Illegal drug use in Greater Glasgow
David Shewan Research Fellow, Addiction Research Group, Centre for Occupational and Health Psychology, University of Strathclyde
It has been suggested that since 1986 there has been the emergence of a new public health paradigm in respect of drug policy (Stimson, 1990). Proponents of this view have defined the new paradigm as being focused on risk reduction among drug users and especially intravenous drug users, aimed at promoting behavioural change in the desired direction, and as being non judgemental and ‘user friendly’ as regards relationships with clients. It is suggested that the new paradigm has come about largely in response to HIV/AIDS and the associated risks to public health (Stimson, op cit.), a suggestion which is consistent with the view expressed by the Advisory Council on the Misuse of Drugs that the ‘spread of HIV is a greater danger to individual and public health than drug misuse’ (ACMD, 1988). Harm reduction is, in theory at least, now firmly on the agenda, and the view has been expressed that it is becoming ‘the mat alternative drug policy to abstentionism’ (Newcombe, 1990).
Furthermore, in the light of the ACMD report it could be expected that where abstinence is seen as a final but not immediately achievable outcome, the initial priority should be the reduction of high-risk drug using behaviour.
The role of drug services, such as rehabilitation units, health centres, information centres, clinics and hospital-based units is of obvious importance in implementing an approach such as that outlined above. Unfortunately, not enough is known about current policy and practice at the level of service pro-vision and even less about effectiveness. This applies particularly within Greater Glasgow where, despite there being a significant drug problem in the area, there is an apparent lack of a coordinated policy in response to the problem. For example, a Misuse of Drugs and Alcohol Forum has only recently been set up for Greater Glasgow, despite this being a Scottish Office recommendation in 1987 (SHHD, 1987).
The present study does not address the question of effectiveness but instead attempts to provide an overview of current policy and practice; the views of those involved were sought regarding the appropriateness of current policy and practice and what changes, if any, they would like to see occur.
Results from this study should be seen in the context of drug policy in Britain as a whole, and particularly in the light of the recent ACMD recommendations. Certain aspects of drug policy have been identified as having a high priority. Containing the spread of HIV/AIDS in relation to intravenous drug use has been identified as probably the highest priority (ACMD, op cit.). The potential for the virus to be spread through the sharing of equipment has implications not only for the intravenous drug-using population, but also as a means of introducing the virus into sections of the heterosexual population generally (McKeganey et al., 1989; Rahman et al., 1989l Consequently, government policy now recommends provision of needle exchange schemes, along with making available information and advice on safer drug use (ACMD, op cit.) and current government thinking would seem to be working towards ‘the care of the drug user becoming an accepted mainstream responsibility’ (Black, 1990). In addition, the ACMD recognise the importance of creating a broadly based drug service provision which should aim at having a significant impact in making and maintaining con-tact with a wide range of drug users who would not otherwise come into contact with more traditional centralised drug agencies, for example, drug injectors who wish to continue to inject (Newcombe and Parry, 1989).
Much of the current thinking on service provision tends to suggest that a range of options should be made available to cater for the range of requirements of different drug users at different times (Stimson, op cit.). This approach is not, however, favoured by everyone involved in service provision and, even where this approach is favoured, certain options may not be made available, either through lack of resources or for ideological reasons. Drug maintenance programmes, for example, are only feasible for services where a degree of qualified medical input exists. Even then, a degree of discretion is likely to be exercised in terms of who, if anyone, is offered prescribing as an option and the type of prescribing which may then be made available. It could be, for example, that prescribing is based on a reduction pro gramme aimed at abstinence, which is not the same thing as longer-term maintenance prescribing which aims at stabilisation.
