 The Health and Sport Committee in 2018. Can I ask everyone here to please ensure that mobile phones are off or on silent, and while it's possible to use devices for use of social media, I'd ask you not to film or record the proceedings. We have people who do that for us and all of that is readily available. We have apologies from one member of the committee today, Miles Briggs, can we move quickly to agenda item number one, which is subordinate legislation, an instrument in relation to the national health service superannuation scheme Scotland, miscellaneous amendments number two regulations of 2017, which we considered last week and came to the view that we would seek clarification from the Scottish Government because of points raised with us by the Delegated Powers and Law Reform Committee regarding the drafting of that regulation. Our response has been received from the Scottish Government. The advice from the Government is that there is no detrimental effect on any members of the superannuation scheme and that they will correct the amendments. They will correct the error in the regulation as soon as possible, but it is a drafting error rather than one that has a substantive effect. On that basis, I would recommend to members that we make no recommendations in relation to this instrument and allow it to proceed. Thank you very much. That's appreciated. Now we come to item number two on our agenda, which is in relation to the preventive agenda and an opportunity briefly for members of the committee who have visited local drug support services over recent weeks to put their comments on the record before we open the wider roundtable discussion. If I can start, please, with Arstyn. I visited Turning Point Scotland in Edinburgh and I met a group who used the service there. We sat and had a conversation for about an hour. There were a number of issues that came through quite strongly, so I will outline what those were. They felt that users were definitely being parked on methadone and felt that everyone should be on a reduction plan to try to get them off, but they felt that that was not the norm in their opinion. They felt that GPs were not always able to sign post effectively to what services and support might be available to them. They felt that NPS should be added to the strategy. They said that they thought that it was more addictive than heroin and that users were very unpredictable and that they thought that it was really a growing problem that should be looked at. They also drew out from me that they felt that there was a strong link between mental health issues and the likelihood to start using drugs and that they felt that possible intervention at that early stage could be very preventative. I visited the drug and alcohol partnership in Cercodi yesterday and met with service users for about an hour. The main issues that were highlighted to me were, first of all, in terms of homelessness. People becoming homeless and then a plan for rehousing, Fife and the rurality that that brings in in terms of people being moved around causing great stress because people were moved to far away locations from where their family might have been and where their doctor might have been, so issues around about getting their medication then as a result. There was also a result, I suppose then, in terms of their script not following them. If, for example, they were hospitalised as a result of taking an overdose, for example, their script might not follow them into the hospital and then there would be a lengthy wait in terms of for that to kick in again. There were waiting times that were highlighted as well with regard to referrals, so having to be referred from the doctor, the length of time it took to get a doctor's appointment initially and then to get that referral from the doctor on to the drug and alcohol partnership and then on to a more local service within Fife itself, which can take months, as far as I'm led to believe, from yesterday's evidence. Again, as Ash led to the stigma associated with drug use more generally, and I suppose the sense of shame and embarrassment that causes some people in local communities where people might know each other as well. I visited the alcohol and drug prevention facility at Loughfield Road in Dumfries and met with service users. Stigma and the rurality of our area was one of the big issues because everybody knows your business. Also, the rurality of travel suggested that bus passes are given to people in their treatment while they are in treatment, and that would help facilitate attendance to appointments and engagement. Shared care between GP practices was listed as a problem because some GP practices just don't engage. Also, there was interest and support for decriminalisation, following Portuguese or Canadian models. Also highlighted was from staff members that I spoke to later, a central electronic database for digital prescribing. No paper, traceability, meaning that it would be easier to follow up and improve governance with the prescribing. Issues were raised also with prisons and the fact that when service users were at the end of their sentences, they didn't have a GP, they couldn't register for a GP, they were seen as homeless, so there are challenges there. Other issues related were further challenges of opiate dependence, GABA-penting in the next five to 10 years. We need to think about the services that we are going to have to provide to prepare to meet the need for the knock-on effect for the workload as that progresses. Myles Briggs a I visited the Spittle Street Centre in Edinburgh and met a group of young people who were trying very hard in recovery. I think that what came across from our visit was the support that they felt they got in the practice, which was absolutely invaluable. They said that being able to attend their every day, to meet with peers, some of who had gone on to obtain a degree, for example, gave them real inspiration. They felt that it was possible, but they were absolutely determined that attending the centre was much more helpful than visiting a GP and getting a prescription. They said that the fact that they had to get up and have somewhere to go every day made a huge difference. They started to introduce an element of structure to their lives, which sort of lessened gradually, they might be expected to attend every day, then a couple of times a week, then weekly, as they managed to improve. I think that positive role model, the peer support that was extremely important, spoke to about the difficulties of finding that service, so that pathways need to be much, much clearer. It has to be more easily accessible. The service, too, works with groups who are out on the street in Edinburgh, often finding and working with homeless people and bringing them towards the centre. I think that that was an important part of it, too, but they were absolutely determined that we need more of the services that they are able to access there. I visited the Glasgow North East Recovery Hub. A number of the issues that came up there were very similar to what we have heard. There was certainly an issue that I was concerned about people being part on method on for very long periods of time. There was an issue around that. There was a change in the way in which the services have been delivered. There was some concern about that from what they had called the community day services previously into a new model. There was a lot of comment around that. Previously, they would have had six to eight months to go through a programme, whereas now it was much, much shorter, only a few weeks. There was lack of peer support. They were having to go to different places for the services. Importantly, they said that the previous service had been absence-based, but it was not now. They felt that that was a significant issue. There was also comment about prison. There were examples of people going into prison cleaning and coming out as addicts, which was concerning. There was also a comment about people moving through the recovery journey and then going on to college courses, but it was possible that they were having a low esteem. Some people had experienced that and found it difficult to settle into a mainstream college course. Was there something that could be done to support that in some way? I visited the ad action in Kilmarnock, and a lot of the themes that have already been mentioned reflected in the evidence around being parked on methadone. For example, we had a lady who had been on methadone for 20 years before she realised that she could get off methadone. She did not realise that that was a possibility. That was only by chance meeting with a peer, who, as Alison Johnstone said, had herself come off methadone. I think that one of the things that came across really strongly was the effect of living life on methadone, and that there was no feelings and no dignity, and that the feeling of life slips away, and that every day was kind of like Groundhog Day. Methadone is part of a solution and in itself not a solution. We have also heard that there was no rehab or detox available in East Ayrshire, and there was a lack of resource. GPs do not know where to refer and how to refer, and that mental health teams, as has already been said, should be part of the solution. Finally, one of the things that I thought was quite pertinent was that there was no map of services and opportunities available to those people who are in themselves living a chaotic life and perhaps not the best place to be able to access those services. Thank you very much, convener. I want to thank the people that I met in the North West Cat and ADP. They were very honest and were users and people who had been users, who were actually working there. I was set four questions to ask. The first one was about the psychoactive substances, which are not included in the strategy. They feel as though they should be included in the strategy. There was one young boy who, through using these illegal highs—some people call them legal highs—had become addicted and had been in and out of prison, so they felt that it absolutely should be recognised more and that it should be within the strategy. The next question that I was asked was what evaluations had been done. The group has said that sometimes they felt that they could over-evaluate too much and that there was no outcome, so they thought that maybe in a strategy it should be six months, and then they should know what the actual evaluation is and there should be a follow-up. After that, they felt that they did not get enough information, but they evaluated too much and did not know what the outcome was. The methadone programme is one that I was asked also—absolutely the same as others. People have been part of methadone for 23, 25 years. They said that any other drug, such as heroin or anything else, you would get a six-week detox or six-month detox. You would not be there for 20-odd years. That really has to be put in place. People are on it absolutely far too long. The next question that I was to ask was the current strategy. Was it effective? They mentioned that, in some instances, it was effective. It could be for individuals, but they did not cover older drug users, 45 and over. They needed to look at that again at the strategy. They wanted a more holistic policy to put in place, such as employment, training. Staff should be trained in addiction, so that people come in to see them, job centres, that type of thing. They felt that education, training and employment were also part of it. One area that came up very strongly was that there was one lady who said that women were treated differently from men. There were not enough services for women drug users. I noticed that in some of the policy documents that I was reading. They were less likely to be able to get into rehab, and there were no women and children's rehab centres. They wanted to look at that as well. They mentioned that the Portugal model, too, was raised with me a couple of times. Thank you very much to all my colleagues. That has been very helpful in setting the scene for a wider discussion. I should also note that my predecessor, as convener of the committee, Neil Findlay, visited West Lothian drug and alcohol services in Livingston. We will provide us with a written report of that visit, so that we can publish that as well, which we will do on our website in order to provide a complete picture of the visits that were made. We now move on to a round-table discussion of the very same issues around substance abuse. The round-table format for anyone who has not taken part before is informal in the sense that it is not a panel discussion, but it will be helpful if comments could come through the chair either questions or responses. I will try to call everybody. However, to get us under way, I will ask everyone to introduce themselves very briefly. For those who I have not met, I am Lewis MacDonald, convener of the committee and MSP for North East Scotland. Good morning. I am Ash Denham. I am the MSP for Inver-Eastern Scotland and I am the deputy convener. I am Lorna Holmes, head of services for sireenians. Good morning, everyone. I am Alex Cole-Hamilton, MSP for Edinburgh Weston and Lib Dem Health spokesperson. Good morning. My name is John Mackenzie. I am a chief superintendent with Police Scotland with responsibility for the safer communities department. Good morning. I am Jenny Gouldith, MSP for Midfaith and Glenrothes. Good morning. I am Poole Darnay. I am the chief executive of the Scottish Recovery Consortium. Emma Harper, MSP for South Scotland region. Alison Johnstone, MSP for Lothian. Hello. Good morning. I am Fiona Moss. I am the head of health improvement and equalities for Glasgow health and social care partnership. I chair the prevention education component of Glasgow alcohol and drug partnership. Good morning. Ivan McKee, MSP for Glasgow proven. Good morning. Craig says that the clinical lead for prison healthcare in Forth Valley and the Scotland representative on the RCGP secure environment group. Good morning. Brian Whittle, MSP for south of Scotland. Good morning. Sandra White, MSP for Glasgow Kelvin. I am Carol Hunter, lead pharmacist with addiction services in Great Glasgow and Clyde. I also manage the needle exchange programme in the health board. Good morning. I am Deb Stewart. I am the MSP for Hans Lyleins region. Thank you very much. You will all know that the purpose of our inquiry is to highlight the preventive agenda across health services, but in this particular area to consider whether the strategy in relation to substance abuse and the approach to that needs to be revised or reviewed or reformed in any way and to gain as much evidence from as many different angles as we can in order to understand that better. In order to begin our discussions, I ask Brian Whittle to open. Thank you. Good morning to the panel. If I could start on a more general question, some of the evidence that we heard today was around this belief that people are being parked on methadone and that it should be part of a solution, not the solution in itself. Given that, one of the things that I did here was that not enough reviews on the control of methadone are put in place. I wonder what the panel's views were as to how the system should work and the evidence that we have heard reflect the way in which drug rehabilitation should be carried out. I used to run several treatment services in the Glasgow area and in the Forth Valley area, and I head up the Scottish Recovery Consortium. In terms of the questions that you are asking about methadone, first of all, I would like to say that you asked those questions about any other medication that is offered for a serious illness. That is a question to think about what kind of stigma we might be bringing to the drugs area that we are not bringing to other areas of public health. In terms of the question, the meat point is that people are being parked on methadone. That is a question that the WRT review looked at and said that there was a need for wraparound services for methadone to be a part of that. We in the Scottish Recovery Consortium looked at that review and then said, what can we in the recovery community contribute to that? That tells you about what is good practice. What is good practice is to ask people when they go on the programme, when they would like to come off. It is a very obvious question. Where are you seeing that fitting into your recovery journey? That is a tool in recovery and methadone is a helpful tool. Nobody has disagreed that it is a helpful tool. It takes people from extreme states of mind and behaviour around having to score drugs to be able to find a landing space in order to be able to consider their next steps and to move more cautiously towards a problem-free drug-free lifestyle, if that is what they are choosing. That is the first step. The second step is to invite people to take part in mutual aid support outside of treatment. What happened in Scotland, which you might not have noticed, is that Scotland is unique and we created the ORT recovery network, which is a brand-new mutual aid to help people to come off methadone. With that, there are 14 meetings that have been set up by volunteers across Scotland, people in recovery from methadone, to help other people to hear the stories of how they come off, get the inspiration and get the