Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 24 July 2012

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Contents

Offender drink problem screening in Britain

First three entries in the bulletin explore the feasibility of screening arrestees or offenders in Britain for risky drinking. Among the samples heavy drinking was the norm but screening implementation was patchy and there was scepticism from staff about whether screening and brief intervention were the appropriate answers. The preference was to target the obviously problematic minority rather than the problem drinking majority. Last entry is a major EU report which reminds us of the public health roles of easy-access syringes and heroin substitute drugs.

Single question enough to identify most heavy drinking offenders ...

Despite senior support most detainees not screened for risky drinking ...

Screening offenders for risky drinking not a priority in Scotland ...

EU calls for widespread methadone and syringes to prevent disease ...


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Alcohol screening and brief intervention in a policing context: a mixed methods feasibility study.

Brown N., Newbury-Birch D., McGovern R. et al.
Drug and Alcohol Review: 2010, 29, p. 647–654.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Kaner at e.f.s.kaner@newcastle.ac.uk.

Risky drinking was widespread among the disorder and assault suspects screened for alcohol problems and (as indicated) offered brief advice by civilian staff at a police station in north east England, but they constituted just a quarter of the arrestees intended to have been screened.

Summary In Britain police contact is generally the first step for someone entering the criminal justice system, and up to a quarter of police work is associated with alcohol-related incidents. It follows that police personnel may be well placed to deliver interventions to reduce excessive drinking and related problems. If such an approach were feasible and effective, it might save police time spent responding to alcohol-related crime.

As a first step this pilot study aimed to explore the feasibility and acceptability (to arrestees and staff) of screening for risky drinking and if indicated offering brief counselling during routine practice at a police station in a town in north east England. Targeted arrestees were primarily those arrested for public order or assault offences, offences closely linked with alcohol misuse. Senior police officers had identified the station and approached the research team about exploring the potential for such work.

Civilian detention officers were considered suitable staff because they are not police officers, reducing the perception of conflicting interests, and because they fingerprint arrestees immediately before release, an opportunity to screen and intervene when the arrestee is least likely to be still be intoxicated and has had time to reflect on their arrest. In a two-hour course tailored to the setting, all 10 detention officers at the station were trained on-site by the research team to screen arrestees using the AUDIT alcohol screening questionnaire and deliver five minutes of advice to those who screened positive Scoring 8 or more. for at least hazardous drinking. The advice followed the How much is too much brief intervention protocol which targets hazardous and harmful drinkers and aims to evoke change by providing information about their drinking and how to reduce it to sensible levels. At the discretion of the officer, screening and brief advice were conducted while the arrestee was detained in the cell or during fingerprinting, and the questionnaires were either completed by the arrestee or with the detention officer. Shortly after screening and advice had been completed, detention officers were individually interviewed about the professional barriers and facilitators which influenced the feasibility of this work.

Of the 2318 arrests at the station during the three-month study period in 2009, 704 were for the target offences and 229 screening questionnaires In 41% of cases the arrest was for public disorder and in 50% for assault. were completed and collected from about a third of the eligible caseload. Participants were mainly young white men and most were screened in the early hours of the morning and at weekends.

Main findings

Of 229 participants, 23% declined or were unable to complete the AUDIT and 176 completed it, a quarter of the arrestees targeted by the project. Of the 229, 134 or 59% screened as at least hazardous drinkers; of those screened, 76%. Half the AUDIT-positive arrestees were hazardous drinkers, 15% harmful drinkers, and 35% showed signs of alcohol dependence. Heavy single occasion ('binge') drinking was common: 41% of participants reported drinking 10 or more UK units (each about 8gm alcohol) on a typical drinking day and a further 21% between seven and nine units.

Nearly all AUDIT-positive arrestees accepted the offer of brief advice. Additionally, two thirds who screened negative were nevertheless offered and accepted brief advice.

