'Topping up' methadone: an analysis of patterns of heroin use among a treatment sample of Scottish drug users.

OBJECTIVES: To determine: (a) whether Scottish drug users on methadone maintenance use heroin less frequently than their peers following other forms of drug treatment; and (b) to what extent those on methadone maintenance 'top up' with heroin. DESIGN: A cohort study followed-up for 33 months from 2001 to 2004. METHODS: Four hundred and ten interviewees who responded at all four interview sweeps, recruited as new treatment entrants from 28 drug treatment agencies across Scotland. RESULTS: Sixty-eight of the 401 interviewees had commenced an episode of methadone-maintenance treatment at the start of the study. There was no significant difference between the methadone-maintained sample and the other interviewees in their propensity to abstain from heroin use, nor was there any difference between the two groups in the mean reduction over time in their self-reported dependence on drugs. However, if the outcome measure used is the change (between baseline and 33 months) in the number of days that the interviewee reported having used heroin in the previous 3 months, the reduction in the number of days that heroin was used was significantly greater (52 days) in the methadone-maintained group than in the rest of the sample (36.4 days). This fall in the number of days of heroin use was greater still if the comparison was restricted to those who had continued on methadone-maintenance treatment, although 67.4% of those still on methadone maintenance had 'topped up' with heroin at some point in the 3 months prior to 33-month follow-up. Those on higher maintenance doses were not significantly more likely to have reduced the number of days on which they used heroin compared with those on lower doses, and those still on methadone maintenance were not more likely to have reduced their criminality (measured by the number of days on which they committed acquisitive crimes in the previous 3 months) compared with the rest of the sample. CONCLUSIONS: Methadone-maintained drug users are not more likely to achieve abstinence than drug users receiving other forms of treatment, but they are significantly more likely to achieve a reduction in the frequency of their illicit drug use; they 'top up' on methadone, but the frequency of their illicit drug use is less than that of drug users in other treatment modalities. These data confirm the value of methadone-maintenance services as part of a 'mixed economy' of services for the treatment of drug use.

Should we prescribe heroin? A current Scottish debate.

There have been recent calls from within both Scotland and England for the wider prescription of heroin to heroin addicts as a way of coping with our burgeoning drug problem and as a route to reducing drug related criminality. But how feasible is heroin prescribing in this context? This paper considers some of the existing research evidence relating to heroin prescribing and looks also at the ethics and practicalities of prescribing heroin to heroin addicts in Scotland. We conclude that whilst the evidence on the benefits of heroin prescribing is far from clear cut there is a case for mounting a Scottish trial of heroin prescribing. Such a trial would need to be tightly controlled and rigorously evaluated. It would need to show that heroin prescribing was associated not only with a comparable level of harm reduction, as methadone prescribing, but that it was also an effective route towards drug users' eventual recovery and drug cessation.

The attendance pattern of clients at a Scottish needle exchange.

AIMS: To examine the pattern of attendance at a Scottish needle exchange. DESIGN: Semi-structured interviews and retrospective analysis of attendance patterns. SETTING: A needle exchange in a Scottish city which covers the whole of the city. PARTICIPANTS: Clients and staff of the needle exchange. MEASUREMENTS: The attendance pattern of 1556 clients of the needle exchange over a 4-year period 1995-1998. FINDINGS: The average frequency of attendance over the 4-year period was 12.7. In 1998, 23% had only visited the needle exchange once and 11% had only visited twice. CONCLUSIONS: A significant minority of clients only attend the needle exchange once or twice a year. There is a need to include information on client retention in future evaluations of needle and syringe exchange clinics and to specify the kind of relationships needle and syringe exchange clinic staff are expected to develop with clients and what level of client retention they should be aiming towards in a well-run clinic.

Addicts' narratives of recovery from drug use: constructing a non-addict identity.

