Chamber and committees

Again, Richard Foggo can come in on this, but yes, they do tie in. Addictions were identified as one of the key themes in the target operating model. The implementation and embedding of MAT standards is a key part of ensuring that that approach works effectively within the system.

Buvidal is, or should be, available all over Scotland. The Scottish Medicines Consortium has assessed it and has made recommendations about where and how it should be used.

Please indulge me, because I am a pharmacist as well as a Government minister. In some ways, it can be seen as a wonder drug. It is a little bit different to other opioid substitution therapies because it is a mixed agonist-antagonist, which means that it has some inherent, built-in protection against overdose. That is really important for the prison population, given the recognised risk of overdose immediately after liberation from prison.

The generic name is buprenorphine, and Buvidal is the brand name. It is a long-acting injection, which means that it is given by injection at intervals and reduces the need for individuals to present daily at a chemist’s, which can be quite degrading. Some people find that a supportive intervention, whereas others find it degrading and feel that it interferes with their getting on with rehabilitation and resuming caring duties, employment, volunteering or whatever else they need to do on liberation from custody.

The fact that it is a long-acting injection means that it is impossible to divert, which is another advantage. I would not call it a wonder drug, but the inability to divert it is a real advantage when decisions are being made on the best choice of opioid substitution therapy—given that, globally, the evidence is very strongly in favour of opioid substitution therapy and shows that it reduces deaths, harm and criminality and helps people to recover and stabilise. In the most recent detailed interrogation of drug deaths data, we found that 53 per cent of people who died had methadone in their system, but 40 per cent of the individuals who died after taking methadone were not prescribed it. There is a level of diversion in the system that is dangerous and contributes to drug deaths. That is another reason why long-acting buprenorphine, which cannot be diverted because it is injected into the patient, has an advantage over other forms of opioid substitution. The MAT standards make it very clear that individuals who are receiving the medication and accessing healthcare should be a part of the decision-making process around which drug is right for them.

Yes. A lot of work is being done. The Scottish Drugs Forum recently did some peer research on long-acting buprenorphine, which talked about the fact that buprenorphine tends to make people more alert and awake. That goes back to its being a mixed agonist-antagonist: it has some blocking effects and also acts directly on the receptors, which means that people are more alert. Some people really struggle with that, and that was picked up in the peer research. It can be very difficult for people who—I suppose you could describe it this way—have been anaesthetising themselves to life for a very long time to suddenly be aware of their circumstances, and they need intensive psychological support through that stage. To go back to your question around the economics, having a drug on which people are more alert has obvious implications for their working, caring and resuming their role in society.

There will be significant differences between the two. There are also significant differences in the amount of health professional time that is required for either prescription. A methadone prescription generally requires to be frequently written and frequently reviewed, and there is a cost to supervision within the community. The costs for a long-acting injection are lower, but the costs of the psychological support that is required might be higher—although you might get significantly better outcomes. All of that is being examined at the moment, and there is a keenness to understand it across the UK.

Last week, when I met UK ministers, there was a great deal of keenness to understand all of that rich information with a view to making recommendations. In Scotland and Wales, Buvidal is reasonably widely used—we can get you the statistics if neither of my officials can provide you with them now. It is significantly less frequently used in England, and English colleagues have advocated that it should be used more, because it clearly has a role and some advantages over the alternatives.

On how it works in Scotland, I have heard anecdotally that different health boards have concerns about the arrangements for prescribing long-acting buprenorphine on discharge and on liberation from custody. However, my concern and the Government’s concern is that drug prescriptions should not be changed for bureaucratic or administrative reasons on discharge from prison, which is recognised as a high-risk period. Changes to medication in that period should happen for clinical and personal reasons that are agreed between the individual and the clinician who is prescribing for them, because the risks in that period are well acknowledged.

Alison Crocket might be able to give you more detailed information. We are certainly seeing third sector organisations and recovery communities putting in a lot of work to reach into prisons and support people as they transition and are liberated from custody. Our data shows that, in the really high-risk liberation period, we are seeing fewer drug deaths than previously, so our work is having some impact.

I will emphasise exactly the same points. Alcohol is definitely a feature in offending behaviour. For many people coming into custody, there might be a need for medical detoxification on admission. That illustrates very clearly that abstinence is not recovery. While people are in prison, they might not be able to access alcohol, but that does not mean that the problem has gone away. It needs to be dealt with during their time in custody and needs to be anticipated as a problem on release from custody.

We have some good work going on with recovery communities reaching into prisons. There are long-established routes for organisations such as Alcoholics Anonymous to come into prisons and do peer support work, which can then continue when people are on the outside. We also have some good work going on on the prison-to-rehab pathway, which covers alcohol as well as drugs. Alcohol certainly is an important factor.

Alcohol is simply a drug. If people are abstinent for a period of time, on liberation the risks of consuming and overdose are high. That risk needs to be acknowledged and planned for. During their stay in prison, they might have reduced their tolerance to alcohol and not be able to consume the levels of alcohol that they were consuming in advance of admission to the prison estate, so they might face some enhanced risks on liberation that they are not aware of.