help from their peers to come off. You have heard how peer support is helpful. In the first case, put people on it, but have a programme of when they think they would like to come off and review it regularly. Secondly, there are medications that people are on their whole lives, antidepressants. Some people are on antidepressants their whole life. Not everyone who has a mental health or mental distress is on antidepressants, but they need to go on it from periods in their life. I would not want to be imposing upon someone's personal medical care journey at the beginning from outside saying, you can only be on this drug for six weeks, because we are uncomfortable with that being on any longer. In a sense, we need to maintain the orange guidelines in terms of methadone. I am sure that Carol knows a lot more of that than I do, but in terms of making a good patient-centred care plan, which includes the best available treatment for that problem and also includes a vision of how they are going to come off it. I agree with most of what Caledonia has said. From a pharmacy perspective, there is a role here that there is a lot of untapped potential within the pharmacy profession. It is interesting that the three visits from the MSPs have all been part of method, but there has been no mention of any alternatives in terms of buprenorphine or heroin-assisted treatment. In terms of pharmacy, the pharmacy profession has most contact with this group of patients higher contact than any other healthcare professional. I think that there is a role for the pharmacist to be more formally involved in, for example, relaxing supervision, identifying patients who are chaotic or destabilising. I think that that is a role that should be looked at. Thank you very much for those responses. I recognise the system that you are describing that should be in place. The question is that do you recognise that that is perhaps in our evidence? That is not necessarily what is happening in all times and in all areas. Perhaps there needs to be a refresh around what good practice is and how do we share that to make sure that that good practice is in evidence across all areas? I agree with you that that practice is not in evidence, but we have had a policy for 10 years and we have not yet shown that the systems to which you are referring that have parked people on methadone are resilient to policy change. In a sense, you will look at how we encourage major institutions of the health-giving situation of the NHS to take on the policies that already exist. To me, that has been the challenge in terms of recovery. How do we see those policies being enacted on the ground? Some areas are doing brilliantly, some areas are doing brilliantly, and in other areas, there is no teeth in requiring them to do that. Others told me that they use other drugs as well as methadone. That is quite unfortunately common in certain circumstances, but you have got 23 years on a particular drug, methadone, so you mentioned the fact that there are other substances. Are people advised on that? That is what they were being told. You are on methadone and that is it. What help do they get to say that you can have an alternative? One of the things that you need to consider here is that you are dealing with current patients. All of the conversations that you had were with current patients. I remember some of your conversations with people on longer-term recovery. We have written a book that is available on our website, the Scottish Recovery Consortium, called Methodon Memoirs. We did a major piece of work gathering in people's perspectives and stories about their experience on methadone. What you have described is a very common experience. When we go back into that dialogue, we look at the fact that our perspective is skewed and you talked about that by the drugs that we are on. What we have seen is an experience of not having heard that there have been offered alternatives. I saw a front page in the daily record a few years ago in which somebody, they face-fronted somebody on methadone. You have seen it. It was a shocking thing that said, I have been on this methadone programme for X number of years and nobody has ever offered me help. None of the treatment services that he got on the phone and go, actually, that guy was offered three types of help. He may not have been, but I knew, just looking at the area that he was in, that there were three community rehabs in that area and that there were at least 12 mutual aid meetings, all of which were trying to help. You are looking at people's internal experience of, and I am not doubting their internal experience in that moment, but to get perspective on that experience, you need to go for the whole range of the recovery journey. I have spoken to it and I have been involved in many people's recovery journey from methadone. I have been involved in supporting this new mutual aid ORT recovery, so I have heard in many journeys that their perspective shifts a year in recovery and they start to own responsibility for their part in it. Yes, the treatment service could have been better and yes, they could have been better. We are not looking for evil here and we are not looking for bad guys here because I do not think that we are, but what I am saying is that it is a complex situation involving people's internal experience and the actual objective reality. You will be able to count in any given area how many places are available in treatment today and they should know, and you will be able to know if that is objectively true or not. In the case where I saw it, it was not objectively true, there were spaces in community rehabs. I think that we do not want to stigmatise anyone who is on a methadone programme any more than we want to stigmatise someone who has been on antidepressants for a long time, but we want to make sure that best practice is employed in all situations and that we are using pharmacists. We have heard in different inquiries in the committee that we could be doing far more with our pharmacy model than we are. We want to be making sure that no one is parked on any drug unnecessarily, but our briefing for today says that Scottish outcome research has shown that, while methadone maintenance leads to improved outcomes in a range of domains, it is associated with low rates of sustained abstinence. I would like to understand if the alternatives or if the opportunity to move on beyond methadone is there in the degree that we would like it to be. When I went to visit the practice, the people I met were really keen to get into a residential situation, a 12-week programme, and they really wanted to move on. I am just wondering whether those alternatives are there. I do not know. That is the short answer. I am not going to sit here and go, but I definitely know that in Dumfries and Galloway there are follow-on services, because I do not know about Dumfries and Galloway, because it has not really connected in that sense. It can always improve. I am not saying here that the situation is fantastic. I am just saying that you need to find a new tool to encourage policy change into practice among the existing treatment services. We need an extended community support, and in Glasgow I was involved in community rehab, so that was really good. I am no longer involved in treatment provision, I am involved in campaigning around recovery issues. Continued use of abstinence, and I know that piece of research. Continued use of methadone, yes, is not associated with abstinence. Long-term employment opportunities, and it is a very small piece of research that is not associated with methadone use either. You think about that practically having to go to pick up your medication on a daily basis, but it is not preventing people from getting it. You can work and stay on methadone. However, the point that I am making is that people need to be asked when they want to come off and supported off of it when they are ready. That is the only point that I am making. Alison, I know that you also had some questions around substance abuse and misuse in prisons, and I wonder whether you would like to ask them. Yes, thank you, convener. Dr Sayers, in your evidence, highlighted a number of areas of concern about drug use in prisons. I would like to understand what the misuse service looks like in prisons. There are a couple of areas in particular that you have highlighted that people are much more susceptible to overdose harm on liberation. I would like you to expand on why that is the case. We have had a short inquiry into that with the committee, so we have heard directly from some prisoners. The abuse of prescription medications obtained through prison GPs, you mentioned that, and you say that there is no evidence that they are being illicitly produced, so they must be prescribed properly, so that was a concern, too. If you could expand on those points, I would be grateful. As you are aware, we have a high volume of patients using illicit and prescribed medications for purposes of intoxication and admission, and that continues to be a degree within prison is one of our greatest challenges. In terms of services available, all prisoners admitted are seen by addiction services within one day, and harm reduction is issued. If we have patients for long enough, we offer substitute treatments mainly in the form of methadone but also buprenorphine. There is take home naloxone, which is offered as well for liberation. The reason for drug-related deaths on release is the loss of tolerance to the medications and substances that patients are using on arrival, so it is not uncommon—certainly in the female estate where I mainly work for a long time—for patients to be taken in excess of £100, £200 of illicit substances a day. Very quickly, the tolerance to those substances disappear, so, on release, a patient's body cannot handle those amounts of drugs, and the numbers that are, quote, the increased risk of mortality are from a recent England on Wales study, looking at all prison admissions and liberations over a couple of year periods, and it is striking the risk of death being 50 times greater all-cause mortality in the first two weeks for an equivalent age-sex patient on release, 11 times greater in the first four weeks and eight times greater in the first four weeks of drug-related death if not released on a substitute treatment. There is definitely a prevention of immediate post-release deaths, so there is a drive or a keenness, from our point of view, to have the most vulnerable people liberated on a substitute treatment. I fully agree with the comments about not parking people on methadone for 20, 30 years, and we do see patients coming in who have no motivation, who collect their methadone every four weeks, but there is no objective work going on to try and address that or move that forward. I think that that is where we need to revisit the group of patients who feel parked. Methadone use well can be extremely beneficial for patients. Increasingly, the addition of prescription medications is a concern and is notable in terms of gabapentinoids. I have highlighted those because they are the biggest difficulty in prison in terms of routine consultations, so prisoners will access gabapentinoids for neuropathic pain is the main reason for nerve pain. Most patients have examined thoroughly and taken a full history if there is a cause of neuropathic pain. There isn't one, and you have to have confidence to say no. Unfortunately, you will be aware of the lack of GPs within all services outside and that mirrors inside. We are also very short of our medical resources, so we are often operating with locums or less experienced GPs who do not have the confidence to say no to patients who can be intimidating and threatening. It is not necessarily initiated that often in prison, although that does occur. It is more the continuation and admission of a prescription that is given outside and it is the reluctance to challenge the prescription. It is far easier just to carry it on. My concern is that the recent figures are the gabapentinoid deaths. If we notice in 2012, gabapentinoids were present in Scotland in 29 drug-related deaths. That increased to 225 in 2016. Recent testing suggests that more people are positive for illegal drugs when they are on liberation than they were several years ago. I just wondered why that might be the case. I could not speak to that. I have seen the prevalence test in results of 30 per cent of patients on liberation having illicit substances present. I am struggling to say why that would have increased. The services and the resources in prison to address drug misuse have increased dramatically. I am surprised because we have reduced the short-term sentences. One of the greatest races that patients have demanded for a matter of weeks or a six-month sentence where patients would serve half of that and maybe get a tag and be out six or seven weeks later is an insufficient period of time to address those things in any meaningful way. Thankfully, over the last four or five years, that number has reduced significantly. It is disappointing that the number is that high and I cannot give you a reason as to why it is considering the patients now that we have for a longer period. You would hope that interventions offered might have reduced the amount of illicit use in prisons, but it does not appear to be the case. Can I ask one more question? It is clear that prisoners need more support when they are liberated to prevent that overdose situation and, obviously, homelessness and has a part to play in that, too, but the NHS taking responsibility for healthcare in prisons, has that made any difference? It seems that prisons sat in isolation in terms of healthcare up until the transition. There are pros and cons to that. Prior to the transition to the NHS, all Scottish prison healthcare was delivered via the Scottish Prison Service, so we had uniform prison policy. Our prisoners still move among prisons. By moving it to the NHS, that joined-up prison network has been lost. We tend to work for our health boards and it is very hard to get agreed policy amongst all the different health boards because we do not have the forum to get people together anymore. The benefit is that overall healthcare was poorer prior to transition to the NHS. We now have more support from our primary and secondary care colleagues, but the link on liberation is extremely difficult for a couple of reasons. The computer service in the prisons is quite—we do not prescribe computer-wise. There is no electronic prescribing. When patients come into prison, I can electronically access what medications prisoners are receiving from the GP outside. That does not happen on reverse. We therefore have to provide a handwritten letter, which the prisoner may or may not give to their GP. They do not have a GP if they have been in for a sentence over six months, so they have to re-register. That can be difficult. It is very difficult, if not impossible, to arrange that in advance because even more often they do not have an address that the patient is going to. The through-care out is difficult and would be addressed by provision—well, would be certainly improved—by provision of accommodation prior to release, so we could have a GP set up in advance. I appreciate that it is difficult, but that is a big barrier to a smooth through-care. I thank everybody for coming along to talk to us this morning about your input on that. I have just touched on the prisons issue. I have got Barlinny in my constituency, which I have visited a number of times. I think that we have seen from the evidence that Alison Johnson mentioned the significant increase in the prevalence on release, which is clearly something that is not working there. I would like to explore a bit more detail about the issues on release and how we join that up, because it looks like we all agree that there is a significant problem there. I think that others around the table will probably have input on that, because it affects the services that pick up the pieces of the like on the outside, but it also sounds like there are some simple practical things that we could do with some joined-up thinking and procedures there. I do not know if you might want to talk through that, and I am sure that others would want to come in as well. The key things that were improved from a personal point of view is that if we had access and registration with the GP prior to release, we could transfer information, not just about medication, about all healthcare interventions that have been received in prison. One of the difficulties with some of the larger jails is that Barlinny will have mainly patients from Glasgow but are more distant. Cônton Vale has changed over the last few years with where the female population is distributed, but previously it has housed all women from a national basis. It is incredibly difficult to arrange through care for Aberdeen, for Dumfries and for long distances away. I appreciate the community-facing units being introduced. I am hopeful that, by having prisoners working with people who they will continue to work with on release, they should smooth that transition back out and probably increase engagement on release, as opposed to just meeting a named person that they have never met before. Hopefully, if that model has some improvement of uptake and through