In interviews detention officers were fairly evenly divided in their views about the screening and brief intervention work they had been engaged in. Around half thought it inappropriate to the venue or their role and that the policing environment was not conducive to a helping relationship. Typically they questioned the work's value and were reluctant to carry it out, citing lack of time and hostility from arrestees and their dishonesty. These officers tended to have negative and/or hostile interactions with arrestees.

The other half of officers felt the venue and their role to be entirely appropriate, welcomed the training, and appreciated the potential value of screening and brief intervention among a caseload often drinking to excess, and for whom the consequences could be linked to their offences. These officers felt able to develop high levels of rapport in their interactions with arrestees and expressed a belief in their potential to change and in the effectiveness of the intervention.

Most officers found screening and brief intervention straightforward and largely problem-free. However, nearly all said there were times when they were too busy for this work, and some were also influenced by the arrestees' hostility towards them or towards the screening process. However, other officers felt that arrestees were happy to consent to screening and intervention as long as they did not feel judged or threatened.

The authors' conclusions

That three quarters of the arrestees in this study were risky drinkers demonstrates the potential for alcohol screening and intervention in police stations, and this feasibility study has shown it is possible for detention officers to conduct this work with arrestees. Around a third of the people arrested for targeted offences were approached, a quarter completed screening, and nearly all to whom this was offered accepted brief advice – encouraging levels after just two hours of training. However, the setting is highly challenging; police cells can be a hostile environment and arrestees may be aggressive and resistant to support from police personnel. On the other hand, the immediate hours after an arrest may present a 'teachable moment' which can be capitalised on to make a clear link between drinking and subsequent arrest. The officers who did this work were divided in their views about its feasibility and value; more intensive training might have helped improve attitudes and performance.


Findings logo commentary For the researchers the coverage achieved after such brief training was encouraging, but a more jaundiced view seems just as valid. Implementing the pilot in the police station not only had the support of senior officers but was instigated by them; top-level support is an important influence on whether such initiatives get implemented. Yet still just a quarter of the intended arrestees completed screening. However, in this case management support does not seem to have been expressed in practical ways such as providing incentives, officially monitoring performance, and extra resources to enable staff to add these duties to their routine work.

Another study in England, which as well as police station custody suites also included prisons and probation, found that the FAST Alcohol Screening Test broadly duplicated results from the AUDIT screening tool, yet generally required just a single question. In so far as insufficient time really was a barrier to the work, this test would make screening more acceptable and improve coverage. The fact that in the featured study two thirds of AUDIT-negative detainees were nevertheless offered and accepted alcohol advice seems however to cast doubt on the degree to which screening results were relied on by the officers, perhaps because they thought respondents were minimising their problems.

The decision to use detention officers for the project, and associated with this to delay screening often until just before release when drunk detainees had sobered up, may have helped raise the proportion who joined the study and were screened to 25% compared to the 10% in police stations in another English study, in which intoxication of arrestees was a major barrier to their participation.

Instead of brief advice from police staff, another approach is for police custody officers to refer alcohol-involved arrestees to specialist alcohol counsellors, one trialled by the government in England. However, this trial offered no reassurance that the result was the desired reduction in crime as offenders were helped to control their drinking. The reason may have been that there was very little documented (in the form of arrests) evidence of crime by the arrestees before they had been counselled, so very little scope on this measure for crime to be reduced. The researchers suggested that arrest seems to provide a valuable opportunity to identify dependent drinkers who are more motivated than 'binge' drinkers to do something about their drinking, and to direct them to more intensive intervention (such as specialist treatment for alcohol dependence), potentially justified on health and broader social as well as crime reduction grounds.

