Drug Deaths in Tayside, Scotland 2017 Annual Report. Tayside Drug Death Review Group

Transcription

1 Drug Deaths in Tayside, Scotland 2017 Annual Report Tayside Drug Death Review Group

2 Executive Summary The recent and sustained increase in the number of drug deaths both locally and nationally is of significant public health concern. The Tayside Drug Death Review Group reviews each case where a drug death has occurred to identify emerging trends and key themes to inform strategic work going forward. In 2017 there were a total of 73 drug deaths in Tayside, compared to 56 in 2016, with the greatest number of deaths occurring in Dundee City (51, compared to 38 in 2016). The mean age of drug death casualties was 38 years. This is slightly younger than in 2016 (39.1 years) but the general trend has been one of increasing age. The approximate ratio of the number of male deaths to female deaths is 3 to 1. There is a clear inequality gradient associated with drug deaths, with more than half of drug deaths occurring in areas of greatest socioeconomic deprivation. Of the 2017 drug death casualties, 27 are recorded as having experienced at least one adverse childhood event, with 15 experiencing two or more. Of note, 22 of the casualties had started using drugs under the age of 16, some as young as 10, and this may be directly related to adverse traumas experienced earlier in their lives. 65 of the 73 drug death casualties had suffered from a mental health issue at some point in their lives, with 54 individuals known to be suffering from an existing mental health condition at the time of death. 57 had been convicted of a crime at some point in their lives. The mean number of substances found in toxicology was 5 (range 2 11). The proportion of drug deaths where etizolam, pregabalin, alprozolam and cocaine were listed in the cause of death has increased markedly between 2015 and Fentanyl was detected in fewer than five cases. Over half (56%) of drug deaths involved an opioid (heroin or methadone) plus a gabapentinoid (pregabalin or gabapentin) plus a benzodiazepine (typical or atypical). Recommendations are listed in section 5 and concern: Substance misuse in the context of mental health and wellbeing for individuals affected and their families Monitoring and reacting to emerging drug trends Wider physical health concerns for people with problematic drug use Harm reduction, including the availability of and accessibility to naloxone Medication prescribing Substance misuse in the justice setting 2

3 1. Introduction The recent and sustained increase in the number of drug deaths both locally and nationally is of significant public health concern. Each drug death is a tragedy and impacts on a wide range of people, often including children, and has far reaching implications for families and communities. Drug deaths often occur as the culmination of multiple life circumstances, few of which are within the direct control of the individual affected. In recognition of the current impact of drug deaths in Dundee in particular, the Dundee Drugs Commission was established to consider the reasons behind this locally and recommend action for services and partner agencies. The Commission is gathering evidence from a range of sources, including from people and communities affected by substance misuse, services involved in delivering care to people with problematic drug use and experts in the substance misuse field. Whilst the work of the Dundee Drugs Commission is ongoing, the three Tayside Alcohol and Drugs Partnerships (ADPs) continue to review and develop the way in which support is provided to people with problematic drug use, their families, friends and wider communities. The Tayside Drug Death Review Group provides intelligence and strategic guidance to inform the work of the ADPs. Historically this has been through an annual report but we recognise that a report published towards the end of the year about deaths that have occurred the year previously is less relevant where current emerging trends are concerned. As such, the Tayside Drug Death Review Group has been reviewing its processes and changing the way in which it considers cases, with the ultimate aim of providing more immediate feedback to the public and partner agencies of the ADPs with regards to current substance misuse concerns. The format of the annual report is also changing. This year we have produced a more streamlined, targeted version which considers the national trends reported in the National Records of Scotland, Drug-related Deaths in Scotland 2017 report, contextualised for Tayside, and local trends that we have identified through the Tayside Drug Death Review Group. By providing a shorter but more specific report we aim to provide concise relevant information that has the greatest potential to impact wider preventative work in this field. This report provides: A brief overview of the work of the Tayside Drug Death Review Group Summary statistics for fatalities of drug deaths Overview of current and emerging trends Key recommendations Future work of the Tayside Drug Death Review Group 3