care to all services, such as housing, employment, college, healthcare, and medications, there is the potential in the future to expand that to the male estate as well, but the transition is the big difficulty. On one point that Craig had made, he described the pathway when a prisoner came in and he looked on the records and he had access to the GP records. What that would tell him was when the prescription—I have been talking about methadone here, butprenorphine, for example—was the last prescribed, but what it does not tell you is when it was last consumed, and that is a really important point. The only place that information is in the pharmacy, and I think that that is a really strong argument for linking up the pharmacy as well to the patient records, and the same when someone is being discharged. Yes, well, most cases methadone is prescribed by a secondary care cat team, which does not appear on the electronic record, so that medication, unless it is GP prescribed, we actually phone the service A to let them know where the patient is, but on top of that, I also phone the pharmacy to confirm the last collection date as well and whether that was supervised. It would be really good if we were all linked up. It would be far better, absolutely, yes. That is a good message to drop, Dr McLeanie. I expected to be talking about it because I talk about recovery, but actually I happened to run one of the prison through care from Cortenvale. I watched from Cortenvale, I set up the 218 service for women who commit crime in order to fund the drug use, so I have got about 10 years' experience in that. People use drugs in prison because they are in pain. People die on the way out of prison because they are a population in movement, they are a population in movement and we have difficulty dealing with populations in movement. The colleague of yours that went and saw that homelessness was a big issue in terms of being able to get consistent service. If you consider that everyone in prison is now homeless, they are a population in movement. They are in pain the same way that people in the streets are in pain, but in any immediate cause of dislocation, whether their family is busted up or whether they have been pulled out of prison, they are more likely to be using drugs to soothe their discomfort and their pain. That is why more people die because there are more people in pain. I have set up through care all of those conversations that I have been party to. I did lib day lifts from Cortenvale, took women direct from Cortenvale to their home, bypassing all the opportunities to use drugs in the city centre and trying to get them connected up to a service. We try to create a service. I am not saying do not do that, continue with the efforts to do that, but there is a bigger question that we fail to look when we try to look at a technical fix between your computer and your computer. The fact is that we have a population in movement and we are not good at dealing with populations in distress in movement. The preventative agenda is very hard to link up with the treatment agenda because you are asking the wrong question. You are asking the question of how a policy can make it so that women in Cortenvale do not die on the way and you are seeing it in isolation. You are seeing that women in Cortenvale in isolation and some of the messages that you have got from mental health is that you are not seeing the mental health at the same time. Most of the women in Cortenvale had extreme mental health problems as well as drugs. They are the tip of the iceberg. However, when you put the whole prevention—this is about prevention—if you stop isolating drugs and alcohol behaviour in the community as if you can isolate that and put it together with the whole ranges of ways that we as a human population are expressing our distress, you will see that, across all those indices, there is an increase. Suicide is on the increase. Depression is on the increase. Obesity is on the increase. That is what my overall point that I want to leave here without making. Do not go too small. You will stick with a technical fix when we need a paradigm shift. We need a complete sea change in how we look at this. All of those problems are real and you can do all of that. You have said great, but we need a bigger thinking. I think that we need a bit of both in truth, Alex. We do. Thank you, convener. Good morning, everyone. My question stems very neatly from that. It strikes me that what we have heard from the prison services that are represented around the table is that that focus is very much on physiological stabilisation, recovery, treatment and the rest of it. Just picking up on the last point, I think that most drug use is, as we heard, an antidote to pain that people are experiencing. Oftentimes, it is a human response to trauma that is not resolved. It is cyclical and it is self-sustaining. To that end, what additional services that are bolted into the prison offer are specifically to address trauma recovery and mental health recovery in that respect, to stem the original catalyst to drug misuse? Yes. All prisons have an extensive team of mental health nurses supported by psychology and visiting forensic psychiatrists. We are acknowledged, particularly in the female group, but also in the male group, that the drugs are a symptom of a coping strategy. That happens outside and if they are able to use drugs within prison to address that coping strategy, we fully understand that. In terms of moving that forward, the patient focus usually on coming in is their physical health, their actual physical withdrawals. You need a week or two weeks to remove the illicit substances from the person, to get them not concentrated on the physical health and then offer them the opportunity to engage with mental health services. That goes hand-in-hand with the addiction services. Quite often, the addiction nurses are their mental health nurses at the same time. The key thing, and that is why I mentioned the short sentences, is that it is welcomed there, less of those, to effectively intervene to deliver CBT or counselling, needs to be with the same person for a significant period of time. It would be wrong to open up kind of worms of some of our females' child sexual abuse for a matter of two or three weeks. You will make the emotions worse and then, if they walk out of the door with the head struggling, they are going to go back to what they know. It is having people for a sufficient period of time telling them what we offer and pretty much almost back to the initial comments about instead of just parking somebody on a treatment and leaving them, planning this journey with them and saying, what are your issues? What do you feel ready to tackle at this time and working through one thing at a time? That may be their mental health issues. It may be they are more focused on addressing hepatitis C treatment, but it is using substitute treatments, if we are going to use them, to help the patient to work through their mental pain and physical pain or whatever issues they have with a view to at the end, albeit that outside prison or in the long sentence within prison, reducing and stopping, so there needs to be a full journey in. There are extensive mental health services within all prisons and mental health and addiction scores hand in hand. They are not separate issues, so I agree. I had a follow-up, which again sounds very nicely from that. You talked quite a lot about the impact of short-term sentencing on your ability or lack thereof to make a meaningful difference in stabilising and treating and helping prisoners to recover, without wanting to draw you in to endorse lived and dead policies around legalisation and decriminalisation. Do you think that our Scottish courts should consider addiction and substance misuse when they hand down sentencing? They know that we have an opportunity there to meaningfully address some of those issues, but there is no point in doing it if, in some cases, you are only talking about it. I know that we have a presumption against short-term sentencing, but we all know that sentencing of less than six months still happens and people are liberated within three months of that. Should we completely radically reform our sentencing agenda when it comes to drug-related crime so that we can do something meaningful with those people or just treat them in the community rather than taking them into incarceration? I certainly welcome that. The use of the DTTOs has been—many of our prisoners have already been on a DTTO—lots of faces that I have dealt with over the past 15-20 years have used a DTTO well and have not come back to us, so there are certainly successes there. If ultimately people have been in that route or do not wish to engage in a DTTO or the court feels a sentence in prison is required, from my perspective it needs to be of a sufficient duration to do anything meaningful. The shorter sentences are the introduced risk for decreased tolerance overdose on release, but I do not really afford us an opportunity to do meaningful work. I think that when we are speaking about people, as Caledonia pointed out, of people who are in pain, we are asking them to invest in the services that we are offering them. In order to do that, they need to have trusted relationships. Those relationships need to be able to follow people and instead we are putting them into systems that only work with them for short periods of time. We are looking at health boards that cannot work across boundaries. We are looking at prisons that are geographically serviced. I think that there are solutions and I think that the third sector is in an ideal position in order to bring some of that because we can work with people across those boundaries and I think that it is incredibly important at this stage that we do not overlook the importance of those trusted relationships for people. Those are people who have been let down at every point in their lives and if we are only going to engage with them for very short periods of time, why would they work with us? Why would they engage in what we say we are going to offer and the help that we are going to give them? Just a quick point back to the beginning of Craig's point about national digital prescribing, which would link prison GP's pharmacies. That was raised to me in the Friday session last week when I spoke to staff members and the fact that many complaints in prison come from the fact that I am not getting the drugs that I want, whether there are other interventions that are non-prescribing that could be delivered as well. So just your thoughts on national prescribing and the other issue was about addressing adverse childhood experience. That came up from the staff members, but the service users did not use that language at all about any trauma that they had experienced in childhood. One service user blamed the fact that he was coming home to Dumfries Backfey elsewhere and it was the place that caused him to take heroin again after being 14 years clean. That was interesting for me that there was no issue around his own personal history. Certainly, from an overall point of view, from a big prisoner point of view, there are past traumas, not just childhood, but young adulthood and late adulthood. The drugs are certainly used not for fun by the time I'm getting them. They are used to blank them out. In terms of the electronic prescribing side of things that you mentioned there, the complaints about not receiving medication probably are because there is a doctor capable of saying no. So it certainly might speak into any complaints about medication, about not getting medication. There has not been an oversight or we haven't chased it up properly. The majority are because when patients are coming in on commodity medications that are traded in prison—the gabapentinoids, sleeping tablets, benzodiazepines, opiate analgesia—which are maybe not felt to be clinically justified and are stopped by the clinician, that tends to be the complaints. To me, that would be good clinical practice. I don't think that that would be improved by electronic prescribing. The electronic prescribing for us would help more if it could join up to GP services, more for the getting back out of the way. The electronic prescribing for the whole system and the complaints process, what the feedback I got was that positive prescribing isn't just about giving people what they want, it's about giving them what they need. So you mean complaints about on release, they weren't getting medication. Unfortunately, there are several reasons for that. The fact that we can't directly communicate with a GP electronically. The handwritten paper liberation note and supply of medication, I am well aware of many of our prisoners who I know have received this, who have presented to a GP to register, but if that doesn't have on what they may be seeking, they will suggest their own other medication and often receive that medication. It would safety net the GP outside as well. They do have the option in the same way that I have if they are not sure to ring into the prison to say what was this patient on release, but we don't really get many calls that way. I am keen to move on and hear from some of our other witnesses as well. Emma, did you have a question also on the security of police or on the handling of substance abuse issues from the police point of view? Perhaps that was Jenny. My question links into some of what Alex Cole-Hamilton spoke about with regard to trauma. The Police Scotland submission mentions that more could be done to identify the drivers to problem drug use and tackle these underlying factors collectively. He also mentioned social inequality and ACEs in that part of the submission. Again, in the Glasgow submission, you talk about a stronger recognition of adverse childhood experiences and trauma as a predictive risk for drug use and misuse. However, just under 4 per cent of your spend is on preventative spend. There is a disconnect with the rhetoric with your submission and what is happening on the ground. What needs to be done in terms of joining up services to identify childhood trauma when it happens and identify those risk factors? We are hearing week-in, week-out on the committee about the disconnect between the health system and the education system at the moment, which is tasked with closing a poverty-related attainment gap and dealing with a lot of the problems that we are identifying here today. I wonder what work you might do with local schools, or do you think that that is where the disconnect is happening, or is it a bigger problem than just health and education not talking to each other? I am not convinced that the terms about police and education not speaking to each other are accurate reflections. From a police perspective—just if I may when you talk about the quantity spent on prevention—we have a number of areas that we address in terms of the prevention aspect, but we will always pursue the aspect of enforcement and the aspect of intelligence in relation to the wider drug issue. However, just in terms of prevention, I think that there is a lot of good work taking place between partners, health, education, police and third sector in relation to the issue of drug use. We have highlighted in the submission the work on going in relation to working schools in relation to education, and that is clearly a primary issue to address at some longer term impacts in relation to drug misuse in our communities. The aspect of ACEs is an interesting term that has come up recently, and I think that ACEs have been dealt with in Scotland since 2004 under getting it right for every child. That is ultimately a number of key factors of ACEs in terms of how we work collectively. If you look at the getting it right for every child piece of work that is undergoing across agencies, that can be transposed into the area of ACEs. Also, there are other aspects within ACEs that talk about poverty and incarceration within the ACEs piece of work. However, there are areas in which we work collectively. The challenge here is that it is that point of evaluation, is it not? It is that understanding of the work that we do, how does that prevent on a longer term basis and how do you evaluate that piece of work. However, the misnomer that agencies are not working hard or collectively, I would suggest that there is an inaccurate comment to make. I do not think that agencies are not working hard enough. I think that there is a disconnect. We have certainly taken evidence before from Harry Burns, who spoke about that. He was very complimentary about the system, but what he said was that it is not going far enough and on the ground, we are not joining up that knowledge with professionals and highlighting where risk could be intervened at an earlier stage in the process. For example, when children at school in primary 1 perhaps are coming to school and do not have enough speech and language skills at that age at primary 1, so at age 5 level, that information should be communicated at an earlier level and that might be a wider indication of trauma or things that have happened in that child's life at an earlier stage. I guess that it is about the systems talking to each other and that is certainly something that has come through in a lot of our evidence, that there is a disconnect. It is not that systems