4 Maximising Contact with Drug Misusers

4.1 We discuss in this chapter ways in which more drug misusers can be brought into contact with helping services. The next chapter looks at ways of bringing about behaviour change once contact has been established. The distinction is a slightly artificial one which is made here for ease of presentation: we do not advocate increasing contact for its own sake but in order to provide the opportunity to inform and influence behaviour. The issue of prescribing, which we believe is relevant both to maximising contact and changing behaviour, is discussed in Chapter 6.

Extent of Contact with Services

4.2 Chapter 1 notes the difficulty in establishing how many people are misusing drugs at any given time. In addition, there is no centrally held information about the total number of drug users in contact with helping services; the only such data relates to misusers seen, and notified, by doctors. Local studies do however provide some insights and the evidence we have received suggests that the proportion of opiate misusers in touch with helping services at any given time is in the 5 per cent to 20 per cent range. Misusers of stimulants (mainly amphetamines) are generally much less likely to be in contact with services than opiate misusers. Clearly, the picture will differ between localities according to the nature of local drug services and the local drug problem but undoubtedly, the large majority of opiate and stimulant misusers are not in contact with helping services. Of this large majority, some will have been in touch in the past but have broken contact either temporarily or permanently, others will never have sought help. Whilst some of those who have not sought help will be relatively new to drug misuse, evidence shows that others will have been misusing drugs regularly for many years.

4.3 This low level of contact with services must be seen against a background of services having been developed primarily to help `problem drug takers". Many drug misusers may not think of themselves as having a drug problem, nor may they experience drug-related problems (e.g. with health, money, the law). 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. (See Annex D).

Factors Affecting Contact with Services

4.4 There are a range of factors which influence the extent to which drug misusers make and maintain contact with helping services. For many of those who currently seek help, motivating factors in doing so often include concern about dependence, depression, legal, health, employment, accommodation and financial problems, and worries over relationships. Whether motivation results in contact actually being made depends on factors such as the type of service available locally, the individual's knowledge of local services, the accessibility of services, and whether the individual perceives the service as accepting of, and relevant to, their needs.

4.5 A strategy to maximise the number of drug misusers who make contact with services must therefore include:

—    additional motivation to seek help
—    the provision of services which are relevant to the needs and problems of potential clients
—    effective dissemination of information about the existence and nature of the services
—    easy accessibility of services
—    non-threatening services.

4.6 Taking each of these factors in turn:

a. Additional Motivation
Evidence from many parts of the country indicates that AIDS, and the publicity surrounding it, is influencing an increasing number of drug misusers to seek help. This trend needs to be reinforced by continued publicity both nationally and locally. However, there is also a need to develop positive motivation to seek help. Evidence suggests that contact with helping agencies and commitment to behaviour change is most effectively achieved when an individual can identify real benefits through such contact. Local publicity is particularly important here as it can not only provide motivation but also give details of the help available locally. Better information (see (c) below) and the development of accessible services can contribute to increasing motivation and providing additional grounds for seeking help. Finally, drug misusers who have made contact with a helping service can be an important source of information to other drug misusers about that service. Influencing those drug misusers to promote a positive image of the benefits of the service can encourage other drug misusers to seek help.

b. Relevant Services
Services must be relevant to those whose principal motivation is avoiding HIV and AIDS as well as those who are motivated to seek help in reducing their drug misuse. Advice and help with risk-reduction for those who continue to misuse drugs is therefore essential. Availability of advice and practical help with other problems which drug misusers often face will offer an additional incentive for drug misusers to contact helping services. Common problems include areas such as housing, welfare benefits and finance generally, primary health care, employment/training, the law and child care.

c. Dissemination of Information
Even amongst drug misusers who seek help many do not know about the full range of helping agencies in the area nor do they have an accurate image of the service available. Knowledge and perceptions amongst those who have no contact with an agency is still more limited and clouded. More detailed and imaginative local publicity is needed to inform drug misusers of the existence of agencies and the type of help available, and to dispel their fears about seeking help. Local publicity must emphasise that help in avoiding HIV is available to those who do not yet feel motivated to reduce their drug misuse.