4 2. Overview of the Tayside Drug Death Review Group The Tayside Drug Death Review Group comprises representation from multiple agencies across Tayside including: NHS Tayside (Public Health, Substance Misuse Services, Primary Care, Pharmacy, Prisoner & Police Custody Healthcare); Police Scotland; Third Sector organisations; Community Justice; Children & Families Service; the three Tayside ADPs. A full list of membership is given in Appendix 1. Suspected drug deaths are notified to the Health Intelligence team within NHS Tayside Public Health. Details are then collected from partner agencies, assimilated and subsequently reviewed by the Tayside Drug Death Review Group to determine if the case should be considered a drug death or not and to identify any emerging trends and key themes to inform strategic work going forward. Specific areas of feedback in relation to a reviewed case are provided directly by the Tayside Drug Death Review Group to the service involved, where appropriate. Recommendations identified by the Tayside Drug Death Review Group inform the work of the Tayside Overdose Prevention Subgroup and are presented to each of the three ADPs in Tayside. The Tayside Overdose Prevention Subgroup is a multi-agency operational subgroup of the Tayside Drug Death Review Group which works to develop and implement a range of preventative approaches to overdose across Tayside. 2.1 Definition of a Drug Death The methodology of the drug death review process in Tayside relies on case finding and subsequent data collection being initiated by Police Sudden Death reports. Deaths directly resulting from the presumed non-intentional overdose of illicit (or illicitly obtained controlled) substances in Tayside are included and considered. It is acknowledged that there are complex cases where the cause of death cannot be explicitly related either to the consumption of a substance(s) or to other health causes. In such cases, the Tayside Drug Death Review Group considers the individual case, including the results of post-mortem toxicology, and comes to a judgment in relation to the contribution of the substance(s) to the death. Where, on review, toxicological findings indicates the presence of a controlled substance, but this substance may not necessarily have been a crucial factor contributing to the individual s death, this would be considered a drug-related death but not a drug death and therefore not be included as a confirmed case for the purposes of the Tayside Drug Death Review Group. Of note, the use of the definition for a drug death by the Tayside Drug Death Review Group is subtly different to that of a drug-related death used by the National Records of Scotland for their annual report. 1 The National Records of Scotland uses the ICD 10 classification system 2 to identify cases of drug-related death once a death certificate has been issued. However, if a similar system were to be introduced for the Tayside Drug Death Review Group, this would involve a delay of up to six weeks 1 National Records of Scotland. Drug-related deaths in Scotland in Published 3 July Accessible from 2 World Health Organisation's (WHO) International Classification of Diseases, Tenth Revision (ICD-10) 4

5 prior to starting the initial data collection whilst the post-mortem result was awaited. Furthermore, the National Records of Scotland, in their definition, will include deaths that have occurred where an illicit substance has been present on toxicology at post-mortem but that it was not considered to have had any direct contribution to the death, for example where a person has died as a result of suicide. In Tayside, these fatalities are considered by the Tayside Suicide Prevention Group. Therefore, by using a slightly different definition to that of the National Records of Scotland the numbers will not be directly comparable across this report to that of the national report. However, by continuing to use the definition for a drug death (as opposed to a drug-related death) we have the potential to work more reactively to emerging trends (as we are relying on police notifications and not ICD-10 coding). We can also consider deaths that have occurred as the result of a nonintentional drug overdose specifically, and can compare year-on-year trends for the local population using the information gathered on drug deaths in Tayside previously. Occasionally in the report, drug-related deaths are referred to when considering the national context. The distinction between drug deaths as reported by the Tayside Drug Death Review Group and drug-related deaths reported in the National Records of Scotland, Drug-related deaths in Scotland in 2017 will be made clear by the use of footnotes to highlight the use of national drugrelated statistics where applicable. 5

