Dipipanone

Since 1983 parts of Scotland, unlike England, have experienced a major drug-related HIV epidemic. Edinburgh and Lothian currently have a known HIV-infected population of 1,105. A variety of harm-reduction measures, including needle exchanges, methadone prescription, community drug agencies, and targeted prevention campaigns have been implemented since 1985. The number of drug-related HIV infections reported has fallen significantly since 1988. However, sexual transmission remains a cause for concern, particularly among the injecting and non-injecting partners of HIV-positive drug users.

Introduction

Edinburgh, the capital of Scotland, is renowned for its culture and architectural beauty. It is also said to be one of the most socially segregated cities in the United Kingdom. Problem drug use in the form of heroin consumption became evident in some multiply-deprived districts in the early 1980s. Pharmaceutical preparations subsequently became popular among problem drug users, particularly following the identification of a drug-related HIV epidemic in 1985 and a tailing off in heroin supplies. A rapid and concerted response to HIV based on the concept of harm reduction has determined the success of treatment and prevention services over the past 10 years in influencing drug-use practices. Drug use in prisons remains a cause for concern. As elsewhere, services have been less successful in changing the sexual behaviors of injecting drug users.

Context

Edinburgh has a population of 415,000. The region of Lothian in which it is located has a population of 0.75 million. The overall population of Scotland is 5.4 million. Difficulties arising from problem drug use in Scotland, especially the HIV epidemic, need to be viewed in the context of the past 15 years. Initially, there was little evidence of illicit drug consumption in depressed urban areas. However, in the early 1980s a black market in heroin emerged, accompanied by a rapid increase in the consumption of other drugs, particularly in Edinburgh and in Glasgow. It did not take long for illicit opioids and those who injected them to become part of the landscape (Barnard and McKeganey 1990). Typically, addicts were young, injectors, frequently from poor urban areas and unemployed. In 1986 when unemployment throughout Edinburgh approached 13, male unemployment in one area with a large addict and HIV-infected population was estimated at 32.3 (Robertson and Bucknall 1986).

Patterns of Consumption

In the early 1980s heroin dealers in Scotland's largest city, Glasgow, who bought and sold in ounce quantities, seemed to be heavy users themselves. Other user-dealers operated at the gram level as retail outlets for other suppliers. Distribution tended to be organized at a local community level, reflecting the traditional organization of the Glasgow criminal subculture. Anecdotal reports suggest a similar pattern occurred in Edinburgh. Until the mid-1980s, heroin arrived in Edinburgh in ounce or multi-ounce quantities. It was subsequently broken down for distribution by minor wholesalers employing user-dealers. By the late 1980s the Glasgow market was far more sophisticated than that of Edinburgh, with established connections to bulk suppliers in England. Stealing and dealing were two common ways of financing heroin consumption, shoplifting being seen as less risky than other forms of revenue-raising crime.

The incarceration of a number of wholesale heroin dealers, a move from heroin into mortgage fraud by local career criminals with disposable capital, high levels of HIV infection, and a significant increase in substitute prescribing led to a reduction in the supply and consumption of heroin in Edinburgh by the latter 1980s. This reinforced a growing trend towards the consumption of pharmaceutical products The `illicit pharmacopeia' is remarkably varied and subject to continuous change (Hammersley et al. 1990). Prior to the identification of HIV, Scots experimenting with heroin tended to initiate consumption by injection or rapidly shift to that route. Injection of pharmaceutical products, such as buprenorphine (temgesic), temazepam, and tranquillizers, was increasingly reported in Glasgow and Edinburgh from 1984 and became a problem in both cities (Haw 1985; Haw and Liddell 1987). Since 1987, injecting has declined significantly in Edinburgh, which now has the lowest reported injecting rates in Scotland (Scottish Drug Misuse Database 1995a).