d. Accessibility
Easy accessibility is important even for drug misusers who are highly motivated to seek help. Now that services must make contact with many who are not so highly motivated it is all the more important. Easy access by public transport is essential. Flexible opening hours may also help, particularly in reaching drug misusers who are in work. Waiting times are also highly significant: if drug misusers are kept waiting a long time for an appointment, or kept waiting when they arrive at the agency, their motivation is likely to fade and they may break contact.

e. Non-threatening Services
In general, services which are run by sympathetic, non-judgemental staff in informal community-based settings may be seen as less threatening than those sited in hospital premises which may convey an authoritarian image. In addition to this general point there are two specific fears amongst some drug misusers: first, fear of the notification process and second, fear that their drug misuse may lead to their children being taken into care. There is conflicting evidence about the deterrent effect of the notification procedure but it does appear to act as a deterrent to some of those who might otherwise seek help. Similarly, worries over child care do seem to deter some drug misusing parents from seeking help particularly from any source associated with authority (see also para 4.20). These specific fears reinforce the need for additional services separate from formal or hospital-sited services.

Developing the Pattern of Service Provision

4.7 In the light of the considerations above, we do not see hospital-sited services as offering the most appropriate focus for attracting significant numbers of new clients from the hidden population of drug misusers. Community-based services have a greater chance of reaching many elements of this population by the provision of more varied and acceptable sources of help and advice. General practitioners can also play a key role as readily accessible points of contact who are well placed to help drug misusers move towards safer practices. This does not mean that the role of the hospital-sited specialist treatment unit is in any way diminished; on the contrary, these units can provide vital support for primary services and have important contributions to make in combating the spread of HIV. The role of each of these types of service along with that of generic services and outreach work is discussed below.

Community-Based Services

4.8 In the light of the conclusions reached earlier in this chapter we consider that community-based drug services should be substantially developed and expanded. In addition to their present role of providing services to `problem' drug misusers it is now essential that they should reach drug misusers who do not perceive themselves as having a drug problem. In order to do so they will need to adopt a more positive approach to attracting and contacting drug misusers than has hitherto been necessary. They will also need to provide services which are relevant to people who continue to misuse drugs and particularly to help them avoid acquiring or transmitting HIV. This represents a major extension to the role of existing community-based drug services. This expanded role is illustrated in more detail in the pattern of community-based developments outlined in Annex C, and developed in Chapter 5, which examines the issues of advice on risk-reduction, supply of injecting equipment, and antibody testing, and Chapter 6 which looks at prescribing. We recommend that a pattern of community-based services, along the lines of that outlined at Annex C, should be available in each health district.

4.9 Some of the community-based drug services which have developed over the last few years provide many of the ingredients we have identified as important and could be developed as outlined in Annex C. Other such services could not easily adapt to this model but may nevertheless continue to do valuable work. Annex C does not provide a standard model to be followed by all community-based drug agencies but every drug misuser should have access to the type of service described. District Drug Advisory Committees will be best placed to determine with service providers which services can be adapted and/or whether entirely new services need to be established. Either way, a major expansion of provision will be needed so that many more drug misusers can be reached. Where an existing service is adapted, publicising the new features of the service will be especially important. We emphasise that these services constitute one element of the service provision needed in each District: they do not represent a complete response in themselves. Their place in the overall pattern of services needed to combat the spread of HIV through drug misuse is illustrated at Annex D.

