Background and intention
Questions of higher policy
Responses at the individual level
Author: C. DRUMMOND, G. EDWARDS, A. GLANZ, I. GLASS, P. JACKSON, E. OPPENHEIMER, M. SHEEHAN, C. TAYLORand, B. THOM
Pages: 29 to 35
Creation Date: 1987/01/01
This article presents a policy analysis of the needed responses to the problems associated with the acquired immunodeficiency syndrome and drug misuse that are now being experienced in the United Kingdom of Great Britain and Northern Ireland. Among the issues considered is the overall organizational and administrative capacity of a country to deal with a new acute demand and the probable need for more national centralization of planning and effort in the drug field. Policies must aim at small multiple gains rather than at master-strokes. International communication must be strengthened. The human immunodeficiency virus (HIV) epidemic requires re-examination of the penal handling of drug misusers. Treating more patients earlier may contribute significantly to prevention strategies, and methods for "harm reduction" deserve attention. Compulsory treatment or testing of HIV infection is not favoured. The importance of professional training and of research is stressed. Although the immediate focus is on one particular country's policy needs, the issues raised are of wider relevance.
This article presents a policy analysis of the problem of acquired immunodeficiency syndrome (AIDS) and drug misuse which now confronts the United Kingdom of Great Britain and Northern Ireland. Although discussion is directed particularly at the United Kingdom situation, the authors believe that many of the issues identified are of wide international relevance.
The article does not seek to approach a level of comprehensive and referenced review. The aim is instead to stand back from the detail and identify the central and underlying policy questions that the Addiction Research Unit saw as important. Some of the questions raised are obvious, but others run perhaps the risk of being overlooked because they are troublesome. Even if some of the questions are difficult or contentious, the basic intention is to be firmly constructive.
* This article is based on evidence submitted by the Addiction Research Unit to the Advisory Council on Misuse of Drugs. The views expressed in this article are those of the authors alone.
The issues identified are rather arbitrarily dealt with under two headings, namely "questions of higher policy" and "responses at the individual level". Brief notes are then also given on training and research.
The adequacy of the United Kingdom's overall organizational system for dealing with drug misuse will be put sharply to the test by the emergence of the human immunodeficiency virus (HIV) epidemic. The Department of Health and Social Services has always stressed the principle of regional autonomy and the clinical freedom of the individual doctor, and on all sides there is distrust of too much reliance on directives. The British response to drug problems over the last 20 years has therefore been far less planned and directed than in the United States of America. The advantages of the British approach are many, and it would be difficult to propose that AIDS and drug misuse should lead to the abandonment of general and well-tried modes of administration. The British treatment system today includes, however, the drug dependence units and community drug teams, increasing involvement of general practitioners of the national health services, the significant presence of private general practitioners, a vast involvement of non-statutory agencies and (by default) the prison service. The bits are easily listed but it is not nearly so easy to grasp the intentions, flows, workings, overlaps, contradictions and degrees of integration of the whole system. The system is not closely monitored as to either cost or effectiveness, a serious disadvantage at a time when difficult decisions will have to be made between competing resource demands. Many of the recommendations put forward later in this article have resource implications, but the information base for hard decisions is very inadequate. It may also be doubted whether the system has much capacity to respond quickly to changing needs. The AIDS epidemic must therefore force the question whether the degree of monitoring, planning, intentionality and central direction of the system should be strengthened. The establishment of a special or enlarged office under the auspices of the Department of Health and Social Services deserves consideration.
Policies should be based on attempts to secure multiple small gains rather than on hoped-for master-strokes. The Addiction Research Unit believed that several potentially useful strategies for strengthening the response to HIV and drug misuse could already be discerned. With evolving experience other possibilities for action will emerge. It is, however, probable that benefit will accrue more from the sum of multiple small gains produced by an integrated and responsive total strategy than from any one or two master-strokes. This perspective again points to the need for a closely monitored system that enables possibilities for incremental gain to be identified and exploited.
