Health in Scotland 2009 Time for Change: Annual Report of the Chief Medical Officer

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CHAPTER 3 Scotland and problem drug use

Scotland has a mature drug treatment capability - based on 'shared care'. The process of enhancing control within individuals as outlined in previous chapters is central to promotion of recovery. Expectations contained in the promotion of recovery and delivery of personalised care must be balanced with the existing public health benefits of well evidenced approaches to reduce drug-related harm. More effective methods of primary care engagement are required to increase the likelihood of consistently delivering evidence-based interventions in the users' own environments through effective systems of shared care. This will also increase recovery capital and re-engage substance misusers with important care systems which will be needed to address their emerging health needs.

Substance misuse can be seen as a multi-factorial problem with biological, physical, mental and social components. Clearly no single discipline acting alone has the ability to effect a successful outcome. The Scottish Government has a widely supported strategy which recognises the need for harm reduction but also promotes recovery and prioritises the needs of children and substance misusing parents as well as recognising the need to act effectively to prevent the development of drug problems. Whilst it is important that all individuals should be supported in their aspirations for recovery it must be recognised that within a spectrum of people with substance use problems there is a huge gap in the distance some must travel to be re-integrated into mainstream society.

Treatment of substance misuse always stimulates controversy and strong views among politicians, the media and the caring professions. Despite this, or perhaps because of the resulting intense interest, Scotland has concentrated considerable effort and expense in assembling a treatment service with many qualities. Born out of the disaster of HIV infection in injecting drug users, the medical problems evident among young drug users, the strain on the criminal justice system as users fall into its orbit and the emotional and tragic child care implications associated with parental drug use, drug services have developed a range of approaches, designed to minimise these problems, to reduce drug deaths and improve prospects for drug users and their families. Support for these controversial policies has come from all political parties. The Conservative Government of the 1980s supported the provision of needles and syringes (Scotland had the first National policy endorsing this in the world), and successive governments of all parties have supported opiate substitute treatment as part of the overall care provided. Recently attention has focussed on child care and child protection as well as driving forward a new agenda of holistic personal care designed to meet the aspirations of each individual in their progress to their own personal manifestation of recovery.

A person's journey

In a very simplistic sense, a person's journey through a dependency could be split into three sections. The treatment or action which would be appropriate for each of these sections would necessarily be different. Assessment and development of an individual care plan for each person is vital to providing effective interventions.

Consider the first section: initially the quantity of drugs taken is small and use infrequent. The drugs are enjoyed (something not to be forgotten) and may provide relief from anxiety, give excitement, or blot out emotions linked to physical or sexual abuse. The person can afford the drugs and their lifestyle is not greatly affected. As their use continues more of the drug needs to be taken for less effect. Occasionally becomes frequently then daily. Problems emerge physically and mentally, with relationships, family and employer but their drug use is still functional and continues. The second section: the person is now dependent and subject to cravings, loss of control, increased tolerance - so more drugs are needed or ingestion changes to intra-venous use - withdrawal symptoms, physical and mental harm and the loss of salient alternatives to drug taking to avoid pain or induce pleasure. This person is frequently unemployed and outwith family support, possibly homeless by this time and well acquainted with the criminal justice system. The drugs are still functional and the misuse goes on. The third section sees the complete breakdown of the addicted individual, physically, mentally and socially. They are thoroughly exhausted by the interventions of the criminal justice system - usually imprisonment - and are often homeless. The drugs are no longer functional and are only taken to keep withdrawal at bay and to numb the mind to loss and misery.

With this scenario in mind it is obvious that a range of interventions is necessary to impact on an individual's situation. This involves cooperation between housing, education, employment, criminal justice, social services, specialist drug treatment services, and community based services which must include the General Practitioner and broader primary care team. The GP is well placed to assess and treat individuals with problem use, engaging them with local specialist and generic services. This role should be a core primary care service, and not an 'enhanced service' that can be opted out of. There is a maxim 'If you are not part of the solution you are part of the problem'. This is especially so in drug treatment services. Government has the responsibility to require services to provide a full range of effectively governed evidence based treatments in each area without a "post code lottery". When being in treatment at the very least reduces the likelihood of premature death, exclusion from a cheap, cost effective, evidence based treatment must be unacceptable.