Experience in Scotland shows that preparations intended for oral administration are not necessarily used in that way. There is much trading and bartering between drug users. The methadone and benzodiazepines that may be prescribed are not necessarily the consumer's drug of choice and may be exchanged for another product. Street reports in Edinburgh indicate that methadone, dihydrocodeine, temazepam, diazepam, triazolam, and temgesic have all been traded on the illicit market in recent years. Fifteen years ago in Edinburgh the opioids used were almost entirely heroin and dipipanone. Although these drugs are far less available in the city today, an illicit market in benzodiazepines has developed. (Cannabis is ubiquitous as a recreational drug among most age groups and all social classes, whereas LSD along with MDMA (ecstasy) became popular among young people following the development of the "rave" phenomenon in Scotland in the early 1990s.') Polydrug use appears to be nearly as extensive in Glasgow as it is in Edinburgh. Temgesic and temazepam have been consistently popular, as has heroin, which is more readily available in Glasgow and Aberdeen than it is in Edinburgh or Dundee (fig. 1).

Diversion andDistribution

After cannabis, pharmaceutical preparations appear to be the most commonly used drugs in Scotland for non-medical purposes; in England and Wales cannabis is followed by illicitly manufactured amphetamine and opioids, pharmaceutical preparations rank third. Despite growing concern in England about prescribed and over-the-counter drugs, Scotland seems to have the larger problem (Home Office, 1994). Diversion of pharmaceutical preparations may take place through bulk fraud at wholesale level, theft from a manufacturer or from pharmacists, and through over-the- counter purchases. Recent legal cases in Edinburgh and London have revealed fraudulent diversion on a massive scale through bogus sales and export deals involving millions of tablets.

Even while undergoing or receiving treatment, many patients continue to use non-prescribed drugs for prolonged periods, obtaining them from a variety of sources, for pleasure or to routinely augment a prescription. As might be expected, prices of illegally imported drugs tend to be higher in Scotland than in London, which is the prime focus for wholesale and retail distribution in the United Kingdom. Geographical distance and extenuated supply routes add additional cost to a product. Similarly, prices are higher in Edinburgh than in Glasgow, which has a larger retail market and a more developed distribution network. Edinburgh's local middle-level heroin distributors never seemed to fully recover from the effect of a series of arrests in the mid-1980s, their own drug dependency, and the impact on injecting of an HIV epidemic that touched some of them personally. Those primarily concerned with criminal careers moved into other forms of illegal business.

Scotland, England, and Wales

Broadly speaking, the typical Scot experiencing physical, psychological, social, or legal problems related to their drug use is likely to be male, in his mid-20s, unemployed, living in a deprived urban area, injecting a variety of illicit and pharmaceutical preparations, and at a high risk of HN infection. The Scottish scene differs from that of England and Wales in a number of ways. Scottish addicts officially reported to the British Home Office by medical practitioners as dependent on a limited number of opioid drugs and cocaine are more likely to be younger, to be injecting, and to be reported from prison than their English counterparts. The extent of drug-related HIV infection is far higher in Scotland with immediate consequences for statutory and non-statutory services and drug users themselves. There are also marked differences in patterns of consumption within Scotland. Glasgow, Edinburgh, Dundee, and Aberdeen are the main centers of problem drug use. Glasgow has particularly high levels of heroin use, injecting, and death by overdose (Scottish Drug Misuse Database 1994; Home Office 1994). There were 139 drug-related deaths in Scotland among individuals known or suspected to be drug-dependent in 1994 (Scottish Drug Misuse Database 1995a). Glasgow has particularly high rates of death by heroin overdose. Collaborative mortality studies have been proposed in both Glasgow and Edinburgh. These may help to cast further light on the way mode of administration, type of drug used, HIV status, access to services, and prescribing policies affect drug-related mortalities in both cities.

HIV Infection

The epidemiology of HIV infection in Edinburgh and Lothian is changing from injecting drug use to predominantly sexual transmission. By December 1995,1,105 residents of the Lothian region had been diagnosed HIV-positive (Scottish Centre for Infection and Environmental Health 1996). Lothian's HIV register indicates that up to October 1995, 1,310 individuals from Lothian and elsewhere had been tested or treated for HIV infection by local services. The epidemic continues to be centered in particular districts within the city of Edinburgh, primarily areas of multiple deprivation.

Over the past 3 years, between 50 and 75 new HIV infections per year have been identified in Lothian (Scottish Centre for Infection and Environmental Health 1996). The region, with only 14 of Scotland's population, accounted for 44 (74) of newly reported HIV cases (169) in Scotland in 1994-95 (Lothian Health 1995). Partners of former or current IDUs seem to be particularly at risk as Edinburgh's cohort of drug users infected in the early 1980s become sicker and increasingly infectious. Fortunately, the level of injecting drug use has declined markedly, although heroin and amphetamine continue to be injected. Pockets of injectors have also been identified in some rural areas and there appears to be extensive drug use and equipment sharing in Scottish prisons (McKenna 1993; Bird et al 1995; Taylor et al. 1995).

