Drug Abuse

Inter-relationships between low-threshold socio-medical care, methadone, AIDS and wound treatment in addicted prostitutes
Gust de Wit
Municipal Health Service, Amsterdam, The Netherlands

The spread of human immunodeficiency virus (HIV) infection among homosexuals in The Netherlands seems to be stabilising, probably as a result of the emancipation of gay men as a group and successfully implemented AIDS information campaigns. Information campaign efforts to minimise the further spread of HIV should continue undiminished, and should be focused on the entire population in future. Special attention should be devoted to youngsters, people of foreign descent, prostitutes and drug users.

Despite the specific information campaigns and free needle exchange facilities, the spread of HIV among drug users has unfortunately not been stopped. In recent years, the number of AIDS patients who are intravenous drug users has exceeded the number of homosexuals with AIDS in Western Europe. This is not yet the case in the Netherlands. However, in the near future, hospital and out-patient healthcare facilities are anticipating -a high rise in the number of AIDS patients who are or have been addicted to drugs.

PROSTITUTES AND FOREIGNERS OUT-PATIENT CLINIC (PROSTITUTIE EN PASSANTEN POLIKLINIEK, PPP)

In Amsterdam, approximately 2250 drug addicts are given methadone on a daily basis. However, drug users who are not officially registered as residents of Amsterdam do not have access to this methadone programme. This group includes many women who work as street prostitutes. For this group, a separate out-patient clinic has been set up in Amsterdam, the Prostitutes and Foreigners Policlinic (PPP).

Aims of the clinic

The PPP is a low-threshold methadone facility providing socio-medical care for male and female addicted prostitutes regardless of whether they are legal residents of Amsterdam. In addition, drug users with medical problems from outside Amsterdam or from abroad have access to the clinic.

In the target group, there is a high prevalence of tuberculosis, HIV, hepatitis, various sexually transmitted diseases (STDs), inflammation and needle abscesses. The out-patient clinic focuses on the prevention and treatment of these diseases. If necessary and if desired, the prostitutes receive extra attention and support in the form of counselling. Many of the problems they are confronted with, such as violence and rape, are related to their work as street prostitutes. The clinic works in close conjunction with the Women's Crisis Centre, where addicted women.can be admitted in the event of a crisis.

There is a multidisciplinary team at the clinic. If necessary, social workers provide practical material assistance in arranging for benefits, settling debts or applying for health insurance. Nurses devote a great deal of attention to individual and group counselling, particularly regarding `safe use' and `safe sex'. Every month, the clinic gives 3500 condoms to the male and female prostitutes.

Methods used at the clinic

If an addict is to be eligible for methadone treatment, he or she must have acute medical or severe psychosocial problems in addition to being addicted to hard drugs. For drug users who have been in Amsterdam for a considerable length of time but are not legal residents of the Netherlands, the possibility of repatriation to their native country may be a reason to give them methadone for the journey home.

Most of the prostitutes come to the PPP via the outreach (medical) field workers or because they have heard about it by word of mouth. A file is drawn up for everyone who comes in. The patients have to give written permission for registration. One of the questions they are asked at intake is whether they work as prostitutes. If this is the case and if, for the time being, a foreign patient is not willing or able to return to his or her native country, then the patient is registered for the methadone distribution programme on the grounds of prostitution.

This is done for public health reasons, since the main aim is to reduce the spread of STDs. This is clearly explained to our patients, and they are told that we therefore expect them to have themselves checked for STDs every three or four weeks. Since the target group tends to sleep in the daytime and be active at night, special STD consultation hours for addicted prostitutes have been scheduled in the evenings near where they work (the red light district).

In treating the wounds of drug users, one should bear in mind that their often hectic lifestyle tends to prevent them from keeping appointments. Administering methadone and having a pragmatic attitude makes it easier to cope with this. Drug users often have a reversed day and night rhythm. This makes it difficult to refer them to a doctor whose visiting hour is at nine in the morning.

Nurses play a central role in the day-to-day care of patients. In addition to distributing methadone, they work with the doctor at the visiting hours every day. Nurses also engage in outreach activities in the neighbourhood where the prostitutes work on the street.