The handling of the problem of HIV and drug misuse in the United Kingdom should be continuously informed by international experience. Many general aspects of the AIDS epidemic are already resulting in a heightened awareness of the need for international sharing of information and experience. Despite the activities of the European Economic Community, the United Nations, the World Health Organization and the Pompidou Group of the Council of Europe, it is doubtful whether efficient mechanisms have existed up to now for appropriate international communication on the health as opposed to the control aspects of drug misuse. Formal exchanges at official level are valuable, but that type of communication does not necessarily filter down to inform, stimulate and probe the front line of treatment and prevention activities. The emergence of HIV makes an unsatisfactory situation even less acceptable, and there is an urgent need to find a remedy for this potentially dangerous degree of isolation.
Although everything must be done to curtail the further spread of HIV infection to drug users and through them to the wider population, the limits of prevention should be admitted. Whatever the health field, prevention is nearly always relative rather than absolute, and what in reality is usually being talked about is minimization or the feasible limits of containment. The vigorous institution today of appropriate policies will reduce the prevalence of HIV infection from what it would otherwise become five years hence, and that is a very worthwhile goal. If laboratory science is meanwhile able to offer advances in treatment or prevention, a halt to the spread of the epidemic will have been highly advantageous. Although everything possible must be done in the name of prevention, planning must not blind itself to the fact that many drug users will become infected with HIV. In designing new policies it will therefore be important to determine how a balance is to be struck between measures to prevent infection and those that will focus on helping the increasing number of drug users who are likely to become seropositive.
The reaction of society to the combined problems arising from HIV and drugs is a phenomenon requiring continuing scrutiny in its own right. As argued above, HIV and AIDS are not in the forseeable future going to be conquered. Society will have to coexist with drugs, the virus, and the connection between the two, rather than pretending that they can be wished away. Aspects of this forced coexistence that will require watching will include the impact of HIV on the stigma that attaches to drug misuse, particularly as regards informal discrimination, access to general medical services, employment and life insurance. Understanding of responses to present anxieties would be helped by historical studies of the way in which other societies have reacted to, or dealt with, earlier manifestations of what might generically be described as a plague.
The HIV epidemic requires a re-examination of the penal handling of the drug misuser. This recommendation is phrased cautiously and proposes a re-examination of a difficult question rather than offering immediate answers. The emergence of HIV, however, undoubtedly forces the need to look again at the routing processes that lead to a significant element of penal rather than therapeutic handling of drug users, and at what better can be done for the care or after-care of the drug misuser who goes to prison. Although persuading addicts who are living in the community to enter treatment at an earlier stage may be very important, it would at the same time be extravagant to ignore the fact that a large number of misusers are already coming to notice through the penal service, and frequently then being offered no effective help at all. The current resources of the Prison Medical Service cannot be expected to meet this demand.
Thinking must go beyond the imperative of urgency and cope also with longer-term needs. Any discussion on HIV and drug misuse today rightly stresses the need for urgent action. Without seeking to discount this very proper current emphasis on urgency, space must be found for thoughtful examination of matters which may perhaps only relieve society's suffering in the long term, and which are more fundamental than the immediate imperatives. Thus the AIDS epidemic must be seen as implying that continued efforts should be directed at prevention of drug misuse in general, and at general issues relating to the understanding of such matters as human sexuality or risk-taking.
Further investment aimed at increasing the percentage of patients in treatment who come off drugs is likely to produce steeply diminishing returns. This question is not concerned with the possible benefits of expanding services so that a greater percentage of the total addict population enters treatment, nor with the related question of how to bring drug misusers into treatment earlier. The focus here is simply on whether the direct clinical efficacy of treatment is likely to be capable of easy or large improvement. Could a given clinic or therapeutic community, for instance, be expected to increase the two-year success rate with their present clients from 35 to 45 or 55 per cent within the forseeable future as a result of improved treatment technologies? In the context of the AIDS epidemic such a consequence would contribute to diminishing the total prevalence of active drug use. The nature of the issues involved suggests, however, that such technological advances are not likely. There is no great probability of a much more sharply designed and effective method of treatment in the near future for the multiply-determined human behaviours called drug misuse or drug dependence.
