conundrum or continuum

Harm reduction and drug policy in Lothian

Drug misuse in Lothian

Drug misuse is a concern worldwide; Scotland is no exception. While it is difficult to quantify the exact size of the problem due to the 'underground' nature of drug misuse, it is estimated that in Lothian there are approximately 8,100 people with a drug problem1. The extent of problematic drug use can also be monitored, up to a point, by analysis of activity at specialist drug services. In total, 3,068 clients reported to specialist drug services in Lothian in 2004 - 20053, an increase of approximately 15% on the previous year. This exceeds the Scottish Executive's target of 10%. Figure 1 illustrates the number of new clients attending specialist drug services in Lothian2. It is presented by Drug & Alcohol Action Teams (DAAT) area and clearly shows the steady increase in client numbers.

Although there is a growing incidence of increased use of stimulant drugs such as cocaine throughout Scotland, heroin use, injecting and the sharing of injecting equipment remain a priority that must be addressed. In Lothian official statistics suggest that 20% of heroin users inject; the average age for first injecting in Lothian is 22. Furthermore, 24% of new clients in Lothian reported sharing needles/syringes in the previous month4.

The HIV epidemic of the 1980s predominantly focused on injecting drug users in Lothian and resulted in innovative harm reduction policies and services. As a result, transmission of HIV has reduced greatly amongst injecting drug users. But the rise in needle sharing is once again causing concern, particularly because of the rise in Hepatitis C cases.

Hepatitis C is a blood borne virus that can seriously damage the liver and affect its ability to function. It is currently estimated that 1% of the Scottish population is Hepatitis C positive and the greatest risk of acquiring the virus in the UK is through sharing injecting equipment. It is also estimated that in Scotland, 85% of people infected with Hepatitis C were infected through sharing injecting equipment5.

The needs of families, especially children of drug using parents, is another major concern. In the UK between 2-3% of children under 16 have a parent who is a problem drug user and in Scotland this is even higher6. While using drugs does not necessarily result in an inability to parent, the need to identify children at potential risk and assess and respond to their needs is clear. In this the work of the PrePare team is recognised in Lothian.

What are we doing now?

Over the past two decades, significant investment has been made in drug treatment services. In Lothian, we have built on the shared care scheme and expanded our substitute prescribing programme to get many drug users into treatment. Needle exchange initiatives operate throughout Lothian and community based drug projects are funded to respond to local needs. Specialist projects address the needs of specific groups such as pregnant drug users, young carers, children of substance misusing parents, repeat offenders or people with hepatitis C.

All of this work has achieved a great deal. HIV transmission has reduced dramatically in the Lothian drug using population, drug related deaths have remained fairly stable over the past 10 years, despite an increase in drug use, and many more drug users are getting help than ever before.

Evidence tells us that a harm reduction approach results in positive outcomes. This includes reduction in blood borne viruses, reduction in crime and reduction in drug related deaths. However, are these outcomes good enough? Is it acceptable that someone may be on methadone for ten or maybe even fifteen years? If substitute prescribing is supposed to stabilise drug users to give them an opportunity to sort out other difficulties in their lives, then how good are we at addressing these difficulties? These are all very important questions, and ones that we are asking In Lothian. Current levels of funding in drug treatment services have never been higher. We now need to take stock of where we are and review what we want to achieve.

Where do we go from here?

DAATs are local multi-agency strategic planning groups that exist throughout Scotland. They are accountable to the Scottish Executive for addressing local issues relating to drug and alcohol misuse. NHS Lothian has remained a key partner since DAATs first met in 1996, working closely with colleagues in local authorities, Lothian & Borders Police and the voluntary sector.

Now is the time to go back to some basics. Working together is key, but it is only effective if all parties involved are signed up to the same goal. Are we trying to get people off drugs or are we trying to reduce the harm associated with drug misuse? Are these questions mutually exclusive? It is important to think of harm reduction as a continuum, where abstinence is one end. While we may wish to have everyone in Lothian drug free, we know this is not realistic in today’s society and to try and create such an environment in the short term would result in increased blood borne virus transmission and drug related deaths. It is not a risk worth taking. We do need to readdress the balance of services available and increase social care opportunities to help people achieve being drug free, when they are ready.

NHS Lothian is clear that this issue needs discussion and debate, internally and externally. A process has been initiated for discussing these issues locally and will help feed into the national review of methadone. One thing that remains clear is that drug misuse will be a part of our society for the foreseeable future and we need to ensure that we are able to respond positively to meet the challenges we face.


1. McKeganey (2003) National Prevalence Study, Centre for Drug Misuse Research (Glasgow University) and Scottish Centre for Infection and Environmental Health

2. ISD Scotland (2006) Scottish Drug Misuse Database Personal Communication

3. ISD Scotland (2005) Drug Misuse Statistics 2005 Edinburgh, ISD Publications

4. ISD Scotland (2005) Drug Misuse Statistics 2005 Edinburgh, ISD Publications

5. Scottish Executive (2006). Hepatitis C Action Plan for Scotland Phase 1: September 2006 – August 2008

6. AMCD (2003), Hidden Harm: Responding to the Needs of Children of Problem Drug Users’, HMSO, London