5 Specialist Drug Misuse Services

5.1 The specialist drug misuse services ("drug services") are any services which cater specifically for drug misusers. Services offered can vary from hospital-based treatment clinics (both in-patient and out-patient facilities) to outreach projects, needle and syringe exchange schemes, counselling centres, advisory services, day centres, and residential rehabilitation units. Over recent years there has been an increase in multi-disciplinary community-based services with input from medical and nursing staff, social workers and the non-statutory sector. This chapter is about the extent to which drug services can care for people with HIV-disease, and the ways in which they will need to develop to do this.

5.2 Many drug services have already begun to adapt the services they offer along the lines of our Part 1 report. We have heard heartening evidence that some services are embracing the concepts of harm-reduction and setting goals short of abstinence where abstinence is not immediately achievable by individual clients. Some are also able to provide pre- and post-test counselling, and medical examinations. We welcome these advances.

5.3 However, a number of services appear to have made inadequate changes, even with regard to prevention of infection. This is worrying as most drug services will now be seeing people with HIV-disease even if neither the staff nor the clients realise it. For example, we have received evidence that some staff in specialist drug services have deeply entrenched attitudes on management of drug misuse by withdrawal. Such people are unwilling or unable to countenance the different philosophy of management — which might entail accepting some continuing drug use — which could be needed in dealing with drug misusers with HIV-disease. Some are resistant to new ideas, particularly if these are proposed by people who do not have a background in the drugs field. As more drug misusers become ill, staff will find themselves called upon to provide a service for more and more clients who have no intention of becoming abstinent, and who would never have approached drug services in the past. The service offered by specialist drug services today and in the future is radically altered by the advent of HIV-disease, and rigidity of attitude and approach will greatly restrict the amount of help that they can provide.

5.4 Drug services are already beginning to see drug misusers who are ill with HIV-disease, and many more who are infected with HIV but asymptomatic. Some of this latter group can be expected to become ill quite soon, as can some seropositive drug misusers (who will not necessarily know that they have been infected) who are not currently in contact with services. As these people become ill, many are likely to approach a drug service for help because of its reputation for treating drug misusers sympathetically.

Allocating Priorities

5.5 We have given much thought to the question of whether people with HIV-disease should be given priority treatment at drug services. Most drug misusers will first contact services during a period of personal crisis, and clearly it is desirable that all people in crisis should be seen and treated immediately, regardless of whether they are HIV-positive. But perhaps more importantly, giving priority to seropositive drug misusers would almost certainly result in reduced access to services for presumed seronegative clients, which would be counterproductive in terms of preventing the spread of HIV infection. There would also be problems verifying claimed antibody status, which might lead to tacit encouragement of testing.

5.6 However, we recognise that within the constraints under which services operate, informal systems of priority will inevitably arise as it is rarely possible for all applicants to be seen immediately. In general, we do not support the concept of priority treatment for seropositive drug misusers. For prevention purposes, it is essential that services and resources are actively directed towards those drug misusers who are presumed to be seronegative as well as those known to be seropositive. With clients who appear to be exceptionally chaotic, who are likely to be at high risk of acquiring or transmitting HIV-disease, special efforts should be made to provide treatment as soon as possible. This should be the case whether their antibody status is known to be positive or not.

Medical Care

5.7 Drug misusers, especially those who inject, are prone to infections and commonly feel ill. In the past, both drug workers and clients may have accepted this as a fact of life, and may not have been unduly concerned if a client was feeling "under the weather" . Attitudes must change now that there is a possibility that clients could have HIV-disease. All staff working in drug services should have sufficient knowledge and awareness to be alert to early symptoms of HIV-disease.

5.8 If possible, drug services should be able to offer facilities for regular medical examinations available to all clients; these might comprise a private room with a couch, and the services of a medical practitioner — who might be a local GP employed on a sessional basis — and a nurse. Such examinations may be a client's only access to primary health care, as well as offering an opportunity for routine monitoring for clinical signs of HIV-disease.