Bringing more people into treatment and doing so at an earlier stage are strategies worth attempting. The two concepts of "more into treatment" and "earlier into treatment" are to some extent distinct but can here usefully be considered together. The first heading relates to the broad possibility of increasing the percentage of the total drug-using population that enrolls in treatment over a given time (whether late or early in their drug-using careers and whether for the first time or after relapses). The aim here is to contrive that instead of, for example, one out of 10 using addicts being in contact with a helping agency over a 12-month period, treatment services would be so enhanced and recruitment so encouraged that five out of 10 subjects would have such contact. The second and related heading, which today is beginning to receive increasing attention, focuses more strictly on efforts to encourage the user to seek help at an earlier stage in his or her career. What they have in common is that in both instances the intention is to bring into treatment drug users who would not otherwise be receiving help at a given moment. Such measures might have a number of potentially beneficial consequences: the total pool of users might be reduced; people might be weaned earlier from needle use; and counselling might reduce dangerous injecting practices or dangerous sexual behaviour among drug users. However, such policies of active recruitment into treatment would be so contrary to the previous practices of many institutions as to be breaking very new ground. It is not self-evident that if a new segment of patients were recruited they would in fact always readily accept the intended help; and the new recruits may be less motivated than the former patient group. This is not a negative comment, but a reminder of the complexities that may be involved. Although it was the view of the Addiction Research Unit that strategies can be identified which are indeed "worth trying", encouraging wider or earlier help-seeking should not be accepted prematurely or unthinkingly as a key policy component. The Unit was firmly of the opinion that a series of action experiments dealing with these issues should be given priority.
Persuading the injecting drug misuser to change from dangerous to safer behaviour is a difficult but potentially promising approach which will require sustained and multiple strategies. It must embrace a range of specific strategies bearing on such issues as persuading individuals to desist from sharing apparatuses, to change from injected to oral drug use, or to modify dangerous sexual behaviour. Considerable research experience has been gained over recent years in the study of "health behaviour", and particularly useful analogies might be drawn with cigarette smoking. The background climate of opinion is likely to be highly important in proposing and supporting personal changes in behaviour, and this suggests that public health campaigns on the connection between HIV and drug misuse may be worthwhile if they are well-designed, sustained and appropriately targeted. A second broad strategy for encouraging behavioural change consists in offering easily accessible and acceptable alternatives, which in this case would imply free needles and syringes, longer-term and perhaps higher-dose methadone prescriptions than have recently been usual, and free condoms. A third strategy relies on persuasion in the one-to-one counselling context, and here there are many questions of great potential importance relating to how the relevant messages are in this instance to be phrased and given, who is to give them, and how the necessary training is to be provided.
