Substance Misuse – where are we and where are we going?

Substance Misuse – where are we and where are we going?
Holyrood Magazine, Oct 22, 2012
Opinion piece by Dr Richard Simpson MSP Mid Scotland and Fife
previously a Justice Minister in charge of drug policy and a consultant psychiatrist in addictions

In the 1980s the UK entered its current wave of serious substance misuse. By 1990 the numbers of women being admitted to HMP Cortonvale where I worked as a medical officer was rising rapidly. By 2003 drugs were part of almost every woman prisoner’s history.

The number of people misusing drugs on a national basis is estimated to have reached 54,000 by 2002 remaining largely stable since then.

The early approach was to ensure harm reduction through methadone opiate substitution and needle exchanges with the objective of minimising HIV and Hepatitis C. This was based on sound medical evidence and indeed the anticipated HIV epidemic has been averted though the numbers with Hepatitis C are massive. Methadone consumption and costs have risen hugely, partly due to more effective prescribing and partly due to increased levels of supervision. But partly also due to increased numbers of misusers in treatment.

At the same time all political parties feel that insufficient progress has been made. Hence the cross party agreement to move to a recovery strategy. Recovery is a journey which begins with a desire of the misuser to come off heroin. Some misusers achieve abstinence on their own with family support. More commonly treatment is delivered via addiction teams deploying methadone or suboxone substitution or abstinence programmes. Still too many of those on methadone appear to be just ‘parked’ and not progressing. Progress can only be made with a readiness to address the underlying problems which led to addiction, problems of poor education, illiteracy, low skills, lack of training and employment, poor relationships with family, low self esteem, difficulties in housing and for some a history of bullying, abuse or mental ill health.

’Wrap around’ recovery services to deliver individual personalised care plans addressing these issues are still not properly developed. The third sector which delivers many of the programmes are under huge pressure. Statutory staff are equally under pressure being required to make ‘savings’.

One of the greatest dangers is that a policy of ‘one strike and you are out’ may be adopted i.e. any evidence that the misuser has relapsed using heroin on top of their prescription resulting in discharge from treatment. This has not been a policy promoted by the English National Treatment Agency which has a policy focussed on retaining misusers in treatment. This approach may be reflected in the reducing deaths in England compared to the increasing deaths in Scotland, which have doubled since 2001 to 585 last year.

There is no national contract with GPs undertaking drug misuse care. the diverse local agreements should be renegotiated underpinned with some core national agreed principles promoting a recovery strategy. Unless a holistic approach is delivered by primary care alternatives deploying the newly trained nurse and pharmacist prescribers backed by third sector teams should be considered.

The cuts in midwive posts and 40% cut in midwifery student intake is another concern. There are continuing issues around antenatal care for substance misusers. We need specialist multidisciplinary teams in every Health Board area. There are also concerns about long term damage to children where early development is less than optimal as a result of poor parenting in drug misusing households and failure to achieve strong attachment.

The service to drug misusers in our prisons is dysfunctional for many prisoners on remand or on short term sentences, disconnected as it often is from community addiction services. However on the positive side, there has been praise for the Time Out Centre at 218 Bath Street Glasgow, which was proposed when I was Deputy Justice Minister and has diverted 500 women drug misusers annually from short custodial sentences. But if it is successful why has it not been extended to other cities? I hope that the Angiolini Report and the push to reduce the number of short term sentences will provide renewed impetus to this approach.

The extension of the use Drug Treatment and Testing Orders (DTTO) to lower courts is also welcome. But, with increasing misuse of both drugs and alcohol, Alcohol Orders (ATTO) are also required. Arrest referral programmes covering drugs and alcohol have not been fully mainstreamed in every sheriffdom.
The Naloxone programme roll-out is something I worked hard for and positive government action on this is a good example of effective cross party working.

There is also some good news with the welcome decrease in drug misuse by teenagers reported in SALSUS (The biennial adolescent survey) since I changed the education strap line in 2002 from ‘Just Say No’ to ‘Know the Score’.

But there remains a cohort of ageing misusers who are dying. For this difficult to treat minority of around one percent of misusers, perhaps we should consider initiatives such as prescribing injectable heroin which has been tried in various European countries and successfully piloted recently in England by Professor Strang. We need to examine all approaches in other countries. Sweden has a zero tolerance approach to possession. Conversely some success has been achieved over ten years by the Portuguese approach which replaces criminal courts with tribunals for possession. Needle exchanges in prison as a way of preventing Hepatitis and HIV is now routine in many other countries. We need to debate whether such measures have any place in Scotland.

Recovery is a welcome rhetoric but it will need strong national leadership if it
is to succeed. Yet another review of methadone use was announced by the
government last week, only three years after the last review. This is an
inadequate response.