6 3. General findings 3.1 Incidence of Drug Deaths In 2017 there were a total of 73 drug deaths in Tayside, compared to 56 in 2016, with the greatest number of deaths occurring in Dundee City (table 1). Table 1: Tayside drug death casualties by local authority area of residence, 2017 Local authority area Number of deaths Angus 14 Dundee City 51 Perth & Kinross 8 Tayside total 73 For national context, the NHS Board area with the highest rate of drug-related deaths, averaged across , was Greater Glasgow and Clyde (0.19 per 1,000 population). The next highest was Tayside (0.15). 4 The Scottish average was Within Tayside, by local authority area, the rate for Dundee was 0.25 per 1,000 population, and the highest of all local authority areas in Scotland. Angus was 0.11 and Perth and Kinross was When considering the average drug death rate by council area for , relative to estimated problem drug user numbers in 2012/13 (most recent estimated numbers available), Dundee was 11.6 per 1,000 problem drug user (11 th overall in Scotland), Angus was 14.6 (4 th overall) and Perth and Kinross was 6.4. The Scottish average was Drug death trends over time The number of drug deaths over the past ten years have been increasing both locally (chart 1) and nationally. In Scotland in 2007 there were 479 drug-related deaths; in 2017 the number was Using 5-year moving averages, the number of drug-related deaths in NHS Tayside between and increased by 135% and similar increases were seen in NHS Lothian (138%), NHS Ayrshire and Arran (134%) and NHS Fife (153%). 3 A moving 5-year annual average is used to smooth out any fluctuations that may occur on a year-to-year basis 4 National Records of Scotland. Drug-related deaths in Scotland in Published 3 July Accessible from 6

7 Age in years Number Chart 1: Confirmed drug death numbers, Tayside and local authority areas, and Tayside 5 year moving average Tayside Angus Perth & Kinross Dundee City Tayside 5 year moving average 3.3 Demographics The mean age of drug death casualties in Tayside in 2017 was 38 years, slightly less than 2016 (39.1 years). The general trend however has been one of increasing age (chart 2). Chart 2: Tayside drug deaths: mean age at death, Year 7

8 Number ratio male: female In each of the past nine years more males than females were casualties of a drug death. Of the 2017 drug deaths, 55 were male and 18 female (chart 3). Expressing these deaths as a ratio of number of males per 1 female death: In years 2009 to 2014, the ratio has been under 3 males for every female drug death In years 2015 to 2017 the ratio has been greater than 3 males for every female drug death, with the greatest discrepancy between male and female numbers in 2016 (ratio 3.7 males to every female) Chart 3: Number of Tayside drug deaths by gender, 2009 to 2017, and ratio males to females male female ratio male:female Tayside has shown a greater percentage increase in drug deaths that have occurred in males than females over time as demonstrated in Table 2. This contrasts with the national figures for drugrelated deaths 5 which showed a greater increase in drug-related deaths in females compared to males. Table 2: Tayside drug deaths percentage increases over time by gender Annual average Number in 2017 % increase over time Persons % Male % Female % 5 National Records of Scotland. Drug-related deaths in Scotland in Published 3 July Accessible from 8

