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Drug Policy In Scotland Health And Social Care Essay

It has often been quoted that a society is best judged by the way it treats its weakest members.[1] In Scotland, the provision of healthcare services regardless of an ability to pay has a proud tradition and can trace its roots back to the Highlands and Islands Medical service which was set up in 1913.[2] Following this, the formation of the National Health Service in 1948 formalised the provision of free healthcare for all men, women and children across the United Kingdom.[3] Presently, the devolution of health care responsibility to the Scottish Executive under the 1998 Scotland Act gives a Scottish government minister overall responsibility for health care policy within Scotland.[4]

Notwithstanding the desire to care for the less fortunate or less well off in society the massive scourge of drug and alcohol abuse in Scotland has led to much debate about how to treat those afflicted by addiction and its associated problems. The attempt to tackle these problems has not been entirely altruistic in nature as the effect on society at large and the financial burden of these problems has been well documented.[5-7]

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Drug policy is often seen as the implementation of strategies to reduce drug related harm -although different jurisdictions will place emphasis on different strategies to achieve this and these are usually driven by cultural or political values and ideologies. The harm reduction framework for British Columbia in Canada has proposed the model in figure XX. Here it can be seen that funding (requiring political commitment) forms the basis of the policy. It can also be see that there is essentially a three pronged approach in terms of the responsible agencies including; policing, various health agencies and social welfare agencies. It is also noteworthy that the overall aim of the reduction of drug-related harm is achieved not just by any one of the three approaches but by a combination. Policing may lead to a reduction of supply while the healthcare and social care agencies can provide interventions that may lead to a reduction in both drug demand and in risk to the user.[8]

In Scotland current government drug policy is based on the policy document "The Road to Recovery-A new approach to tackling Scotland's drug problem".[9] Within this document a new emphasis has been placed on the need to help individuals to "recover" which the authors of the report define as "a process through which an individual is enabled to move-on from their problem drug use towards a drug-free life and become an active and contributing member of society". The methods by which this is achieved is broken down into prevention (which includes economic strategies to tackle poverty as well as information and education), policing and law enforcement, promoting recovery (which will be different for different individuals but may include finding a job or reconnecting with old friends, re-engaging with education etc) and a specific programme to protect and support children that are adversely effected by drug use. In the case of promoting recovery the report sets out to implement some of the recommendations that had come out of two other reports. The first of these reports, "Reducing Harm Promoting Recovery" evaluated the role of methadone provision in drug treatment whilst the second report "Essential Care" evaluated the provision of services not concerned with the drug user's addiction.[10, 11] Essentially, the policy in Scotland is moving more towards a holistic approach in terms of care for the user and is multi faceted in terms of its approach to reduce drug related harm.

Figure XX

Harm Reduction

In the context of dealing with the problem of drug use and associated harms the latest treatment strategies have been based on the model of harm reduction. Harm reduction has been defined as "policies, programmes, services and actions that work to reduce the health, social and economic harms to individuals, communities and society that are associated with the use of drugs".[12] Harm reduction as a philosophy of treatment has been an accepted policy of many governments for perhaps 25 years or more although it has not been adopted without some controversy.[13-15]

It represents part of a spectrum of different strategies which endeavour to deal with the problem of illegal drug use. At one extreme of this spectrum are those who support a "zero tolerance" approach to drug use while the other end of the spectrum is represented by those who perhaps adopt a more pragmatic and sometimes "liberal" view. These more "liberal" groups include those who support tolerating some drug use (or indeed drug legalisation). Those who believe in tolerance do so as they see the "war on drugs" as an unwinnable war that is best contained. They support the adopting of harm reduction strategies which accept or tolerate the existence of drug use in society. However, these strategies set about providing services that help to reduce harm to the individual user and by extension specific communities and society at large.

