Transcript Strengthening Responses to Drug Injectors “Resistant to

Strengthening Responses to
Drug Injectors “Resistant to
Treatment”
Oliver Aldridge
Edinburgh, Midlothian & East Lothian
DTTO
Harm Reduction Team
Archibald Ingram 1699 - 1770
1600’s
Alexander Wood
Edinburgh Physician
IM Morphine Injections in
1850’s
Heroin Discovered in 1874
First Reports of IV
Heroin use
Methadone Treatment starts
in New York
>13 000 000 IV Drug Users
• 80% Live in 3rd World
• 90% of Methadone produced is consumed
in 1st World
• 20% of people get 90% of available
substitute treatment
IV use is not going to disappear
• No political edict can end it
• No conference can debate it away
• We need effective, sustainable, evidence
based solutions
Language Can:
• Depersonalise
• Introduce an “Us” vs “Them” culture
• Introduce blame – centred on the “Drug
Injector”
• Reinforce someone’s self image as that of
a “treatment resistant injector”
Samuel Taylor Coleridge
“The stimulus of shame, like other powerful
medicines, if administered in too large a
dose, becomes a deadly narcotic poison.”
What is “Resistance”?
• NOT fixed
• Depends on factors both internal and
external to the individual
3 STRIKES AND YOU’RE
OUT
What Works?
• Substitute treatment has some effect given
alone
• Is FAR better given WITH “wraparound”
support
Corollary:
• “Wraparound” support given WITHOUT
substitute prescribing is not particularly
effective.
What is Effective Substitute
Prescribing?
40 years of evidence suggests that:
• Methadone doses averaging between
60ml and 120ml are effective
• In 1965, Dole and Nyswander used
average doses of 103ml with a range of
10ml to 180ml
• Continued for as long as the individual
needs it – often may be several years
Scotland Today
• Difficult to get a good picture
• DORIS study reports average Methadone dose
of 50ml
• Prof. Bloor describes this as a “starvation dose”
• At this dose, many people would be called
“Resistant”
• Reports that Methadone treatment has poor
success rates
• Ineffective treatment IS ineffective
Edinburgh, Midlothian & East
Lothian DTTO
• 125 people on an order
• >90% retention in treatment rate at 3
months
• Average Methadone dose 108ml
• Intensive “wraparound” care in a
multidisciplinary team environment
DTTO Injecting Rates
80%
70%
60%
50%
40%
30%
20%
10%
0%
Ever
Used IV
IV at
Start
1 Month
6
Months
Harm Reduction Team
• 60 people in treatment
• 100% of people entering treatment are
“chaotic” and injecting, usually >5 times
per day.
• >90% retention in treatment rate at 3
months
• Average Methadone dose 103ml
• Intensive multidisciplinary support
providing “wraparound” care
Harm Reduction Team
• Abstinence rate of 77% as measured by
drug tests negative for illicit opiates.
• Reduction in expenditure on illicit drugs of
>90%, from an average of £2500.00 per
month to around £80.00 per month for
those not abstinent.
Harm Reduction Team
Overall Injecting Behaviour
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
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Harm Reduction Team
Injecting Behaviour with TIME
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Previous IV
Current IV
IV Abstinent
Existing Services
•
•
•
•
•
Time
Continued Support & Involvement
Access to good Harm Reduction services
Offer Evidence based treatment programs
Ensure that services are responsive and
relevant through User Involvement
Programs and Surveys
New Services
•
•
•
•
Consider:
Supervised injecting facilities
Heroin prescribing for people not yet ready
to cease use
But:
Need to be available nationally
Need to ensure that such programs would
not reduce funding for conventional,
existing treatment
Do the Most Good for the Most
People
• We already have a national network of
treatment services: lets use it as
effectively as possible.
• Encourage evidence based treatment
nationally by developing and monitoring
national standards.
• Political challenge is to accept that people
need time to change and that Methadone
prescribing needs to increase NOT
decrease.