9 There is a clear inequality gradient associated with drug deaths, with more than half of drug deaths occurring in areas of greatest socioeconomic deprivation (table 3). Table 3: Tayside drug deaths by deprivation, 2017 SIMD 2016* Number Percentage 1 (most deprived) 37 51% % % % 5 (least deprived) <5 - Unknown <5 - *Scottish Index of Multiple Deprivation, 2016, Scottish Government 3.4 Location of death The majority of drug deaths in 2017 occurred in a dwelling (table 4). Of the 73 individuals who died, 51 (70%) died in their own homes while 17 (23%) died at an address different to their usual place of residence. Five (7%) individuals died elsewhere including hostels, hospital or prison. Table 4: Tayside drug deaths by location of death, 2017 Place of death Number Percentage Hospital/A&E <5 - Hostel/supported accommodation <5 - Others home % Own home % Prison <5-3.5 Adverse Childhood Experiences Evidence shows that adversity suffered in childhood can have a significant impact on future adult health and health harming behaviours 6. The most common adverse events experienced by casualties of drug deaths in 2017 are indicated in table 5. Given that these figures are contingent on reporting mechanisms - and not all adverse childhood experiences for all casualties of a drug death will be recorded - these figures will inevitably be an underestimate of the true exposure to adverse childhood events experienced by casualties of drug deaths. Of the 2017 drug death casualties, 27 experienced at least one adverse childhood event, with 15 experiencing two or more. Of note, 22 (30%) of the casualties of a drug death had started using drugs under the age of 16, some as young as 10, and this may be directly related to adverse experiences earlier in their lives. 6 Scottish Public Health Network (ScotPHN) 'Polishing the Diamonds'. Addressing Adverse Childhood Experiences in Scotland (Sarah Couper and Phil Mackie), May

10 Table 5: Adverse childhood experiences (ACEs) of drug death casualties Number Percentage Parents separated/divorced % Unstable schooling situation % Regular contact with only one parent % Unstable residential situation % Parent(s) with substance misuse/mental health issue(s) % Physical abuse/violence % Sexual abuse 7 9.6% Death/suicide of a parent/close relative <5-3.6 Adverse experiences in adulthood The most common adverse experience in adulthood was experiencing periods of incarceration (n=37, 51%), closely followed by problems with ill-health (table 6). Some individuals experienced multiple adverse events. Table 6: Adverse events in adulthood Number Percentage Ill-health/deterioration/recent diagnosis 32 44% Relapse 10 14% Mothers with children looked after elsewhere 10 14% Fathers who had no contact with children 11 15% Periods of incarceration 37 51% Periods of homelessness/unstable accommodation 19 26% Breakdown of a significant relationship 8 11% Bereavement including suicide* 22 32% 8 11% Lost friends or family to deaths due to substance misuse Sexual abuse 7 10% *Bereavement includes the deaths due to substance misuse also listed separately Again, it is likely that these numbers are an underestimation of the true impact of adverse life events in adulthood for casualties of a drug death. 3.7 Concurrent mental health problems Mental health issues are common amongst people who misuse substances. Individuals can, and do, suffer from multiple psychiatric difficulties and may have multiple diagnoses. Eighty nine percent (n = 65) of the 73 drug death casualties had suffered from a mental health issue at some point in their lives, with 54 individuals known to be suffering from an existing mental health condition at the time of death. Of these, 36 (49 %) suffered from more than one issue at the time of death. The most common mental health problem, as in previous years, was depression (n = 42; 58%), followed by anxiety (n = 35; 48%). 10

11 3.8 Criminal justice and offending As was the case in previous years, the drug death casualties of 2017 had, on the whole, significant criminal histories. Although information is incomplete for this section, analysis of past convictions, arrests and incarcerations showed that: 57 of the 73 individuals (78%) had been convicted of a crime at some point in their lives. In 5 of these cases (7%), it was known that the individual had been arrested, at least once, in the six months prior to their death. Of those who died in 2017, more than half (51%, n=37) were known to have served a prison sentence at some point during their lives. Thirteen of these individuals (35%) had been in prison in the 12 months before their death. It is highly likely that a high proportion of the individuals were imprisoned for a reason directly or indirectly related to their substance misuse, for example to fund their drug misuse. For those who had been incarcerated, table 7 shows the time elapsed since their most recent release from prison. Table 7: Number of 2017 drug deaths occurring following prison release Time since most recent prison release Number of drug death casualties 0-90 days months months <5 More than a year 16 Unknown Contact with substance misuse services More than half of drug death casualties were not attending or waiting and had not been referred to specialist drug services at time of death (table 8). Table 8: Contact with specialist drug treatment services Number Percentage In contact with specialist drug treatment services at time of death 28 38% At time of death, not attending or waiting and had not been referred 39 53% At time of death, on waiting list for Specialist drug treatment service <5 - In the 6 months prior to death, had been referred but did not attend <5-3.9 Impact on children Losing a parent to a drug death represents a significant adverse life event for a child and places them at increased risk themselves for harm and substance misuse in later life. In 2017: 40 (55%) of drug death casualties had children 79 children (including adult children) lost a parent to a drug death At the time of their death, 22 individuals (30%) had children under the age of 16 (31 children) 11