Shared care

In the NHS opportunities arise to deliver services to individuals with problem use in specialist or general settings. Participants include specialist clinics led by a Consultant team and General Practitioners/primary care services. Recently community pharmacists have taken on an increased role. Also involved are voluntary agencies and private providers. Problem users interact with social care and criminal justice agencies but increased medical provision has been required to cater for an increasing number of their needs. Shared care has become the paradigm within which a range of service elements deliver interventions to individuals. These services deliver programmes which aim to prevent harm and support recovery. They include primary and secondary prevention, basic harm minimisation to disorganised and chaotic individuals as well as family support, access to rehabilitation processes and, increasingly, services aimed at encouraging employability or housing support. This model therefore involves primary care in close collaboration with many services.

This path-finding model is envied by other countries but depends fundamentally on the participation of each component to be effective. In areas where all agencies are functional this system works well, providing a robust and accountable infrastructure. In areas where any component is functioning in a less satisfactory way, however, problems arise. When partial failure leads to stress in the system this is most manifest in specialist clinics which carry the ultimate responsibility for local care and cannot opt out. Rising waiting lists, absence of primary care involvement or a malfunctioning support services are warnings of failure of the shared care model. Other indicators are over reliance on one practitioner or practice or fatigue in an overburdened part of the service. Leadership and peer support are critical and this requires skilled and realistic support from local managers and commissioners.

This approach to delivering a complex spectrum of services has become a model for other parts of the NHS. Arising out of the HIV/ AIDS and rapidly emerging drug problems of the 1980s, shared care approaches have been used in the management of many chronic conditions such as diabetes or chronic cardiopulmonary disease. Establishing a functioning link among agencies, a flow of information and an agreement of tasks to be shared or assumed by different parts of the organisation represents a cost effective and person centred approach to delivering heath care.

Primary care may be a fundamental strength or a fatal weakness in the shared care model. Dissention or negative views from one practice/group can disable the system whereas a vibrant primary care sector can carry a large share of the burden providing an invaluable, local, integrated, family approach. If recovery has, at its centre, normalisation, for many service users an important step is the ability to be cared for in their own community by their local doctor. At the present time there are examples of both effective and dysfunctional GP services. In some areas shared care effectively doesn't exist and the responsibility defaults to secondary care. The optional nature of enhanced services allows the emergence of gaps in the system. Persuasion can come in the form of health board inducements or personal chemistry between individuals. On a national basis adjusting the General Medical Services contract seems low on the agenda of BMA negotiators but should nevertheless be encouraged.

An evolving healthcare problem

Specialist services have historically been the responsibility of Psychiatry. Clinics have, however, had to change to manage the complex problems becoming common in drug users better. As the drug using population expands and ages, more areas of medicine need to join the collaboration. Infectious diseases, for many years critically important in managing cases of HIV/ AIDS, now have a rising caseload of patients with liver disease due to hepatitis C and are required to engage with new manifestations of drug use such as the recent anthrax outbreak. Anthrax and tuberculosis in drug users has required shared care between public health, respiratory physicians, surgical teams and the clinical microbiological services. A range of medical conditions are presenting as early degenerative disorders in patients with opiate dependency. Cardiologists and respiratory physicians are finding themselves responsible for drug related diseases. Premature cardiomyopathy from alcohol problems, early lung cancer in heroin and cigarette smokers, chronic pulmonary obstruction, and pneumonia are presenting in extravagant form in chronically under nourished individuals. In addition to this, specialists unfamiliar with opiate dependence treatment find themselves managing difficult patients tolerant to large doses of opiates.

The capacity of treatment services has never been more tested. Not only is demand greater and the requirement for high quality scrutinised but newer more testing responsibilities are being expected. Services which arose as a matter of urgency in the 1980s to curb the epidemic of blood borne viruses are now responsible for personal and individualised care for each patient. In many ways the new demands are simply an extension of existing provision. Health care workers involved with people who use drugs would say that their interests are in total care including a recovery agenda for each individual. It is important that the system focuses on recovery as the overarching outcome it delivers.

The challenges for the next few years are many. Improving services, refocusing the aims and objectives of services and restructuring the overall package to deliver recovery are recurring themes. How to achieve this without damaging the valuable and effective elements of the existing system is work in progress.