In some cases, there will be an insistence on abstinence as a condition of entering treatment and maintenance, therefore, would not be on the agenda. These are clear signs, however, that this debate is now largely driven by issues arising from HIV/AIDS, that containment of the virus is now seen as paramount and that imaginative and innovative service interventions should be developed in order to make and maintain contact with drug users and modify high-risk behaviours (ACMD, op cit.; Black, op cit.; Stimson, op cit.). This should include, where appropriate, maintenance prescribing of injectable drugs, providing the user with a regular supply of pharmaceutically pure drugs. The user is then no longer required to spend time buying impure black market drugs, some of which will be of variable purity and which may have been cut with harmful adulterants. As well as health benefits, the users’ involvement in crime is likely to decrease and their being in contact with agencies is likely to increase the probability that they will take advantages of other services which may be on offer from drug agencies, such as supply of sterile equipment, condoms, health check-ups, and counselling and advice on a range of issues.
The present study was concerned with both pre-scribing and provision of sterile equipment, as well as related areas such as detoxification, provision of condoms, provision of general information regarding drug use and harm minimisation methods, and information and advice regarding safer sex. In addition, where appropriate, the process of inter-agency referral was also looked at.
Methods and Subjects
Data was collected from June-August 1990, by way of postal questionnaire. Services within Greater Glasgow were identified from the latest edition of the Register of Addiction Services in Strathclyde clinics were also contacted. Return rates were as follows:
_Drug agencies ( 15/21 )
_Hospital-based services (¢/¢)
_NHS clinics ( 10/16)
_Health centres (¢/16)
_AIDS units (3/3)
_Social work addictions units (3/3)
Current policy and practice - drug services
Of those services who returned questionnaires, 38/42 had some formalised contact with drug users. In all four cases where there was no contact, the organisation in question was an NHS clinic.
1 Services which did have formalised contact with drug users were asked about current policy and practice in the specific areas listed in Table 1.
Table 2 (columns(a)) summarises by type of organisation the current service provision for the specific areas of drug policy and practice included in the questionnaire.
From Table 2 (columns(a)) it can be seen that overall there is a high level of provision of general information and advice regarding drug use, information and advice on safer drug use, information and advice on safe sex, treatment/counselling and referral to other agencies. The high positive response for a harm reduction approach is perhaps most noteworthy, suggesting that harm reduction is becoming more acceptable to a range of drug organisations.
It is important, however, that specific services are available which enable the drug user to act on the advice given. From the table above, the categories most relevant in this respect are supply of sterile equipment, supply of condoms and availability of pre-scribing (oral only/oral and injectable). As can be seen from the table, generally fewer of the organisation in contact with drug users provided these services. For prescribing (oral only), supply of sterile equipment and supply of condoms, approximately one-third of organisations provided these services for drug users. It is possible that these figures reflect the ability rather than the willingness of organisations to provide these services. It should be noted, however, that the very low incident of provision of both oral and injectable drugs is unlikely to reflect available resources and/or expertise, but is perhaps rather more likely to reflect an overall ideology which would see such a service as encouraging the continuation of intravenous drug use. In addition, most of the pre scribing which took place was occasional and limited to prescription of antidepressants. In other words, during detoxification or as part of a reduction programme rather than as part of the operation of a maintenance scheme.
Most of the organisations saw referral as an option, and tended to list a range of other organisa tions as referral points. It would seem likely that referral would be on the basis of a particular specialist service, but the results don’t show any particular pattern.
Detoxification was an option provided by a relatively small number of organisations, but this is likely to reflect available resources rather than a reluctance to provide this particular service.
Perceptions of the appropriate response - drug services
The 38 organisations already involved in providing services for drug users were asked about whether they considered their current policy and practice to be an adequate response to drug use. Of the 38, 15 organisations thought their current service provision was adequate, while 19 thought it was inadequate and one didn’t know (3 missing cases). Results are shown by organisation in Table 3. Where policy and practice were felt to be inadequate, the most common reason for this tended to be feelings of being constrained by lack of staff and resources, rather than by the ideology of a particular organisation. The 38 organisations were asked which services they thought their organisation should provide for drug users. Results are shown in Table 2.(columns(b))
Chi-squared analysis was carried out to determine if there were any significant difference; between what organisations actually offered and what they thought they should be offering. For the purposes of this analysis all the organisations in contact with drug users were grouped together and a separate chi-squared analysis was performed on each area included in the questionnaire. Significant differences were found in two areas, supply of sterile equipment (chi-squared =8.189, d.f.=1, P <0.005) and supply of condoms (chi-squared =13.328, d.f.=1, P <0.001). In each case, the difference was in the direction of more currently supply. No significant differences were found in other areas.
