The tragedy of Scotland’s drug-related death figures has been in my mind this last week or so. The media may have largely moved on, but those of us who work in the field of addiction, those of us who know individuals who have died and those of us with lived experience of addiction will not be able to do the same.
Why has Scotland got the highest drug death rates in Europe? It’s not a question with a straightforward answer. Deprivation is part of the picture, but it is not the whole picture. It is true that you are much more likely to die of drug related causes in a deprived vs. a wealthy area, but when we compare mortality rates in similarly deprived areas elsewhere, Scotland’s statistics are clearly worse.
Polydrug use is now the norm and the illicit market is flooded with cheap benzodiazepines, some of which are potent. Alcohol problems are prevalent. Physical and mental health comorbidities are commonplace.. Polypharmacy is an issue, with a significant proportion of people in treatment on prescribed sedatives (e.g., gabapentinoids, antipsychotics, sedative antidepressants etc.). Access to treatment varies according to geography and, for various reasons, progress on improving this is slow.
On an individual level despair drives drug use. On the day the drug deaths were announced, I listened to a man on the radio explain how hard he had found it to grow up in a deprived area of Glasgow (Pollok) and how drugs had brought him relief from the challenges. Clearly there may have been better responses to the lack of hope he experienced, but if there were, they were elusive.
There is a culture of addiction that permeates in Scotland. William White has captured this theme.. Drug users are often embedded in social networks where the language of drug use, beliefs about drugs, attitudes values and behaviours around use are deeply ingrained and part of a daily routine. Behaviours are driven by short term rewards. There are few role models or peer leaders who are offering alternatives to the daily loop of despair, where the primary focus of that 24 hours is finding the resources to buy drugs, finding a source for supply, and using. Quality of life is deeply impaired. Desperation becomes a unwelcome but understandable bedfellow. Changing unhelpful social networks has been a bit of a policy priority blind spot.
Medication assisted treatment (MAT) is an evidenced-based way to reduce harms. Setting standards for access to treatment, quality of treatment and effective therapeutic and social interventions is a no-brainer. The MAT standards aim to improve outcomes. There is a highly professional MAT Standards website just launched with nicely produced information leaflets for frontline staff and for the commissioning bodies (ADPs). But I see a problem – a kind of mammoth in the morning room. What is it? Well, nothing other than MAT is mentioned.
There is no mention, for instance, of another central plank of the Scottish Government’s National Mission – the work to improve access to and capacity in our residential rehabilitation system. This lack of joined up thinking (how would one get from MAT to rehab?) is a blind spot, not only on the website, but indeed in the official Scottish Government paper on the standards.
Impressed by the emphasis on choice embedded in the standards, I asked a question at a MAT event about leaving MAT treatment. I wanted to know what channels and options the architects had in mind. I was told that when people want to leave specialist prescribing services, they can choose to go to primary care prescribing services instead. Kafka came to mind.
To the casual eye, it would appear that MAT is like the Hotel California: you can check in to MAT, but don’t expect to ever leave. Perhaps there is an unspoken doctrine behind this – the public health risks of facilitating meaningful choice for individuals and their families beyond MAT are felt to be too high for the MAT Standards architects to support.
This absurdity – both the thwarting of the abstinence goals of some individuals who will want to choose MAT initially and the perplexing neglect of other treatment options – also part of the Scottish Government’s National Mission – suggests a fundamental disconnect.
While I absolutely agree that MAT should be offered to everyone who might benefit, our policy makers and commissioners need to be aware of the tension between pursuing logical public health approaches to the exclusion of individual health choices. I have lost count of the number of people I’ve treated over the years who have told me they’ve been on MAT for years and no professional ever discussed rehab with them. It’s a depressing fact that some people get to rehab because of treatment professionals and some people get to rehab despite treatment professionals. Rehab is not a silver bullet, but it is a viable option. Too often, there’s a brick wall where a door should be.
And I’m not letting residential treatment services and intensive community programmes off the hook. Rehab also needs to find ways to bridge this abyss. All rehabs need to have a fundamental harm reduction strategy in place, give robust overdose prevention training and dispense naloxone kits to their at-risk residents. They absolutely must be able to connect those who do not complete treatment or who relapse in aftercare back into community treatment quickly and not stigmatise MAT. Those bridges are not always in place. Silo mindsets serve service users poorly.
Although it’s been called for over many years – in papers, policies and by lobby/advocacy groups – we are nowhere near reaching a recovery-oriented system of care. Having robust interfaces between all parts of the treatment system is essential if we are to reduce harm. People fall out of treatment and return to use in both MAT and rehab services. To keep them safe, outreach, harm reduction approaches and early re-entry to treatment are key. As I say, those connections often don’t exist. We need to plug them.
“Recovery-oriented systems of care (ROSC) are networks of formal and informal services developed and mobilised to sustain long-term recovery for individuals and families impacted by severe substance use disorders. The “system” in ROSC is not a local, state, or federal treatment agency but a macro-level organisation of a community, a state, or a nation. ROSC initiatives provide the physical, psychological, cultural, and social space within local communities in which personal and family recovery can flourish.”
I don’t believe it is in the interests of those individuals (and their families) who struggle with dependence on substances for us to maintain treatment turf wars. We can have harm reduction and recovery. We can have MAT and abstinence. We can have outpatient treatment and residential rehab. A joined-up, comprehensive treatment system with strong links between its component parts will serve individuals best.
I have worked in community clinics where I prescribed opiate substitution treatment which reduced harms and improved lives. I would gladly do the same if I went back into that setting. The MAT Standards raise the bar – it’s clear that treatment should be about much more than a prescription. If MAT helps people and their families reach their goals, then there is much to celebrate. But not everyone wants MAT, not everyone reaches their goals in MAT services and not everyone wants to stay in MAT forever.
When we silo issues, we end up with solutions that are in conflict with each other
Individuals deserve meaningful choices, but those choices are elusive if we operate our treatment system in silos and are not using shared decision making with our clients and patients – offering the range of options available and seeking to mitigate risks.
The problem of developing policy strands and treatment services in hermetically sealed silos is that we end up with this disconnect (and, if we are honest, conflict of solutions). If we have no exit route and no bridge to other evidence-based treatments we are seriously letting people down. If we want to give those we are trying to help the best chance, we need to bulldoze brick walls and get better at building bridges.
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Photo credit: Kirkikis