The Opioid Replacement The Opioid Replacement Therapies Review:Therapies Review:

Dr Kennedy Roberts Dr Kennedy Roberts Lead Researcher, ORT ReviewLead Researcher, ORT Review

Scottish Prison Service College Scottish Prison Service College Polmont 20Polmont 20thth. March 2015. March 2015

The Opioid Replacement The Opioid Replacement Therapies Review:Therapies Review:…….one year on.one year on

Dr Brian KiddDr Brian KiddChairChairDrug Strategy Delivery CommissionDrug Strategy Delivery CommissionandandDr Kennedy Roberts Dr Kennedy Roberts Lead Researcher, ORT ReviewLead Researcher, ORT Review

•Methadone- evidence Methadone- evidence basedbased•Suboxone/bup. Evidence Suboxone/bup. Evidence based but dissentersbased but dissentersNot reviewed but Not reviewed but currently importantcurrently important•Prescribed opioids mainly Prescribed opioids mainly for painfor pain•Abuse of OTC opioidsAbuse of OTC opioids

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 Why was the ORT review review

undertaken?undertaken?

Progress 1994-1999

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

system (DATs)

- Consolidation and investment

- Strategic thinking (e.g. STRADA)

- Delivery system improvements

Progress: 1999-2008

Progress from 2008

- Recovery focus- Outcomes- Delivery reform

2011 584 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:Methodology:how was the ORT how was the ORT review delivered?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 findingsMain 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

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

RecommendationsRecommendations

ORT in Scotland

Delivery of recovery outcomes

Accountability of the delivery system

Social exclusion & health inequalities

Information, evaluation & research

Mechanism for Change

In conclusionIn conclusion

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

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

In conclusionWhat does it mean?This situation must changeInstitutional memoryConsistent action should follow the evidence-baseEvidence base must developFocus on accountability and on delivering measurable outcomes

Real progress?

…Not as much as hoped… yet