HIV and Injecting Drug Use

Most individuals requiring medical and social care for HIV and AIDS until the turn of the century in Lothian will have acquired HIV infection through injecting drug use. Of a cumulative total of 1,105 HIV-positive residents, 596 (54) had acquired their infection through injecting drug use (Scottish Centre for Infection and Environmental Health 1996). However, newly diagnosed drug-related HIV infections have fallen dramatically since the late 1980s. In 1994-95, injecting drug use accounted for only nine new diagnoses (Lothian Health 1995). Findings from the Medical Research Council-funded Edinburgh serial HIV prevalence study suggested a stable seroprevalence rate of 19 (95 confidence limits, 15.7 to 22.9) over a 3-year period (1992 to 1994) among current injectors (Richardson et al. 1995). Encouragingly, 93 of those who proved to be HIV-positive through anonymous testing were aware of their serostatus. Injecting between 1982 and 1984 had the strongest correlation with HIV positivity. Over 50 of respondents interviewed between 1992 and 1994 injected less than once a week and 73 had not shared injecting equipment over the previous 6 months (Richardson et al. 1995).

A considerable body of drug research has been developed in Scotland over the past 15 years both within a university and service delivery context. A recent ministerial task force has encouraged further research at a local and national level (Ministerial Drugs Task Force 1994). Prevalence studies are being planned to estimate the full extent of all problem drug use in Edinburgh and Lothian. Earlier prevalence studies were conducted in Glasgow (1984), Edinburgh (1986), and Lothian (1993). The most recent study contributing to what has effectively became a national cycle was completed in Tayside in 1996 (Haw 1985, 1993; Haw and Liddell 1987; McKeganey, personal communication 1996). Until recently, injecting drug use has constituted the primary focus of research because of its implications for HIV infection.

HIV and the Prison Population

Injecting drug use among the prison population is a particular cause for concern The Edinburgh serial HIV prevalence study of injectors found that 195 (31) of injectors had been in prison in the previous 6 months, of whom 35 (18) had injected while in prison (Richardson et al. 1995). Sixty-five percent (23) of those who had injected in prison utilized used injecting equipment and 71 (25) passed on used equipment. The first year of the study found that IDUs who had been incarcerated on more than 19 occasions were 3.7 times more likely to be infected than those who had not been incarcerated (Davies et al. 1995). A medical drug reduction program has been in place in Edinburgh's Saughton Prison since 1993. Interestingly, the introduction of mandatory drug testing in British prisons may result in greater resources being devoted to prison treatment programs in Scotland The Scottish Prison Service wishes to ensure that such treatment programs are compatible with services that exist in the outside community (Stewart 1996). Health social work, and voluntary street agencies are encouraged to participate in the delivery of the program and there is ongoing liaison between the prison and other treatment, care, and prevention bodies.

HIV and Heterosexual Transmission

The potential for heterosexual transmission to the partners of IDUs remains considerable. Fifty-four percent of the seropositives in Edinburgh's serial HIV prevalence study sample of IDUs never used condoms with steady partners and 28 never did so with casual partners (Davies et al. 1995). Cumulatively,13.8 (152 of 1,105) of all infections had been heterosexually acquired in Edinburgh and Lothian by the end of 1995 (Scottish Centre for Infection and Environmental Health 1996). Although still relatively low in absolute numbers, heterosexual reports contributed 30 of all newly known infections in the financial year 1994-95, and 24 in 199394 (Lothian Health 1994,1995). The Lothian HIV Register indicates that over the past 3 calendar years, 34 individuals developed AIDS within 12 months of having their first positive HIV test. Seventeen (50) of these individuals had been infected heterosexually. It would appear that those infected through sexual intercourse may be less aware of the risks of transmission, only coming forward for testing when they develop an HIV-related illness. This is unfortunate given that people who are aware of their seropositive status may be more likely to practice safer drug use and safer sex.

