NHS Health Scotland



G .Evidence for effectiveness of harm-reduction services and improved uptake of treatment and support services (Recovery Model)


There is highly processed and review-level evidence of the effectiveness of harm reduction services such as IEP, THN, ORT and provision of foil, to prevent or reduce the significant harms associated with problem drug use, including bloodborne viruses and drug-related deaths. Harm reduction services have immediate public health benefits and are widely acknowledged to contribute to engaging and promoting recovery programmes.


Injecting equipment provision (IEP)

There is highly processed evidence from NICE public health guidance on needle and syringe programmes (2014) that states:

The main aim of needle and syringe programmes is to reduce the transmission of blood-borne viruses and other infections caused by sharing injecting equipment, such as HIV, hepatitis B and C. In turn, this will reduce the prevalence of blood- borne viruses and bacterial infections, so benefiting wider society. Many needle and syringe programmes also aim to reduce the other harms caused by drug use and include:

  • advice on minimising the harms caused by drugs
  • help to stop using drugs by providing access to drug treatment (for example, opioid substitution therapy)
  • access to other health and welfare services.

NICE public health guidance PH52 (2014), which updates and replaces NICE public health guideline 18 (published on February 2009  and available from: ww.nice.org.uk/guidance/ph18) has 10 recommendations:

  • consult with and involve users, practitioners and the local community
  • collate and analyse data on injecting drug use
  • commission both generic and targeted services to meet local need
  • monitor services
  • develop a policy for young people who inject drugs (To note: under-16s are not currently included in Scottish Injecting Equipment Guidelines)
  • provide a mix of services
  • provide people with the right type of equipment and advice
  • provide community pharmacy-based needle and syringe programmes
  • provide specialist (level 3) needle and syringe programmes
  • provide equipment and advice to people who inject image- and performance- enhancing drugs.

The guidance outlines a number of factors and issues it took into account when developing the recommendations and updating the guidance:

  • Needle and syringe programmes (NSPs) need to be considered as part of a comprehensive substance-misuse strategy that covers prevention, treatment and harm reduction.
  • The remit of this guidance was to consider the optimal provision of NSPs, not whether or not these programmes should be provided. Evidence from systematic reviews shows that NSPs are an effective way to reduce many of the risks associated with injecting drugs.
  • Public Health Intervention Advisory Committee (PHAC) emphasised the important 'gateway' function that NSPs may perform in bringing people who inject drugs into contact with a range of services. In particular, NSPs may bring them into contact with services that may help by:
    • emphasising the dangers of overdosing (about 1% of people who inject drugs die of an overdose each year)
    • encouraging people to switch to less harmful forms of drug taking
    • encouraging people to opt for opioid substitution therapy
    • encouraging people to stop using drugs
    • encouraging people to be tested and treated for hepatitis C and HIV
    • encouraging people to address their other health needs.

PHAC considered a summary of the findings from the health economic modelling undertaken for the original guidance. This showed that providing people who inject opioid drugs with sterile injecting equipment is estimated to be cost-effective from an NHS/personal social services (PSS) perspective (that is, excluding the costs of crime). It is similarly cost-effective from a societal perspective. If the indirect  'gateway' effects of needle and syringe programmes – of increasing the proportion of people who inject drugs who take up opioid substitution therapy, or take part in other drug treatment – are included, a fall in the number who inject drugs is likely. This would, in turn, lead to a reduction in crime. If that is the case, modelling shows that these programmes are likely to be cost-effective in the longer term. However, the figures in relation to the size of the 'gateway effect' are subject to considerable uncertainty, as are figures relating to any effect that an increase in needle and syringe programmes will have on the number of people injecting drugs. [1]


Take-home naloxone (THN)

Naloxone is an opioid antagonist, which temporarily reverses the effects of heroin and other opioids, it has no intoxication effects and no abuse potential. Naloxone is recommended as an intervention to prevent overdose by the World Health Organization as an essential medicine and is already used by the emergency services. In their review of UK and international evidence on the effectiveness of naloxone provision the ACMD (2012) recommends that naloxone should be made more widely available to tackle the high numbers of fatal opioid overdoses in the UK. The report highlights the educational and public health benefits, in that the provision of naloxone will widen awareness of the risks opioid overdose, and emphasises the importance of basic life support training as part of the package of interventions to prevent opioid overdose.