Last revised 24 July 2012

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2011 Delivering alcohol brief interventions in the community justice setting: evaluation of a pilot project

STUDY 2012 Alcohol screening and brief intervention in probation

STUDY 2012 Alcohol screening and brief intervention in primary health care

STUDY 2012 Alcohol screening and brief intervention in emergency departments

STUDY 2014 The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

STUDY 2013 Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial

STUDY 2012 Summary of findings from two evaluations of Home Office alcohol arrest referral pilot schemes

STUDY 2011 Scoping study of interventions for offenders with alcohol problems in community justice settings

STUDY 2009 Evidence-based practice? The National Probation Service's work with alcohol-misusing offenders

STUDY 2011 An evaluation to assess the implementation of NHS delivered alcohol brief interventions: final report





Delivering alcohol brief interventions in the community justice setting: evaluation of a pilot project.

Skellington Orr K., McCoard S., Canning S. et al.
NHS Health Scotland, 2011.
Unable to obtain a copy by clicking title? Try this alternative source.

Though drinking problems were widespread, Scottish probation and community service staff were unconvinced of the appropriateness of screening their offender clients for risky drinking and (if indicated) offering brief advice. Not a priority, was the common feeling.

Summary This research report presents the findings of an independent evaluation of the feasibility and potential effectiveness of screening for risky drinking and offering brief advice as required to adult offenders in community justice settings in Scotland. It describes the set up and operation of pilot schemes in three local authority areas between January 2010 and April 2011. These offered training to 121 probation and community service staff supervising offenders to enable them to conduct screening for risky drinking using the AUDIT questionnaire during the initial appointment with an offender in day-to-day practice. A randomly selected half were also trained to offer a brief intervention based on motivational interviewing to offenders who screened positive Scoring 8 to 19, the range associated with hazardous or harmful drinkers. for risky drinking but did not exceed the threshold for probable dependence, using as appropriate an alcohol advice booklet as a supplement; the other half were merely to hand the offender the booklet in addition to usual care and supervision. Offenders who had in the past year been screened and offered a brief intervention in these or other settings, or whose sentences required alcohol treatment or education, were excluded from the pilot.

The featured schemes and study arose from a commitment in the Scottish government's 2009 alcohol strategy to fund research on the delivery of brief alcohol interventions in non-medical settings. Such interventions have been widely researched in primary care but not in community justice settings. The project aimed to help fill this research gap by testing the feasibility and effectiveness of screening and intervention during the routine practice of criminal justice staff working with clients newly sentenced to probation or community service orders. Staff views and responses were tapped via an online survey of the staff who conducted screening and intervention, their feedback on the training, and depth interviews with strategic, policy and operational staff. Views from participating clients were also to be obtained but in the end just one was interviewed. It was also planned to assess impact on drinking by repeating the AUDIT survey three and six months later, but this data was available at either stage for just 16 of 82 hazardous/harmful drinking clients.

Main findings

Around 70% of the 295 eligible offenders said they were willing to take part in alcohol screening, encouraging as an indicator for uptake within this setting. However, this included only just over half (51%) the community service clients compared to 93% of probation clients. Overwhelmingly they were white men and averaged 31 years of age.

Among those not eligible to take part, for around two thirds this was because they were already receiving alcohol advice and support from another source, so the incidence of drink problems in those who did take part is likely to underestimate the level of need among offenders in probation and community service settings.

Among those who were screened, the results showed that:
• Around 59% of offenders on community service or probation orders in the pilot areas, and who fulfilled the eligibility criteria, screened positive for at least hazardous drinking.
• Of these, 42% fell into the hazardous/harmful rather than dependent category and might have benefited from brief intervention.
• Almost 1 in 5 scored as high risk drinkers who might be dependent.
• Those in the high risk/possibly dependent group were more likely to be on probation than community service orders.
• Although client numbers were small, men were almost twice as likely as women to register screening scores in the intervention range; almost two thirds of women fell below the threshold.
• Offenders in the 18–24 age band were more likely to screen positive than offenders in older bands.

Frontline staff were sometimes not committed to the pilot, feeling it had been imposed on them, but in one area ready access to and support from a coordinator allocated to the project bolstered enthusiasm for the work.