AIDS Cases

By December 31, 1995, 340 cases of AIDS had been reported in Edinburgh and Lothian, 46.5 of all AIDS reports (732) in Scotland (Scottish Centre for Infection and Environmental Health 1996). Exposure categories reflected the evolution of the HIV epidemic in Edinburgh, which first affected gay men followed by a cohort of IDUs infected between 1982 and 1984. Studies show that progression to AIDS may be slower in IDUs compared to other risk groups (Brettle et al. 1995), although as a result of prophylaxis some HIV-infected people develop symptomatic disease, and even die, without developing AIDS-defining illness. IDUs have also suffered a high mortality from suicide and violence, as well as the synergistic effect of HIV, overdose, pneumonia, hepatitis, and septicemia

Service Delivery and Take Up

Ten years ago little attempt had been made in Edinburgh to examine the work conducted in drug services, the effectiveness of interventions, and the impact on drug-using communities. To a certain extent this reflected a lack of official interest in the drug field and the hostility of many psychiatrists, physicians, and community groups to substitute prescribing prior to the identification of a drug-related HIV epidemic in Edinburgh in 1985. The endorsement of harm-reduction policies, the establishment of needle exchanges, the creation of a specialist service, the mobilization of health and social service professionals, and the expansion of the voluntary sector stemmed from the HIV crisis. HIV infection in Edinburgh more closely resembles the situation in Spain, southern France, and Italy than that of the rest of Britain where HIV transmission has mainly occurred sexually (Lewis 1992). In 1994, HIV infection in Edinburgh was significantly associated with being 27 to 36 years of age, starting to inject between 1975 and 1980, injecting in 1980 through 1987 (particularly 1982 through 1984), injecting in more than 7 years since 1979, reusing injecting equipment already used by another IDU in 1980-1987, being imprisoned, using equipment used by a fellow prisoner, and residing in north Edinburgh (Davies et al. 1995). There is now increasing concern about levels of hepatitis C infection among injecting drug users and their partners. Estimates of infection rates as high as 80 among drug injectors have been suggested (Brettle 1995).

The drug strategy adopted by Lothian's health service, local government bodies, and private and voluntary agencies, subsequent to the identification of high levels of HIV infection, followed a harm-reduction model. Its main objectives were to reduce the incidence of drug-related HIV infection; to reduce the physical, psychological, legal, and social harm associated with drug use; and to encourage users to move toward abstinence. The United Kingdom's Advisory Council on the Misuse of Drugs (ACMD) believes that "low levels of injecting risk behavior and the presently low HIV prevalence among drug injectors provide solid grounds to affirm the success to date of the strategy adopted in the United Kingdom., and are in sharp contrast to the position seen in some other European countries" (ACMD 1993:2). Unfortunately, the implementation of such measures came too late for the proportion of Edinburgh's IDUs population that was already infected, if not for their fellow injectors.

The drug-related component of the HIV epidemic in Lothian is such that problem drug users and ex-users are served to a greater or lesser extent by most HN services as well as drug services. The needle exchange work of the Harm Reduction Team is particularly targeted at IDUs. The team, which conducts HIV prevention work among IDUs and men who have sex with men in public environments, collaborates with, but is quite distinct from, the Community Drugs Problem Service, which provides treatment and care for all problem drug users.

The Scottish Drug Misuse Database Bulletin for 1994 indicated that the age of 940 drug users recorded as seeking assistance with problems in Lothian was similar to the rest of Scotland. Sixty percent of service clients were aged 20 through 29 years, 64 were male, and 82 were unemployed. Only 5 of the sample in Lothian reported heroin as their primary drug. What differentiated Lothian from other areas was the predominant consumption of oral and non-injectable preparations. Monitoring of problem drug use and general practice case loads in 1993-94 (Scottish Drug Misuse Database 1995b) suggested a continuing trend away from injecting. Whereas Lothian has made very significant gains in reducing injecting, its remaining pool of injectors contains a high proportion of individuals that still share equipment. New initiatives are required to reach this hard core of injecting risk takers.