General Practitioners

4.10 The network of general practitioners offers an unrivalled system of heath care provision with great opportunities for intervention with drug misusing patients. GPs and the primary health care team, including health visitors, are particularly well placed to intervene early in cases of substance misuse and to work with families in helping misusers to move away from dangerous behaviour and towards abstinence. It has been estimated recently that between 30 and 44 thousand new opioid misusers in England and Wales consult general practitioners each year. These opportunities for intervention have not yet been adequately seized in most areas. Evidence suggests that some GPs are unwilling to provide health care for drug misusers and that many others do not provide help with drug problems. GP involvement is often considerably greater in areas where support is available through community drug teams or other specialist drug services and this is clearly a desirable arrangement. We conclude that 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.

4.11 General practitioners already possess the skills needed to help drug misusers but some may need to improve their confidence and knowledge of the field through further training. Training which facilitates early identification of, and intervention in, drug misuse is particularly important. The Council's forthcoming report on training will make recommendations about GPs' training needs and how they can be met. We note that some GPs have obtained valuable training and experience in the field through clinical attachments to local specialist drug services (as recommended in the Council's report on Treatment and Rehabilitation). We consider that such attachments should be actively encouraged and recommend that 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.

4.12 In the longer term, the best opportunity to promote greater involvement of all doctors is through training. We recommend that all doctors should receive some training at undergraduate level 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.

4.13 The recent White Paper `Promoting Better Health' emphasises the need for GPs and primary health care teams to play an increasing role in health promotion and preventive medicine. Clearly GPs can play a vital role in preventing the spread of HIV infection by increasing their contacts and involvement with drug misusers. The White Paper proposes that a new postgraduate educational allowance should be available to GPs who maintain a regular programme of education and training throughout their career. Discussions of the range and provision of approved training courses should recognize the importance of enhancing the expertise and involvement of more GPs in working with drug misusers.

4.14 Once contact between a drug misuser and a GP has been established, the principles described in Chapter 5 (Changing Behaviour) and Chapter 6 (Prescribing) will play an important part within the context of the care that a GP may provide.

Hospital-based specialist services

4.15 Hospital-based specialist services play two important roles. First, they provide essential back-up for `front-line' drug agencies and GPs. Second, they can play an important role in attracting some drug misusers directly and in helping them move away from HIV risk behaviour.

4.16 The need for, and role of, hospital-based treatment services was discussed in the Council's report on Treatment and Rehabilitation (see particularly para 6.25 of that report). The back-up these services provide, through giving advice and accepting referrals, is critical to the smooth running of front-line agencies. If this more specialist support is not available the capacity of front-line agencies and GPs can be quickly sapped by a small number of the most difficult cases. We have heard evidence of this happening in Scotland, where psychiatrists play only a very limited role in the treatment of drug misuse; as a result front-line agencies are working under immense strain. It is also clear that some hospital-based specialist services have such long waiting times (6 weeks or more) that they do not provide realistic back-up for other services. We emphasise that 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. In some areas, particularly Scotland which we discuss in Chapter 10, major improvements are needed urgently.

4.17 Although hospital-sited services are not best placed to attract new clients in large numbers they should nonetheless take steps to improve their accessibility and acceptability. There are two aspects to this:
— making other professionals more aware of their service and how best to make use of it; and
— making the service more accessible and acceptable to clients so that drug misusers, whether referred by other professionals or not, are more likely to make and maintain contact.

Many of the suggestions in the guidelines for community-based services (Annex C) will apply to some degree to hospital-based services. We recommend in particular:

a. Better dissemination of information
This needs to cover both the existence of the service and clear details of the type of help available. It should be aimed both at `front-line' drug workers (including GPs), at other professionals including hospital staff, particularly those working in Accident and Emergency Departments, and at drug misusers themselves. Initiatives such as open days, annual reports, talks to groups of GPs and other generic workers should be considered. Better publicity about specialist units and their role should, if properly handled, encourage GPs and other generic professionals to become more involved in the field.

b. Flexible opening hours
Evening opening may be important for drug misusers who are in work. There is evidence of working drug misusers being expected to attend clinics daily in working hours to collect prescriptions or participate in psychotherapy. If regular attendance is essential then ways should be found of making it compatible with the client's employment. Some drug clinics already operate flexible hours for such clients and we commend this approach. This flexibility should be well publicised so that potential clients are not put off accepting referral.