The ACMD (2012) report on the consideration of naloxone notes that risks and concerns regarding the provision of naloxone programmes potentially increasing drug using risk(s) are not supported by evidence. The report cites literature (see Gaston et al 2009) that participants in naloxone programmes have been found to have an ‘increase in self efficacy and more insight in relation to personal safety and health’. [2]

Opioid replacement therapy (ORT)

In their commissioned independent expert review of the place of ORT for the Chief Medical Officer for Scotland [3],  the Drug Strategy Delivery Commission (DSDC) (2013) cite consistent conclusions from systematic reviews that ORT is effective treatment for opioid dependency and is associated with improved retention in treatment, reduced illicit heroin use and reduced risk of harm related to injecting and transmission of BBVs. Less consensus from the systematic reviews is noted in relation to positive effects on criminal activity and mortality. Factors identified with positive outcomes are treatment dose and quality of therapeutic relationships. The DSDC authors conclude that despite the limitations noted in the quality of research the benefits to physical health and reduction in BBVs is strongly supported by the evidence. The final report of the independent review makes 12 recommendations, including the following:

  • Opioid replacement is an essential treatment with a strong evidence base. Its use remains a central component of the treatment of opiate dependency and should be retained in Scottish services.
  • In all settings, ORT should be delivered as part of a coherent person-centred recovery plan with SMART (Specific, Measurable, Attainable, Relevant, Time-bound) goals and based upon an assessment of individual recovery capital.
  • The quality of ORT should be governed and delivery should be in line with national standards and guidance. NHS Medical Directors should hold this responsibility on behalf of local partnerships.
  • Fit-for-purpose information systems should be able to identify individuals on this care pathway and objectively demonstrate what progress is being made.

The provision of foil
In their report considering the provision of foil as a harm reduction intervention, the ACMD (2010) [4] concluded the balance of benefit favours exempting foil from Section 9A of the Misuse of Drugs Act 1971.  

The following was provided as rationale:

  • There is no evidence of harmful effect of the provision of foil; previous studies indicate that the intervention does not encourage the use of illegal drugs.
  • Potential benefits include:
    • Potential for decrease in BBV transmission.
    • Increased contact and engagement with drug services.
    • Reduced systemic infections.
    • Reduced soft tissue and venal damage.
    • Lower risk of overdose.
    • Reduced litter.
    • The ACMD noted the provision of foil is specifically designed to move individuals away from injecting.

(Reference to the ACMD’s previous recommendations on drug paraphernalia are also included in the report – namely to amend the misuse of drugs legislation to permit the supply of swabs, bowls, spoons, stericups, citric acid and water for injecting (May 2001) and filters (May 2003) – these recommendations were accepted by government and changes made by secondary legislation -Regulation 6A of the 2001 Regulations.)

On 5 September 2014 a statutory instrument was announced as a change to the Misuse of Drugs Regulations 2001 to authorize, subject to strict conditions, the lawful supply, or offer to supply, of foil by persons employed or engaged in the lawful provision of drug treatment services. [5]

 “The legislation only refers to a ‘treatment plan’ but the clear ambition of the drug strategy and of the Home Secretary in allowing for the provision of foil is that this will be treatment aimed at recovery from dependence, not only the reduction of harm. A treatment plan is not a requirement at the stage when steps are being taken to engage a patient in treatment.

Although not covered in the legislation, the expectation is that in the vast majority of cases foil will be provided at the early stages to engage a patient into treatment, or at a time when a patient has been assessed and commenced treatment but has yet to stop taking drugs. However, it is also recognized that there may be exceptional circumstances when provision of foil may be necessary later in a patient’s treatment at a time when they are at risk of a relapse to help them avoid returning to injecting.”

NICE Clinical Guidelines for Drugs Misuse: Psychosocial Interventions' (CG51) key priority for implementation [6]:

  • Opportunistic brief interventions focused on motivation should be offered to people in limited contact with drug services (for example, those attending a needle and syringe exchange or primary care settings) if concerns about drug misuse are identified by the service user or staff member.
  • Drug services should introduce contingency management programmes to reduce illicit drug use and/or promote engagement with services for people receiving methadone maintenance treatment, with incentives offered based on regular screening and concordance with, or completion of interventions to improve physical health (e.g. hepatitis B/C and HIV testing; hepatitis B immunisation; tuberculosis testing)

There is review-level evidence of the effectiveness of screening and brief interventions for secondary prevention of drug use in multiple settings. Results from one study found brief interventions in a clinical setting can reduce cocaine and heroin use (even without meaningful contact with the treatment system). There is evidence from single studies that motivational interviewing is effective in students to reduce cannabis, alcohol and tobacco use and to reduce consumption among regular amphetamine users. Limited evidence of effectiveness of the impact of GP and primary-care-based brief interventions to reduce excessive benzodiazepine use and other illicit drugs.