12 3.10 Summary This section illustrates the significant adversity experienced by people with problematic drug use in terms of socioeconomic deprivation, offending, adverse childhood and adult experiences, co-morbid physical and mental health issues, adult and child safeguarding and wellbeing issues. To reduce the incidence of drug deaths in future requires the input from multiple organisations and agencies working with individuals, families and communities affected to address these complex needs. 12

13 4. Substance-specific Findings The mean number of substances found in toxicology was 5 (range 2 11). The most common groups of substances found on toxicology at post-mortem were opioids, benzodiazepines and gabapentinoids (chart 4). Chart 4: Substance grouping within toxicology (n) Opioids Benzodiazepines Gabapentinoids Other Antidepressants 54 Cannabis Cocaine 106 The drugs included in each category in chart 4 are as follows: Opioids include buprenorphine, codeine, dihydrocodeine, fentanyl, methadone and morphine. Benzoidiazepines include alprazolam, clobazam, diazepam, diclazepam, etizolam, lorazepam, lormetazepam, oxazepam, phenazepam and temazepam. Gabapentinoids include gabapentin and pregabalin. Antidepressants include amitriptyline, citalopram, fluoxetine, mirtazapine, sertraline and venlafaxine. Other included all other substances not categorised above, where n 5: olanzapine, paracetamol, tramadol and zopiclone. This is further detailed in figure 1 which shows the number and percentage of the main individual substances found in the toxicology of drug death casualties. Fentanyl was detected in fewer than five cases. 13

14 Figure 1: Main substances found in toxicology (where n >= 6) Substance Class Number % of confirmed DD (n = 73) Morphine Opioid % 6-MAM Heroin metabolite (recent use) % Codeine Opioid % Etizolam Atypical benzodiazepine % Methadone Opioid % Pregabalin Gabapentoid % Cannabis metabolite Metabolite % Diazepam Benzodiazepine % Mirtazapine Antidepressant % Gabapentin Gabapentoid % Alprazolam Benzodiazepine % Cocaine/cocaine metabolites Stimulant % Dihydrocodeine Opioid % Amitryptiline Antidepressant % Oxazepam Benzodiazepine % Olanzapine Anitpsychotic 7 9.6% Paracetamol Analgesic 7 9.6% Sertraline Antidepressant 7 9.6% Temazepam Benzodiazepine 6 8.2% Of note, not all substances detectable on toxicology can currently be tested for by clinical services. Opioid, gapentinoid and benzodiazepines More detailed analysis was done of drug deaths which had an opioid (heroin/methadone) plus a gabapentinoid (pregabalin/gabapentin) plus a benzodiazepine (typical or atypical). The total number of deaths with all three substance types in the toxicology was 41 (56.2%). The three substances that appear to be at greatest risk of diversion are diazepam, gabapentin and pregabalin. Of the 23 deaths where gabapentin was found in toxicology it had not been prescribed to 18 of the casualties. Of the 31 deaths where pregabalin was found, it had not been prescribed to 19 of the casualties. Of the 29 deaths where diazepam was found, it had not been prescribed to 23 of the casualties. Cocaine The mean age of drug death casualties where cocaine was present in the toxicology (n = 10) was 34.7 years, a slightly younger mean age than for overall drug deaths (38 years). All were male. 14