are not working hard enough, it is just that they do not seem to talk to each other. I anticipate that the aspect to then talk about the name person process, I think that that was an attempt to allow agencies to identify issues within education at an early stage and has a number of positive aspects to it. There had been attempts by agencies to progress this matter to understand how you identify issues of trauma at an early stage. Education is a key role as there is health, but name person was one of those areas that was hopefully going to and hopefully will move on to assist that. I think that that is the mechanism to allow agencies to speak, to share data, to share data on a legal framework. I think that that is a challenge that has to be overcome and I think that that is an issue that has existed for the last couple of years, certainly, with regard to the name person service. You have covered a lot of issues for us there and certainly I sit here and I think quite defensively, yes, we are absolutely working well together, but you always do that when you are challenged. Within Glasgow, we are building together the work that we are doing around prevention for community justice, the work that we are doing around child poverty and addiction prevention. We have a prevention forum, but the challenge is that we could always do more. You get pockets where it works extremely well together because people get it, they get the same language and they work well together and you get other pockets where that does not happen. I do not think that any of us in this room would probably say that we have it all tied together fundamentally. The issue around drug prevention and your opening question is drug prevention where it needs to be in our road to recovery strategy. I would say that it is not. We have done an awful lot with education, but that is only one of many areas of prevention work that we need to do. In Greater Glasgow and Clyde, we have a model that has 12 component parts. Education is one of those 12. I think that it is making sure that the other 11 are very strong as well. Nationally, where we need to do more, is working with people who are more vulnerable to addictions. Whether it is through childhood trauma or other reasons, there are a whole range of people that we do not have the range of engagement with and support for to make prevention really come alive. We have been doing some work around what we have called constructive connections, which is working with families affected by the justice system and addiction, and particularly the children within those families. What has become very evident to us from that work is the stigma associated with that and the way that young people are trying to keep themselves distant from some of that stigma. How do we engage with young people to be able to support them with what they are experiencing? There is a lot that we are yet to discover around needs and vulnerabilities and how we work around issues. We have also been doing some work doing trauma needs assessment for staff working within prison and within addiction services. To what extent are staff that are supporting people with addictions trauma aware, and what learning and education needs do they have? This all comes into prevention, but unless you have a broader scope of prevention, you will not see it, you will not investigate it and you will not address it. Thank you, convener. Fiona Moss is very helpfully linked into the question that I am interested in, which is understanding a bit more about the role of stigma in treatment. Is stigma a real issue when it comes to treatment in Scotland today? Yes, absolutely. Just in terms of the young people that we were working with, to the point of which young people would not necessarily know that their parent was in prison and addiction issues, or if they knew that they would not tell anybody at all? If that is not a stigma that maybe prevents you from getting your emotional issues dealt with that might have longer-term impacts on you as an individual, I do not know what is. Do you believe that there is a hierarchy of stigma, multiple layers of exclusion such as homelessness, mental illness and drug-injecting? Absolutely, yes. I would agree with that. There is a hierarchy. I think that there are cultural patterns to stigma as well. Something could be quite stigmatising just now, but in a couple of years' time it is more acceptable, but something else comes along. It is not as if we have stigma and it just stays there. It is absolutely embedded and it changes with our culture. I feel as if other people have come as well, but perhaps I throw out another question. I was very interested in the 2016 Scottish Government social attitudes survey. As the panel will know, it was very contradictory. At one hand, it said that people were basically very tolerant of people that injected drugs, but the key point was that they would not want them living next door to them. Do people understand that contradiction? I would be grateful if the panel could cast some more light on that Scottish Government survey. I can cast light on that survey because we sponsored it in the first initiative. It was a rubbish survey and they asked my opinion. Is this a technical term? So, when did you stop beating your wife question, that classic question that managed to get through an ethics question, was, would you live next door to a drug user? Is anybody going to answer yes? Is anybody going to actively answer yes? Would you live next door to a woman who is struggling a bit? Yeah, I do. Would you live next door to somebody who has had a bit of trouble this week? Yeah, I already do. Do you already live next door to somebody who is using alcohol, popping pills on anti-depressants? Yes, I do. But if you say, do you want to live next door to a drug user? I don't know anybody who is going to put their hands up and say yes, and I have worked in the field for 20 years and I am in personal recovery. Do you know what I mean? What are you saying? That is what I am saying. It is a question of when did you stop beating your wife? There is no way that you can answer that question and come out with it. We have recently done—we had an event for 350 representatives of Scotland's recovery communities in the tramway in September last year and carried out a new piece around the theme of stigma. I have the draft report that will be available for you within the next month. What we discovered was that 96 per cent of the participants experience stigma in their lives. They experience it in a way that is preventing them from accessing services. We know that the stigma around addiction and the stigma that is all part of creating is preventing people from seeking help. Not me, it is them. I did not seek help because I was not one of them. Do you know what I mean? I am an educated woman who runs a business. I am not one of them. Then we discovered that I am. I had to get over myself first to get help. In terms of stigma, it prevents people, but what we do know is that visibility of recovery, the visible face of recovery, which I am doing right now, is that it allows people to think that it is possible to get better, so that they are more liable to seek help. That is what we do with recovery work. In terms of stigma, it is there. Public services were found to be the most damaging place to experience stigma—not businesses, not in the street, not the name calling, but when you rock up to a service and ask for help, those were the ones that people came back and said, were the most damaging experience of stigma. That is the most recent research that we have done. People are still experiencing it, and the most damaging place is not where we expected it to be. It is in the services. We suggest that the 2016 survey should be re-run with more balanced questions. You might get a fairer representation of what we will actually feel. I think that we should not do it. I think that we should do something else altogether. It is an interesting point that you make about stigma, and reference has been made to the tramway event, which was a fantastic event that day. Even coming here demonstrates the issue and the difficulty of the subject in terms of some media outlets and the perception that the police should not be involved in the conversation or should not be involved in the conversation about stigma. That in itself raises concerns on how society stigmatise the issue of drugs. If I may, I want to make a point on that aspect of stigma and open it up slightly, just from a police perspective. If police were not involved in the wider conversation about stigma and the public health aspect of drug misuse within society, the question should be raised by the public. Why? Last week, we had plaudits across the world about 70 per cent reduction in knife crime, and we have taken a public health approach to knife crime. Actually, I do not see it any different with regard to the subject matter. In addition, we have a situation in which, a few weeks ago, the bravery of officers and members of the public resulted in 87 years of incarceration time being placed on an organised crime group. Still today, when we come here to have this discussion about the issue of public health, we find ourselves criticised because we are using such terms as the stigma aspect linked to drug misuse within society. It is just an interesting dynamic across some media outlets. I do not have a balanced approach to the whole subject matter. That is very helpful. Brian, I think that you had a follow-up. I think that one of the things that I was interested in, especially around the police involvement, police intervention, is that you have to work to directives that you are giving. In general terms, from my benefit, what kind of directives are you giving in terms of when you are interacting? Obviously, you will come across, your officers will come across drug misuse and drug users all the time. What is your directive in those particular instances? What objectives are you giving to work with? I think that our directives are quite clear. There is a legislative framework in which we work under the misuse of drugs act. The Lord Advocate's position is clear. However, let me make a point here. That does not mean that we do not recognise individuals who are substance users or stroke abusers who may have wider issues such as mental health and other challenges in their life. We undertake all possible action in referring individuals to agencies. You are highlighted in your opening comments about the challenges of getting agencies in which you can refer to. That is a challenge, but in terms of the directive to officers, officers are clear. We work to legislation, but we also have the challenge of ensuring that we protect people at harm within our communities. That means that we are referring agency into partner agencies to try to support individuals who are drug users or stroke abusers. That is the position that we will hold. The issue of drugs is multifaceted. We recognise that we cannot impact on the issue of demand as a single agency. It is a collective approach, but we will continue to work with regard to the legislative framework that we have. It is interesting that, in the 2008 strategy, there is a chapter about enforcement. We would be keen to continue to have at least reference to enforcement in any new strategy that exists. We have made a position clear in that chapter about enforcement, what our aims are, in tackling serious and organised crime, and ensuring that the legislation is adhered to. However, we will refer individuals who have wider challenges in life. You have latitude within the law to do that kind of referral and looking at the greater health issue rather than the judicial issue. Do you have that ability to work with other agencies? We have the latitude in as much as there is a two-route approach here. There is the legislative approach in terms of reporting the set of circumstances if a criminal act has taken place, but that does not prevent us considering the wider health-based issues or the wider partnership opportunities that exist to refer individuals in. We will always ensure that Crown officers are clear of the wider circumstances so that a judgment can be made as the criminal justice process and appropriate process to be adopted. That is a decision for Crown ultimately to make, but we have the opportunity to refer into wider agencies. I just want to take a wee step back. Maybe we should have had this question earlier, but just to set the scene, I am looking at the data points that we have in the evidence that we have seen. It is quite confusing. We are seeing a situation where the data says that drug use is down, but deaths are up. The age profile is changing. Maybe that is part of the driver of the deaths. I do not know. The prevalence looks to be flat. Hospital admissions are drug-related. We have talked about prisons as well. I do not know if anyone has got any comments on that in a general sense, whether we think that we are making progress over the last number of years and what data there is to evidence that. A very small point on that is something that occurred to me. When we have that data, maybe Spice can go and look at it, but I would be interested to know of the drug deaths and how many of those individuals had been through the prison system. That would be a very interesting data point. Does anyone want to respond on that data question? I do not know the data of the number of drug-related deaths. I know that we have seen previously that about 90 per cent of all patients within CAT teams have been through the prison system within a five-year period. It is the same population in terms of the actual number of deaths, particularly in those early deaths. I cannot give the exact number, but it is the same group that is transitioning between services. A quick point on the data that we have from the needle exchanges. That reflects much of what has just been said there. The most common age group is 35 to 39, and it is predominantly heroin and opiate injectors that we have. By far, the second biggest group that we have is those that have not been mentioned today at all. It does not appear in any strategy as those who are injecting and using imaging performance enhancing drugs. That is our second biggest number. Interestingly enough, it is a much younger age group. Some of the risks are the same, but some are different. However, there are definitely health harms and health risks there. The question is to put together the drug death increase with the alcohol death increase with the suicide increase with the increase in obesity and ask ourselves the bigger question of how we can look at all of this distress in our culture in a much more proactive way. You were talking about ACEs. ACEs do not restrict themselves to people with alcohol or drug problems or depression. 