Community Drug Problem Service

The Community Drug Problem Service (CDPS), which is medically led and provides shared care in collaboration with general practitioners, was established in 1988. Treatment programs are designed to help reduce the harm that problem drug use has on the user, their families, and the community. Drug dependence is viewed as a chronic relapsing condition that requires a wide range of approaches from prevention to early intervention to harm reduction to clinical treatment. The service has adopted extensive use of longer term substitute prescribing and flexible stabilization programs designed to meet individual needs. Safer injecting, stopping injecting, safer oral drug use, reduced consumption, and abstinence are all seen as important goals. Drug users are seen in a variety of community settings including health centers, social work departments, and in their own homes. Opioid dependent and/or benzodiazepine dependent patients typically are offered oral substitute medication as a discouragement to continued illicit drug use, particularly by injection. Medication is usually prescribed by the user's general practitioner (GP) following recommendations by the service. Treatment plans are negotiated with the client. GP prescribing programs are generally flexible and subject to regular review following a detailed initial assessment of the degree of physical dependency.

Clinical assessment and discharge questionnaires have been developed, which give information on patient behaviour, drug trends, and many other variables. GPs are encouraged to prescribe oral methadone and other drug substitutes in an attempt to reduce injecting and the spread of HIV infection. Over 70 of Edinburgh's GP practices now prescribe for around 1,600 drug users who have altered their patterns of drug taking, with a marked shift away from injecting drug use, and toward oral pharmaceutical drugs. HIV rates among new referrals to the CDPS have fallen since 1988 (Community Drug Problem Service 1994; Bury 1994, 1996; Haw 1993).

Internal audit and evaluation show that significant gains have been made in the areas of injecting, crime, prostitution, and levels of consumption of opiates. Thirty-one percent of a cohort of 256 patients assessed in 1990-91 by the CDPS were retained in treatment for at least 12 months. No HIV seroconversions were reported in the cohort while in treatment. Satisfactory discharge was achieved for 28 of patients overall and 40 of users in treatment for at least 6 months (CDPS 1994; Peters et al 1994). The promotion of further behavior change in a relatively hard core of injectors, and a much larger population with poor condom use, will require novel methods of intervention. Prescribing policies throughout Lothian will require regular review to fine tune an intervention that has proved attractive to clients, general practitioners and policy makers.

Reduction in Drug Injecting and Sharing Equipment

Although the sociodemographic characteristics of individuals referred to the CDPS remained similar over the years, the pattern of drug use at the time of referral changed progressively, especially in the first 5 years of the service. The proportion of drug-using clients who had ever shared injecting equipment fell from 85 in 1988 to 51 in 1993. Sharing equipment in the preceding month fell from 39 to 13 in the same time period.

The proportion of new referrals who had ever injected fell from 97 in 1988 to 43 in 1993. Among those who had ever injected, injecting in the month prior to referral fell from 88 to 14 over the same years. Study of CDPS clients in treatment after 6 months (n=74) and 24 months (n=57) showed that injecting rates continued to fall (Greenwood 1996).

CDPS and HIV Seropositivity Rates

The HIV seropositive rates of CDPS clients tested prior to referral fell from 21 oro in 1988 to 8 in 1993. Condom use did not change in the same time interval suggesting that there has been no equivalent move towards safer sexual behavior despite extensive local public health education programs. Staff are vigilant about encouraging reduction of injecting and sharing behaviour, but the prevention of sexually transmitted HIV and other infections is a particularly difficult task. Staff have indicated that sexual harm reduction was an area that some found difficult to discuss with clients. It would appear that some specialist drug workers find the same difficulty in addressing sexual issues that some genito-urinary medical staff find in addressing drug-related issues in the United Kingdom and, probably, elsewhere. The European literature suggests that effecting changes in sexual behaviors is far harder than effecting changes in drug-related behaviors. IDUs do not prioritize safer sex in the way that many prioritize safer drug use. It might be argued that sex is more fundamental to human behavior and sexual behaviors are correspondingly harder to change.

By offering GPs specialist support, the drug service has been able to deal with more patients than would have been possible with a conventional, centralized prescribing service. Although most patients remain on drugs, they are on safer, long-acting oral pharmaceutical preparations, and half are on gradual reduction programs. The majority now rarely inject, with a consequent reduction in the risk of contracting HIV and other morbidity associated with injecting drug use (Greenwood 1996).

The CDPS appears to have made a significant contribution to altering the pattern of drug use and associated high risk behavior in Edinburgh. The HIV transmission rate among IDUs has decreased. The rate of injecting has fallen, and many users are now stabilized on oral drugs. A high proportion of drug users in Lothian appear to be in contact with primary care services. Heroin use has declined. Although there is a combination of reasons for these improvements, it is clear that the shared care prescribing regime between the CDPS and GPs has been influential (Williamson 1994).

