11 Summary of Conclusions and Recommendations

11.1 A summary of the main areas covered by the report and our conclusions on each are provided in the Overview at the start of the report.

11.2 Our detailed conclusions and recommendations are:

Basic Principles

1. The spread of HIV is a greater danger to individual and public health than drug misuse. Accordingly, we believe that services which aim to minimise HIV risk behaviour by all available means should take precedence in development plans. (2.1)
2. We must be prepared to work with those who continue to misuse drugs to help them reduce the risks involved in doing so, above all the risk of acquiring or spreading HIV. (2.2)
3. A change in professional and public attitudes to drug misuse is necessary as attitudes and policies which lead to drug misusers remaining hidden will impair the effectiveness of measures to combat the spread of HIV. (2.3)
4. Prevention of drug misuse is now more important than ever before and in the longer run the success or failure of efforts to prevent young people from embarking on a career of drug misuse will have a major effect on our ability to contain the spread of HIV. (2.5)

Service Provision

5. In all areas, substantial further expansion of drug misuse services will be necessary if services are to reach more drug misusers and play an effective role in curbing the spread of HIV. (3.10)

Maximising Contact with Drug Misusers

6. The advent of HIV requires an expansion of our definition of problem drug use to include any form of drug misuse which involves, or may lead to, the sharing of injecting equipment. This in turn means that services must now make contact with as many of the hidden population of drug misusers as possible. (4.3)

Community-Based Services

7. A pattern of community-based services should be available in each health district. (4.8)

General Practitioners

8. The advent of HIV makes it essential that all GPs should provide care and advice for drug misusing patients to help move them away from behaviour which may result in them acquiring and spreading the virus. Health authorities should ensure that appropriate support is available and that GPs are made aware of it. (4.10)

9. Clinical attachments by GPs to local specialist drug services should be actively encouraged. Short-term (e.g. 6-12 months) sessional contracts should be available to help build a pool of GPs with this experience. Wherever possible, their medical contribution should be provided with the support and advice of a consultant with special expertise in drug dependence. (4.11)

10. All doctors should receive some training at undergraduate and postgraduate level on the problem and management of drug misuse. Further training for GPs should also be provided at postgraduate level both during the three-year vocational training period and for established practitioners on a regular basis. (4.12)

Hospital-Based Specialist Services

11. If `front-line' services are to be successful in making contact with more drug misusers the support available from hospital-based specialist services will need to be expanded and strengthened. Such support must be available in every District backed up by more specialist Regional support as outlined in the Treatment and Rehabilitation report. (4.16)

12. Hospital-based services should attempt to maximise contact with drug-misusers through: better dissemination of information about the service on offer; flexible opening hours; minimisation of waiting times. (4.17)

Generic Services

13. In the light of HIV, early identification and intervention by agencies which are not drug-orientated but which nonetheless come into contact with large numbers of drug misusers is of heightened importance. (4.18)

14. If drug misusing parents are not to be deterred from seeking help, Social Services Departments should work hard to ensure that drug misuse per se is never, and is never seen as, a reason for separating parent and child. (4.20)

15. Drug services should experiment with a variety of approaches to outreach work and monitor carefully their effectiveness in reaching drug misusers not in touch with services, and in conveying help and advice. (4.29)

Changing Behaviour

16. All services in contact with drug misusers should inform them of the risks of HIV and how they can avoid and reduce these risks both sexual and of injecting. (5.9)

17. All services for drug misusers, including general practitioners, should have the facility to provide free condoms. (5.10)

18. Further syringe exchange schemes should be set up drawing on the experience of the more successful pilot projects. Monitoring of these schemes should continue so that their success in reaching drug misusers and changing their behaviour can be assessed. We emphasise, however, that for some drug misusers behaviour change may take several months to occur and these schemes should not be judged wholly by short-term results. Ultimately they must be judged on lasting evidence of behaviour change. (5.16).

19. Community pharmacists should be encouraged to sell equipment at reasonable cost to injecting drug misusers, and, wherever possible, pharmacists should advise customers about any local exchange facility, encourage the use of condoms, and provide health education and information on local facilities for drug misusers by provision of leaflets and, where possible, by verbal advice. Health authorities should provide pharmacists, on request and free of charge, with disposal facilities for used equipment and pharmacists should encourage customers to return used equipment. (5.17)

20. All syringes should bear an indelible warning about the danger of sharing injecting equipment. The Government should discuss with syringe manufacturers how this can be achieved as soon as possible. (5.18)

21. District Drug Advisory Committees and Local Pharmaceutical Committees should immediately agree a plan for ensuring and advertising the availability of injecting equipment in the light of local circumstances. Local police should be consulted on and should co-operate with the agreed plan, to ensure that police activity does not discourage drug misusers from obtaining sterile equipment and/or returning equipment. (5.19)