60 per cent of the population will score frequently on ACEs. I score 10, but you can only work well. In a sense, the big question is, can we put it all together? Those are all the diseases, as Phil Hanlon says in the fifth wave of public health. Those are the diseases of modernity. Each one is a symptom of a greater malaise that is going on. Until you attack them and look at those deep-seated difficulties in our culture, we are just going to be moving things from one place to another. Can we solve the drug problem when the alcohol problem goes up? If we put the alcohol in the drug, it is going to be like that. We have to sit back and go, actually, that data is telling us something quite extreme about Scotland, particularly that we are still suffering in a way that we did not expect. I was going to pick up partly on that issue. I think that the drug's issue is a complex issue. If you went to any single data source, it would give you a skewed picture. You have to look at it in the round. We are seeing some positive moves in terms of reporting by young people around drug use and a whole range of other things, which are good indicators. At the same time, we are seeing some really concerning issues. In Glasgow ADP, we had a meeting dedicated looking at our drug deaths, our alcohol deaths and our suicide deaths. To try and look across the piece at what is going on here for us in the city and what we can do about it. Piecing together some of the policy and some of the change is one of the areas that we have to do. We have to put together what is going on in community planning and local regeneration. We have to put together what is going on in our mental health strategy. We have to put together around our alcohol and drug work and our children's work. In terms of a road to recovery, perhaps it is not linking those strategic elements enough and enabling us to work across agendas to actually be able to do that. I have read in the paper that only about 30 per cent of problem drug users are women, but they might have specific circumstances and specific experiences that might be different from their male counterparts. I wonder if anybody could shed a bit of light on the differing patterns of behaviour and risks for women problem drug users. We need to take an equality sensitive approach to all the work that we do. There will always be gender issues in there and there will be other issues in there as well. It does not just relate to your drug taking patterns, it relates to all the other aspects of your life as well. We have certainly found and we have seen that in our addiction services in Glasgow. There are components where women have asked us, can we do something different because we need it, but it is being able to bring that equality sensitive approach to our prevention, our treatment and our recovery work that is absolutely critical. Is that women are at the bottom of the pile? If a man is using his drugs—I quote my experience, I set up and ran the 218 service and turned around service in prison, so I have got 10 years experience working directly with women who commit crime in order to fund the drug use. They were at the bottom of every pile, the lowest of every denominator. A man who is using drugs maybe often has a woman in the background or a family member in the background who is helping them to keep his life together. When a woman goes down, the kids go down, the whole ship goes down, and she has nowhere else to go. When a woman goes down and is working in the streets to fund her drug use, there is not anywhere lower you can go in terms of society's stigma and it is disbelief in you as a human being and as a potential human being. Women will be raped, starved, kidnapped, attempt murder, violently abused in order to get their drug use. When they go down, they go down further and faster and harder and it is harder to come back up. In terms of working with women to come, women's trauma-sensitive services is what I set up, but trauma-sensitive services but also women's spaces where women can reconnect with being a woman as part of their journey to coming more well, because often they had lost that. You spoke about particular services that are targeted to be beneficial to women. Do you think that services in general are isolated or across the system there are enough services that target specific vulnerable groups like women? I think that I am open to my colleagues who are more up-to-date because I say that I have been off the field. In terms of gender-specific groups, I am not just talking about women's gender, I am talking about men's gender. Gender-specific groups are a helpful part in any recovery programme because you are safer generally speaking in a gender. Women can be vulnerable to predation in early recovery and can be vulnerable to seeking approval through sexual behaviour because that is what they are used to trading in. There are not any safe people generally for women, but you are trying to create a safe environment, so creating safety for any gender group. I have to say that we found that in the sense that we did some experiment with male prisoners coming out. I can also say that male suicide in prison is just as high as women at times and that male gender groups were also helpful in helping men in their long-term recovery journey, so I think that gendered approaches are helpful additions. I have heard from the women that I spoke to that they felt that they suffered from stigma more than others because they were seen as a bad mother, etc. They would go out to use the drugs to steal money, etc. They would not just feed the drug habit to feed their kids as well, so they were absolutely spot on. However, what they asked for was more rehab centres for women. They said that they were at the bottom of the pile and that rehab centres for women and their children were able to go along and backed up with help. I agree that there are not enough rehab centres for women and that there is not enough support for women trying to get off drugs. I would not like to make a comment on the existing service right now, but it is worth exploring. There used to be women's rehabs in Glasgow, and they were closed down because of, I do not know why fully. It may well have been that they were not meeting the outcomes that were necessary. When we created recovery programmes and recovery changes to landscape, community rehabs and day rehabs were found to be really helpful for everybody across the board, women and men, because they were allowed to keep their house. If you go into a residential rehab, then you become part of this homeless population again. You have lost your house. Women and children support very helpful. That is a complex issue that needs a bit more look. I ran services for women for 10 years and I can tell you that I needed a nursery twice. Finally, Lorna, I wonder if I could ask you, from the Serenian's perspective, around the wider issue of prevention and particularly the role that general practice might play if there is anything that you would like us to note on that? Yes, certainly our experiences. We are on dedicated recovery services in Westlothain, but across all the work that Serenians do, we touch on recovery due to the homeless nature of the work that we do in working with rough sleepers. Going back to when we started the conversation today, we definitely feel that there is a much larger role for GPs to play in signposting people into recovery services and understanding that there is more to people's recovery than just prescribing substitute prescriptions for people. I came here today thinking about recovery and speaking about recovery. In terms of prevention, I think that there are three separate elements that we absolutely need to think about and be aware of. That is the prevention work that takes place in schools in terms of ensuring that people do not go down the pathway into substance misuse in the first instance. We then need to look at the prevention of harm when people are misusing substances and the prevention of relapse when people are on their recovery journeys. Each is of equal importance when we are looking at substance misuse to people. I get a real sense that there is a real appetite to look at the systems that sit round about the work that we do and a real appetite for systems change in relation to that. We are incredibly hopeful that Serenians, at the moment that the right conversations are taking place, tell us to support people better moving forward in that journey. I think that that is a very positive note on which to conclude our round table discussion and I think that it does reflect the evidence that we have heard this morning. So can I thank all the witnesses very much for coming in and giving us of your experience and knowledge and I will suspend the session briefly to allow witnesses to move on. Thank you very much colleagues. We will resume our formal session now and welcome to the committee David Liddle, the chief executive officer of the Scottish Drugs Forum, Andrew Horne, the director of Adaction Scotland, Emma Crosshaw, chief executive officer of Crew 2000 Scotland, Teresa Medhurst, the director of strategy and innovation with the Scottish Prison Service and Dr Adam Brody of the Faculty of Addictions Psychiatry from the Royal College of Psychiatrists in Scotland. I think that we will go straight to the first question if we may. As we have so many excellent witnesses in the course of two sessions this morning, we are tight for time, but of course the first question I think will give you witnesses an opportunity to answer the question but also touch on any wider points that we wish to do. David Liddle is coming along and providing your expertise to us. As you heard from the previous session, I am very interested in stigma and I know from the 1970s that there was quite a lot of academic work done around stigma. I think on memory it was Irving Goffman's famous book. Do you see stigma then as being a big barrier to treatment in Scotland today? Kick off. Absolutely stigma is a huge issue that we face. Of course, as you have highlighted, there is a whole hierarchy of stigma and I think that is the real challenge in knowing how to deal with that because there are different stigmas for people in long-term recovery compared to those who are currently using and I think that also touches on the discussion we have had earlier today around methadone. Actually methadone itself now is also stigmatised, so you also have the stigmatisation of the services which mean that people now are probably more reluctant to go on methadone than they were because of the stigma associated with the drugs. I think there is a whole range of issues and the problems we do as part of our work stigma training with both the specialist and the generic workforce. I suppose that you maybe would not be surprised to know that actually a lot of the stigma from the wider society is also apparent within the workforce. That is something that we are working on really hard to deal with those attitudes and stigma within the workforce and I guess particularly around the notion that it is a lifestyle choice rather than that as we have heard around the fact that these are people presenting with serious problems and their drug use is a symptom of the underlying problems that they experience so I think if we can get beyond using terms like addict, abuser, misuser and start talking about people with problems then we start to deal with some of the stigma and we have had discussions with the media around that as well and the classic refrain from the media as well, addict is shorthand, everybody knows what that means but actually it just reinforces the fact that the person is defined by their drug use rather than by the wider aspects of their lives and who they are. One example and again I'm quoting into the history but I remember in the 1980s the old Scottish Health Education Council had an excellent poster which I think out of my office as a young social worker which was six months after Alice had her nervous breakdown, her friends are still recovering which I think was a very interesting way of looking at stigma. Could you relate to that in your occupation? Absolutely and of course there is that wider stigma on the family and as we heard in earlier presentations you know that this particular issue is around stigma for the children growing up in those households as well in terms of how they deal with that and how they're dealt with which also leads to potentially adds to the possibility of them going on and developing substance problems themselves. So it is a massive issue I think the challenge is to see it holistically rather than I suppose if you like simplistically and as you say the whole hierarchy of stigmas because otherwise I think if we look at reducing the stigma on those in recovery from drug problems we might inadvertently increase the stigma on those that are still in the midst of a serious problem. Could you ask perhaps another question to your conveners? I was keen, I know there are other witnesses who would like to respond to your opening general question and perhaps take those first and then come back to you, Andrew. You convener, it's a really interesting question. I suppose it's endemic, the stigma it sits at all levels so you often spend some time with people in recovery and they talk about being clean but if somebody's clean then somebody else is dirty. So stigma is right deep in thinking even in the thinking of recovery and about six months ago we set up a live chat which is just on our website we didn't know what we were going to get and within six months and now it's UK wide but it's run from Glasgow we've had 4,000 interventions. Now these are people who are never going to put their head above the parapet, they're never ever ever going to see, they're never going to go to service. So if we are thinking about a strategy for the future a refresh for 10 years we have to think much more creatively about how people will engage with service given stigma so will they be much more anonymous online engaged recovery communities. So it is we need to think of solutions to stigma because we won't get rid of it we can't say. I'll tell you how endemic it is. I was listening to Ask K, is it call K? I don't know why I must have been having a bad day and it was listening to call K and a person came I can't even remember what the topic was but she allowed a woman caller to get away with saying well at least I'm not a junkie and she allowed that to happen on the phone in and I immediately tweeted her and sent an message to say how can we didn't challenge that because if you think about people with drug misuse problems which are which are which are not a group because it's all of us you know there's coffee it's all of us but if you think about the perception of of people with drug misuse problems a homeless perception you could think about a minority group and you could think would we allow any other any other minority group to be treated in the same way would we allow a minority group to be sometimes refused basic primary health care because it belongs to a specialist organisation because you know that's somebody else's problem we just wouldn't tolerate it for any other group and and that's how deep it is it makes my blood boil. You've both put it really really well but I would like to add that I'm really really hopeful that we're not going to make the same mistake in our refresh of the road to recovery than has perhaps been made in England in which I think such a clear focus on abstent recovery a limited view on recovery and tackling drug problems in that strategy has resulted perhaps inadvertently in a lack of focus on prevention and harm reduction which in itself replicates that stigma and you know suggests that only those who are willing to to quote get clean are those deserving of support so I think we have to learn from the mistakes that have been made down south. I mean I think from the session earlier reference was made to the stigma that's attached to people with addictions but those people with addictions are very often the same people who've been custody are the same people who experience homelessness so that stigma is attached to them in a number of different guises and different results occur because of the services that they then need to link in with so if they're not seen in one service you know as an addict they will be seen in another as either a prisoner or an ex-offender and they'll be seen in another you know as a homeless individual so the stigma is attached to the one individual in a number of different guises and results in an impact in a number of different ways. Thank you very much. I suppose again it's hard to add to what's been said already but certainly with reference to older drug users this is perhaps equally if not more important because it's the access to universal services that's so critical to help people with longer lasting or emerging health problems whether physical or mental and I would have to say on the note stigma there's still considerable amounts of stigma around mental health problems which are incredibly prevalent in people use substances as well. David, did you hear us? Touched a final point and I think some of the panelists already covered this is it clearly in that there's multiple layers of stigma homelessness drug use and drug injecting is so is there a hierarchy of stigma? I don't know what other people think it's probably less than there used to be. There used to be clear separations about how people viewed themselves with that term junkie being one of the worst. I suspect there's more crossover now but clearly if you've got multiple things all playing a part at the same time then it becomes harder and harder and I definitely agree with the internal attribution as well. People believe they're bad for doing certain things and it's not a moral choice, you're not intrinsically bad for if you like the path that life is taking you down and I think that's also something we need to address because from my point of view with regard to mental health guilt is a huge, huge issue and leads to relapse and all sorts of problems. Stigma can be substance specific so we've mentioned words like junkie and there's a lot of conversation been around Mastong and heroin. Cocaine's not particularly stigmatic, it is when it becomes a problem then it's got stigma but in fact you know our media centres, our clubs, our bars everywhere is full of cocaine it's the number one drug that we see online is cocaine use when it's becoming a problem. MDMA among young people not particularly seen as stigma, new psychoactive substance not particularly stigmatic, you know it's normal behaviour at universities it's just it's seen as very norm and drunkenness might be stigmatic it might actually be less acceptable particularly in a highly engaged social media era being drunk at 20 years of age in university you really want to think about your Facebook Instagram page you really need to think so people are young people are very savvy as to what they use and how they use so my point there is is you can you can change stigma is often tied to a drug rather than just in the reverse Andrew that for high income groups using cocaine there's actually a status symbol rather than a stigma yes and the new the new the new five panel to brilliant I think the complexity of the hierarchy is also people also have multiple stigmas so for example the the drug injectors in Glasgow who also have HIV they're actually also homeless they also have mental health problems so I think it you know it's actually far far more complex I guess that most people they'll have the primary label is is as a as a problem drug user whereas in fact you know they have multiple problems and actually can be stigmatised across a whole range of them so so I think the yeah the task is is pretty big as we've observed certainly from the training we've done with professionals