Harm Reduction Team

The Harm Reduction Team was established to provide outreach needle exchange and support for those at risk of HIV infection in 1987. They provide a number of services including the provision of injection equipment and safer drug and sex clinics (with both fixed and mobile sites), outreach work with male sex workers and men who have sex with men in public environments, and management of condom distribution. The current balance of service encompasses direct and indirect services promoting safer sex and safer drug use.

During 1994-95 the team saw 825 individual clients. There were 2,287 contacts, 730 (31.5) of which related to injection equipment exchange. Drug-use interventions related to safer drug use, safer injecting, safer disposal, dressing ulcers and abscesses, needle exchange, and distribution of bleach. The team recently has been adopting a more facilitative and coordinating role for generic services, and has concentrated on being a specialist and innovative service in relation to clients. Twenty-five pharmacies in Lothian participate in the needle exchange scheme, supplying free injecting equipment exchanges to addicts (Gavin 1995). The impact of the CDPS and other prescribing services has meant that there has been less demand for needle exchange delivery compared to other Scottish cities such as Glasgow. The remarkable popularity of needle exchanges in Glasgow suggests that in the past they may have been the only source of primary health care for some IDUs in that city. A CDPS with close general practitioner co-operation has now been established following extensive ground work by HIV and drug specialists in Glasgow, Scottish Office support, and liaison with Edinburgh. Other Services for Drug Users

During 1993-94, 1,191 individuals were served by community-based and shop-front drug agencies in Lothian involving 9,475 interactions with clients (Centre for HIV/AIDS and Drug Studies 1994). General practitioners, the Social Work Department, and the CDPS were likely to be the commonest alternative service contacts, illustrating the pivotal role that GPs play in responding to drug problems in the region. Opioids and benzodiazepines created the greatest problems for the clients of these agencies. Although cannabis was ubiquitous, reflecting the polydrug use patterns of most clients, it did not seem to be a cause for concern in itself

The dominant issues affecting clients' lives were perceived as being predominately drugs, followed by relationships. Importantly, the possibility and implications of HIV infection appeared to concern clients less than finance, housing, and legal problems (Centre for HIV/AIDS and Drug Studies 1994). This presents critical issues for HIV prevention and education work and confirms anecdotal observations by professionals working in the HIV field. Because Lothian's problem drug users and HIV-infected population live primarily in areas of multiple deprivation, most worry more about the practicalities of daily survival than the eventual consequences of HIV infection.

Monitoring and Evaluation

HIV/AIDS and drug services in the region participate in a monitoring and evaluation system in collaboration with service planners and purchasers. Service evaluations are conducted externally by research staff at the Centre for HIV/AIDS and Drug Studies, a unit within Lothian's medical department of public health. Researchers and an increasing number of providers take the view that effective self-evaluation, with appropriate feedback supplemented by objective, external evaluation, can strengthen and give affirmation to a service. Specifications are reviewed in the light of evaluation and in collaboration with provider agencies and planning partners.

There are currently 12 street, residential, prevention, treatment and care drug services in Edinburgh and Lothian. Each agency undergoes a full external evaluation within a 3-year cycle. Initially, evaluations were primarily process oriented. As services have bedded down, outcome measures are being increasingly implemented. Outcome measures of effectiveness include clients becoming drug free, stabilized or reduced drug use, change from injecting to oral drug use, stopping sharing injection equipment, improved social situation, improvement in relationships, reduced episodes of use, reduced episodes of imprisonment, and reduced episodes of overdose. Clinical services offering stabilized and reducing prescribing are impacting on drug-related risk behavior and stabilizing lifestyles, as are short-stay crisis intervention services. Outcomes achieved by outreach services have proved harder to measure. The flexibility of the Harm Reduction Team in conducting outreach programs for both hard-to-contact IDUs and men who have sex with men in public environments has proved effective in reaching quite disparate groups.