In the light of the recent ACMD report, current provision of drug services within the Greater Glasgow area would seem to err on the side of conservatism, particularly as regards the availability of maintenance schemes. Of all the categories of services currently on offer perhaps that which refers to providing information about a harm reduction approach is most noteworthy. However, a harm reduction policy should not simply be viewed as good advice of a non-judgemental nature. While appropriate information is central to this approach, it is also important that specific services are available which enable the drug user to act on the advice given.
From Tables 2 and 4, the categories most relevant in this respect are supply of condoms and availability of prescribing (oral only/oral and injectable). As described in the results section above, in general fewer of the organisations in contact with drug users provided these services. However, results concerning perceptions of the appropriate response suggest that at least in respect of supplying sterile equipment and condoms there are a significant number of organisa-tions who would like to do more.
The operation of maintenance schemes would, however, seem to be the exception in Greater Glasgow. Obviously, some organisations might see their providing such a service as impractical, but even where prescribing did occur it was mainly prescribing of antidepressants, during detoxification or as part of a reduction scheme. The very low level of prescribing of injectable drugs is disturbing, as this is a strategy which would seem to have some potential in stabilising users and providing some sort of brake on the spread of HIV/AIDS among the drug using population. There is a slight but non-significant number of organisations who would like to be able to prescribe injectable drugs, but overall the results do seem to suggest an ideological resistance to doing so.
The majority of organisations offering services to drug users indicated their acceptance that generally a harm reduction approach should be on the agenda, supporting the view that harm reduction is becoming more acceptable to a range of organisations (Newcombe, op cit.). It is crucial, however, that this inten tion be matched by the provision of services which enable the drug user to minimise the harm to him- or herself and to society. Otherwise, those involved in shaping policy are merely paying lip service. The ACMD has recommended - among other things - the provision of sterile equipment and condoms and it is encouraging to find the trend as being towards providing these services, although there is still scope for a greater involvement in such schemes.
It is disappointing that there is an apparent lack of any real willingness to offer maintenance schemes as an option for drug users, particularly intravenous drug users. Maintenance is not everything, but experience in Merseyside and elsewhere has shown that it is central to pragmatic and effective drug policy. It is specifically recommended as a useful and valuable option in the ACMD report. Moreover, the ACMD also state that ‘In some cases - a small minority - prescribing of injectable drugs may be necessary to keep the individual in treatment and/or ease the change from injecting the drug of dependence to taking a substitute orally’ (ACMD, op cit., Part 1, p.51). The ACMD report is generally positive towards the provision of prescribing services, including the prescribing of injectables, and accepting of the need for them. It would appear that the same could not be said of drug policy in Greater Glasgow.
Of course, the current prescribing ‘policy in Greater Glasgow will suit some users - probably those who want to stop and are ready to stop. It’s difficult, though to see what it offers in the way of stabilising users, and providing an alternative to black market drugs. This doesn’t mean blank-cheque prescribing - it means that agencies have to provide a full range of service options which cater for the needs of different users at different times.
The onus to explain the current state of affairs regarding maintenance prescribing in Greater Glasgow is on those who can prescribe, but will not pre-scribe. Are their judgements based on moral concerns about whether or not people should use drugs, or do they have a medical and scientific foundation? To put the question another way, how many people believe we can stamp out drugs and make drug users stop when they don’t want to 7 And how many believe that we should instead be prioritising the aim of reducing the negative effects associated with drug use ?
If ideological considerations overrule the possible consequences for public health - especially in connection with HIV/AIDS - then this will have a serious and adverse effect on people’s lives. In simple terms, it is not enough to make and maintain contact only with those drug users who want to give up. Services should exist which enable drug users who want to continue using to do so in a way which minimises harm to themselves and to society.
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This research was supported by the Nuffield Founda tion Social Sciences Small Grants Scheme, grant no.