Methadone treatment in the Scottish context: outcomes of a community-based service for drug users in Lothian
Introduction
By December 1996 a cumulative total of 1167 people in the Scottish region of Lothian (whose main urban centre is the city of Edinburgh) had been tested positive for human immunodeficiency virus (HIV) antibody, representing 46% of all individuals in Scotland known to have been infected (Scottish Centre for Infections and Environmental Health, 1997). A total of 52% of these became infected as a result of injecting illicit drugs with contaminated equipment.
Awareness of the extent of the epidemic among intravenous drug users (IDUs) in the region in the mid-1980s prompted the establishment of a range of health, education and social services with the expressed aim of preventing further transmission of the virus. The Community Drug Problems Service (CDPS), the subject of this study, was established in 1988 and represents one element in Lothian Health’s HIV prevention strategy. The service adopted a hierarchy of goals consisting of: (i) recruiting and retaining drug users in treatment; (ii) seeking to influence those in treatment to avoid equipment sharing and unsafe sexual practices; (iii) discouraging injecting, (iv) discouraging illicit drug use; and (v) encouraging, where appropriate, the adoption of a drug-free lifestyle. This approach is broadly in keeping with the harm reduction model of service provision for drug users (O’Hare et al., 1992) which has gained wide international support with the advent of the HIV epidemic and which has been advocated as best practice by the UK government-commissioned Advisory Council on the Misuse of Drugs (Department of Health and Social Security, 1988).
In seeking to achieve these goals the CDPS developed a relatively novel, shared care approach with general practitioners (GPs) in Lothian (Greenwood, 1990). The core feature of treatment offered to opiate dependent clients is the prescribing of methadone by the GP following assessment by the CDPS team, who in turn provide parallel drug monitoring, counselling and other specialist support services. Some clients with a complex clinical presentation receive their prescriptions centrally from the drug team. By 1995, 79% of general practices in Lothian were involved in prescribing oral substitute medication to a total of 1508 drug users (Bury, 1996).
Methadone maintenance (MM) has been the subject of more research than any other treatment for opiate addiction (Ball and Ross, 1991, Ward et al., 1992, Farrell et al., 1994). Although there is not a consensus regarding its effectiveness and underlying premises, most contemporary reviewers of the literature have concluded that it is a treatment of considerable efficacy. It is more effective than other treatments in achieving high treatment retention rates and is associated with benefits in the areas of illicit opiate use, criminal involvement and employment status, especially where treatment lasts at least 12 months. MM clients tend to relapse quickly if they drop out of treatment.
With regard to HIV risk behaviour and infection, several studies have reported improvements in injecting drug use and equipment sharing (Selwyn et al., 1987, Ball et al., 1988) and lower rates of HIV seroconversion (Blix and Gronbladh, 1988Chaisson et al., 1989) among MM clients compared to those not receiving the treatment, although none of these have been fully controlled trials. More recently, Caplehorn and Ross (1995)have presented evidence that MM is associated with a reduced likelihood of injecting drug use rather than less risky methods of injecting. In contrast to injecting risks, Ward et al. (1992)have concluded from their review of the literature that MM has not been shown to have any beneficial effects in the area of sexual risk reduction.
However, the vast majority of outcome research on MM originates from the United States where programmes are structured to fulfil relatively circumscribed federal government requirements. Although MM treatment in the UK is widespread, few research studies have described how the treatment is administered, or investigated its efficacy. Programmes in the UK exist in the absence of a statutory regulatory structure and their administrative procedures are not standardised (Farrell et al., 1994). The repeated finding that MM programmes vary greatly in their relative effectiveness, even within the more controlled US environment, indicates that research comparing outcomes of diverse programmes in the UK is a priority.
The present study provides a description of the administrative procedures of the drug service in Lothian and data pertaining to outcomes up to 2 years in treatment and at discharge.
Section snippets
Setting and procedures
The Community Drug Problems Service is a specialist, secondary level service for problem drug users living in Lothian region. The staff team comprises approximately 18 whole time equivalent clinical members including psychiatric and other medical personnel, community psychiatric nurses, a clinical psychologist, a social worker and four administrative support staff. Most clinical keywork is carried out by community psychiatric nurses with back-up support or specialist input from other
Referral and attendance rates
The service attracted a steeply rising number of clients over the years from 139 in 1988 to 928 in 1994. Not surprisingly, numbers of those referred who had previously experienced a CDPS treatment episode rose as a percentage of all referrals during the first few years and then levelled off between approximately 20 and 30% after 1990. As the referral rate increased and the size of the clinical team expanded the number of appointments offered rose from 414 in 1988 to over 12 000 in 1994.
Recruitment and retention in treatment
This study demonstrates that Lothian Health’s Community Drug Problems Service has been highly successful in recruiting drug users into treatment having received 3863 referrals, comprising 2952 individuals, in the seven year period 1988–1994. An estimate of the extent to which the service has attracted the drug-using population was provided by a recent study which found that, 192 (33%) of a sample of 579 drug users with a history of injecting, recruited at multiple non-treatment sites throughout
Conclusions
The results of this study offer provisional evidence that methadone treatment as a harm reduction strategy in the British context is highly attractive to drug users and in common with methadone programmes elsewhere, is associated with specific beneficial outcomes notably reduced injecting and criminal behaviour. Treatment was not associated with significant change in the use of illicit drugs, injection equipment sharing among the minority who continued to inject, unsafe sexual behaviour and
Acknowledgements
The authors would like to thank all members of the CDPS team and the clients who took part in the study. We are also grateful to Lothian Medical Audit Committee and the Scottish Home and Health Department for financial assistance.
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