Sociological accounts of the process of recovery from dependent drug use have emphasised the importance of the individual constructing a non-addict identity for themselves. Following Giddens we identify the process of providing a narrative of their recovery as one of the mechanisms by which addicts may seek to achieve this. The narratives of recovery which are the subject of this paper were elicited in the course of semi-structured interviews with a sample of 70 recovering addicts. There were three key areas in which the addicts' narratives of recovery could be seen to be constructing a non-addict identity for the individual; firstly, in relation to the reinterpretation of aspects of their drug using lifestyle; secondly, in relation to the reconstruction of their sense of self and thirdly, in relation to the provision of convincing explanations for their recovery. In certain respects, the addicts' narratives of recovery are similar to the accounts of recovery provided by drug workers and addictions researchers. The paper argues that the correspondence between addicts' own accounts of their recovery and those of professional drug workers may be not so much the result of the intrinsic nature of the recovery process as a product of the socially constructed nature of the narratives and the fact that the latter may have been developed in conjunction with those working in the drug treatment industry.

Association between illegal drugs and weapon carrying in young people in Scotland: schools' survey.

OBJECTIVES: To identify the type and extent of weapons being carried among young people in Scotland, and to determine the relation between use of illegal drugs and weapon carrying. DESIGN: Questionnaire school survey. SETTING: Independent schools in central Scotland and schools in Lanarkshire and Perth and Kinross. PARTICIPANTS: 3121 students aged 11 to 16 in 20 schools. MAIN OUTCOME MEASURES: Self completion questionnaire reporting history of drug use and weapon carrying. RESULTS: Overall, 34.1% of males and 8. 6% of females reported having carried a weapon (P<0.0001), ranging from 29.2% of boys aged 11-13 (classes S1 to S2) to 39.3% of boys aged 13-15 (S3 to S4). These values are higher than those in a recent survey of young people in England. Weapon carrying in Lanarkshire was 70% higher for males than in the rural area of Perth and Kinross. Both males and females who had taken drugs were more likely to carry weapons (63.5% of male drug users versus 20.5% of non-users and 22.8% of female drug users versus 3.7% of non-users; both P<0.0001). The proportions of males carrying weapons who used none, one, two, three or four, or five or more illegal drugs were 21%, 52%, 68%, 74%, and 92% respectively. A similar trend was found among females. CONCLUSIONS: Better information is needed on the nature and extent of weapon carrying by young people in the United Kingdom, and better educational campaigns are needed warning of the dangers of carrying weapons.

Musical preference as an indicator of adolescent drug use.

AIMS: This paper aims to demonstrate whether a relationship exists between adolescent drug use and identification with styles of music linked to specific youth culture. DESIGN: Survey data were collected by researchers, under exam conditions, from two contrasting samples of Scottish secondary schoolchildren. SETTING: Fieldwork was conducted in five comprehensive schools in the city of Dundee in 1994 and five comprehensive schools in the rural area of Perth and Kinross District in 1996. PARTICIPANTS: Questionnaires were administered to two randomly selected mixed ability classes in each of the four compulsory school years (S1 to S4), at each participating school. The eventual sample (n = 1523) was approximately 10% of all children in these school years from the geographical areas surveyed. MEASUREMENTS: Comparisons were made between life-time measures of legal and illegal drug use and current favourite style of music. FINDINGS: Although few children in this study had ever taken the drug ecstasy (MDMA), 'fans' of rave music were more likely to have used drugs than those who preferred other styles of music. This relationship held true across a range of drugs used, across two geographical areas, over time and controlling for age, gender and parental social class. CONCLUSIONS: The paper is one of the first to quantify a possible relationship between drug use and music style. On the basis of the evidence presented, a significant relationship was found between identification with rave music and life-time drug use.

Contrasting methods of collecting data on injectors' risk behaviour.

In this paper two contrasting methods of collecting data on drug injectors' needle and syringe sharing practices are considered, namely: direct questions about any previous sharing in the last 6 months, and vignettes in which injectors are asked to indicate whether they would be prepared to share injecting equipment in a range of situations. Injectors' statements of their preparedness to share are far in excess of their reports of actual sharing. The possible reasons for this discrepancy are considered, including that injectors may have under-reported the level of their actual sharing. It is suggested that in future studies aiming to collect risk behaviour data should seek to combine methods rather than to rely solely upon direct questioning of any past sharing.