Pre-training questionnaire were completed by 34 staff compared to 89 who completed a post-course questionnaire, and it was not possible to match the pre- and post-course respondents, complicating interpretation of the results. After training, almost all the respondents (91%) who provided an answer thought it was quite or very relevant for them to be able to offer brief alcohol interventions. Large proportions said that whether they did so would depend on resources (time and a suitable intervention room) and administrative and management support. Also after training, 8 in 10 said they felt as able to work with risky drinkers as with other clients, over 8 in 10 felt clear about their responsibilities with drinkers and that with the right support, these clients can make good progress towards sensible drinking, and 9 in 10 felt confident about helping clients with their drinking problems. However, a quarter who answered this question did not agree they had a right to ask clients about drinking, and in-depth interviews revealed some feeling that the training had been too low-level and longer than was needed for staff already familiar with addressing problem drinking.

In practice though, staff often felt the pilot was not suited to their client groups, largely because they faced more serious issues such as money problems and housing, and addressing their drinking was not a high priority. Some said if it was a priority it would already have been incorporated in sentence planning, that they would have dealt with it anyway in normal practice and perhaps more adequately than through five minutes of brief advice, that their clients were often too extreme in their drinking to be suitable for a brief intervention, and that excessive drinking was too intertwined with other problems to be dealt with in isolation. The AUDIT screening tool was generally seen as easy to apply and by some as a useful way to broach the issue of drinking, while other staff thought it was inappropriate to have to complete it even when drink was clearly not a relevant issue. Few staff felt offenders generally had engaged well with the brief intervention. Commonly, a post-sentence appointment was seen as too late to assess drinking because the results could not be used to inform sentencing decisions; the pre-sentence social enquiry report to the court was seen as a better stage.

The process of establishing eligibility, screening and delivering an intervention averaged around 25 minutes with an estimated cost of around 67 per person, including overheads.

The authors' conclusions

Despite the challenges inherent in applying alcohol screening and brief intervention to this setting, the pilot has shown that community justice does afford an opportunity to identify and intervene with many people at high risk of alcohol-related harm who might otherwise not be identified as being in need. Screening results show a high level of need in this population. The training provided seemed necessary since most previous training had been delivered a long time ago, or had not been appropriately focused.

Due the lack of follow-up outcome data and the inability to adequately assess the reactions of the offenders, the evaluation could not assess the impact of the brief interventions delivered. In turn this was partly due to some lack of enthusiasm on the part of frontline staff. Although the AUDIT screening tool and the brief intervention seem to have been easy for them to administer, and were seen as useful tools in themselves, staff were in some ways negative about the appropriateness and likely success of screening and alcohol interventions in this environment. In particular, they felt that alcohol problems were of less immediate concern than other issues for their clients, perhaps one of the strongest themes to emerge from the analysis of staff views. There was a strong view that screening and intervention may capture more people and be of greater use in determining sentencing outcomes if undertaken before sentencing.

Learning points from the pilot include a need for greater involvement of operational staff during the planning and implementation of such schemes to ensure that models of working take into account workloads and client-staff protocols. Also, training should be targeted at the criminal justice setting and tailored to the participants, and regular refresher training arranged which can take advantage of actual experience of doing the work. Alcohol screening and intervention in this context would perhaps work better if a local manager/champion took overall responsibility for these processes and 'managed the managers' across (if appropriate) split sites, so that a consistent approach is adopted to allow for comparable data within and between areas. This is the main workforce development requirement to improve engagement with frontline staff by providing education and evidence on the effectiveness of these interventions.

On administrative and resource grounds, there should be few barriers to introducing alcohol screening and brief interventions to community justice settings, although there is clearly some scope for reducing the time these take so that they do not impact too greatly on workloads. Time and costs might be reduced through better training and as staff become more practised and increasingly familiar with the process. Further uptake could also offer economies of scale in the form of coordinated central resources and training.