Arrangements pertaining to the patients and methadone registration are entered into a computer system called DOSIS at the out-patient clinic. These include:

• extra daily medication if called for

• daily treatment of shooting abscesses or other wounds if necessary

• a medical examination every three or six months • an X-ray of the lungs every six months

• an STD check every three weeks for patients who work as prostitutes

• an injection of Depo Provera every three months for patients who use it as a hormonal contraceptive

• an appointment at the out-patient department of a hospital once a month or more frequently.

GENERAL FEATURES OF PPP PATIENTS

In 1993, 702 patients were treated from more than 20 different countries, of which 271 male and female patients were working as prostitutes (44% from the Netherlands, 35% from Germany, and 21% from other countries).

The HIV status was known for 523 patients: 204 were HIVpositive. Of the prostitutes who were tested for HIV, 30% were HIV-positive (female prostitutes 32%, n = 57, male prostitutes 14%, n = 3).

Our project exchanged 100 000 needles and syringes in 1993 2.

SPECIFIC FEATURES OF ADDICTED PROSTITUTES

Addicted women usually do not view themselves as professional prostitutes, and simply see their work as something they do to get money for drugs 3. In other words, the addicted prostitutes who come to our clinic first became addicted to hard drugs, which is why they then started to work as prostitutes.

Street prostitution takes place outside the law. This is one of the reasons why our target group is so often confronted with clients whose preferences tend toward violence. There were 31 cases of assault and battery and 16 cases of rape in this group in 1993.

Since their work has so little appeal for them, many addicted prostitutes can only serve their customers when they are high on drugs. However, in order to pay for the drugs, they have to work as prostitutes. This is a vicious circle which is difficult to break. Many of the prostitutes had a bad start as a child. They often come from broken homes and were battered or abused in their youth. Most of them never finished school.

In addition to severe addiction problems and the fact that many of them have been HIV-positive for quite some time, their physical, social and living conditions are extremely poor. They are often homeless, which is illegal in the Netherlands, and have no fixed income. Some of them do not yet know where they are going to spend the night when we see them in the afternoon.

Although they are confronted every day with this bleak situation, it is still extremely difficult for these women to stop using drugs. In fact, quite the opposite is the case. Most of the women increase their drug use, which, in the event of frequent intravenous use, can manifest itself as a form of self-mutilation.

INTRAVENOUS DRUG USE

Intravenous drug use gives the most immediate effect. Injecting drugs is also cheaper, because a smaller quantity is needed. In many of the members of our target group, a great deal of damage has been done to the blood vessels in the extremities. This is why they use blood vessels in the throat, breasts and groin as sites for injection. Of course we advise against this, and suggest smoking drugs as an alternative.

At the initial intake and repeated intake talks, we always ask whether they use drugs intravenously. A total of 57% of the Dutch addicts who consult us have used drugs intravenously and 41% never have (details are not known for the remaining 2%). Of the foreign patients, 88% have used drugs intravenously and 12% have not.

The drugs that are used are never pure, and are often diluted with various other substances. Since drug users have not always mastered the technique of injecting and the drugs are often not prepared in a hygienic way, there is a high likelihood of complications. The custom of front loading, i.e. filling one injection needle using another (used) syringe, and the use of contaminated needles may lead to the transmission of infections, including the AIDS virus.

TREATMENT OF ABSCESSES AND WOUNDS

Drug users usually do°not take good are of themselves. They often only show the doctor their wounds or abscesses if explicitly asked about them. They are afraid of being treated by doctors and nurses. Usually their fear of pain plays an important role. There are still misconceptions among drug users about how to treat abscesses themselves.

The purpose of a protocol on abscess and wound treatment is to ensure the uniform treatment of skin infections in all the branches of the Drug Department of the Municipal Health Service in Amsterdam. The most prevalent skin infections in this patient population can roughly be divided into two categories. Firstly there are abscesses, especially needle abscesses resulting from self-injection. Secondly, there are open infected wounds mainly due to poor hygiene.

The definition of wounds prepared by the Wound Care Consultancy Society is used:

• black wounds - the surface is covered with a black scab of necrotic tissue

• yellow wounds - these contain a yellow substance (fluid, necrotic tissue, pus etc.)

red wounds - the surface is clean and has a healthy granulating bottom.

