National Mission on Drugs: annual report 2022-2023

Outcomes 3 & 4: People at most risk have access to treatment and recovery & people receive high quality treatment and recovery services

5.1 Overview

Treatment is a protective factor against drug-related deaths and harms, and it is vital that treatment is high quality, evidence-based and promotes a recovery orientated system of care to get more people in to the treatment they need by making sure services are accessible and effective. This includes the wide range of treatment provision available, both community based and residential. All 10 MAT Standards are key elements in delivering these outcomes.

Summary of MAT Standards

1. All people accessing services have the option to start MAT from the same day of presentation.

2. All people are supported to make an informed choice on what medication to use for MAT, and the appropriate dose.

3. All people at high risk of drug-related harm are proactively identified and offered support to commence or continue MAT.

4. All people are offered evidence-based harm reduction at the point of MAT delivery.

5. All people will receive support to remain in treatment for as long as requested.

6. The system that provides MAT is psychologically informed (tier 1); routinely delivers evidence-based low intensity psychosocial interventions (tier 2); and supports individuals to grow social networks.

7. All people have the option of MAT shared with Primary Care.

8. All people have access to independent advocacy and support for housing, welfare, and income needs.

9. All people with co-occurring drug use and mental health difficulties can receive mental health care at the point of MAT delivery.

10. All people receive trauma informed care.

5.2 Progress in 2022-23

5.2.1 MAT Standards

The Medication Assisted Treatment (MAT) Standards were published in May 2021 and are a set of evidence based standards which define what is needed for the consistent delivery of safe and accessible drug treatment and support in Scotland.

MAT Standards Implementation Support Team (MIST)

Based with Public Health Scotland, MIST supports local areas to put the structures and systems in place to facilitate the implementation and ongoing operation of MAT standards in the short, medium, and long term. MIST support is provided through networking (weekly MATSIN and fortnightly JUSTIN) and regular support visits. Improvement work has focused on establishing that local areas have written procedures in place, have numerical information and data available and have a means in place to gather experiential data – all of which are required to help drive improvement. MIST reports annually (June) to Minister on progress towards the standards being in place.

The second National Benchmarking Report on Implementation of the MAT Standards was published in June 2023 and reported on progress up to April 2023.

Over the year to April 2023 there has been substantial progress made with implementation of the MAT standards. For MAT standards 1-5, 66% were fully implemented compared to 17% the previous year, with the remainder of standards 1-5 being partially implemented. For MAT standards 6-10, areas have achieved 88% partial implementation.

The Ministerial Letter of Direction, issued in June 2022, required all areas to publish and submit Implementation Plans to the Scottish Government on how the MAT standards would be implemented and to nominate a senior leader to be responsible for implementation locally. Signed and published implementation plans were received for all areas and the nominated local senior leader provides a report on their progress to Government either on a monthly or quarterly basis.

Ministers have set ambitious targets for each area of Scotland for implementation and sustainability of the MAT standards. By April 2025 to fully implement MAT standards 1–10 in community and justice settings, and by April 2026 there should be sustained implementation of all the standards.

For the remainder of the National Mission, Ministers are also committed to focusing more on the care and support for people who have problems with benzodiazepines, stimulants, and alcohol, rather than focusing only on opioid use.

5.2.2 Long-acting injectable buprenorphione

The MAT benchmarking report published in June 2023 shows a significant upturn in the use of long-acting injectable buprenorphine (brand name Buvidal) as an alternative to methadone and oral buprenorphine. The use of long-acting buprenorphine is most notable in Dumfries and Galloway, but other areas have also seen a significant rise in the proportion of people who have chosen this treatment option. The benefits for patients and services come from the fact that it requires one weekly or monthly injection rather than daily visits to a pharmacy.

While the MAT standards require that the option is available, no target for adoption has been set as the decision on treatment option is a matter for the individual on the advice of the prescriber, and Buvidal will not be suitable or desirable for some people.

There still remain some local areas where Buvidal is not being made available, reportedly because of its relative cost over other options. We are providing advice and support to areas which have identified a reluctance at health board level to fund this approved treatment option.

5.2.3 Primary Care

The successful implementation of MAT Standard 7 will see better joined-up working between drug treatment services with broader Primary Care. This will help to address the wider health needs of people who use drugs, providing benefit from improved support from General Practice, Primary Care and Community Pharmacy.

In order to accelerate the adoption of Enhanced Services for drug services across Scotland, we have ringfenced £10m from the Scottish Government’s Enhanced Services Allocation to NHS territorial Boards, from April 2023, for this purpose. Local areas have been asked to prioritise use of this funding to improve outcomes for people who use drugs.

We have been working collaboratively with colleagues in Public Health Scotland to develop best practice models of care for drug treatment services within primary care settings. These best practice models will support Boards in establishing or improving their own models of care to support the successful implementation of MAT 7.

5.2.4 Substance Use Treatment Target

In March 2022, the former Minister for Drugs Policy announced a new target to increase the numbers of people in community-based OST by around 9 per cent to 32,000 people by 2024.

We continuously accrue new data, evidence, and insights into the dynamic trends in the prevalence of drug use. This data shows us that the crisis we face in Scotland remains primarily an opiate one, but that poly-drug use, including an increasing trend of stimulant and benzodiazepine uptake is a growing issue.

We know from a wealth of international evidence that Opioid Substitution Therapy (OST) is effective in reducing drug deaths and harms and appropriate provision of, and ready access to, this form of treatment remains a key pillar of our National Mission.