I answered a question in the Parliament recently about the selling of vapes that contain synthetic cannabinoids to children over social media. There is undoubtedly a market out there for vapes that contain drugs other than nicotine. In harm reduction terms, vaping nicotine is less harmful than smoking nicotine, and I imagine that that is why there is a difficulty in assessing how nicotine substitutions should be available in prisons and how to reduce the risk of access to drugs that are unintended, as well as nicotine.

I, too, thank the committee for the opportunity to be here. I will say a few words about the progress that is being made in providing appropriate and timely treatment to those in the prison estate with drug or alcohol issues. However, it is important to acknowledge at the outset the recent drug and alcohol-related death figures. Far too many lives continue to be lost to substance misuse, and that has to remain at the forefront of our response.

We know that around two fifths of those in prison self-report problematic substance use prior to imprisonment. Prisons should therefore be somewhere where substance use is dealt with both sensitively and effectively and, on that point, the medication assisted treatment implementation support team is working to deliver a programme of support for justice and custodial settings. The MAT standards reinforce a rights-based approach for people and the treatment that they should expect, regardless of their circumstances or where they are.

On recovery work, we provide funding to the Scottish Recovery Consortium to embed a person-centred, recovery-focused approach that benefits prisoners, families and staff. That continues into transition and resettlement back into the community. As I am sure that members know, we have expanded access to naloxone to all prisons and we are funding the Scottish Drugs Forum to deliver peer-to-peer naloxone supply within the estate. We have also made funding available to the prison-to-rehab pathway that enables suitable and motivated individuals to access residential rehabilitation immediately on release from prison.

Providing support to those with drug or alcohol issues is not distinct from providing them with other healthcare. As a Government, we have supported the national prison care network to develop a target operating model for healthcare delivery in prisons. That sets out a nationally consistent service model for the delivery of the range of clinical services that are provided in prisons, including drug and alcohol services. Despite the very challenging operating environment, I am encouraged to see steady progress in the number of services that have been implemented across the prison estate.

I also highlight that the period that our national mission covers will conclude next year, but we are currently developing a refreshed alcohol and drug strategic plan to continue the important work to address the alcohol and drug-related challenges that Scotland faces, and I expect the plan to be published early next year.

I hope that I have given the committee a flavour of the activity that is taking place. I look forward to taking questions on anything that I have said or any other related issue.

Certainly. I will bring in Richard Foggo to tell you a bit more about how we are approaching the issue.

The cabinet secretary mentioned our ministerial cross-portfolio group on prison healthcare. The Scottish Government has worked closely with the SPS and the NHS to develop a target operating model for service delivery. There are undoubtedly constraints in the prison system and in the healthcare system. In health, there are also staff shortages and workforce challenges when it comes to recruiting the multidisciplinary team for the prison estate. A full multidisciplinary team is required. All of us in the room understand well the complex multimorbidity of people in prisons, who, in general, tend to have more illnesses and to be older than their years, so there are lots of health challenges with that population.

I will hand over to Richard Foggo to explain how we have come up with the target operating model and how we are working to embed it in the prison estate. It is a complex challenge.

I can certainly look into that. The issue of the risks of passive inhalation was raised at the cross-party group last week, and I made a note to look at what evidence we have on that. I will look, from a health perspective, at whether there is any elucidation with regard to the risks of passive inhalation of these substances.

It is clear that stigma prevents people from accessing the treatment that they need. It prevents them from asking for help and from getting the help that they not only need but have a right to. It is a serious issue that cuts across the work of the national mission.

There is work going on. Since I have come into this role, I have recognised that work on stigma probably needs to be done at a population level, but we probably also need to start with certain communities. I hear very clearly from the work and the analysis that is being done among communities and people who are affected by substance use that health professional stigma is a significant challenge that they face. I am reflective about the specific actions that we can take to try to reduce that challenge.

The charter has involved powerful and important work. A lot of upholding of rights starts with people knowing that they have rights and that they are able to articulate that when they are asking for help and support. Working with people with lived and living experience is how we will close the implementation gap, which is the torment of most Government ministers’ lives. We have great and lofty ambitions and ideas, and what we see is largely absolutely outstanding. However, what happens on the ground and at the coalface does not always reflect that ambition. Involving people with lived and living experience will help us to get that right in the first place—to get our policy right, get our legislation right and get our frameworks right, and then our feet can be held to the fire on delivery.

I am very thoughtful about the issue of stigma. This is probably an opportunity to put a challenge to the committee about how institutional and systematic stigma can be. I go back to the earlier exchange that I had with Rona Mackay about the availability of Buvidal on discharge from prison. I have heard that point raised before, and my immediate thought as a health professional and as a minister was, “Why would somebody’s medication be changed on discharge for bureaucratic and administrative reasons and not clinical reasons?” I am not confident that that would happen if we were talking about an antihypertensive drug or an asthma drug, rather than a drug that is used to maintain someone’s stability and which is a well-recognised and well-evidenced treatment for drug dependence. It is important that we reflect on that.

There are all sorts of things that happen to people who have substance use challenges that would not happen to the rest of the population. It is worth us considering and reflecting on that. There is a double stigma for people who have been in the justice system. As the cabinet secretary said, our citizens have a right to access the same quality of healthcare wherever they live in Scotland, whether they are in custody or whether they are in the community.