15 4.1 Trends in substances implicated in drug deaths The proportion of drug deaths where etizolam, pregabalin, alprozolam and cocaine were listed in the cause of death have increased markedly between 2015 and 2017 (chart 4). Chart 4: Drugs stated in Post Mortem cause of death by number of drug deaths and as a percentage of deaths (in table) (The total number of drugs deaths for the years shown was: 48 in 2015, 56 in 2016 and 73 in 2017.) 4.1 Naloxone Naloxone was administered to fewer than 5 out of 73 drug death casualties, by a family member or friend using take home Naloxone. Five individuals were administered emergency Naloxone by paramedics. 15

16 5. Recommendations The number of drug deaths is increasing nationally and globally and therefore altering this trend locally will be extremely challenging. However, organisations in Tayside have the ability and expertise to further develop plans to reduce the risk of people dying as a result of drug use in future. Based on the review of fatalities that have occurred in 2017 and the key characteristics and evolving trends noted in chapters 3 and 4, the recommendations of the Tayside Drug Death Review Group are as follows: GENERAL FINDINGS Develop and implement a plan to foster resilience from substance related harms in communities with high levels of socioeconomic deprivation. Ensure all people closely affected by a drug death are offered the opportunity to engage with and be provided with appropriate psychosocial support. Of particular concern is the impact of a drug death on any children in the family and every effort should be made to support children affected at this time to reduce the trauma incurred and the risk of the inter-generational problematic substance use occurring. Develop and implement a plan to ensure specialist substance misuse services, and those beyond, are resourced and have staff with the relevant competencies to assess patients with problematic drug use holistically and manage complex needs and risks. Develop and implement a plan to support services to work in an integrated structure to assess and manage complex needs and risks. Support prison and police custody services to provide safe patient-centred care for both those already known to substance misuse services and also individuals identified as being under the influence of substances who wish to take up support. Support innovation and research to reduce risk of drug deaths in future, including in relation to substance specific findings below. SUBSTANCE SPECIFIC FINDINGS Ensure oral fluid testing and urine drug screening is available for all opiate substitution treatments and substances identified in drug deaths, in particular gabapentin, pregabalin and benzodiazepines (both typical and atypical). Develop and implement a plan to reduce diversion of GABA agonists* present in drug deaths that are listed in the British National Formulary, in particular pregabalin, gabapentin, diazepam 16

17 and alprazolam, oxazepam and temazepam. This plan should be cognisant of the guidance, Quality Prescribing for Chronic Pain, a Guide for Improvement and the Chief Medical Officer s annual report Practising Realistic Medicine 8. Develop and implement a plan to understand and reduce the supply of cocaine and atypical benzodiazepines, including the emerging role of internet supply. Ensure that all people in contact with services with substance use related to GABA agonists, opioids and stimulants have an overdose risk assessment and management plan and, where appropriate, be offered overdose awareness training and naloxone annually. Ensure that the availability of naloxone continues to be widened, with all professionals who work with people with problematic drug use supported to be able to carry, administer and issue naloxone, as appropriate. Carers and significant others should also be offered training in how to administer naloxone. Design and develop a harm reduction messaging campaign to raise awareness of emerging drug death trends (including the increased risk associated with concurrent opioid and GABA agonist use, and cocaine) in the population and health and social care staff. Ensure there is sufficient staff with relevant competence to prescribe opioid substitution therapy (OST). This will facilitate timely access to and quality of OST provision. *GABA agonists are drugs that act on the gamma-aminobutyric acid receptor in the brain and include gabapentinoids and benzodiazepines. 7 NHS Scotland and the Scottish Government. Quality Prescribing for Chronic Pain. A Guide for Improvement Accessible from: Chronic-Pain-Quality-Prescribing-for-Chronic-Pain-2018.pdf 8 Scottish Government. Practising Realistic Medicine:CMO for Scotland Annual Report. Accessible from: 17