Evidence of effectiveness of brief interventions with adolescent school-aged children is less conclusive, with limited studies finding mixed results in reducing drug use. [7]


Scottish policy and practice note

The Sexual Health and Blood Borne Virus Framework (2011–2015) [8] combines areas of work surrounding sexual health, HIV, hepatitis C and hepatitis B. It is a multi-agency, cross-agenda approach based on five high-level outcomes:

Outcome 1: Fewer newly acquired blood borne virus and sexually transmitted infections
Outcome 2: A reduction in the health inequalities gap in sexual health and blood- borne viruses.
Outcome 3: People affected by blood-borne viruses lead longer, healthier lives
Outcome 4: Sexual relationships are free from coercion and harm
Outcome 5: A society where the attitudes of individuals, the public, professionals and the media in Scotland towards sexual health and blood-borne viruses are positive, non-stigmatising and supportive.


Guidelines for services providing injecting equipment: Best practice recommendations for commissioners and injecting equipment provision (IEP) services in Scotland (2010) [9]
These guidelines aim to provide a consistent framework which can be used across
Scotland to support the delivery of IEP services. The objectives of the guidelines are:

  1. To promote good practice in relation to the planning and development of IEP
  2. To improve the accessibility of sterile needles, syringes and other injecting equipment to injecting drug users who are at risk of acquiring HCV and other BBVs
  3. To improve the quality and consistency of IEP services
  4. To promote integration between IEP services and other services for injecting drug users, including primary, secondary and social care services
  5. To ensure that local areas are taking active steps to protect the health and safety of IEP service staff and clients, and the community in relation to the disposal of used injecting equipment.


A National Take Home Naloxone Programme [10] has been centrally funded by the
Scottish Government since June 2011. Local programmes have been developed in
29 out of 30 Alcohol and Drug Partnerships in Scotland.

Scottish Government investment in the programme provides

  • A national coordinator and training and development officer based at the Scottish
    Drugs Forum (SDF)
  • Continued support to Alcohol and Drug Partnerships and Health Boards in the development of their local programmes
  • Training, information and awareness materials
  • Reimbursement to Health Boards for kits issued
  • A national monitoring and evaluation programme based at NHS ISD Scotland.

Further information can be found here: www.sdf.org.uk/index.php/drug-related-deaths/take-home-naloxone-thn-overdose-intervention-training/ or www.naloxone.org.uk

NHS Scotland Strategy for workforce education and development related to BBV service delivery (2014) The strategy, developed by NHS Education for Scotland (NES) in partnership with stakeholders at the request of the Scottish Government, is to support implementation of the Scottish Government Sexual Health and Blood Borne Virus Framework 2011–2015 within NHS Boards through cohesive workforce education and development activity.


It specifically focuses on the blood-borne virus (BBV) (HIV, hepatitis C and hepatitis B) elements of the national framework, reflecting sexual health issues only as they relate to BBVs. Available online at:



  1. National Institute for Health Care Excellence (NICE, 2014) public health guidance 52: needle and syringe programmes. London: NICE.

  2. Advisory Council on the Misuse of Drugs (ACMD, 2012) Consideration of naloxone. London: ACMD.

  3. Scottish Drugs Strategy Delivery Commission (DSDC, 2013) Independent Expert Review of Opioid Replacement Therapies in Scotland. Scottish Government. Available from (external link): www.scotland.gov.uk/Publications/2013/08/9760

  4. Advisory Council on the Misuse of Drugs. Consideration of the use of foil, as an intervention, to reduce the harms of injecting heroin. London: ACMD; 2010.

  5. Home Office Circular 014/2014: lawful supply of foil. Available from (external link):: https://www.gov.uk/government/publications/circular-0142014-lawful-supply-of-foil

  6. National Institute for Health Care Excellence (NICE, 2011) Clinical Guidelines 51: Drugs Misuse: Psychosocial Interventions. London: NICE.

  7. Strang, J. Babor, T. Caulkins, J. Fischer, D. Humphreys, K. (2012) Drug policy and the public good: evidence for effective interventions. Addiction 2 Series. The Lancet. 2012, page 379.

  8. Scottish Government (2011-15) The Sexual Health and Blood Borne Virus Framework. Edinburgh: Scottish Government. Available from (external link) : www.scotland.gov.uk/Publications/2011/08/24085708/0

  9. Scottish Government (2010) National guidelines for services providing injecting equipment, Edinburgh: Scottish Government. Available from (external link) : www.scotland.gov.uk/Publications/2010/03/29165055

  10. Scottish Government (2012/13) A National Take Home Naloxone Programme. Edinburgh: Scottish Government. Available from (external link) : www.scotland.gov.uk/Topics/Justice/law/Drugs-Strategy/drugrelateddeaths/NationalNaloxon