22. Antibody testing should be used with caution and only undertaken with informed consent following full counselling. All drug-specialist staff and general practitioners should be equipped to provide this counselling and drug services should normally have the facilities to perform tests. Where testing cannot be done on site there should be a streamlined referral system for testing elsewhere. Being tested for HIV should never be a pre-condition of drug treatment or rehabilitation services. (5.25)

23. A campaign of education and information is needed both nationally and locally. In the long run we believe that sustained publicity and education will prove to be the most important influence on changing behaviour. (5.27)

24. Advice on cleaning injecting equipment should be available in all areas. The advice should make clear that cleaning cannot offer full protection against infection and is no substitute for using clean equipment, but that it can help prevent infection when clean equipment is not available. (5.28)

Prescribing

25. Prescribing can be a useful tool in helping to change the behaviour of some drug misusers either towards abstinence or towards intermediate goals such as a reduction in injecting or sharing. (6.2)

26. Subject to our comments about the levels at which prescribing should take place, the range of acceptable goals towards which drug misusers might move with the help of prescribed drugs should include:

a. the cessation of sharing of equipment;
b. the move from injectable to oral drug use;
c. decrease in drug misuse;
d. abstinence. (6.3)

27. No treatment package should continue indefinitely without review if it is failing to bring about, or sustain, a desirable change. This applies equally to non-prescribing interventions where review should include consideration of prescribing. (6.4)

28. There should be a prescribing element to services in each District and Regional Drug Service which should undertake prescribing along the lines recommended in this report. (6.8)

29. Assessing behaviour and behavioural change will be especially important in cases where prescribing is employed to aid the achievement of intermediate goals which fall short of abstinence. We recommend that wherever possible multi-disciplinary teams should be used in assessing and monitoring behaviour change. (6.9)

30. Different assessment procedures should be introduced dependent on the anticipated treatment including the need for, and length of, prescribing. Where prescribing is concerned, a balance must be struck between easy access to appropriate help and proper safeguards. (6.11)

31. Cases in which prescribing of injectable drugs are being considered should be managed by, or with guidance from, the District or Regional specialist team. (6.13)

32. Only in the most exceptional case would long-term prescribing of injectable drugs be both necessary and effective in combating the spread of HIV. Any such cases should be managed by, or with guidance from, the Regional Drug Problem Team. (6.15)

33. In general, publicity and outreach combined with syringe exchange and advice and counselling services are the best means of reaching and influencing the behaviour of non-opioid misusers. There may however be very exceptional cases in which short-term prescribing of non-opioids might be helpful. (6.16)

AIDS and Drug Misuse in Scotland

34. HIV infection in Scottish drug misusers is not a problem for Scotland alone, it is a problem for the UK as a whole. (7.2)

35. All injecting drug misusers must have easy, uncomplicated access to advice on safer practices and to sterile injecting equipment. (7.12)

36. Psychiatric input to the management and treatment of drug misuse is urgently needed. New full-time posts for consultant psychiatrists specialising in drug misuse need to be created in Glasgow and Edinburgh as a minimum. (7.13)

37. The value of substitute prescribing, undertaken with care, must be recognised. (7.14)

38. Local publicity and educational efforts will be especially important so as to get information to those drug misusers who are not in contact with services. (7.15)

39. Crisis Intervention Units should be developed in large cities to provide accommodation and care for injecting drug misusers at times of crisis. (7.16).

AIDS and Drug Misuse in Prison

40. Efforts to identify drug misusers in prison and to encourage them to identify themselves should be further increased. (8.20)

41. Further resources should be made available to enable the probation service to fulfill its role under the Prison Department's commendable new policy on throughcare. (8.20)

42. Urgent measures should be taken to improve the education of prisoners about HIV and risk-reduction. Full use should be made of outside agencies. (8.20)

43. Further consideration should be given to the possibility of prisoners being allowed confidential access to condoms. (8.20)

44. District Drug Advisory Committees should have particular regard to the needs of prison populations and should develop links with local prisons. Regional Drug Advisory Committees should include in their membership a regional representative from the prison service. (8.20)

45. Increased use should be made of existing filters so as to minimise the number of drug misusers actually reaching prison and every effort should be made to avoid unnecessary remands in custody. (8.20)

Management, Organisation, Resources and Training

46. Responsibility for monitoring and co-ordinating service provision to combat the spread of the virus through drug misuse should be clearly assigned to the District Medical Officer who should seek advice from, and report regularly to, the District Drug Advisory Committee. (9.5)

47. The relevant training bodies should take steps to ensure that suitable arrangements for training are instituted as a matter of urgency. Health authorities should ensure that drug workers, including those from the voluntary sector, are not overlooked in arranging training on HIV/AIDS issues. (9.9)

Research

48. All agencies providing services for drug misusers should keep basic records which enable them to monitor the effectiveness of their work, particularly with regard to making contact with drug misusers and achieving behaviour change away from risky activities. (10.2).