as I said which their views tend to represent the views of the wider public unfortunately helpful and I think you're perhaps indicating yes I think one of the big changes since 2008 when the road to recovery came out is that the drugs market is far more responsive to stigma now and we'll exploit that because we have medications like Xanax which are presented to look like medicines they're illegal in this country they're not prescribed in this country so people do not know what they're getting but because they're packaged beautifully they look like medicines people may think they're actually buying something that's medicinal and as Cullidani expressed beautifully earlier people are very often using these because they're in pain they make sense to people but I would doubt whether people would necessarily see themselves in the same terms as people who are buying heroin fair point now a slight change of tone and territory and I'll ask Alex Cole-Hamilton to thank you. Good morning to the panel. Thank you for coming to see us today. I'd like to ask about the funding environment particularly for recovery services out in the community because in 2015 the Scottish Government budget issued effectively a cut of 23 per cent to alcohol and drug partnerships across the country now some health boards weathered that better than others some found money elsewhere to plug that gap and continue service provisions others did not in the city of Edinburgh alone for example that cut represented a 1.3 million pound reduction every year for those two years that we had that now happily at the end of last year we had a 20 million pound announcement which will plug a lot of that gap but I want to know is there a correlation between that and the delivery on the ground is there a line of sight between that and the reason we are now the worst performing country in Europe in terms of drug deaths and what can you explore what that impact has been on the ground? Okay, I'll start. Thank you. That's a really interesting question. ADACTION is one of the largest providers of drug and alcohol services in the country. About 85 per cent of our money is in people, the rest is rent and overheads, but that's 85 per cent. You cut 20 per cent, you're cutting people, you cut people, you cut hours, you cut hours, you create waiting lists or you cut the quality. The 20 per cent and yes it's been reintroduced but I'd be looking at 100 per cent. If we're really going to take this seriously, we've heard some barbed criticism around treatment earlier on and in some ways it's fair and unfair in terms of some of the attitude and stuff but it's also unfair. If you're carrying a caseload of 60 people, what quality work are you really going to do? What recovery work are you going to do? So lots of conversation around the mesh to substitute prescribing. If you've got 60 people, you've got a machine. That's what you've got. You've got a machine. You're not doing recovery work with people. You're seeing people maybe for 15 minutes once a month. Now I'm a smoker. I don't think I'm going to recover 15 minutes a month. I'm going to have to wait a long time to get myself sorted and we talked about whether people were parked or not parked. You were very eloquent in what you were saying 23 years and why has nobody asked a question? Well if you've got 55 people on your caseload, you're not really going to ask the question. I sometimes give an example. I used to work in Earl's Court in London. I single-handedly ran a needle exchange and there was 1,000 people registered on that needle exchange and I was a single worker. I never asked anybody how they were. It was a pointless exercise for me. It was glorified shopkeeping fast. It was self-service. So you want to talk about the cuts and you want to talk about money. I think we need to really reinvest. I think we need to reinvest to save. I think we all know about our hospital crisis. We all know about bed blocking. This service user group, drug and alcohol service users, block beds when they go into hospital. They go into hospital because they're not engaged in primary care. They're not involved in treatment and I said what that treatment is. There is massive movement in the recovery movement. There's massive opportunities, but people can only get to those opportunities if they are helped to get to those opportunities. If they are stuck in a system living in a flat, isolated in their community, stigmatised, how are they going to, how are they, we just, we just got to reinvest. We got to, I'll repeat myself, we have to reinvest to save. I'm a crosser. I think Andrew is absolutely right. If we don't pay now, we're going to pay so much more later and I think the cuts to surface provision so far have actually reinforced that stigma. I can't imagine another public service being cut by 20 per cent and then not being a public outcry about it and I think the King's Fund has demonstrated quite well how discrimination and disproportionate the cuts to drug services are because I think there's an understanding among the public and there's perhaps a different way of viewing drug services among the public than there is about other public services and I think Andrew made a really good point as well. We are losing good people from the field because of cuts. We are losing years and years of experience because of it. We cannot embed good prevention practice if the front line is at threat and the front line will always take precedent over prevention investment and I think we've seen that across schools and I think what Fiona was talking about earlier, that broader concept of prevention cannot happen without joined up working and without a significant reinvestment of time. What many ADPs did and logically did to manage that 20 per cent cut as they put a lot of their services into contract and use the contract in process as a way of cutting. I won't go into individual ADPs but if they had a budget of £400,000 currently in service they thought that service was coming up to contract. Let's put it out to contract because we can now get the new one for £300,000. You're just laying off people. There's certainly good evidence from England and I guess it's the same in Scotland of actually changing providers on such a rapid rate of every three years and with the focus on cost reduction. The point I was going to make around the funding was the one that Emma made really around. It goes back to the issue of stigma and the fact that that would be seen as an acceptable thing to do to take that £15 million out. I think also that in a way the regrettable thing but that's the way policy works is that the key argument around the reinvestment is around unplanned hospital admissions which we've made and done work with the information services division around the modelling of those costs which is in our evidence. I think that in itself we've got in the last year we had 867 fatal overdose deaths which has doubled in the last 10 years and that is not as great a concern as it should be clearly in terms of that. I think the other bit of that if we're looking at the wider prevention agenda is that what we know in terms of the drivers as we've talked about underlying trauma but also the links with poverty and inequality and deprivation which are very clear in the Scottish context compared to lots of other countries in terms of that and you can see why we have probably the highest rate of drug problem per head of population in Europe and that is largely driven by that so clearly if that's driven by those factors it's also we need that investment in terms of a range of support services to help people out of their problems as well and that's the bit where we may come to later I guess in the questioning but that's a key bit of actually where we need that extra investment and the government's talking about a strategy around seeking people and getting more people into services and then actually keeping them there for as long as they need to but the key bit is and maybe come back to the issue around methadone in particular but keeping people there for as long as possible in terms of them needing the service and then dealing with all the wider issues around housing, employability, welfare support etc and those are the bits that we largely forget about in terms of you know not firstly keeping people alive long enough so they can recover but also we need things for people to recover too and that's the big issue that we're missing out on and that's the substantial investment that we need so we don't end up blaming methadone for the failure of the strategy which is clearly nonsensical methadone is one part of the overall solution and I think the the bit and and maybe just just add to that just just now in terms of the previous discussion around that I think the risk around the notion of the part on methadone and actually we don't have the data on that so that's the first thing we've got potentially 24 000 people on methadone but our research around the 35 and overs was that in fact the big issue is actually people are not being on it long enough for it to make an impact so there's a huge cost to the system with people actually being on methadone for too short a time the other issues around widening that offer around the range of support medication as well so I think the you know other countries that are far more successful than us in terms of the whole system actually have a higher rate of people in the services longer term but also to pick up on Emma's point their goal tends to be around quality of life and improving people's quality of life rather than a narrow assessment of success around whether people are still using or not I suppose to partly to make the point that these are wider societal issues and things like substance use problems will impact across a large number of domains in the public domain in Scotland irrespective of whether you're talking about health or social care or anything else the other point about the alcohol and drug partnerships is that there's a big value in the fact that the money is if you like dispersed by a multi agency grouping that can include everybody from statutory to third sector providers to the voluntary sector to people who represent both the carers and families as well as the actual folk themselves who see our services so that's really helpful and the fact that it's ring fenced in what might be called straight and financial times as well is actually deeply helpful as well because there's certainly probably higher visibility or more acceptable targets if you like for that money and one of the things that we're sort of wondering about coming along here was again from the point of view of certainly health and social care treatment services are seen as core business and shoring them up is seen as core business and you sort of alluded to that in the question you do sort of wonder because some of the possible preventative work is clearly a lot more important down the line and also hard to impact hard to evidence with regard to impact in the short term and I suppose before coming here I was wondering whether ring fencing or something like that might actually protect the values for the future rather than just reacting reacting reacting to what the current situation is and I suppose I would I would echo the point as well that seek even treat balanced against a heat target of standard of three weeks referral to treatment may take resources. Thank you very much. Brian, I think you're a brief supplementary on this topic. If I may, I'm going to use an illustration that I wanted to use actually in the other one is this idea of in the preventive agenda of the through care. There's a group catalyst in Ayrshire who work from prison through to release and use art music and drama as their sort of hook and in visiting them there was two things came out and to your point David was number one there's a chap in there who is an incredible artist and they now have some place where they can now go and and be attached to something of importance so I asked him why did he take him to go to prison to find out he could be an artist to which his answer of course is and they've had access. So the two preventable health agenda is one if they have access early enough and two preventing that there's a huge their figures show that a huge decline in re-enmission as well so I think my question is really around how do we when we're discussing financing of the preventable health agenda we need to look at education at a young age and we also need to look at that through service as well and so how are those how are those being connected up and how well are we managing that process? I think I know the service that you're talking about and it is very good. There was some mention made in the earlier session about people leaving custody and support not being available for them. This is in relation to short term sentence prisoners so they're a group that we know and understand are often revolving door and can be quite chaotic individuals but since 2015 after a couple of pilots pilots been undertaken in Lomos and Greenock we established through care support officers who are prison officers who work with individuals in the six weeks up to release those in short term sentences and through the door for the first three months into community and the first day without a doubt is spent attending appointments for housing for registering with GP and for signing up with addiction support services but we had an independent evaluation done of that service last year and the benefits and the impact both in terms of supporting the connectivity between services sustaining the individual as was mentioned earlier that initial period when they do step out over the door and some of the risks that they face in terms of passing by an off licence or they're known dealers there is a support there for them and also to help sustain that support and one of the things that was mentioned earlier which which really resonates I think with us certainly at the moment is that issue about trust and trusting relationships and that's certainly something that we have experienced and knowing now how difficult it can be for people stepping over the door how much they have to go through in terms of sitting waiting in a housing office for two hours just to be seen we've now started to use that to inform other work that we're doing so in December we've been working with a lot show and Solace from COSLA to establish a set of housing standards for people who aren't coming into custody and being released from custody to try and ensure that we're possible we can sustain tendencies particularly for those on remand in short term and try and alleviate some of the difficulties that people have been experiencing I'll take a cool Adirani approach to this and go sort of global why are these people in the prison in the first place the simple question why are we imprisoning this group of people and and you know I have discussed one of my my roles as I am a part of the pads group so I'm advisor to Scottish Government and in its conversation it happens quite a lot which is you'll hear this answer it's a reserved matter well it's policing and policy is not a reserved matter it belongs in this building and we can make a decision in this building as a group as a country we can make a decision about how we want to police and how we want to make policy regards to how we treat people with drug and alcohol problems we heard Cool Adirani speak very eloquently and others speak about pain and hurt mental health problems and social care and background and privilege and lack of chance and what do we do we put them in prison and how do you manage your own question David around stigma we put them in prison so my view is well let's let's three or four times we heard the portuguese model what's portuguese model even it only goes halfway there because it talks about the decriminalisation of drugs I I would go further and talk about the decriminalisation of people so it's not just their drug use it's the acquistive crime because very few people go to prison for possession of drugs they go because of shoplifting soliciting a minor fraud a fray things that you really you just think you know we just said it why do we put people in prison for under six months well the prison services were absolutely up front what are we supposed to do you know stick a plaster on it and say go back out of the policing you know I often fail for the policing because on the number one they're the front line of social care and what are they doing they're just they're thinking oh god I've got to arrest this person I don't want to arrest them I've got to arrest them and I'm just putting them back into a system hobby horse I'll get off just to to to follow on from the the issue around drug law reform and and and Portugal what is also interesting about Portugal which is not I think you know widely understood actually at the same time as as decriminalisation they also increase significantly resources into drug treatment employability programs welfare reform so they did all of the wider things necessary you know to to make recovery possible and that's the bit you can't you can't separate out the decriminalisation from the rest of it but but I think the point is well made around the fact that we're we're sending far too many people into into the prison system I think the more you know specific