The total cost of alcohol misuse to Scottish society in 2007 has been estimated at around 3.56 billion, of which 727 million (about 20%) was related to crime. There is evidence to suggest that brief alcohol intervention are a cost-effective way of tackling alcohol misuse in some settings and have similar potential within community justice.


Findings logo commentary This study and others to date leave Britain with no persuasive evidence that brief interventions are an effective way to curb drinking and crime among offenders in the criminal justice system, and with questions over the appropriateness of screening and whether it will be widely implemented under current systems.

The scepticism expressed by the criminal justice staff in Scotland who took part in the featured project echoes the feelings of probation officers in a similar trial in 20 probation offices in England. Of the nearly 200 staff in the trial, about a fifth did not recruit any offenders to the study, and only about a quarter were able to implement screening and brief intervention as intended without extra help from researchers and specialist alcohol workers. Despite apparent staff enthusiasm, barriers to implementation cited by staff included workload pressures, lack of knowledge, and lack of follow-up treatment services. Compared to staff in two other settings (primary care and emergency departments), screening and brief intervention was felt to meld more naturally with routine probation work, but staff were less convinced these procedures would be useful and tended to feel they were best reserved for offenders with obvious drinking problems.

That study and a preparatory study which also included prisons and police station custody suites found that the FAST Alcohol Screening Test broadly duplicated results from the AUDIT screening tool, yet generally required just a single question. With the AUDIT averaging ten minutes in the featured study, this could save considerable time and make screening more acceptable because it would be less likely to be seen as overshadowing more pressing concerns.

There may remain however the perception of staff and offenders too that drinking levels which are almost normative among young Scottish men are not worth bothering with in the context of the other concerns facing newly sentenced offenders, and that more serious problems would in any event be exposed during the criminal justice process. Such perceptions limit implementation in criminal justice settings more than in health settings, because in the latter there is a credible argument that even low-level excessive drinking poses long-term risks to health and that routine screening and brief intervention are justified on public health grounds. When crime is the primary concern, this justification carries less weight, even though both Scottish and English studies highlight the high frequency and severity of drinking problems among offenders.

These trials cast doubt on whether screening will be widely implemented in criminal justice settings, as did an audit of probation alcohol work in England which found that even among offenders known to be problem drinkers, under one in three had been screened using the AUDIT survey.

Last revised 26 July 2012

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2012 Alcohol screening and brief intervention in probation

STUDY 2014 Alcohol screening and brief interventions for offenders in the probation setting (SIPS trial): a pragmatic multicentre cluster randomized controlled trial

STUDY 2012 Alcohol screening and brief intervention in primary health care

STUDY 2013 Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial

STUDY 2012 Summary of findings from two evaluations of Home Office alcohol arrest referral pilot schemes

STUDY 2009 Evidence-based practice? The National Probation Service's work with alcohol-misusing offenders

STUDY 2012 Alcohol screening and brief intervention in emergency departments

STUDY 2014 The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

STUDY 2010 Alcohol screening and brief intervention in a policing context: a mixed methods feasibility study

STUDY 2011 Scoping study of interventions for offenders with alcohol problems in community justice settings





Prevention and control of infectious diseases among people who inject drugs.

European Centre for Disease Prevention and Control and European Monitoring Centre for Drugs and Drug Addiction.
Stockholm: European Centre for Disease Prevention and Control, 2011.

European Union drug misuse and disease control agencies have come together to offer guidance on how to prevent injection-related disease spread in Europe. Towards the top of the list are widespread injecting equipment supply and heroin substitute prescribing, but neither chime well with the UK's recovery-focused addiction policies.

Summary This guidance aims to support policy makers in Europe plan adequate, evidence-based, pragmatic, and rationally designed public health responses for the prevention and control of infections among people who inject drugs. Intended readers are national and regional public health planners and decision makers in the fields of infectious diseases, general public health, addiction and mental health care, social services, and drug control.