The following points are of special importance for the success of the approach defined above:
Strategies aimed at converting injecting drug users to oral use deserve further attention. That methadone could accomplish this goal was an implicit assumption underlying the original concept of methadone maintenance. Experimental investigation of methadone maintenance in the United Kingdom has not, however, so far been undertaken with sufficient rigour. Little is known for certain about the relative efficacy of different dosage levels, different durations of maintenance, the benefits which may derive from different types of treatment, or the gains from psychological or social help given in addition to the methadone. Questions such as these deserve in the light of the AIDS epidemic to be reopened, although the reservations which some clinicians will entertain as to the desirability of reintroducing methadone maintenance must be understood;
Needle and syringe exchange schemes should continue to receive experimental support. Results of the current experimental schemes are keenly awaited. The Addiction Research Unit believed that even if results proved inconclusive or disappointing this potentially important strategy should not be abandoned. The psychological determinants of changes in behaviour are complex, and if one exchange programme is unsuccessful other approaches based on other "reinforcement" conditions should be tried experimentally;
The HIV-positive drug user who continues to share needles or syringes constitutes a very special danger to public health. More needs to be learned about the prevalence and characteristics of such high-risk users and the measures needed to identify them and to improve their behaviour. There is in addition the worrying possibility that the drug user who has developed an AIDS-related dementia may be especially irresponsible. It could be pleaded that policies should not centre too much on the hypothetical or unlikely case, but general experience of infectious diseases suggests that the occasional carrier of a highly infectious disease can indeed cause widespread transmission. Legal opinion should be sought as to the relevance of the Mental Health Act, but it seems likely that its provisions would only be relevant when there is conclusive evidence of dementia. Of greater importance than application of legislative controls must in any case be the provision of advice and help for the drug user who has become HIV positive.
Reintroducing the prescription of injected opiates as a routine clinical practice should not be favoured. Champions of this approach contend that it will lure patients into treatment earlier, hold them there longer, and offer many consequent gains such as introducing them to exchange schemes. Others contend that within the specific context of the concern to diminish the spread of AIDS, prescribing injectable heroin is unlikely to provide a "harm-reduction" strategy. They suggest that prescribing could actually prolong rather than curtail injected drug use and would reinforce precisely the behaviour from which it is hoped that the user will be persuaded to desist. Furthermore, the prescribing of injectable drugs does not guarantee that needles and syringes will cease to be shared. Thus for every argument a counter-argument can be put forward, and one is left to form an opinion on a balance of conjectures. The judgement of the Addiction Research Unit was that reintroduction of the widespread prescribing of injectable drugs would be a step with only uncertain potential benefits. It would, however, disturb and confuse many elements of current practice and affect the work and morale of every agency in the field. In the view of the authors of this article, the potential benefits that would arise from making the prescribing of injectable opiates a routine clinical practice are not worth the potential risks and disruptions.
Testing for HIV infection among injecting drug misusers should not be made compulsory, but helping agencies should seek to establish a climate in which such testing is seen as acceptable and routine. Everyone must be aware of the anxieties that attach to testing, and of the need to deal with this issue sensitively. It is, however, possible that too great a timidity in proposing testing will itself encourage a reluctance that is in no one's best interest.
The drug user who has become terminally ill with AIDS will require special personal help. It is inevitable that before long society will be faced by the problem of how best to help an increasing number of drug users who have developed AIDS and who will require terminal institutional care. Neither existing facilities for care of the young terminally ill nor present residential centres for persons suffering from drug problems have as yet come to terms with this demand or its likely future scale. A range of experimental approaches should be tried and much consultation will be needed.
Compulsory treatment for drug misusers is unlikely to make any worthwhile contribution to curtailment of the HIV infection. Many people would on principle object to any such further curtailment of civil liberties, while others might argue that in the face of the threat otherwise unwelcome measures may have to be tolerated. Leaving matters of principle aside, it is the opinion of the authors of this article that compulsion would be costly, ineffective, and quite probably counter-productive.
The rethinking of drug policies that must result from the HIV epidemic has many implications for training, and it is assumed that these needs are currently being considered by another working group. The Addiction Research Unit stressed, however, the great importance of the provision and updating of training to enable workers in the drug field to deal confidently and effectively with the problems raised by AIDS. More widely, this epidemic underlines the basic need to strengthen training, for both the generalist and the specialist, on how to recognize and help persons who are misusing drugs.
This paper has in nearly every paragraph pointed to research or information needs. The fact that research issues have been considered in an integrated fashion with policy questions, rather than being listed in an appendix, highlights the Addiction Research Unit's belief that research must indeed be recognized as vitally integral to future planning in this area. The authors of this article strongly recommend that a mechanism be found for ensuring the flow of the necessary policy-relevant research.