We will continue to use all intelligence at our disposal, as part of our efforts to actively expand and review the Treatment Target beyond 2024, to ensure that we are responding to the full range of known and emerging harms.

5.2.5 Residential Rehabilitation

We have committed to increase the number of statutory funded placements in Residential Rehabilitation by 300% and increasing the number of beds available by 50%, so that by 2026 there are at least 650 beds, and 1,000 people are publicly funded for their placement each year.

The National Mission includes a commitment of £100 million to be available for residential rehab and associated aftercare over this parliamentary term. There are three key parts to our national approach to achieving improvements in treatment options and recovery pathways: improving pathways into and from rehabilitation services, in particular for those with multiple complex needs; investing in a significant increase in the capacity of residential rehab services; and developing a standardised approach to commissioning residential rehab services.

2022/23 saw the completion of many of the projects supported through the first round of the rapid capacity fund. This included the opening of Harper House, the new National Specialist Families Centre, by the Former First Minister in November 2022, the former Minister for Drugs Policy officially opened the expansion of Lothian and Edinburgh Abstinence Partnership (LEAP) and the first of the two mother and baby units by Aberlour. River Garden recovery community opened the first phase of their expansion in early 2023.

Later in November the Residential Rehabilitation Rapid Capacity Programme (RRRCP), was reopened for a second round this time with a special focus on increasing provision for residential rehab in underserved areas. Three projects were successful with an investment of more than £14m.

Phoenix Futures will receive almost £11.4m for a facility in the North East which will eventually support 80 placements at any one time – up to 200 placements annually. The charity will also provide a structured day programme to enable local people to access the rehab services. In Inverness six new beds, equating to up to 22 placements per year, will be created by CrossReach at their existing Beechwood House Inverness facility with a grant of nearly £2.4m. The Maxie Richards Foundation in Tighnabruaich was awarded £468k to fund a renovation and expansion of their premises, which will result in one additional bed – three additional placements per year.

These two rounds of investment in RR capacity mean that upon opening, this additional capacity will take us to almost 600 residential rehab beds in Scotland – well on our way to our commitment to increasing capacity by 50% from 425 in 2021 to 650 by the end of this Parliament.

• 812 approved placements for Residential Rehab in 2022/23, from 540 in 2021
• 600 residential rehab beds in Scotland (425 in 2021 -> 650)
• Eight rehab facilities built or expanded through the Rapid Capacity Fund

Case Study: Cowan Grove Mother and Child Recovery House

As outlined in 2012/2022 report, children’s charity Aberlour received a grant of more than £5.5 million over this parliamentary term to develop two Mother and Child Recovery Houses – one in Dundee opened in December 2022 and the other in Central Scotland, to be opened in late 2023.

Aberlour’s first recovery house, developed in partnership with Hillcrest Housing Association, was completed and opened for referrals on 5 December 2022. The service was named Cowan Grove, and an official opening event was held with the former Minister for Drugs Policy on 18 January 2023.

The house has been designed to enable children of women with problematic substance use to stay with their mothers during their recovery, and Cowan Grove can support up to four women and their children at any one time.

Since opening for referrals, Cowan Grove has supported 6 families: 6 women, from age 21 to 36, and 6 children, from birth to 18 months.

As Cowan Grove continues to develop and grow, Aberlour will work with families in residence to ensure that the desire to ensure that women and children’s voices are heard, listened to, and acted on is at the heart of their service delivery.

Development is now underway on the second recovery house.

Source: Mother and Child Recovery Houses - Aberlour

To improve pathways into rehab, Healthcare Improvement Scotland’s (HIS) “Pathways to Recovery” programme has established regional improvement hubs across the country that support all ADPs and wider services to come together to share learning, best practice and work collaboratively to address the common challenges that exist to ensure residential rehab pathways are clear, easy to navigate and accessible for all. Building on this work, HIS are currently supporting all ADPs to undertake a detailed self-assessment of their current pathways against the principles contained within the Good Practice Guide for pathways into, through and out of Residential Rehabilitation. This will result in local action plans for improvement across all aspects of the Residential Rehab pathway from referral, assessment and pre-rehab support, through to placement and effective after care.

2022/23 also saw a continued increase in placements being approved across the country, with 812 placements approved in 2022/23.^[5]

In order to further support ADPs to increase the number of residential rehab placements, Scotland Excel completed their engagement work with ADPs, as well as providers, on the current provision of rehabilitation in Scotland, and made their recommendation to us that a National Commissioning Framework should be established. This recommendation was provisionally accepted, and they have begun the process to take the framework to tender. In an example of partnership working HIS produced a paper entitled “Embedding Lived Experience in the Commissioning and Contracting of Residential Rehabilitation Services in Scotland” in order to support Scotland Excel with ensuring Lived and Living Experience were at the heart of the design of the framework.

The Prison to Rehab pathway (P2R) enables individuals with problem substance use to access residential rehab on release from prison. P2R was reviewed in 2022 to assess practices and procedures. We consulted prison staff and providers to understand what changes are needed to improve the process and received feedback from Alcohol and Drug Partnership’s on their interaction with the pathway. In March 2023, we published an updated Prison to Rehab Protocol. A key change to the protocol is the replacement of the 12-week limit on placements in favour of an upper cost limit, ensuring better value for money and more flexibility. Between April 2022 and March 2023, 45 Prison to Rehab placements were approved.^[6]