Estimating the prevalence of drug misuse in Dundee, Scotland: an application of capture-recapture methods.

STUDY OBJECTIVES: To apply capture-recapture methods to provide an estimate of the prevalence of opiate and benzodiazepine misuse in Dundee, Scotland. DESIGN: A four sample capture-recapture method using data from both statutory and non-statutory data sources to estimate drug misuse prevalence in Dundee between January 1990 and December 1994. PARTICIPANTS: Users of benzodiazepines or opiates residing within Dundee. RESULTS: Altogether 855 drug misusers were identified from various sources within Dundee; many were identified from more than one source. Using this data, the estimated unknown population was 1702, giving a total population of 2557 (95% confidence interval (CI) 1974, 3458) who misuse benzodiazepines or opiates. This represents a prevalence of 28.8 (95% CI 22.3, 39.0) per thousand. CONCLUSIONS: Capture-recapture techniques can be applied to statutory and non-statutory agency data to produce an estimate of at least certain sections of the drug misusing population. However, it is important to recognise the limitations of this methodology and in future to seek to combine a range of approaches to the problem of estimating prevalence rather than sticking rigidly to any single approach.

The preparedness to share injecting equipment: an analysis using vignettes.

This paper reports on the use of vignettes to study drug injectors' preparedness to share injecting equipment. Separate vignettes referring to borrowing and passing on injecting equipment have been submitted to 505 injecting drug users in Glasgow. Injectors were asked to identify their own likely response in each of the situations described within the vignettes. It was shown that even among those injectors not reporting any actual sharing in the last 6 months a significant proportion would still be prepared to share injecting equipment within certain situations. The preparedness to share injecting equipment was seen to be influenced by such factors as social distance, sex and length of time injecting. It is suggested that even in situations where drug injectors may have modified their behaviour in the direction of lower levels of reported sharing, a propensity to share may remain. This suggests the continuing need to provide injectors with easy access to sterile injecting equipment; in addition, services working with injecting drug users may need to focus not only upon actual sharing behaviour but also upon what we have described here as the preparedness to share. Indeed, the latter dimension should stand as a warning to services of the potential for sharing injecting equipment to increase in the future.

Prostitution and HIV: what do we know and where might research be targeted in the future?

PIP: A review of the literature indicates that the association between human immunodeficiency virus (HIV) and prostitution varies by geographic region and can be altered substantially by well-planned public health interventions. In most African countries and in Asian countries such as Thailand, the rate of HIV infection among female prostitutes is substantially higher than the rate in the general population. Relatively few commercial sex workers in South and Central America are HIV-positive; however, their extremely high rates of infection with sexually transmitted diseases indicates the potential for future epidemic spread of HIV. In Europe and North America, HIV infection is most prevalent among drug-injecting or crack-using prostitutes. Neglected has been research on the high incidence of HIV among male transvestite and transsexual prostitutes. The lowest levels of condom use in commercial sex encounters have been recorded in regions in developing countries with the highest HIV prevalence. Also of concern are high condom breakage rates (20-50%) among female prostitutes who use petroleum-based lubricants and male prostitutes who practice anal sex. Valuable would be quantification of the additional HIV risk resulting from sex with a prostitute. Other recommended research areas include estimates of the number of male and female prostitutes working in certain geographic areas, mechanisms for monitoring condom use and substance abuse among prostitutes, the impact of HIV infection on movement into and out of prostitution, the dynamics of prostitute-client condom negotiation, and profiles of the clients of male prostitutes.^ieng

Mobility of Scottish injecting drug users and risk of HIV infection.

