  

Proposed – With the increasing emergence of synthetic opioids, it is proposed that we combine these topics to seek a clinical view of the potential impact of this in the next 12 months.

AOB & Close 

The next meeting is scheduled to take place 13 March 2022 at 1.00 pm.- 3:00 pm.

Subsequent meetings as follows: 

•    Wednesday 19th June 2024 1 pm – 3 pm

•    Wednesday 18th September 2024 1 pm – 3 pm

•    Wednesday 11th December 2024 1 pm – 3 pm

These meetings will be held in-person at St Andrews House in Edinburgh.