In part the guidance is based on a systematic 'review of reviews', which together assessed a large number of primary studies on the key interventions, combined with findings from the most recent studies not yet captured by review papers. Primary studies were also analysed when no systematic reviews about the effectiveness of an intervention were available. The guidance also relies on a foundation of core values derived from public health and human rights principles and on expert knowledge and advice on benefits and harms. Best practices as well as user preferences have contributed to the development of the key interventions suggested.

Background

Since the emergence of the HIV epidemic among people who inject drugs in the mid-1980s, many European countries have achieved substantial progress in implementing evidence-based measures to prevent and control infectious diseases among this group. In the 1990s, EU countries started to develop common prevention policies both in the fields of HIV/AIDS and drugs and drug addiction, which included the establishment of EU agencies to monitor the drug situation (the EMCDDA in 1993) and to prevent and control infections (ECDC in 2005). In the past two decades, prevention and treatment interventions have been expanded and brought to scale. According to reports for the year 2009, more than half of the estimated population of problem opioid users received substitution treatment, and many countries have established needle and syringe programmes with increasing coverage among people who inject drugs. Data from countries with well-established surveillance systems suggest that the number of new HIV infections among people who inject drugs has decreased considerably in most, but not all, EU countries during the last decade.

In the European neighbourhood, injecting drug use remains a major reason for vulnerability to acquiring blood-borne and other infectious diseases, including HIV, hepatitis B and C, tuberculosis, bacterial skin and soft tissue infections, and systemic infections. Estimates of the number of people who inject drugs suggest that there are significant populations at risk of these infections in all European countries. Unaddressed, these infections result in a large burden on European health systems, significant individual suffering, and high treatment costs.

It has been shown that a pragmatic public health prevention approach can have a strong effect on reducing the spread of blood-borne and other infections among people who inject drugs. Prevention is feasible and effective, if properly implemented.

Seven key interventions

On this basis the following seven key intervention components should be applied and, if possible, combined to achieve the maximum prevention effect through synergy:
Injection equipment: Provision of, and legal access to, clean drug injection equipment, including sufficient supply of sterile needles and syringes free of charge, as part of a combined multi-component approach, implemented through harm reduction, counselling and treatment programmes.
Vaccination: Hepatitis A and B, tetanus, influenza vaccines, and, in particular for HIV-positive individuals, pneumococcal vaccine.
Drug dependence treatment: Opioid substitution treatment and other effective forms of drug dependence treatment.
Testing: Voluntary and confidential testing with informed consent for HIV, hepatitis C (and hepatitis B for the unvaccinated) and other infections including tuberculosis should routinely be offered and linked to referral to treatment.
Infectious disease treatment: Antiviral treatment based on clinical indications for those who are infected with HIV, hepatitis C or hepatitis B. Anti-tuberculosis treatment for active tuberculosis cases; tuberculosis prophylactic therapy should be considered for latent cases. Treatment for other infectious diseases should be offered as clinically indicated.
Health promotion: Health promotion focused on: safer injecting; sexual health, including condom use; and disease prevention, testing and treatment.
Targeted delivery of services: Services should be combined and organised and delivered according to user needs and local conditions; this includes the provision of services through outreach and fixed site settings offering drug treatment, harm reduction, counselling and testing, and referrals to general primary health and specialist medical services.

Recent studies and experience from successful prevention programmes document the added value of offering a range of effective intervention measures in the same venues, and of providing a combination of interventions according to clients' needs, to achieve the maximum effect in preventing infections. A prerequisite to the effective delivery of the key interventions is national and local cooperation, and coordination between sectors. National consensus building and mutually respected objectives are essential when it comes to the successful implementation of interventions. Objectives should be agreed on by actors across all sectors, particularly those who engage with people who inject drugs.

In order to ensure that interventions best serve the population of people who inject drugs, as well as prevent and control infectious diseases, there must be sufficient surveillance of problem drug use and infections on national and sub-national levels. Measures taken should be continuously monitored and evaluated in terms of response, impact, relevance and scale of coverage. Investment in adequate surveillance systems of both drug use and infectious diseases is necessary and cost-effective.

