|Written by David Shewan|
|Monday, 20 December 1993 00:00|
THE INTERNATIONAL JOURNAL OF DRUG POLICY 1993 4 3
DRUG SERVICE PROVISION IN GLASGOW
The present study is concerned with monitoring changes in service provision for drug users. Monitoring the services actually available to drug users can provide some indication of whether harm-reduction objectives are an enduring part of drug policy generally.
Providing a description about what is takingplace at the level of service provision can also be of some use in informing the broader debate about the position of drug users in society. It cannot automatically be assumed that the demarginalisation of drug users is shown by the provision of harm-reduction services. However, where harm-reduction initiatives have been introduced and remained in place over time, this provides some indica., TABLE 1: Availability of particular service options tion of prevailing policy trends, as does the desire of drug agencies to expand or reduce the harm-reduction basis of their service.
DRUG USE AND DRUG SERVICE PROVISION IN GREATERGLASGOW
The present study offers an opportunity to compare policy and practice among drug agencies in Glasgow from 1990 to the present. A survey was carried out among the city's drug agencies in each year from 1990, the aim being to provide an overview of the service options generallyavailable todrugusers in Glasgow. Neither survey addressed the question of the effectiveness of particular options and no claim is made that these surveys take the place of a more in-depth analysis of changing trends in drug policy. What this research does provide, however, is some indication of how drug policy is developing in the 1990s in one major city.
A recent study estimated the numbers of injecting drug users in Glasgow at between approximately 7000-12 000, a prevalence rate of approximately 15 per 1000 population aged 15-5 5 (Frischer et al., 199 1 ). These figures are by no means insignificant, and although Glasgow has, as yet, not experienced the high rates of HIV infection among injecting drug users associated with other Scottish towns and cities (Haw' et al., 1991), a range of personal and social problems will occur among the city's drug-using population.
Since 1990 there has been some movement towards developing a more integrated and coordinated drug policy in Glasgow. This is proving to be a slow process, however. The Misuse of Drugs and Alcohol Liaison Forum was set up in 1990 (3 years after the initial Scottish Office recommendation), but has still to produce a policy statement for drug service provision in the city. Individual aspects of service provision deserve to be highlighted, however. The city's needle-exchange schemes have continued to expand and attract new clients, but, conversely, there is still no city-wide policy on prescribing for drug users, and provision of this particular service option remains sporadic.
The previous survey (Shewan, 1992) indicated a general acceptance among drug agencies of a harmreduction approach, with a high proportion of agencies providing information and advice on safer drug use (90%) and safer sex (84%). But although appropriate information and advice are central to a harm-reduction approach, it is also important that specific services are available that enable the drug user to act on the advice given. In this respect, the lower level of provision of equipment exchange (30%), supply of condoms (39%), prescribing of oral drugs (26%) and prescribing of injectable drugs (3%) indicated that in some cases actual delivery of these specific services lagged behind good intentions. Most of the prescribing Which took place was occasional and limited to prescription of antidepressants during detoxification or as part of a drug-reduction programme. Significant numbers of agencies were in favour of adding certain of these services to what they already offered to drug users, namely equipment exchange and supply of condoms. There was, however, no significant trend for greater availability of prescribing schemes.
The present survey involved contacting all of the statutory and voluntarydrug and/or HIV agencies within the Greater Glasgow area. Thirty-eight such agencies were contacted by way of a postal questionnaire with follow-ups where necessary - with a return rate of 61% (23 of 38) which is not unacceptably low by the standards of postal surveys.
In addition to the service options listed in Table 1, agencies were also asked if they made any other service options available. This produced a range of varied response, the most common of which were group work with drug users (4 of 23) and providing transport to needle exchanges (2 of 2 3).
Where prescribing was offered as a service option, the agencies concerned were asked about the nature of these prescribing schemes. The eight agencies who made prescribing available only prescribed oral drugs, with no prescribing of injectable drugs. Seven of the eight agencies prescribed on a reduction basis only; the remaining agency prescribed on both a reduction and a maintenance basis. Four of the agencies concerned prescribed oral methadone.