18 6. Future aims of the Tayside Drug Death Review Group The Tayside Drug Death Review Group recognises the value of sharing information about emerging drug trends and related health harm promptly to partners and the wider public and this is currently the principal focus of the Group s work. This past year processes have been reviewed and changed, extra meetings have been convened and the time between notification of a suspected drug death to time of review has been reduced. Our aim moving forward is to produce an annual report similar to this in future years, but published earlier in the year, in addition to quarterly reports to the ADPs to identify and report on emerging trends more rapidly. We want to strengthen the support we provide to ADPs and recognise the prompt collation, assimilation and dissemination of information concerning drug deaths is integral to achieving this. Tackling the concerning rise in the number of drug deaths must be a priority for everyone. These are potentially avoidable deaths that are occurring as a result of a wide range of factors far more complex than simply what substances a person may or may not be taking. We look forward to hearing the observations and recommendations of the Dundee Drugs Commission and will continue to work with partner agencies to develop and improve the work of the Tayside Drug Death Review Group in future. People should not be dying as a result of drug use and we are committed to seeing these current trends changed. 18

19 7. Appendix 1 -Tayside Drug Death Group Members 2017 Dr Emma Fletcher, Consultant of Public Health Medicine, NHS Tayside (Chair from September 2017) Dr Drew Walker, Director of Public Health, NHS Tayside (Chair until September 2017) Ms Shiona Tasker, Senior Public Health Officer, NHS Tayside Constable Kim Adams, Prevention Hub, Police Scotland Mrs Isla Anderson, Personal Assistant, Tayside NHS Board (Note taker) Mr Robert Bain, Clinical Team Manager Learning Disabilities, NHS Tayside Mr David Barrie, Service Manager, Access Service, Addaction, Dundee Dr Roberto Cotroneo, Consultant Psychiatrist, Integrated Substance Misuse Service Dr Fiona Cowden, Consultant Psychiatrist, Integrated Substance Misuse Service Mrs Jillian Galloway, Head of Primary Care Development, NHS Tayside Ms Louise Glover, Assistant Team Leader. Drug and Alcohol Team, Perth & Kinross Council Mr Alessandro Insalaco, Team Manager (Temporary), Dundee Health & Social Care Partnership Mr Daniel Kelly, Team Manager, Harm Reduction Services, The Cairn Centre Ms Laura Kerr, Lead Officer Alcohol & Drugs (Tayside) Inspector Nicola McGovern, Police Scotland Mr Liam McLaughlin, Development Officer, Perth & Kinross Alcohol and Drug Partnership Ms Karen Melville, Principal Pharmacist, Integrated Substance Misuse Service Ms Gael Murphy, Senior Charge Nurse/Clinical Improvement, Dundee Substance Misuse Service Mr Colin Paton, Team Leader, Drug and Alcohol Team, Perth and Kinross Council Mr Grant Paterson, Team Manager, Criminal Justice Service, Dundee City Council Mr Stuart Payne, Area Service Manager Dundee, Scottish Ambulance Service Mr Muhammad Sadiq, Procurator Fiscal Depute, Crown Office & Procurator Fiscal Service Mr Graeme Shand, Senior Charge Nurse Clinical Improvement, Angus Integrated Drug and Alcohol Recovery Service Dr David Shaw, General Practitioner, Erskine Practice, Dundee Mr Neil Sneddon, Team Manager, Drug, Alcohol and BBV Team, Dundee City Council Mr Brian Stephens, Outreach Nurse Specialist in Hepatitis, NHS Tayside Dr Michelle Watts, Associated Director Primary Care, NHS Tayside Ms Marion Wilson, Acting Team Leader, Substance Misuse and HMP Open Estate Ms Jill Wright, Nurse Team Leader, Integrated Substance Misuse Service 19