In terms of dealing with illegal drug use the relative emphasis of different strategies is quite diverse. In the United States for example there is quite a large lobby of "conservative" voters who prefer to adopt an "abstinence" or "zero tolerance" approach.[16] They represent quite a large group of voters and consequently drug policy in the United States still focuses on prevention, treatment (usually involving abstinence) and recovery[17] while in the UK and Europe generally a more liberal view predominates. It is worth pointing out however that within the UK the political pressure to continue to maintain classification of drugs at a certain level has meant that in the past the expert opinion forwarded by the UK Advisory Council on the Misuse of Drugs (ACMD) has been ignored. This led to resignations/dismissals most notably that of the councils chairman Professor David Nutt in 2009.[18]

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Harm reduction is often seen as an amoral or non-judgemental series of interventions that set as its goal the target of minimising harm to both the individual and society. Harm reduction in most jurisdictions is implemented as part of an overall drug policy and is usually not used in isolation. Used in combination with policing measures to reduce drug supply it can help to reduce demand for drugs and can allow the drug user the time required to ultimately desist from drug use completely. Specifically, in relation to the strategy of care for the intravenous drug user harm reduction policies are primarily health driven and include many services including; provision of injecting equipment paraphernalia, safe injection sites or drug consumption rooms, opioid substitution therapy for opioid injectors, peer naloxone distribution for intervention following overdose amongst others.[19] As part of an approach to tackling Hepatitis C prevalence in Scotland the introduction of various harm reduction strategies has been carried out. This has formed a large part of the Scottish government's strategy for dealing with Hepatitis C and will be discussed in more detail later in this report.

Hepatitis C

With between 130 and 170 million people chronically infected with the Hepatitis C virus worldwide it represents a serious threat to global health.[20] In Scotland, it is estimated that in the region of 50,000 people (or 1% of the population) are infected with the Hepatitis C virus, the majority of these being injecting drug users (90%).[21] An infectious disease affecting the liver, Hepatitis C is caused by the Hepatitis C virus -a positive strand RNA virus, belonging to its own class of genus, Hepacivirus within the Flaviviridae family.[22] Normally asymptomatic, the disease may not manifest itself clinically until the sufferer is in the advanced stages of infection after many years. Scarring of the liver may ultimately lead to cirrhosis and possible liver failure or other associated problems including cancer.

Figure xx Natural history of disease progression following Hepatitis C viral infection.[23]

The natural history of disease progression of Hepatitis C is complicated by a number of factors including age, race, gender, and viral immune response. The long period of disease persistence without serious morbidity or mortality and the effect of other lifestyle related factors such as alcohol consumption on outcomes further complicates the potential outcomes for infective patients.[23, 24]

Following exposure to the Hepatitis C Virus the host usually develops acute Hepatitis C from which they may recover or can go on to develop chronic infection. Following chronic infection they may then go on to develop liver inflammation and fibrosis which can lead to cirrhosis and hepatocellular carcinoma (HCC) and possible death. Another possible outcome following chronic infection is the development of chronic fatigue leading to cryoglobulinaemia (a disorder of the blood the symptoms of which include vasculitis and kidney disease amongst others)[25] followed by low grade non-hodgkin lymphoma. Some patients who develop chronic infection develop minimal or no inflammation or fibrosis and may remain Hepatitis C Virus carriers without liver disease.[26]

Although it had been known for several years the specific agent responsible for the condition originally classified as non-A, non-B hepatitis (NANBH) was not formally identified until the late 1980's.[27] This discovery and subsequent publication of the diagnostic method use to test for the presence of the virus in blood plasma helped to develop new methods of combating the disease.

Structurally the virus is a relatively small (~60nm) enveloped virus containing a lipid core with viral RNA, Figure XX.

Figure XX The structure of the Hepatitis C Virus[28]

The virus is subdivided into 6 genotypes which are further subdivided into subtypes which are represented by letters. The division of the virus into different genotypes is based on variation in the viral genetic material. The most common and difficult to treat genotype of the virus is genotype 1.[29]


Testing for Hepatitis C initially involves testing for Hepatitis C antibodies in the blood. If antibodies are detected then a further sample is taken to determine if the individual is still infected with the Hepatitis C virus. This is done since some individuals are able to fight off the infection following exposure and thus will display antibodies but will not actually have any of the viral RNA in their system.

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Figure xx Flow chart indicating the procedure for dealing with hepatits C in primary care[30]


Modern methods for the treatment of Hepatitis C are based on the use of pegylated interferon α 2a or 2b in combination with the anti-viral pro-drug ribavirin.[29] The pegylated interferons work by stimulating macrophages and natural killer cells to bring about an anti-viral response. The anti-viral drug Ribavirin given concomitantly with the pegylated interferon is structurally similar to the natural nucleosides used as building blocks in RNA synthesis. A number of mechanisms of action for ribavirin have been suggested most notable the inhibition of IMP dehydrogenase. This leads to a reduction in guanosyltriphosphate (GTP) levels in the cell. This reduction in the levels of GTP and dGTP most likely interferes with viral replication and may lead to the substituting of other nucleoside for GTP in the replication process. This would therefore lead to increases in mutations within the viral genome. Other mechanisms suggested mechanisms include ribavirin acting as an alternative substrate which may or may not lead to chain termination during replication.[31]