point in terms of you know the alternatives if you like to drug use and problematic drug use is the issue of access to to employability and employment and there we do really really badly in the Scottish context of that I mean we run a very small programme to train former drug and alcohol users as addiction workers and we have about 20 people a year on that programme but hugely successful in terms of the 80% of those go into long-term employment but what we've identified is is very clear that actually that you know those opportunities in terms of employment opportunities and training opportunities are very very limited and actually that it needs to be across a whole range of of you know training programmes like horticulture catering you know building trade etc etc so we could do far more and there's been examples in the past like the new futures fund which actually put that employability into the frontline services and we could certainly learn lessons from that in terms of revisiting that because I think that's hugely important the other thing is just to conclude the work we've done around the older drug users the 35 and over specifically we did a survey of 123 individuals and what we identified with that group that 79% average age 41 were actually living alone so the issue of isolation for people who are still using is hugely important now to some extent we've dealt with that with people in recovery because there are those recovery communities and groups but they're primarily for people who have stopped using so there's a big issue about some of the work around working with current drug users and fitting them into local community groups art groups etc etc to encourage them to have a view that actually there is a life beyond their drug problem and there is hope in terms of actually what they can achieve and I think that's the bit that we're we're certainly missing just now is that too many people and classically one of the people we interviewed in that study a 41-year-old in Glasgow said that he hoped the study would be useful for others because it was too late for him and that's somebody age 41. I want to touch on what you've all said basically and really around the strategy and you've given some ideas when I spoke to the north west when I went out there they mentioned the fact that there were people there who were in training and they've submitted to the strategy their paper and what they think it should be and I just wonder it's holistic reports yeah it's definitely employment and we're talking about budgets surely we should be looking at all of the budgets of the parliament and bringing it forward into not just health but employment etc for the specific group that we're talking about and maybe we should re-educate ourselves in the language pick up and Andrew's point there but what I'm seen is speaking to the drug users themselves they were saying that basically they had what you might say no hope no aspirational hope and their aspirations was to yes to come off the drug get better and get a job and then be independent themselves so I just wondered I know we've got the strategy here and that's what we're talking about but should we be looking at a whole different sphere of the strategy which goes into each budget from from all of the committees and you know the strands of this parliament should we be looking at that rather than tinkering around the edges with the strategy as it is at the moment I think that the challenge always around drug policy is to assume that that drug policy can fix everything um and it clearly can't because it's a wider social problem and and it needs all of those things as you say and that would be the ideal the problem that goes back to the first question around stigma is that the reason you know employability programmes don't target these people with drug problems is because they're not seen as worthy so you have that across a whole series of policy agendas so I think you're right we should be doing that for sure but the question is then how do we actually deliver that in practice because we've been struggling with actually trying to pull in resources from other areas but you know for example that small program and we've struggled that we've funded it for the last 18 years the problem is it's expensive at £20,000 per person but actually in terms of the outcomes and people then being in long-term employment and paying taxes it makes perfect sense but but you know how do you fund it those are the those are the problems I'm sure we'll get the witnesses who have an opportunity to comment on that in responding to other questions ash thank you convener I just wanted to pick up on something that was raised in the earlier session and I believe most of you if not all of you were here for that so obviously you know the strategy's been going for 10 years and then it was characterised as maybe being an uneven service provision through that time and across Scotland as a whole and you know there was an observation made that it's resilient to policy change and I'm wondering if you would think that's a fair comment and if you have anything else to say about that? I'm not sure probably whether or not that I would comment on whether or not it was fair I think the public sector landscape has changed so much in the last number of years since the policy was introduced you've got Police Scotland now you've got the IGIBs in place so a number of changes and certainly from our perspective the transfer of NHS of medical services to the NHS so much of the work that is reflected in there is probably outdated and then the patterns of drug use are changing and we've heard a lot about that today as well so I think that it would be fair to say that because of some of the changes in the way that the public sector works and how that's manifest itself and how that's developing it is the right time to do a refresh in order to enable the services to be appropriately brigaded now within a refreshed strategic approach. I'm sure it's probably been said already unfortunately I did miss the morning or the other session but you know there are a lot of positive things in the road to recovery document and actually I think they touched on probably one of the most important things for me at the time when I read it which I still remember is about hope and positivity and about recovery potential and I think that if there is obviously going to be a new strategy it's almost the attitudes and values that displays are as important as anything although clearly that's being a bit over-optimistic but without that general feeling that people can recover and I agree totally a 41 year old if I was seeing that gentlemen terrible as it is I would be challenging those beliefs because I would refuse to accept that that somebody ever loses the ability to recover so there's some things about this which are sort of timeless I think and sometimes attitude no things are those. Unfortunately I was around 10 years ago and was possibly party to the road to recovery I still think it's a fantastic document I think it's aspiration is still alive today I still think around the world people still look at it and think the road to recovery has it has aspiration it has hope attached to it and I work for a UK wide organisation I've just seen the English drug strategy if I was marking it at 10 it means a lot to be desired and it's still looking at a sort of outcome payment by result idea which is not helpful. Is it is it resistant? Yes there are there are resistors we're 10 years on I think in my evidence I talked to and the Salces report says that we need to think to the future that there is a cohort and David speaks really really eloquently there is a cohort and we see them every day when in service of and I hate the word older because it's 35 so it's not older it's people who are not even middle age and there are there is a cohort who have been using drugs since since the 1980s 1990s and there will be casualties and we can't stop it and there will be you can see them in Edinburgh you can see them in Glasgow and we can work really hard and we were right to focus and we're right to focus on on the the that phraseology that we hear about seek treat keep and well I'd like to say seek keep proper properly treat and recover I'd like to see all the words in but we do need to think about what's coming around the corner and so I'm I'm know that Emma will follow up on me so there are two things that we need to think about it what are we going to do with our cocaine users our MDMA users who are not going to be like our opiate users but they are going to have problems and are our current treatment services fit for purpose no is the answer what happens in Scotland if we repeat what's happening in America what what happens to us are we ready for another opiate epidemic I hate the word epidemic but are we ready and would we use the same tools as we used the last time because we made a lot of mistakes and so the refresh is absolutely timely and it has to take a number of different elements to it I'm going to finish just on one point in terms of road to recovery a lot was said this morning about about prevention and this is the the catch for this was prevention at this moment in time and I'm possibly disgracedly while we have seen drug use shift and diminish among young people where it is a problem there are very few services it is a complete postcode lottery if you are going to get a service at all and if you do get a service it may be based in an adult service so those 14 15 16 year olds who could cost us a fortune in the future not just financially but in terms of their family themselves on their communities there's very little intervention and that's the age group that we really want to get those people who are coming to the attention of A&E departments our police and our school pastoral care truant in whatever we have to put the money in yeah I think Angie's really wise to highlight cacain because obviously you'll have seen in the evidence that I presented that we had four cacain deaths in 2000 and we had 123 in 2016 people can now buy drugs much much more easily nobody needs to go to a dealer anymore if they have a debit card and they have access to a computer so the road to recovery does highlight the need to investigate further what we need to do about deaths from stimulant drugs if the problem continues to increase and I think we can see fairly conclusively that it has I think as well in terms of the new strategy having teeth we need to recognise that this complexity we have with technology with communication and with movement of drugs around the world we can also exploit that to try and reach out to people better and more effectively and use that in how we make sure that we get help to people like the live chat at adoption the micro service that we operate the last thing I'd like to say as well is that whilst Salsus does give us a picture of declining drug use among young people public health England have said that rates of heroin are decreasing while cacain, MDMA and cannabis rates are increasing the global drug survey says the same thing for Scotland what we have to remember is to complete Salsus the school has to choose to do the survey in the first place and this is the basis for our sort of drug policy and work but those young people who cannot sit still for 45 minutes under exam conditions because they're suffering at home they're experiencing trauma those people are not being heard in Salsus so we need to reach out to those young people we need to make sure they've got a voice in this refresh it's so important that we do this thank you very much just in in terms of the question around being resilient to change I think that the the road to recovery was very clear about moving towards a person-centred care now I think the challenge particularly with the big NHS addiction services is how you do that when you've got three or four thousand people in that service and I think those are the bits we need in particular to look at is how we deliver those services in a more person-centred care the refrain we get from a lot of the surveys we do with people with drug problems is that they have to fit the service rather than the service you know responding specifically to their needs and as part of that we should include looking at extending the prescribing beyond methadone to other choices such as buprenorphine other countries use slow release morphine and also heroin assisted treatment so actually you know we're much clearer that actually in a lot of other countries they recognize that they're for a certain group who've failed on other treatments that actually heroin assisted treatment you know is likely to be the only thing that will keep them in the service and I think I suppose in terms of the last point picking up on Andrew's point about casualties and we can't stop them I would disagree with that in terms of the fatal overdose is that the evidence from other countries if we have enough people held long-term in treatment actually their overdose rates have gone down to very very small numbers and actually the deaths then become other factors like underlying health conditions and things like liver disease so there is strong evidence from other countries that actually if we keep more people in the services for long enough we can actually make an impact and I guess my going back to the vulnerable young people stuff I agree entirely actually that that's an area that we've actually taken our eye off the ball in terms of because there continues to be a population of vulnerable young people whose life experience is very similar to the people with drug problems so you know they are a group as has been described as a group in pain with a whole range of problems you know including mental health childhood trauma etc so we need to actually focus on that group as well to ensure that we're not you know just storing up another generation of problems for the future you very much do it I think you're a very brief brief comment due to Andrew's point about opiates in America I was over there last year and was really struck by the explosion in opiate deaths CNN were showing middle-class couples found dead at their 4x4s no other stigma issues no deprivation but like your cocaine users is there anything we can learn from America because that is very serious what's happening in America in terms of deaths sorry we have to understand America's we have to understand America's relationship with its medicine is very odd if you spend any time in America just watch any I watched an iron and something game at 10 o'clock in the morning there were 22 ads for drugs the transaction between the patient and the doctor is a financial transaction I want to get my patent I will get it I will get it that's that's the culture and what we do need what we do see in America it's very interesting it you just watch people's teeth in America because all they always have fantastic teeth and then you meet people and you think they've got a drug problem and it's it's mad it's when you go into the middle of the country and you find the huge areas of deprivation the no hope the sinking towns that's but it's also but it's also so one of the I just want to jump back one of the things that we need to understand also about America and about its medicine and not just at paying medicine it's insurance medicine so if if you go and you've got severe back pain here or we will probably be referred to physio it's so much cheaper to give a drug so that's why you see so much middle class stuff it it's so much cheaper in and out in six weeks rather than say that's going to take four months of treatment just going back to the question of stigma it's very interesting in terms of a lot of the media coverage of the problems in America they refer to victims and you never hear that in the Scottish context thank you convener it's just a quick question really um the road to recovery document does it need a radical rewrite as far as um like that's maybe target the media the print media do they have a job of not using words junkie alky druggy and also um as far as i'm aware in the 15 years of taking a radical approach in portugal there's now a 50 reduction in heroin injectors so that was from the TED talk that was given to us in our evidence from Johann Harry so i'm interested about what would be the key asks for a radical change in our policy i think exactly as Sandra was saying we need um a genuinely cross cutting broad approach looking at every single area of policy and i think dave mentioned this in his evidence the idea of having an impact assessment when we're developing the policy and then an impact assessment when we're reviewing the policy what impact have we had on this vulnerable group because they don't have legal equality specific protection yes but maybe maybe we should think about that because they are clearly a highly disadvantaged group in our society who experience death at a differential rate so we need to do something about that and as you say why not bring the media in on this and why not give them some responsibility because i couldn't believe when i saw the the guardian had started using the term junkie again after years and years of knowing it couldn't get away with it so we can't let all these other areas take the right of the ball either there's not one person in this room who is not personally affected by