1. Strengthening Responses to Drug Injectors “Resistant to Treatment” Oliver Aldridge Edinburgh, Midlothian & East Lothian DTTO Harm Reduction Team

2. Archibald Ingram 1699 - 1770

4. 1600’s

5. Alexander Wood IM Morphine Injections in 1850’s Edinburgh Physician

6. Heroin Discovered in 1874

7. First Reports of IV Heroin use

8. Methadone Treatment starts in New York

10. >13 000 000 IV Drug Users 80% Live in 3 rd World 90% of Methadone produced is consumed in 1 st World 20% of people get 90% of available substitute treatment

12. 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

15. 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” Language Can:

16. Samuel Taylor Coleridge “The stimulus of shame, like other powerful medicines, if administered in too large a dose, becomes a deadly narcotic poison.”

18. What is “Resistance”? NOT fixed Depends on factors both internal and external to the individual

19. 3 STRIKES AND YOU’RE OUT

21. 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.

22. 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

23. 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

25. 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

26. DTTO Injecting Rates

27. 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

28. 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.

29. Harm Reduction Team Overall Injecting Behaviour

30. Harm Reduction Team Injecting Behaviour with TIME

32. 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 Existing Services

33. 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

35. 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. Do the Most Good for the Most People