Evidence suggests that higher levels of coverage of needle and syringe programmes and opioid substitution treatment per drug injector are more effective than lower levels of coverage. The goal should be to ensure that the services offered meet local needs and demand. Unmet demand for needle and syringe exchange services or waiting times for drug treatment indicate inefficiency in prevention.

Staff and service values

Implementation of preventive measures should adhere to the following core principles derived from the need to adopt a client perspective in service provision. Without the application of these core principles, it is difficult to effectively apply the key interventions suggested in this guidance:
• Ensure confidentiality.
• Promote service accessibility.
• Create a user-friendly atmosphere.
• Engage in dialogue with users and promote peer involvement.
• Adopt a practical approach to the provision of services.
• Refrain from ideological and moral judgement.
• Maintain a realistic hierarchy of goals.


Findings logo commentary As also emphasised by Findings in a series of reviews on hepatitis C and needle exchange, the featured guidance stresses that "the best way" to curb the spread of HIV and hepatitis C among injectors is high coverage supply of injecting equipment, enough and sufficiently easily available for a fresh set to be used each time. If requiring the return of used equipment stands in the way of this ambition, the guidance says 'requirement' should be watered down to 'encouragement'.

High coverage was also at the heart of recommendations from Britain's National Institute for Health and Clinical Excellence, based partly on a review of the evidence which (as later studies not included in the review reinforced) found that more liberal equipment supply policies most effectively controlled spread of infectious disease. Allied (as the featured guidance recommends) with high coverage substitute prescribing, high coverage needle exchange has research suggests substantially curbed the spread of hepatitis C among injectors in Britain, a virus which requires particularly complete defences to intercept its transmission.

However, complete coverage in terms of the supply of injecting equipment is very far from the norm in Britain, with the result that at the end of the first decade of the 2000s hepatitis C was spreading more rapidly than in it did in the early 2000s, infecting a quarter of injectors within three years of their starting to inject. Set against this, the pool of injectors in the population available to be infected is declining as drug users turn away from heroin and with it the injecting route, presumably helping make service provision more adequate even if resources are static or declining.

In turn the decline in heroin use and injecting is thought partly due to the greater penetration of effective treatment in recent years, spearheaded by programmes which substitute drugs taken by mouth (methadone and to a lesser extent buprenorphine) for heroin. The dominance of these approaches is challenged by government policy, which now seeks to "ensure that open-ended substitute prescribing in the community is only used where absolutely necessary" and favours individual recovery from addiction in the form of abstinence, social reintegration and treatment exit.

This policy runs counter to the characteristics thought to make methadone and allied programmes effective public health tools in the prevention of infection: a widely provided and easily accessible frontline treatment rather than one reserved for the "absolutely necessary" and provided long-term without expecting early or even any termination. An expert group acting on behalf the British government has sought to reconcile this dilemma, allying a recovery orientation with continued long-term methadone prescribing for those who need it, but there are concerns that the public health achievements of recent years will be jeopardised by the new policy focus.

Last revised 13 February 2013. First uploaded 21 July 2012

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Top 10 most closely related documents on this site. For more try a subject or free text search

DOCUMENT 2014 Needle and syringe programmes

DOCUMENT 2014 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations

STUDY 2011 Hepatitis C infection among recent initiates to injecting in England 2000–2008: Is a national hepatitis C action plan making a difference?

DOCUMENT 2013 Community loses from failure to offer maintenance prescribing in prisons

REVIEW 2010 Optimal provision of needle and syringe programmes for injecting drug users: a systematic review

STUDY 2012 Can needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence?

STUDY 2014 Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions

REVIEW 2012 The effectiveness of opioid maintenance treatment in prison settings: a systematic review

MATRIX CELL 2013 Drug Matrix cell B1: Practitioners; Reducing harm

OFFCUT 2005 Hepatitis C is spreading more rapidly than was thought





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