The Opioid Replacement Therapies Review: ….one year on Dr Brian Kidd Chair Drug Strategy Delivery Commission and Dr Kennedy Roberts Lead Researcher, ORT Review

Plan Why was it done? What did we do? What did we find? What does it mean? What has happened in a year?

Why was the ORT review undertaken?

Progress Drug issues (harm reduction) “on the map” - Creation of delivery system (DATs)

- Consolidation and investment - Strategic thinking (e.g. STRADA) - Delivery system improvements Progress:

Progress from Recovery focus -Outcomes -Delivery reform

deaths

Drivers for review Reports of loss of political consensus Progress towards delivering recovery remains elusive despite clear strategy Increase in drug deaths continuing –Methadone implicated in many Ongoing negative media reports on balance, quality of services

Methodology: how was the ORT review delivered?

Methodology Agreed remit with Minister & Chief Medical Officer for Scotland Lead researchers employed: Dr Kennedy Roberts and Dr Charles Lind Representative Steering Group – drawn from DSDC and National Drug Death Forum Secretariat from Scottish Government Aim to deliver “spring 2013”

Remit

Methodology A review of the research evidence base on ORT (focus on methadone) Validated review group conclusions with an international panel of expert reviewers Gathered views of Scottish academics on strengths and weaknesses of the evidence-base in Scotland Examined the delivery system in Scotland –Took evidence from a wide range of stakeholders NB Accessibility to the review was paramount

Stakeholders Scottish academics Written and verbal evidence from all ADPs Relevant government agencies Politicians National representative organisations Health & social care professionals Residential detox and rehabilitation providers Those advocating particular therapies/approaches National and local events

Main findings

5 key themes The strong evidence for ORT with methadone – but the need for quality assurance The lack of progress in delivery of recovery outcomes The apparent lack of local accountability and post- ADP integration of the delivery system The link with social exclusion and health inequalities – and need to make this drive access to more generic services & solutions The need for valid information, evaluation and research

ORT with methadone Strong evidence base for effectiveness at reducing drug-related harms Strongest evidence-base for relatively short- term outcomes (<1year) Longer term cohort studies show long-term protective effect (30+ years) Poor evidence base for delivery of “recovery” with ORT (Bell 2012; Best et al 2010) Quality standards and processes essential

Scottish Methadone Review – SG 2007 In summary, replacement prescribing with methadone remains the main plank of medical treatment for opiate dependency in the UK. Harm reduction approaches, incorporating methadone treatment, have evolved rapidly in the face of blood-borne virus infection. It has also been seen to be effective in the Criminal Justice arena by reducing the need for imprisonment. Methadone is more cost effective than any other medical treatment for dependency, though other effective interventions should be part of any comprehensive programme, improving patient choice. Outcomes improve if delivered with associated counselling interventions and these should also be standard. The challenge with methadone is to optimise delivery of harm reduction whilst ensuring that progress to recovery is encouraged, facilitating a way out of methadone treatment whenever appropriate.

Delivery of recovery outcomes Strong representation from families (e.g. SFAD) ADP responses:

Accountability of the delivery system The whole system How held to account and by what mechanism? Information deficiencies – local and national Quality and effectiveness of local partnerships –Organisational v partnership issues –Specialist or generalist responses Lack of institutional memory

Social exclusion & health inequalities Problem substance use a key driver of the “Glasgow effect” (eg SDF/SAADAT 2007) –Prevalence mirrors areas of deprivation –Drug deaths rates mirror areas of deprivation –Scottish research shows clearly the health impacts effecting this long term substance users –Data on social exclusion echoes this Need for generic service elements to “own” this problem and for prioritisation processes to acknowledge and respond to this anomaly

Information, evaluation & research Information systems Long standing failure to deliver meaningful national information systems Variable local responses Programme of research for Scotland Repeated calls – but limited action to date Uniqueness of Scottish dimension – UK research impact limited Opportunity for real, planned change

Recommendations

ORT in Scotland

Delivery of recovery outcomes

Accountability of the delivery system

Social exclusion & health inequalities

Information, evaluation & research

Mechanism for Change

In conclusion

Why was it done? To address criticisms and concerns regarding treatment What did we do? We comprehensively reviewed the literature. We took evidence/opinion from a wide range of Scottish stakeholders We validated our conclusions via international experts

In conclusion What did we find? We reiterated the link with social exclusion and health inequalities We set out the evidence for ORT We found little evidence of a strong commitment to recovery at local level We found the delivery system (from ADP to DSDC) unable to demonstrate effectiveness – lack of valid information

In conclusion What does it mean? This situation must change Institutional memory Consistent action should follow the evidence-base Evidence base must develop Focus on accountability and on delivering measurable outcomes

Scottish Government response

Parliamentary debate 28/11/13 NHS response (Mr Michael Mathieson MSP) ADPs – new accountability process and improvement standards NHS - senior officer accountable for clinical governance of prescribing services Psychology - HEAT target for psychological therapies from December 2014 Pharmacy – “Prescribing for Excellence” Primary Care – include in negotiations (NB no timeframes)

What has happened?

Real progress? …a referendum…. = …..Delays But…in terms of responding to the ORT review… Lack of institutional memory New SG officials and new team leading DPU DPU capacity issues currently a challenge Agenda of change in terms of “landscape” meanwhile…. in England ACMD (a UK institution) asked to look at time-limited ORT…..

Real progress? Evidence base and EBP Research agenda progressing (DSDC lead) but timeframes and CSO commitment not clear Focus on accountability Identified lead officer in each NHS Board Quality principles (Hardly new. Value?) Improvement methodology?

Real progress? …Not as much as hoped… yet

..watch this space…