7 AIDS and Drug Misuse in Scotland

Introduction

7.1 The conclusions and recommendations of this report apply to all parts of the UK. Nowhere is more urgent action needed to implement them than in Scotland where the problem of HIV infection in injecting drug misusers is especially severe. Yet services in Scotland are particularly ill-equipped to combat the spread of the virus. This situation pertains despite the report of the Scottish Committee on HIV infection and Intravenous Drug Misuse (`the McClelland Report'), published in September 1986, which recommended many sensible measures to combat the spread of the virus. We are deeply concerned that many of the report's recommendations have not been acted upon and we consider that valuable time has been lost in tackling the spread of HIV in Scotland.

7.2 This chapter examines aspects of the problem which are particular to Scotland and makes some additional recommendations for action there. In doing so we emphasise that many drug misusers are mobile and that failure to curb the spread of HIV in Scotland will inevitably lead to the virus spreading more rapidly throughout the UK and beyond. HIV infection in Scottish drug misusers is not a problem for Scotland alone, it is a problem for the UK as a whole.

7.3 It is now almost 3 years since surveys indicated a high prevalence of HIV infection in Scottish injecting drug misusers. Subsequent studies in Edinburgh and Dundee have confirmed prevalence rates of about 40-50 per cent in injecting drug misusers in the East of Scotland, suggesting a currently infected drugs misusing population there of 1100-1700. By contrast in the West of Scotland, rates of 2.5-5 per cent pertain albeit amongst a much larger pool of drug misusers. The latter is estimated at 5000 to 8000 strong with a total of about 200 to 400 infected. Thus in Scotland by October 1987, the proportion of injecting drug misusers amongst those known seropositives was 58 per cent (765) of a total pool of 1311. This contrasts starkly with England and Wales where only 7.5 per cent (470) of a total of 6246 seropositives were drug misusers. The youth of those affected is notable. Some 14.4 per cent (109) of those infected were under 20 years of age whilst 59 per cent (443) were under 25 years old. Of great significance for perinatal transmission, is the proportion — 34 per cent (257) — who are female, the overwhelming majority (90 per cent) being under 30 years old.

Special features of Drug Misuse in Scotland

7.4 Evidence indicates that many injecting drug misusers in Scotland are young and disadvantaged, often more so than their English counterparts. The greater proportion of younger injectors might be a consequence of the tendency in Scotland to begin experimental use of drugs by injection rather than inhalation. Whatever the reason, it makes many injecting drug misusers more difficult to contact through conventional services, especially those associated with authority and abstinence. There is also evidence of widespread misconceptions among them about HIV and its transmission. For example it may be believed that transmission occurs through use of heroin but not Temgesic or temazepam, or through needles but not syringes, or that healthy looking individuals will not be infectious.

7.5 Another feature of the drug problem in Scotland is that heroin has become scarce and of poorer quality and alternatives are being sought, leading to much greater poly-drug misuse. Of particular concern is the growing use of temazepam taken alone or injected in combination with heroin. This drug commonly produces serious behaviour disturbance with more chaos, violence and protracted memory blanks encountered.

Services for Drug Misusers in Scotland

7.6 There are four notable features of drug services in Scotland. First, the dearth of psychiatric input: psychiatrists in Scotland accept only a very limited role in the management of drug misusers and there is minimal specialist consultant provision in this field. As a result, advice and counselling agencies and the number of GPs who are prepared to work with drug misusers receive virtually no specialist support. This absence of back-up to help with the most problematical cases means that the energies of those in the front-line are all too easily sapped by small numbers of difficult clients with whom they are ill-equipped to deal. This, in turn, undoubtedly contributes to the unwillingness of many GPs to provide care and help for drug misusers.

7.7 Second, of the few doctors who are prepared to work with drug misusers only a handful are willing to consider the full range of treatment options including prescribing ones. This severely impairs the ability of services to make contact with drug misusers and to help them move away from HIV risk behaviour. It also means that these few doctors are overwhelmed with drug misusers and have to ration their use of prescribing in order to contain their workload. In practice this has led to the absurd position whereby treatment involving substitute prescribing is mostly available only to those already infected with HIV. Its use to prevent a seronegative drug misuser from engaging in HIV risk behaviour and acquiring the virus is virtually non-existent.

7.8 Third, major gaps remain in the provision of community-based services for drug misusers. In a proportion of existing agencies abstinence from drug misuse is the only goal and this emphasis does not attract drug misusers who are not yet motivated to give up. Whilst many agencies do some excellent harm-reduction work they are already severely overstretched.