Voluntary agencies annually self-evaluate their work according to set guidelines that are agreed upon jointly. Detailed service specifications, informed by needs assessment and the evaluation cycle, outline the type, level, and quality of service required as well as targets for specific areas of activity. Medically oriented services such as the CDPS and a short-stay residential drug-crisis center have established appropriate outcome measures. Community-based street agencies find this harder to do, partly because of their responsibilities for prevention and partly because of the nature of their work. The impact of detached activities can be particularly hard to quantify. Yet the positive effect of peer-promoted education within drug user subcultural networks can be considerable. Because of this, emphasis is placed on the importance of qualitative data as well as routine quantitative data.

Conclusion

Epidemiological data suggest that harm reduction policies implemented since 1986 have helped to limit the spread of HIV infection in Lothian and the consequences of injecting drug use (Scottish Center for Infection and Environmental Health 1996). Evaluation has enabled agencies to target their services more precisely. It is hoped that increased emphasis on outcome measures will ensure that every individual and the community will benefit from the treatment and care that is available. Adjustments in policy and direction may be required as patterns of consumption, dependency, and treatment change. It would appear that initially recreational but widespread, low level drug use mainly among young people may prove to be an increasing challenge. Cannabis, ecstasy, and amphetamine are not viewed as problematic by many young people in the United Kingdom. However, their illegality does create difficulties for consumers and for law enforcement. Although there are voices within treatment, care, prevention, and policing prepared to address such issues, a lack of political will on the part of legislators permits no real arena for debate. There is inevitable concern that a small proportion of recreational drug users may inadvertently become involved in more problematic drug use and high risk behaviors, and a question as to whether repression can be an effective response.

Transmission via contaminated injecting equipment is now responsible for a small proportion of newly identified HIV infections. Heterosexual transmission from infected IDUs poses the greater challenge for drug treatment and health services. More immediately, there is increasing concern in Edinburgh and beyond about high levels of hepatitis C infection among the IDU population. This has major implications for clinical care in the future as well as a requirement for clear strategies and protocols.

Notes

1. "Acid house" style music arved in London from Detroit in the eady 1980s, acquiring an undergound status in which illicit drugs were consumed at unregulated and informal dance venues. The use of ecstasy at such events, subsequently described as raves, became popular in England in the late 1980s. The increased availability of ecstasy in Scotland was evident by the early 1990s. 2. General practitioners, CDPS, voluntary street agencies, and the social work department of the local government area work closely together in responding to problem drug use, subscribing to a joint harm reduction strategy. Social services provide a variety of social care, including generic support, residential care, and work with offenders.

References

Advisory Council on the Misuse of Drugs

1993 AIDS and Drug Misuse Update. London: Her Majesty's Stationery Office Barnard, M., and N. McKeganey

1990 Adolescents, sex and injecting drug use: risks for HIV infection. AIDS Care.

2 (2):103-116.

Bird, A.G., S.M. Gore, S. Cameron, A.J. Ross and D.J. Goldberg 1995 Anonymous HN surveillance with risk factor elicitation at Scotland's

largest prison, Barlinnie. AIDS. 9, (7):801-803. Bird, A.G, S.M. Gore, D.W. Jolliffe, S.M. Bums 1992 Anonymous HI[V surveillance in Saughton Prison, Edinburgh. AIDS 6(9): 725-733.

Brettle, R.P.

1995 Hepatitis C - policy considerations. Centre for HtV/AIDS and Drug

Studies. Policy Seminar, City Hospital, Edinburgh, March 23. Brettle, R.P., A.J. McNeil, S.M., Gore, A.G. Bird, C.L. Leen, and A. Richardson 1995 The Edinburgh City hospital cohort: analysis of enrolment, progression and

mortality by baseline. Quarterly Journal of Medicine 88:479-491. Bury, J.

1994 HIV Infection and drug misuse in Lothian general practice, report on epidemiology questionnaire 1993. Edinburgh:Lothian Health.

Bury, J.

1996 HIVInfection and drug misuse in Lothian general practice, report on epidemiology survey 1995. Edinburgh: Lothian Health Primary Care Services.

Centre forHIV/AIDS and Drug Studies

1994 Data analysis of voluntary agency evaluation sheets. Edinburgh: Lothian

Health Board.

Community Drug Problem Service

1994 Lothian's Community Drug Problem Service, a five year review

1988-1993. Edinburgh: Edinburgh Healthcare Trust. Davies, AG., N.J. Dominy, A Peters, GE. Bath, S.M. Bums, and A.M. Richardson 1995 HIV in injecting drug users in Edinburgh: prevalence and correlates. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology. 8, 399-405.