c. Minimising waiting times
This refers both to waiting times for appointments and the time between first appointment and commencement of treatment. The former is largely a matter of adequate resources but a review of working practices may nevertheless reveal some scope for reducing any initial waiting period. It is of course important to ensure that the specialist services do not become silted up with patients who could be adequately managed by GPs and/or community-based services. Regular reviews of each patient and good working relationships with other service providers are important. The question of time-lag before treatment is discussed in relation to prescribing at 6.10.

Generic services

4.18 Some services which are not drug-orientated nevertheless come into contact with large numbers of drug misusers. Examples include social services, youth services, the probation service and some non-statutory agencies (e.g. those which focus on the problems of the young or homeless). These services can play an important role in identifying drug misusers amongst their clients, and providing advice, counselling and referral to specialist agencies. The report on Treatment and Rehabilitation discussed this role. In the light of HIV early identification and intervention by these agencies is of heightened importance. Equally, these agencies now need to be equipped to give advice on HIV and safer practice (see Chapter 5).

4.19 The Probation Service in particular is likely to have a high level of contact with drug misusers many of whom will have no other contact with a helping agency. The proposals at 8.19 for diversion from prison will rely considerably on the involvement of probation officers and their ability to direct drug misusers towards appropriate helping services. However, many drug misusers will not receive a supervision order and there will be an important role for probation officers as health educators about means of reducing the risk of HIV infection and in increasing motivation to seek help amongst those drug misusers who may have only brief contact with the probation service.

4.20 Social Services Departments should be aware that drug misusing parents may be particularly wary of disclosing their drug use to social workers for fear that their children will be taken into care. A Local Authority has a duty to act in the best interests of a child's welfare but drug use by parents does not automatically indicate child neglect or abuse and it is important that fear that their children will be taken into care should not deter parents from coming forward for assistance. Social Services workers can play an important part in increasing parenting capabilities and supporting such parents with advice, guidance and practical services and there should be improved liaison between generic and specialised services. Drug misuse agencies may be unaware of or unfamiliar with resources and practices within generic agencies and this may reinforce a client's fears at a time when multi-agency support is needed. 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.

4.21 Another service which is likely to come into contact with increasing numbers of drug misusers as a result of HIV is the Genito Urinary Medicine (GUM) clinic. Many drug misusers who attend GUM clinics for antibody testing have been referred by drug services and are therefore already receiving some help with their drug problem. However, other drug misusers may present without referral. It is extremely important that staff at GUM clinics should be fully equipped to advise drug misusers about safe practices and to encourage them to seek help with their drug problem. This will apply, whether the result is positive or not. We recommend that staff in GUM clinics should develop streamlined arrangements for referring clients to drug services. In some clinics where large numbers of drug misusers are seen the provision of an on-site drugs worker should be considered. GUM clinics should further advertise the availability of HIV counselling and testing and these services should be made more easily accessible. Although we believe the antibody test should be used with caution (see Chapter 5) it is clearly desirable that as many drug misusers as possible come forward for HIV counselling and that the opportunities presented when they do so are seized. Many GUM clinics are already over-stretched with the advent of HIV and additional space, resources and staffing will be required to enable them to play their proper role.

4.22 Other professionals may also have contact with drug misusers, albeit of a more casual nature. Examples include pharmacists, police officers and staff of Accident and Emergency Departments. We note that the Pharmaceutical Society of Great Britain has recently distributed a handbook on drug misuse to its members and we commend this initiative. Some information on identifying and helping drug misusers should be part of the basic training of all professionals who are likely to have contact with them.

Outreach work

4.23 Finally in this chapter, we consider the role of outreach work as a means of making contact with drug misusers. This form of work has a long tradition in making contact with young people unwilling to use established `centre-based' services, most notably in the youth service. The goal of outreach work has often been to involve young people in existing services, but more recently it has been developed to provide a direct service to those unwilling to utilise existing resources.

