Comment

Intravenous drug misusers — patients, victims or scum? By

By Duncan Jenkins, Hooman Ghalamkari, and Chris Brazil

Throughout its history the pharmacy profession has consistently endeavoured to define drugs as medicines. A recent example is the Royal Pharmaceutical Society's role in bringing about clinical trials of the medical effects of cannabis so that the public can benefit from its use. Professional and Government policies thus legitimise the use of these drugs and subsequently shape the behaviour and attitudes of society towards those people who take them. In contrast, inconsistent policies relating to drug misuse has resulted in conflicting attitudes and behaviour towards those people taking them. Thus people taking legitimised drugs or “medicines” become defined as “patients” and those taking non-legitimised drugs become defined as “drug misusers”.

Health professionals treat drug misuse as a medical problem using the “helpless” addiction model. The addict is perceived as the helpless individual who, having fallen prey to wicked drug dealers, becomes hooked on evil drugs, and is pharmacologically driven in a deterministic way to continue using them. Health policies further “medicalise” the situation by offering support in the form of counselling and the prescription of drugs, such as methadone, that can to a limited extent satisfy the dependency. Services focus on meeting general health needs as well as reducing the potential for harm. However, accepting that the problem is medicalised, do we go far enough?

Needle exchange schemes

Many community pharmacists participate in needle exchange schemes, where intravenous drug users (IDUs) can exchange used needles for clean ones. The provision of clean needles and syringes results in less sharing between users and a reduced risk of transmission of blood-borne pathogens such as HIV and hepatitis. The brave decision in the late 1980s to roll out schemes in the UK has proven to be successful in containing HIV. However, the prevalence of infection with the hepatitis C virus among IDUs remains worryingly high, suggesting that needle exchange schemes alone are insufficient as an infection control measure. Furthermore, transmission of blood-borne pathogens is only one element of the risk faced by IDUs.

The production of street drugs is not subjected to formal quality assurance processes and the user has no guarantee of the purity or content. As IDUs judge how much heroin to use by past experience and according to the intensity of effect they are seeking, inadvertent overdose is common. Factors, such as reduced tolerance through lack of use and the user mixing heroin, say, with other drugs, complicate the situation. Stories of a series of deaths related to an unusually pure batch of heroin are not uncommon. The user is also unaware of the nature of the inevitable diluent, or presence of potentially harmful chemical or microbiological contaminants.

Last year's series of deaths in Glasgow, Dublin and elsewhere illustrate the difficulties faced by public health professionals, police and other professionals in managing a particularly nasty batch of a street drug. The resulting challenges to the authorities included warning users, obtaining and analysing the drug, management of those suffering from the adverse effects of unidentified pathogens, and the possibility that the contamination of street drugs might have been an act of terrorism. In addition, the emotional impact on users, their friends and families should never be underestimated.

Preparation

The preparation of heroin for injection involves heating the product in powder form and dissolving it in a liquid so that it can be drawn up into a syringe for injection into a vein (or less commonly, into a muscle). The injection of particles, hypertonic solutions and micro-organisms can result in damage to veins, sepsis and abscess formation. Users attempt to reduce this harm by using agents that promote solubility, such as vinegar, lemon juice, ascorbic acid and citric acid, by using filters (for example, the filters used to make roll-up cigarettes) to eliminate particles, and by using what they believe to be a hygienic source of water. Although these excipients and devices are used to reduce risk of self-harm, they are often a source of harm themselves. Furthermore, IDUs will often use their own needles but will share other materials and paraphernalia, thus retaining some risk of cross infection.

The injection process involves locating a vein, usually by applying a makeshift tourniquet (often a belt or tie) so that the vein stands out. Failure to remove a belt or similar makeshift device while under the acute influence of an opiate could result in gangrene and the loss of a limb. The user is also often faced with problems of limited venous access due to the deterioration of veins resulting from repeated injection. This in turn can lead to the injection of drugs into veins in areas such as the groin where there is a danger of inadvertently injecting into an artery. Alternatively, users may resort to intramuscular injection, which can result in formation of an abscess (which can act as a reservoir for infectious organisms) and the development of septicaemia.

Harm reduction

Currently the only formal harm reduction policy is the provision of sterile needles and syringes to individuals. However, there are measures that could reduce harm further. The provision of sterile water could reduce the risk of sepsis. The provision of pharmaceutical grade filters and citric acid could reduce the risk of complications from particulate injection. The provision of medical tourniquets could reduce the risk of gangrene. Or perhaps better still, the provision of pharmaceutical grade diamorphine would go a long way to reducing much of the harm associated with the injection of street heroin, including phenomenal levels of drug-related crime.

Perhaps, the availability of clean, supervised injecting rooms with a ready supply of drug and associated paraphernalia, along with the teaching of good injecting technique, would further reduce the potential for harm. These could be discreetly provided in easily accessible environments such as shopping centres or even community pharmacies. Naloxone could be made readily available to IDUs as an antidote to opiate overdose, with drug workers teaching basic first aid and resuscitation techniques.

We would like to pose a number of questions. First, why is it acceptable for pharmacists to provide sterile needles and syringes but not other excipients, paraphernalia or even drugs? All the measures described above have been adopted with good effect elsewhere in Europe. Secondly, when are we comfortable with drug misusers receiving services from pharmacies and what range of services should we provide? The drug problem could be classed not only as a health problem, but also as a social or criminal problem, which in turn shapes practitioners' perceptions of individuals — patient, victim or scum. The profession should help to redefine or breakdown unhelpful boundaries. Thirdly, how should concordance be applied to the management of drug users? The scope for addressing the individual’s needs is restricted with a drug strategy driven by a criminal justice agenda of coercing drug users into a treatment regimen.

We have posed three simple questions, but there are many more that need answering. The Royal Pharmaceutical Society has a chance to shape the future policy towards drug misuse. Let us not be left behind and end up following the lead of others.

Dr Jenkins and Dr Ghalamkari are directors of the MORPh consultancy, providers and strategic advice to stakeholders in medicines management; Mr Brazil is service manager, substance misuse service, Worcestershire Community and Mental Health NHS Trust