5.9 However, because HIV-disease can manifest itself in a variety of ways, many of which are common conditions in their own right, it can be difficult to diagnose and may need to be confirmed by a specialist. If a drug worker suspects that a client has HIV-disease, it is important that the client has speedy access to a medical examination by someone who can make an accurate diagnosis. There are advantages to offering these specialised medical examinations at the same site as the drug service — it is convenient for clients, and difficulties may be encountered in referring drug misusers elsewhere. Where the number of clients merit it, and facilities are suitable, a local hospital physician with experience in HIV-disease could be employed on a sessional basis in the drug agency. The provision of expert medical advice in situ is very useful for agency staff who may find it difficult to obtain reliable, comprehensive medical information that they can explain to their clients. We recommend that specialist drug services should aim to provide medical examination facilities, and on-site access to a medical practitioner with experience of treating HIV-disease. Those services which are unable to fulfil these aims should establish rapid referral routes to medical practitioners with expertise in HIV-disease.

5.10 We should emphasise that we are not advocating the "re-medicalisation" of drug services, counter to the trend — which we fully support — of multidisciplinary, accessible community-based services. If medical examination facilities are available, and clients informed of their availability and of the advantages of regular health checks we believe that many will find physical examinations helpful and reassuring.

Counselling Role

5.11 Drug services should have the capacity to provide advice, support and personal counselling on AIDS as well as on drug-related issues. This aspect of their service, perhaps more than any other, will put agencies under pressure of time. Workers are already finding that even asymptomatic clients who have not been tested for HIV antibodies are more anxious because of the prevalence of HIV-disease, and require more advice and support than previously. Drug agencies now often provide pre- and post-test counselling, although some refer clients elsewhere for this specialised service. Clients who have HIV-disease need counselling on a continuing basis and their partners and friends might also approach the agency for advice and support. We have heard evidence that drug workers can find it difficult to talk to their clients about sexual behaviour, so counselling skills are needed in this area in particular. The degree of counselling provided by any one agency will obviously be determined by its size, workload, resources, and the training received by its staff. However, given that drug services are likely to be in continuing contact with drug misusers with HIV-disease to a greater extent than any other type of service, they will be looked to for the continuing psychological support we identified in Chapter 3. As an absolute minimum, all drug services should provide advice and information on HIV-disease, both regarding the transmission of the virus, and general health care once infected. Those services unable to provide welfare advice, support and personal counselling should arrange for other agencies to meet these needs.

Training Role

5.12 Many staff in drug services have become proficient at providing helpful and sympathetic services for drug misusers, and are experienced in managing drug dependency and providing help with associated problems. These are valuable skills. As drug misusers become ill with HIV-disease, they will require services which are provided by people who have little experience of drug misusers or knowledge of drug dependency. We therefore recommend that staff in specialist drug misuse services should see it as part of their role to advise workers in other disciplines on the care and management of problems associated with drug misuse. This is best achieved in an atmosphere of integration and shared care. We will return to this topic in the next chapter, on hospital services.

Continuity of Care

5.13 There are already many services — in particular Community Drug Teams — who see clients in their own homes or on "home territory". As more drug misusers become ill with HIV-disease there will be a need for this aspect of service provision to be developed to provide help to clients who are not able to attend the service or whose condition may be exacerbated by regular journeys to a service. Drug services should have the capacity to offer home visits, and to provide care for clients in their own homes, and in hospital, where necessary.

Women and Services

5.14 In Chapter 3 we identify some of the reasons why women may have reduced access to services, and suggest a number of ways in which these barriers may be overcome. Certainly, research suggests that although proportionately fewer female than male drug misusers attend drug services, services which make a particular effort to gear what is offered to the needs of women can be successful in attracting a much higher proportion of women clients. Drug services should review their policies to ensure that they are receptive to the needs of women. In addition to adopting as far as possible the measures outlined at 3.31, they should be able to offer contraceptive advice to both women and men, and should have quick and straightforward routes of referral to maternity services for women who present when they are pregnant. Co-operation with Local Family Planning Clinics, or representatives of the Family Planning Association may be valuable in offering help and advice surrounding sexuality and contraception.