Nine hundred and nineteen injecting drug users (IDUs) were interviewed in Glasgow, Scotland during 1990 and 1991, as part of a wider study of HIV risk behaviour, about their injecting and sexual behaviour outside the city in the previous two years. Forty-five percent of respondents injected outside Glasgow, 6% shared needles and syringes (n/s) and 20% had sexual intercourse. Much activity occurred outside Scotland but mainly within the UK, particularly London. Predictors of n/s sharing outside Glasgow during the previous two years included current injecting with and passing on of used n/s and sexual intercourse with casual partners. Predictors of sexual behaviour outside Glasgow included passing on used n/s, having sexual intercourse with casual partners and, for females, engaging in prostitution. Glasgow IDUs are a highly mobile group and although HIV prevalence remains low within this population, considerable potential for importation/exportation of HIV and other bloodborne and sexually transmitted infections exists. Further work is required to establish why IDUs travel to, and engage in high-risk activities in locations outside their home environment, and detailed data about activities such as frequency of condom usage and n/s cleaning practices need to obtained. While there is a widespread network of services for IDUs in the UK, information provided usually relates to local services and may not fully address the needs of this mobile population. Therefore, we recommend that IDUs be provided with details of facilities such as n/s exchange schemes and drug-treatment establishments in centres to where they most commonly travel.

Comparison of four survey methods designed to estimate the prevalence of HIV among female prostitutes who inject drugs.

In Glasgow, during the period January 1990 to December 1992, 4 different methods were used to determine HIV prevalence among female prostitutes who inject drugs: the surveillance of prostitutes undergoing voluntary named tests, an unlinked anonymous survey of prostitutes attending a health care drop-in centre, a community-wide voluntary anonymous survey of injecting drug users including female prostitutes, and a voluntary anonymous survey of female prostitutes recruited in Glasgow's red-light area. HIV prevalence varied from 1.2 to 4.7% though overlapping confidence intervals indicated no significant differences. A comparison of each approach leads the authors to suggest that the former 2 methods which are relatively inexpensive should be conducted, if possible, on high risk groups such as prostitutes and injecting drug users on a continuous basis. If these indicate HIV rates which are stable and less than 5%, implementation of more sophisticated voluntary anonymous approaches need only be done every 3 to 4 years. However, if rates are unstable and/or greater than 5% then such surveys should be initiated more frequently, perhaps biannually.

Low and stable prevalence of HIV among drug injectors in Glasgow.

The first HIV-positive diagnosis among injecting drug users (IDU) in Glasgow was made in 1985. By the end of 1987 prevalence among IDU receiving voluntary attributable tests was 4.8%. Since 1990, an annual cross-sectional survey of HIV prevalence and risk behaviours among 500 current Glasgow IDU has provided a more representative sample. Anonymously-tested saliva samples obtained from respondents revealed prevalence rates of 1.8%, 1.2% and 1.0% in 1990, 1991 and 1992 respectively. Since 1987 a wide range of measures aimed at reducing HIV-related risk behaviour among IDU has been introduced and maintained in Glasgow. Against this background, there is evidence that IDU in the city have reduced their risk behaviours. The findings reported here suggest that implementing harm-reduction measures when prevalence is low may inhibit the rapid dissemination of HIV.

Why do men buy sex and what are their assessments of the HIV-related risks when they do?

The belief that female prostitution might play a key role in the heterosexual spread of HIV infection has led to a great deal of attention being focused on the activities of women who sell sex. By contrast, the activities of men who buy sex has been largely ignored. One of the reasons for this has undoubtedly been the difficulties of contacting such men. In this paper data from telephone interviews with 70 men who had recently purchased sex are presented. It is shown that there was a wide range of factors that the men cited in explaining the appeal of commercial sex. The paper also reports on the males' views as to the risks of HIV associated with commercial sex. Although the men believed HIV to be very widespread amongst women selling sex, hardly any of them felt at risk themselves as a result of their commercial sexual encounters. The basis for the men's optimism about avoiding HIV and their preparedness to inform other sexual partners about their prostitute contacts are also described.