Figure xx Chemical Structure of anti-viral drug Ribavirin and the nucleosides Adenosine and Guanosine.[32]

The standard treatment for Hepatitis C infection is determined by the specific genotype of Hepatitis C virus that the host individual has been infected with. Infection with genotype 1 is generally less responsive to treatment and consequently treatment periods are longer usually 48 weeks. The dose of ribavirin is also determined by genotype with genotype 1 requiring larger doses in the region of 1000 to 1200mg per day depending on patient's weight. Those individuals infected with genotype 2/3 require treatment for only 24 weeks and at a lower dose of 800mg per day.[33]


As a blood borne virus the transmission of HCV is usually through infected blood and amongst IDUs this is most often through the sharing of needles, syringes or other injecting paraphernalia. HCV may also be contracted following blood transfusion with infected blood, by sexual intercourse with an infected person or vertically from mother to child.[34] The prevention of infection in the first place is the most cost effective method of tackling the Hepatitis C problem and consequently many of the harm reduction strategies employed set about preventing IDUs from contracting the infection in the first place. This is achieved primarily by providing IDUs with a supply of injecting equipment free of charge as required; this helps to prevent the risk of needle sharing amongst users. Most services will also offer to dispose of used needles as well thus removing used needles from general circulation or preventing their inappropriate disposal.

Vaccine Development

Development of a vaccine for the Hepatitis C virus would provide a tremendous boost to tackling the prevalence of this disease particularly upon recognition of the fact that the current treatment for patients is only about 50% curative on average.[29] Despite recognition of the potential benefits of a vaccine progress has been slowed by the inherent variability of the virus (in terms of genotype) and the relative ease with which the virus can mutate. As yet no commercially available vaccine exists however, a number of vaccines which provide some efficacy in either preventing infection or clearing viruses from the bloodstream have been developed.[35]

Hepatitis C Action Plan for Scotland

The Scottish Government launched phase I of the Hepatitis C Action plan for Scotland in 2006 following recognition of the challenge that the prevalence of the disease had for the health of the nation as a whole.[36] The plan outlined many of the points and concerns raised following a consultation process involving all of the relevant potential stakeholders.[37]

The main thrust of the plan was to determine a number of actions that needed to be completed in order to target ...The first phase of the plan would run for a two year period after which the second phase of the plan would be invoked. The theory being that all coordination that might be needed between different groups would have been established by then.

The main sections of the plan where to development prevention, testing, treatment, care and support, education, training and awareness raising, surveillance and monitoring.

Following this initial phase a second phase of the Hepatitis C Action Plan was published in 2008

Recognised Prevalence rates twice that of other parts of the UK

The commitment of resources by the Scottish government needed to tackle the crisis

set out many of the


The Hepatitis C Action Plan for Scotland was published in September 2006 and a number of actions were raised broadly divided along the lines of Prevention, Testing, Treatment, Care and Support, Education, Training and Awareness-raising. The total number of actions number 41 and by the time of the publication of the second phase of the Plan in 2008 all but one of the actions had been completed or was nearing completion.

Feedback from service providers as a means of measuring success of harm reduction strategies

Feedback mechanisms

National Needle Exchange Survey (Griesbach et al, 2006); an Examination of

the Injecting Practices of Injecting Drug Users (Taylor et al, 2004); and the Evaluation of

the Lord Advocate's Guidance on Needle Exchange (Taylor et al, 2005).

Evaluation mechanisms

Investigating the views of service providers is an essential component of any harm reduction strategy. Usually, service providers have the experience to assess the effectiveness of a particular strategy or service at the "coal face". They deal with the service user on a daily basis and in most cases receive feedback from service users about their experiences of the harm reduction strategy. The investigation of their views can also help to shape subtle changes in policy to ensure the most effective use of resources. It is also of interest to determine the service provider's personal view on some of the strategies being developed at a higher level. Their views of the suitability of certain projects can help to determine the smooth implementation of new services.

The provision of harm reduction strategies or often based on a model of best practice which usually includes specifications regard health and safety, consistency of service, integration of services and training etc. In most cases a series of guidelines are set up which help to ....

The most frequent method employed to evaluate a specific programme is the generation of a questionnaire.

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