Residential Services

5.15 There are currently places for drug misusers in residential rehabilitation services in Great Britain on programmes varying in length from months to years. The great majority of services are provided by the non-statutory sector, although often with input from NHS staff. These rehabilitation houses fall into four broad categories: concept-based therapeutic communities, community-based hostels, Christian-based hostels, and "Minnesota method" communities. While the approach differs considerably from establishment to establishment, all try to equip residents with the skills and self-esteem to live a satisfying life without drugs. Recently, new ventures have been developed including short-term rehabilitation programmes, short-term crisis accommodation and facilities that allow children to remain with their drug-misusing parents during residental rehabilitation.

5.16 We are aware of only one facility — ROMA, based in London — which does not demand that clients should be drug-free whilst resident. Having supported the prescribing of controlled drugs in pursuit of objectives which for some individuals may fall short of abstinence, we believe that there is a place for an expansion of residential facilities where drug misusers may gain better health, skills and self-confidence whilst in receipt of prescribed drugs. We commend ROMA as an example to be followed.

5.17 Residential facilities are faced with several issues because of HIV-disease. First, what should their policy be on accepting people who are asymptomatic, but known or believed to be seropositive? Our view on this matter is clear. It is quite unacceptable to require potential residents to undergo antibody testing as a prerequisite to admission. Any resident might unknowingly be infected with HIV, and to attempt to keep out people who are seropositive would give residents and staff a false sense of security. Drug misusers known to be seropositive but who are asymptomatic should not be excluded from residential services; for the purposes of effective hygiene and preventative strategies it should be assumed that all clients attending residential drug services may be seropositive. HIV is not transmitted by normal, everyday contact so staff and clients in residential facilities are at negligible risk of infection from a fellow resident, provided basic health and safety procedures are followed.

5.18 Prevention of the spread of HIV-infection has other implications for residential services. Most have rules that residents should not have sexual relationships with each other. Inevitably, these rules are broken on occasion, and staff must face this reality. As HIV can be transmitted sexually, residents should be given advice on safer sex and contraception. Condoms and where necessary other contraceptive methods should be made available.

5.19 Confidentiality can be a difficult issue in therapeutic communities which have a philosophy of trust based on shared experience. Staff should formulate a policy on confidentiality within the establishment which should reassure residents that information about seropositive status will not be made available without the consent of the individual either to people in or outside the establishment.

5.20 Rehabilitation houses are also beginning to adapt in other ways to protect residents who might have HIV-disease. Some aim to maximise mental and physical well-being by reducing levels of stress (which in the past have sometimes been deliberately heightened in therapy) and by providing healthy diets and opportunities to develop physical fitness. We support such action and conclude that as all residential rehabilitation services are likely to accommodate some clients with HIV-disease , staff should re-examine the service offered to eliminate unnecessary stress and to promote a lifestyle conducive to good health.

5.21 Arguably, the most difficult issues of all arise when a client becomes ill with HIV-disease whilst resident. The nature of the service provided by residential facilities results in a strong emotional bond being formed between client and agency, which gives staff an added sense of responsibility towards clients. Clearly, staff may find it difficult to encourage clients with symptomatic HIV-disease to return to the community, particularly if there is no home to go to, and there may be a desire to allow them to live in the establishment for the rest of their lives. We have heard of an ill client who has been lovingly cared for in a residential facility by staff and fellow residents in exactly these circumstances.

5.22 However, while it may be feasible for a large residential agency to care for one or two people who become ill, to try and look after more than this would be enormously difficult without additional resources and expertise, and without undermining the level of help offered to other residents. Furthermore, any service wishing to provide nursing care may well need to register as a nursing home and to fulfil statutory requirements relating to such matters as fire regulations and staff/patient ratios. In short, a decision to take on the new role of caring for residents who are ill with HIV-disease should not be taken lightly. It is evident that many existing residential rehabilitation facilities are not equipped to care for terminally ill people, nor may they be ready or able to take on this role in the future. An important task now facing residential drug services will be to prepare residents with HIV-disease for their return to the community, and to ensure that their needs will be met by appropriate services once they leave the residential facility.