7.9 Finally, the pilot syringe exchange schemes established in Scotland have been very different from most of the English schemes. In particular, they are hospital-based, medically supervised, have limited opening hours and can only issue up to 3 syringes at a time. They could hardly be described as `user-friendly', and one is picketed by local residents. It is perhaps not surprising that they have failed to attract more than a tiny proportion of local injecting drug misusers.

Areas with High Prevalence of HIV infection

7.10 In areas of high seroprevalence, notably Edinburgh and Dundee, existing drug services are working under immense pressure. Advice and counselling services are having to deal with growing numbers of drug misusers and spend more time counselling each of them. The Edinburgh Infectious Diseases Unit is having to cope with the drug problems of seropositive patients as well as their HIV infection, and receives no psychiatric support in doing so. An attitude could be taken that, in these areas, infection is so widespread that energetic efforts to prevent further spread are doomed to failure because they are too late. Apart from justifying a sense of hopelessness in drug misusers and apathy in staff, this attitude misunderstands the nature of HIV infection in two important aspects. First there is evidence that continued injection of drugs stimulates infected lymphocytes to reproduce further virus and pushes the drug misuser towards AIDS which he/she may not otherwise have developed, or at least not so quickly. Secondly, there is evidence that as the immune system deteriorates then infectivity to others may rise dramatically. Therefore good management of infected drug misusers itself contributes to prevention. We will return to this issue in more depth in our Second Report.

Special Measures needed in Scotland

7.11 In addition to the measures recommended elsewhere in this report we make the following additional recommendations in respect of Scotland.

7.12 First, all injecting drug misusers must have easy, uncomplicated access to advice on safer practices and to sterile injecting equipment. The type of community-based service described at Annex C is urgently needed in Scotland. Although some existing community-based services in Scotland may be able to take on this role, new services will be needed in most cases. This is partly because existing services are thin on the ground and already overstretched and partly because some are too strongly associated with abstinence. The current pilot syringe exchange schemes will not provide a suitable base as they are inaccessible and unattractive to the vast majority of drug misusers. Even where existing services can be adapted, additional services will also be needed to bring provision overall up to the level necessary to make contact with the maximum number of drug misusers. These services should normally incorporate syringe exchange facilities but access to syringes through community pharmacies will also be needed (see para 5.17). This will be particularly important whilst syringe exchange facilities are in the process of being set up. Each Health Board should therefore hold immediate discussions with local pharmacists (or their representatives) to ensure that supplies are readily available in every district.

7.13 Second, psychiatric input to the management and treatment of drug misuse is urgently needed. General psychiatric services should provide treatment for drug misusers but psychiatric services specialising in drug misuse are also needed in areas where drug misuse is prevalent. New full-time posts for consultant psychiatrists specialising in drug misuse need to be created in Glasgow and Edinburgh as a minimum. They should be supported by multi-disciplinary teams as outlined in para 3.2(a).

7.14 Third, the value of substitute prescribing, undertaken with care as outlined in Chapter 6, must be recognised. The creation of specialist psychiatric services with a prescribing arm must be matched by an increased willingness at all levels to prescribe for drug misusers in appropriate cases.

7.15 Fourth, local publicity and educational efforts (as outlined in para 5.27) will be especially important so as to get information to those drug misusers who are not in contact with services. Intensive efforts will be necessary in Scotland in view of the youth and deprivation of many of those who must be reached.

7.16 Fifth, Crisis Intervention Units should be developed in large cities to provide accommodation and care for injecting drug misusers at times of crisis. This may be particularly important for HIV positive drug misusers, and increasingly necessary if the trend towards poly-drug use, with all its chaotic effects, continues.

7.17 Finally in view of the severity of the problem in Scotland it is essential that responsibilities are clearly defined, specific objectives are identified at all levels, and that progress towards these is closely monitored. This process must start at national level with the Scottish Home and Health Department and be mirrored at local level. Within each Health Board responsibility for planning, co-ordinating and monitoring measures to combat the spread of HIV through drug misuse should be specifically assigned to one individual, normally the most senior, the Chief Administrative Medical Officer. In exercising this responsibility the Medical Officer may wish to designate one or more appropriate and enthusiastic individuals, perhaps on a part-time basis, to assist him or her in implementing the measures proposed. In any case, the Medical Officer should seek advice from, and report regularly to, the Drug Liaison Committee.