TABLE 2: Summary of services which drug agencies would want to be able to offer their clients
General information/ad vice about drug use Information/advice on safer sex General information/advice HIV/AIDS Counselling Information/advice on safer drug use Referral to other agencies Provision of condoms Help with social/legallhousing problems Services for pregnant drug users HIV testing Detoxification Oral prescribing for users Equipment exchange Primary health care Prescribing oral methadone Prescribing injectable drugs
Services agencies want to see provided in Greater' Glasgow
Agencies were also asked which services they would like to see available in Greater Glasgow as a whole, though not necessarily from their agency. This is summarised in Table 3.
Table 3, by and large, represents a high consensus for providing a wide range of services within Greater Glasgow. The one aspect of service provision that does not attract broad support is the prescribing of injectable drugs; provision of all other services is either given the support of the large majority of drug agencies or is unanimously supported.
Comparisons between existing service provision and perceived required service provision
Statistical analysis (Wilcoxon matched pairs signed ranks tests) was carried out to compare current service provision with: the service provision which agencies would want to be able to provide, and the service provision which agencies would want to see in Greater Glasgow as a whole. This analysis was intended to identify specific and significant trends among agencies towards either greater or lesser provision of a service.
Current service provision and services agencies want to provide
Only one significant difference was found between agencies current provision of services and their perceptions of services they should be offering. This was for prescribing oral drugs to users (p <0.05), the trend being for agencies who are not providing this service to want to provide it.
Current service provision and services that agencies want provided in Greater Glasgow
When current service provision from agencies is compared to the services they want to see provided in Greater Glasgow as a whole, a range of significant differences arises. In each case, the consensus is towards a particular service not available from an agency being made available within Greater Glasgow. These differences were as follows: HIV testing (p <0.05); primary health care (p<0.05); services for pregnant users (p <0.005); detoxification (p <0.005); prescribing of oral drugs (p <0.005); prescribing of oral methadone (p <0.0005); prescribing of injectable drugs (p <0.005); provision of equipment exchange (p <0.0005); provision of condoms (p <0.05).
The high level of availability of information and advice on social, legal and housing issues is to be welcomed. This indicates that, on the surface at least, there is a recognition that a response to clients is required which does not just focus on particular aspects of their behaviour, but which also looks at that behaviour in a broader social context.
Just over half of the agencies surveyed provided services for pregnant drug users. Several agencies noted their concern that adequate services were not being provided for women drug users generally. There is longstanding acknowledgement that women drug users are generally perceived more negatively than their male counterparts, and that while some progress has been made, their specific needs are still not being sufficiently addressed (Dorn er al., 1992; Henderson, 1992).
The agencies surveyed seemed by and large satisfied with the range of services they offered to drug users. Apart from the concerns described above over services for pregnant users, the only other option which significantly more agencies would like to provide than doing so at present was oral prescribing.
In contrast, there was a high consensus that services not being provided at present by individual agencies should be provided on a city-wide basis. This refers to HIV testing, primary health care, services for pregnant' users, detoxification, prescribing of oral drugs, prescribing of oral methadone, prescribing of injectable drugs, provision of equipment exchange, provision of condoms.
It would appear, therefore, that among drugs workers there is a general acceptance that a wide range of services should be made available, and that this should include a range of harm-reduction services, such as prescribing and equipment exchange.
At one level it is necessary to argue that drug use is primarily a public health issue. It is also necessary however, that this is accompanied by an argument for a corresponding shift at the sociocultural level, in that drug use is perceived as neither a 'delinquent' behaviour, which leads to a primarily penal response, nor a'diseased' behaviour, which leads to a primarily medical response. Drug use is a complex social and psychological phenomenon, and suggested solutions based on simplistic theories are not helpful in enabling drug users to minirmse the harm to themselves which results from their drug use, or in helping to stabilise the effects of drugs, drug use and HIV/AIDS on society (Davies, 1992). It is necessary to accept that drug users are a part of society, and that drug policy should be '...assimilative, rather than coercive, that seeks to integrate drug users into society rather than marginalise them' (McDermott, 1992).