5.23 We have, however, heard that some non-statutory agencies with experience in providing residential rehabilitation are considering setting up special units for drug misusers with HIV-disease. It is proposed that these should cater for the needs of those people who would welcome this type of facility as they become ill and throughout the course of illness, except when in-patient hospital care is required. Some of these units would be set up adjacent or close to a "traditional" rehabilitation facility. Some would cater for those who have recently stopped using drugs and wish to remain abstinent; others for those who continue to use prescribed substitute drugs. Given the housing problems we identified in the last chapter, and the consequent problems of delivering care in the community, we support these proposals for a new type of facility. We recommend that two or more residential facilities for drug misusers with HIV-disease should be established with the help of central pump-priming funding. One should be for clients who are drug free and the other for people who continue to use prescribed drugs. These facilities should not be dominated by a single regime but should have an eclectic approach.

Prescribing

5.24 Agencies, where appropriate, will need to consider whether to prescribe substitute drugs as part of the service which they offer. It will not only be specialist drug services who face this decision; GPs or hospital-based services may also be involved. However, because specialist drug services have most expertise in managing drug dependence, and will be looked to for advice from other services, we discuss the role of prescribing within this chapter.

5.25 In our Part 1 Report we discussed the part which prescribing might play in attracting drug misusers into contact with services, and in influencing behaviour away from risky practices. In this report we are concerned with the considerations which should apply with regard to prescribing for drug misusers who are known to be seropositive or who are becoming ill with HIV-disease.

(i) Who Should Receive Drugs?

5.26 We have heard of cases where, because of pressure on resources, a service will prescribe substitute drugs for drug misusers known to be seropositive but not for others. We believe that this is inconsistent and may have damaging consequences, in that it may result in:
—    reduced access to services for those presumed seronegative, which will impede efforts to prevent the spread of infection;
—    an undermining of drug misusers' determination not to become infected;
—    drug misusers being tested for HIV antibodies before they are able to cope with the full implications of the result.
Access to prescribing in the treatment of drug dependence should be equally available – in appropriate circumstances – to both presumed seronegative and seropositive drug misusers in every locality.

(ii) The Goals of Prescribing

5.27 In our Part 1 Report we introduced the concept of intermediate goals to describe the behaviour changes short of abstinence which might be facilitated by prescribing. We see no reason to depart from the principle that prescribing should never be undertaken without an identified goal. If a drug misuser is known to be seropositive, a range of goals should be considered, including the following:

a. to attract seropositive drug misusers into regular contact with services;
b. to promote behaviour change away from practices which carry a risk of transmitting HIV-infection;
c. to promote behaviour change in such a way as to maximise personal health and stability;
d. to encourage compliance with medical treatment, including regular check-ups, and the regular self-administration of zidovudine (AZT).

The first of these goals is not an end in itself, but rather the platform on which the others are founded.

(iii) What should be Prescribed?

5.28 The drug most often prescribed to drug misusers is methadone, a synthetic opiate with a long-lasting action. It is almost always prescribed in an oral preparation, but occasionally it may be prescribed in an injectable form. There has been much debate about the effects of methadone and other opioids on the immune system, and whether or not they are actually detrimental to people with HIV-disease. These arguments are sterile unless in each individual case services assess what the alternative is likely to be. If abstinence is a realistic objective then it is probably in a client's best health interest to aim for abstinence. However, if the alternative to methadone is increased use of impure street drugs, with all the associated consequences for health and lifestyle, then prescribed oral methadone may be preferable. Oral methadone has been shown to help some drug misusers with HIV-disease to reduce or eliminate their use of street drugs, gain weight, and generally improve their health.