Gavin, S.

1995 An evaluation of the Harm Reduction Team. Edinburgh: Centre for

HIV/AIDS and Drug Studies. Greenwood, J.

1996 Six years' experience of sharing the care of Edinburgh's drug users.

Psychiatric Bulletin. 20, 8-11. Hammersley, R., T. Lavelle, and K.A. Forsyth

1990 Buprenorphine and temazepam abuse. British Journal of Addiction; 84:

301-303. Haw, S.

1985 Drug problems in Greater Glasgow. London: Standing Conference on

Drug Abuse. Haw, S.

1993 Pharmaceutical drugs and illicit drug use in Lothian region. Edinburgh: Centre for HIV/AIDS and Drug Studies.

Haw, S., and D. Liddell

1987 Drug problems in Edinburgh District. London: Standing Conference on

Drug Abuse. Home Office

1994 Area Tables. Statistics of the Misuse of Drugs: Addicts notified to the

Home Office UK 1993. London: Home Office. Lewis, R.

1992 Misuse of drugs in Scotland. Proceedings of the Royal College of

Physicians. Edinburgh 22: 18-28. Lothian Health

1994 HIV/AIDS in Lothian - Strategies for survival. AIDS (Control) Act report

for 1993/94. Edinburgh: Lothian Health Board. Lothian Health

1995 HIV/AIDS in Lothian -Ten years on. AIDS (Control) Act report for

1994/95. Edinburgh: Lothian Health Board. McKeganey, N.

1996 Director, Centre for Drug Misuse Research, University of Glasgow, personal communication.

McKenna, C.

1993 Problem drug use and related needs in East Lothian. Glasgow: Scottish Drugs Forum.

Ministerial Drugs Task Force

1994 Drugs in Scotland: Meeting the Challenge. Edinburgh: Scottish Office

Home and Health Department. Peters, A.D., M.M. Reid, S.G. Griffin

1994 Edinburgh drug users: are they injecting and sharing less? AIDS 8(4):

521-528

Richardson, A.M., A.G. Davies, A. Peters, and N. Dominy 1995 Serial prevalence study of HIV infection and HIV risk behaviour among

injecting drug users in Edinburgh 1992-94. Answer AM-17 WR 95/47. Robertson, J.R., and AB. Bucknall

1986 Heroin users in a Scottish city. Final report for Scottish Office Home and Health Department. Edinburgh: Scottish Home and Health Department.

Scottish Centre for Infection and Environmental Health 1996 HIV infection and AIDS: Quarterly report to 31 st December 1995. Answer

AM-19 96/04.

Scottish Drug Misuse Database

1994 Bulletin. Edinburgh:Information Services Division, Scottish Health Service

Common Services Agency. Scottish Drug Misuse Database

1995a Bulletin. Edinburgh:Information Services Division, Scottish Health Service

Common Services Agency. Scottish Drug Misuse Database

1995b Monitoring of problem drug use seen in general practice. Edinburgh: Information Services Division, Scottish Health Service Common Services Agency.

Stewart, D.

1996 Presentation on Mandatory Drug Testing. Scottish Prisons Service

Seminar. Saughton Prison, Edinburgh. 23rd February Taylor, A., D. Goldberg, J. Emslie, J. Wrench, L. Gruer, S. Cameron, J. Black, B. Davis, J. Macgregor, E. Follett, J. Harvey, J. Basson, and J. McGavigan 1995 Outbreak of HIV infection in a Scottish prison. British Medical Journal 310:289-292. Williamson, L.

1994 An evaluation of the Community Drug Problem Service. Edinburgh: Centre for HIV/AIDS and Drug Studies.

Roger Lewis directs Lothian Health's Centre for HIV/AIDS and Drug Studies and advises health service commissioners on policy and planning responses to problem drug use and HlV/AIDS. He is paticulay mte in illicit drug markets. He has recently completed a Pompidou Group sponsored study of the impact of the Balkan conflict on heroin trafficking. Address correspondence and reprint requests to Roger Lewis, Centre for HIV/AIDS and Drug Studies, Ward 14a, City Hospital,Edinburgh, Scotland EHlO 55B.

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