4.24 Outreach workers have been employed in a number of countries to work with drug misusers, especially in a number of European countries.
These services have now been extended to contact drug misusers and provide them with information about HIV and safer practices, notably in the USA. In some places, the approach has focused largely on the provision of bleach and advice on cleaning equipment, in others, advice on safer practices has been the main focus. Contact has been developed largely on the street and in locations where drug misusers are known to meet. In many cases, former injecting drug misusers have been recruited as outreach workers because of their knowledge of the drug scene. In all cases, outreach work has proved a valuable tool in making contact with those not willing to approach services. It has, however, been dependent on the skills and qualities of the workers, on establishment of trust between them and the drug misusers and on the ability to relate to clients on their own terms and in settings of their choosing.

4.25 There are only a few examples of outreach work with drug misusers being undertaken in the UK. One of these is in Strathclyde where with SHHD funding the Social Work Department established six detached drug-worker posts. The emphasis here has been on making and maintaining contacts with drug misusers and their families, providing advice and counselling, including risk-reduction, and helping drug misusers to make use of other services. In some cases it proved easy to establish contacts, but workers in other areas experienced difficulties. An important lesson to emerge was the desirability of operating in teams for mutual support and safety, with an established base and well-defined routes of referral to other helping agencies.

4.26 Strathclyde Regional Council has also undertaken outreach work with prostitutes, a particularly important group as a significant proportion in that area are also drug misusers. Here the emphasis was primarily on the need to avoid unprotected sex. It was found that some prostitutes were willing to help in this work and could be most effective in distributing condoms and advice about safer sexual practices. Nevertheless, drug misusing prostitutes represented a particular problem since they seemed to be more willing to have unprotected sex, especially if offered extra money. Those who engage in casual prostitution when they need money for drugs are likely to be the most difficult to reach through any network of prostitutes.

4.27 The examples of outreach work in mainland Europe, the USA and some parts of the UK, suggest that there is potential in using current and former drug misusers and prostitutes as voluntary or informal `outreach workers' in conjunction with staff employed specifically as outreach workers. The experience of non-statutory street agencies and rehabilitation houses has already shown the benefit of employing former drug users within their services.

4.28 We conclude that the type of community-based services we advocate earlier in this chapter will, if implemented with enthusiasm and imagination, reach a larger proportion of drug misusers than is presently in contact with services. Outreach workers can play an additional role in contacting drug misusers who may not otherwise seek help, for instance, young drug misusers, drug misusing prostitutes, occasional drug misusers and amphetamine misusers. Such work can only be fully effective if backed up by the full range of services outlined in this report. We note the value of undertaking outreach work as part of a team and suggest that community-based drug services would form a natural base for these teams. Health and local authorities should consider collaborating with neighbouring authorities in building such teams, drawing upon the experience of detached youth work. Former drug misusers or prostitutes may be particularly effective as outreach workers because of their knowledge and experience and the trust which they can more readily establish with current misusers. Health and local authorities should ensure that there are no bars to such candidates being appointed as full-time, sessional or volunteer staff at the appropriate grading for similar posts within the authority.

4.29 Beyond these basic points, we consider that the exact model used for outreach work will differ according to local circumstances. The possibility of using regular clients of drug services to disseminate information about HIV and safe practices should not be overlooked as a means of reaching, at a basic level, drug misusers who remain unwilling to make contact with any helping service. We recommend that drug services experiment with a variety of approaches, and monitor carefully their effectiveness in reaching drug misusers not in touch with services, and in conveying help and advice.

' Defined in the 1982 Treatment and Rehabilitation Report as: 'Any person who experiences social, psychological, physical or legal problems related to intoxication and/or regular excessive consumption and/or dependence as a consequence of his own use of drugs or other chemical substances (excluding alcohol and tobacco).