5.29 We have considered carefully whether services should prescribe drugs other than methadone. Undoubtedly there are many regular misusers of stimulants — particularly amphetamine, but increasingly cocaine — for whom oral methadone would have no attraction and would be inappropriate since it would not substitute for their drug(s) of choice. Many of these stimulant misusers are injectors, and some will be seropositive; it is essential that they, as well as opioid misusers, should be encouraged into regular contact with services.

5.30 Our starting point is that if the prescription of drugs other than oral methadone satisfy one or more of the criteria at 5.27 a-d then their use should be considered. However, we believe that in practice, the prescription of stimulants is unlikely to lead to desirable changes in behaviour, and carries a number of risks. This is borne out by previous experience in this country of prescribing stimulants regularly to drug misusers, which is generally acknowledged to have been disastrous, resulting in an increase in chaotic behaviour.

5.31 Similarly, the prescription of injectable drugs may exceptionally have a role to play in encouraging drug misusers to make and maintain contact with services. However such prescribing may prolong the extent and frequency of continued injecting, with the possibility of an increase in risk-laden behaviour. Furthermore, research based on street drug injecting suggests that continuing injecting drug misuse may be a factor in hastening the onset and progression of HIV-disease in seropositive individuals.

5.32 In summary then, we believe that the criteria at 5.27 a-d should guide the prescribing of all drugs. In practice, however, the risks of prescribing nonopioids and injectables, other than in the very short-term, will mean that in the great majority of cases their prescription is unlikely to lead to desirable changes in behaviour. Because of their high potential for abuse, the prescribing of injectable drugs and non-opioids should be managed by or guided by the Regional or District specialist team.

(iv) Applying the goals

5.33 The criteria used to assess the goals of prescribing may vary over time according to the stage of HIV-disease. In particular, abstinence may be hard to contemplate for some people who are ill, particularly when they first present to services, while others who are asymptomatic may find discovery of their serostatus a spur to giving up drugs.

5.34 It can be difficult for services to insist that a client with HIV-disease complies with the conditions attached to the provision of prescribed drugs, and it is probably only natural that considerable flexibility will be required. However, it is important that goals are kept in mind and that drugs are not prescribed naively. The prescribing of controlled drugs, with a high black-market value, in sizeable quantities to clients who have not been thoroughly assessed may exacerbate their drug problem, and those of others, with consequent risks to individual and public health. There will be occasions where it is necessary or beneficial to refuse the client the treatment s/he asks for.

5.35 For those services unused to reaching agreement with clients over the goals of treatment, and inevitably reluctant to enter into confrontation with an ill person they wish to help, these issues may seem foreign and difficult. Specialist drug services have an important role to play in `demystifying' drug misuse; advising on appropriate prescribing regimes; or managing the drug dependency needs of clients in liaison with other services.

Resources

5.36 Many of the recommendations made here and in our Part 1 report have significant resource implications for many service providers. However, in terms of both preventing the spread of HIV-infection and caring for ill drug misusers drug services are already at the forefront. We are asking agencies to make contact with as many drug misusers as possible; offer help and advice on reducing the risk of acquiring or transmitting HIV-infection; become involved in training and advising workers in other disciplines on the care and management of drug misusers; increase medical input to their service; and provide counselling for those who have, or fear they have, HIV-disease. This is all in addition to their original task of providing help and advice on problems associated with drug misuse, including help with detoxification and rehabilitation. Services will be unable to take on all these tasks unless they are provided with sufficient resources to do so. Services need funds not only to expand but also to adopt new strategies. Visiting ill clients at home is staff, and therefore resource-intensive. Wider and more flexible use of prescribed substitute drugs can be expensive. Currently, services in areas of high levels of drug misuse and/or seroprevalence among drug misusers are faced with the choice between providing a comprehensive service for a small number oo, clients; providing a limited service for a larger number, or taking on only some functions and not others. Other service providers with little or no expertise in drug misuse are not proving willing or able to step in and fill the gaps. Additional ear-marked and continued resources are required if drug services are to implement the recommendations both in our Part 1 report relating to preventing the spread of HIV-infection, and those which have been outlined here.