1. The Opioid Replacement Therapies Review: Dr Kennedy Roberts Lead Researcher, ORT Review Scottish Prison Service College Polmont 20 th. March 2015

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

3. Methadone- evidence based Methadone- evidence based Suboxone/bup. Evidence based but dissenters Suboxone/bup. Evidence based but dissenters Not reviewed but currently important Prescribed opioids mainly for pain Prescribed opioids mainly for pain Abuse of OTC opioids Abuse of OTC opioids

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

5. Why was the ORT review undertaken?

6. Progress 1994-1999 - Drug issues (harm reduction) “on the map” - Creation of delivery system (DATs)

7. - Consolidation and investment - Strategic thinking (e.g. STRADA) - Delivery system improvements Progress: 1999-2008

8. Progress from 2008 -Recovery focus -Outcomes -Delivery reform

10. 2011 584 deaths

11. 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

12. Methodology: how was the ORT review delivered?

13. 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”

14. Remit

15. 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

16. 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

17. Main findings

18. 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

19. 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

20. 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

21. 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

22. 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

23. Recommendations

24. ORT in Scotland

25. Delivery of recovery outcomes

26. Accountability of the delivery system

27. Social exclusion & health inequalities

28. Information, evaluation & research

29. Mechanism for Change

30. In conclusion

31. 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

32. 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

33. 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

34. Real progress? …Not as much as hoped… yet