Wounds are classified by examination. Further procedures depend on the classification. If the wound is a combination of more than one type, it is treated as the more severe type. For example, a wound that has a granulating bottom but also contains pus is treated as a yellow wound .

A sufficient dose of methadone will reduce the need for drugs and the injection site can be given the rest it needs in order to heal. An abscess that is not ripe yet is warm and painful and produces swelling and disturbed functioning. If it is bandaged wet according to the protocol, this cools it down and reduces the pain.

This rapid effect almost always leads to a positive reaction on the part of our target group. However, if the complications are less painful, the drug user is generally less interested in daily examinations and treatment. This is why, when treating drug users for wounds, it is important to use bandages or salves that will not be harmful if they stay on for lengthy periods of time. Our experience with hydrocolloid bandages and impregnated paraffin gauze has been favourable.

BIRTH CONTROL

Birth control is an extremely important aspect of the care of addicted prostitutes. At intake, and on other occasions as well if necessary, staff members discuss hormonal contraceptives with the patients. Of 315 female patients, 80% were not using any form of birth control at all at intake. To prevent pregnancy, 67% were given effective contraceptives (36% received Depo Provera injections, 22% received oral birth control pills, 2% received an IUD and 7% were sterilized) during treatment in this programme. Contraception details were not available for 1 % of the population. The remaining 32% could not be motivated to use any form of birth control other than condoms. However, we do not consider that condoms alone provide adequate birth control 2. Addicted women often labour under the misconception that, if their drug use prevents them from having their period, then they can't get pregnant.

According to various sources, the HIV prevalence among addicted women in Amsterdam who use or have used drugs intravenously is as high as around 30%.

The motivation on the part of addicted women for wanting children is often a poor one: 'Once I have a child, everything will be better, then I'll automatically stop using drugs'. Our experience is that the women we see at our out-patient clinic are not generally in a position to take proper care of children. That is why we try to encourage them to use effective birth control. Since many women do not come to us on a regular basis and are apt to forget to take birth control pills, we urge them to have a contraceptive injection (Depo Provera) 6.

OCCUPATIONAL HAZARDS

The personnel at addiction care facilities have to be aware of the occupational hazards involved. They run a relatively high risk of infection with HIV or hepatitis B, certainly compared with personnel at general hospitals. Personnel training should be focused on restricting this risk as much as possible. If necessary, special courses should be given.

In order to prevent infection, methadone distribution points should be architecturally designed in such as way that they can be kept adequately clean. For this purpose, there should be a professional and bacteriologically satisfactory cleaning protocol. Waste matter should be treated as 'contaminated matter' and destroyed. At the Drug Department, dustbins arc used with a sticker saying 'contaminated waste matter'. All of this goes without saying at regular hospitals. Unfortunately, these precautionary measures are not always put into effect at addiction facilities. This has to do with the fact that, historically, addiction facilities have not been located at medical settings.

CONCLUSION

In our experience, most of our patients know very little about health principles. They have a lot of mistaken ideas, particularly with regard to wounds and STDs. They often think that they will simply go away by themselves. The health information and education aspects are extremely important when working with addicts.

If the treatment is to have good results in this group of patients, first and foremost it is important to get them to trust you. Step by step, attention can be focused on the frequently severe complaints and complications. The immediate problems have the highest priority. Our policy is to focus on our aims while still being as flexible as possible. Experience has shown that being exclusively focused on stopping patients from using drugs is only effective in certain exceptional cases.

Professional wound treatment at the addiction facilities can stop drug users having to be admitted to general hospitals. The use of modern bandages simplifies the treatment of drug users' wounds.

A low-threshold methadone programme can provide substantial help in managing public health problems caused by drug abuse and AIDS. In our low-threshold methadone programme with its specific but highly interesting target group, we have to be careful not to over-organise the day-today work with rules that are too strict. Then we would lose contact with the drug users. Restrictions are necessary, but they should never overshoot the mark. If the lives of our patients dramatically change, then policy rules have to change as well. Changing the policy into a war against drugs would be more detrimental than beneficial.

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