drug and alcohol use there's not one person here now whether it's in your family like i'm one of 10 okay there's quite a lot of problems um just being brought up in one of 10 is traumatic enough but there are lots of problems and so it could have been mentioned earlier on it's not somebody else it's not them it's us if you think about your own families and your own workplace and your own brothers and sisters and colleagues and and friends and the people that you go to and the clubs that you go to and the places that you move everybody knows oh yeah that's that's genius she well she does like a drink oh yeah yeah yeah yeah his brother used to have a cocaine problem or a heroin problem or this problem and that's how we hook the media in because of all the groups of people yes of all the groups of people with her with their drinking um and other drugs um we have to stop the blame i think is what i'm saying is that if it it has to stop being them it has to be us has to be thank you convener and thanks very much for coming along this morning on a fascinating discussion and hope to get some more of your your insights and then the area i'd like to explore a bit more um i'd like to touch on some of the data points and i mentioned this in the earlier session and there's a bit some contradiction there um some things are up some things are down some things are flat and just get your reflection on that but then moving on from that um to get your opinion on what should we be measuring because another's been some some of you have said um people having a quality of life is maybe more important not as important than people coming off substances completely so just understand what you think we should be measuring and then maybe touch on this whole area around about funding and costs because we've touched on that number of areas we talked about at the beginning not enough into recovery and treatment then we talked about the justice system and should people be in there and that's a frightening cost per individual to keep people locked up in the justice system compared to what you could do with that money and recovery and treatment and then you touched on vulnerable young people and that's obviously a big issue that harry burns rightly pushes if you look at the whole life costs of an individual and how many millions that adds up to so maybe just to get your reflection on on some of those points if i mean in terms of the the young people's data i think the distinction is there that that's talking about you know whole population drug use among young people so you have to you know recognize that actually a lot of the vulnerable young people actually won't appear in that data for a start because they might not be in school um so actually what we don't we don't have good data on vulnerable young people but certainly we have a lot of anecdotal evidence from the training that we do around services for vulnerable young people that that issue is significant and certainly you know all those issues around risk behaviors among vulnerable young people are very evident in care homes etc in terms of the need to do far more than we're doing and that touches on all of those issues around you know going forward i think in in in in terms of outcomes in terms of drug treatment services england's had um the national treatment agency and and they have what you might say is much better data although i think that the caveat there is actually i would question the accuracy of of some of that data in terms of the level of um drug free um successful exits from from treatment which are apparently 20 000 a year over the last 10 years and that doesn't match with the prevalence figures so i think we have to be quite careful in terms of how you know we the data we collect but also recognizing that some of it can you know potentially be um what shall i say is is not as accurate as as we might hope it should be certainly that the government is developing a an integrated drug and alcohol database system which is due to to come on stream i think from the first of april which will aim to collect a whole range of data linked into that is is a recovery outcome tool which is actually looking at trying to measure recovery across a whole series of domains so i think that you know in in terms of some of that work and and it's been done you know is useful i would argue though that actually what we need to be doing particularly in terms of the the services is actually talking directly to the service users on a regular basis about the services they receive because certainly that the work that we did again going back to the worker and the older drug users what you got from that was you know a much more nuanced view of that and what was frightening within that study was the fact that people and we were using peer researchers for that study was that when we asked people about treatment and they were receiving they actually said a lot more when the tape recorder was switched off because they were fearful of the punitive response of the service so i think that's something we haven't mentioned today but is actually and links back to the issues around stigma and actually that the whole notion of you know drug use being a lifestyle choice so that the people are being continually punished across a range of services for the problems that they have rather than actually being you know actually helped appropriately so so i think that's that's an issue in terms of understanding actually the reality of how services are operating and not just looking at the sort of headline figures of the data and digging beneath that for example we've recently done a a needle exchange study in a part of scotland which is is quite illuminating in terms of some of the responses of the services in terms of how people are treated and it's a brilliant question actually because our number of questions because we struggle at the moment i was quite skating i think in my evidence because at the moment we measure process you know did we hit a waiting time how many people in the system and and why i'm not why i'm not what i what i'm trying to say is recovery what does recovery mean to an individual so recovery is an individual journey for some people that means being drug and alcohol free are are non problematic using of drug and alcohol and we don't have measurement for that we're trying to get measurement but taking davis point recovery is also about quality what's your quality of life because you were because you were involved in a treatment system and we are if i broke my leg and i was going to a surgeon i would want to know the chances i've got dodgy knee i would want to know the chances of my knee being better we're not very good at that in this business and we're once described as as inviting people to around to your house to a party and closing the door locking the door behind them it there was a sense of there wasn't a future aspiration i ask my services to have statements written on every wall in the service which is 60 percent of people who come to add action feel better and do better it's there in front of people because we have to sell that there is a tomorrow and we have to sell hope and we could have run he has come around a few times we have we've spoken about visible recovery you know if if we go back to ashes point about is the road to recovery still applicable it's the idea of the word recovery the idea that all of these recovery movements happened this organic thing happened and is happening every day it is fascinating and i think we can measure some of that i think as a service provider i among my services have had to create targets for ourselves because there is none in scotland i've had to say if we deal with 100 people how many four how many people are going to leave in a planned coordinated happy way and the target that we've said is 40 percent we said let's go for 40 percent now i'd like it to be 70 but let's set a benchmark because i couldn't get a benchmark from anybody else the english benchmark in in treatment services as far as i know is seven and a half percent that's they're expected put to put i'm not but like davin i want to reiterate recovery has many guys as it doesn't have to be drug free it just has to be happier and healthier i think i would say in terms of data we have vulnerable adult groups as well who are very very difficult to engage with and not through their own fault but because we haven't set things up in the right way to make them feel safe enough to do so so for example we do have people who are homeless who use synthetic cannabinoid receptor agonists or synthetic cannabis as it's been called even though it's not actually cannabis and it's very difficult to get data because if people are using scras their behaviour tends not to be conducive to actually getting through the door of a drug service in the first place what i would say as well is you know it's a commendable effort that we've got daisy coming in as an integrated drug database to track outcomes but the vast majority of people who come to cruise seeking help are age 35 plus are using cocaine are on the point of losing their jobs their houses their families they are not going to give their information to the daisy database they want to be recorded anonymously as we record them currently on the clinical outcomes and routine evaluation database and on the Scottish misuse of drugs database but that's not being offered to them so we are going to lose all that data because we're not listening to what people who need help actually need thank you very much Alison Johnson thank you convener thank you all very much for your evidence i think it's been really compelling i sort of you know we've spoken about the the context in which people find themselves requiring your services i mean it's not about choice and it must be if we're talking about outcomes and i think had action you were saying police you know police government ask us to to produce outcomes i mean if the outcome of all our other policies are that people are requiring to use your services it's not great is it um so i just wonder how frustrated you feel about that and you know the road to recovery is going to have to deal with a heck of a broad range of other policies in order to prevent people from having to access your services you know alex coole hamilton was pointing out that we're we're the worst performing in europe when it comes to you know drug deaths and problem drug use is higher here than in many other western countries so does that suggest that all our other policies are failing too you know why are we doing so badly i'm i may have sounded but i'm not that pessimistic i make yes i'm not i've lived in the west coast of scotland for a long time but i've managed to keep some optimism going um and and my optimism is is about the change in drug use we have a very different dynamic a very different so i spoke a little bit earlier about young people what young people think about drug use and how young people use drug use unfortunately for children who are now young adults and every now and again i catch their facebook pages which is interesting and and i can see someone talk about the monday morning fear that's quite interesting so what are they actually talking about you know i know what they're talking about um but i'm not all that worried about that i'm not it doesn't concern me what does concern me is the young people who have had trauma the young people living in traumatic conditions they concern me so there's still a cohort that's going to be that's going to need our help and the earlier we can get the help the better um scotland i don't have to say it in this room is a great country and and we have made huge strides if you think i came to scotland in 1994 like anybody who lives in and around glasgo remembers what castle milk was like and remembers what easterhouse was like and remembers what jumpchapel was like they are completely different places now and when they were like that they you know it was it was like 12 13% of young people using drugs problematically to escape from their own environment there's been a huge shift huge shift across the country in just in terms of the whole dynamic of the country the whole confidence of the country so i go back the road to recovery is still a fantastic document there are good things happening we need to do more and we need to not forget that we have a changing dynamic we need to think smarter we need to think about a digital world and a digital offer given your point about animal municy but things aren't terrible i think one example of that is welfare reform in particular that we're seeing with with you know high rates of sanctioning of of individuals and the impact that has on on on people's lives and i think that's the the point we've been making around you know the wider social policy that that that can have a huge impact and i think that's also the challenge for you know just like in terms of discussion around methadone you know it's quite easy to blame methadone as the cause of the problem you know but it's actually clearly not you know methadone is is is one part of the solution and in fact you know all of those wider social issues come come to bear and there as i said at the beginning you know they're the drivers of the problem in the first place and why scotland has you know the largest drug problem has the you know and the highest death rate or fatal overdose death rate you know so those those same drivers are also the things which should be the solutions but that goes back to the question around the you know the issues around stigma and the fact that we're just not putting the appropriate level of resource because this population is not seen as worthy or deserving and it's it's you know it's seen as people engaged in a sort of self-inflicted pastime i think the other issue and particularly around the the 35 and overs in terms of that group is that they're doubly stigmatised because of their age as well in terms of that and what we've seen interestingly with our employment programme is that actually you know we've had people who've never worked in 20 years getting work so it's actually it's the older group who are actually you know tending to be the ones that are recovering so the key challenge is to is to make sure we can keep folk alive and reduce the harm until such time as they feel capable of recovering and that's the bit you know we've talked about again is that is the the bit about needing those opportunities for people and sadly you know there are a few routes to that and what we've had is the route into the care sector and that's what most people talk about was potential employment opportunities but there should be a range of others that we're facilitating as well and investing appropriately in that. Okay thank you yes last question from Alison. It was specifically to Theresa Medhurst if I may and it's just about who is responsible for prisoners welfare on their release you know we heard from the earlier panel about possible risks you know of liberation and just making sure that prisoners are properly supported before they leave just wondering is there anyone in particular who's responsible for the released prisoner? There are so for those that are serving sentences over four years who are released under statutory conditions then criminal justice social work are responsible for their supervision back in community and the links into case management and how that individual's journey has progressed through their sentence is quite clearly mapped out so there are fairly robust and rigorous processes around about that and that would include anybody that fell into the the remit of map arrangements as well so for long termers I think they're fairly clear well planned out supports in place for when people are released for those on remand and we haven't touched on remand individuals today and those coming into custody on remand can experience the same difficulties as those who are experiencing short term sentences so the same issues with losing accommodation with disruption from services and supports lack of confidence family breakdown etc there is no service or support and part of the difficulty with remand those on remand is that it's very difficult sometimes to not understand when they're going to be attending court and therefore even setting up support around about a kind of court service might be fairly problematic as well because it's difficult to identify when people will be released from custody those on short term sentences there are a number of schemes which are government funded through third sector providers for dealing in particular with young people under the age of 26 and for women and as I said earlier we have our through care support officers who operate in 11 of our prisons at the moment who provide support to those people on short term sentences who agree that they want support on release there is voluntary provision available in social work if people ask for that but invariably those who come into custody don't seek out social work support on release thank you very much and can I thank all of our witnesses this morning that's been another excellent session very informative and stimulating of I have no doubt further discussion among committee members we will now go into private session in order to discuss the remainder of the agenda and we'll take a very brief break while