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Letters to the Editor

Addiction (1994) 89, 95-98

The editor welcomes all letters whether they are short case reports, preliminary reports of research, discussion or comments on papers published in the journal. Authors should follow the same guidelines given for the preparation and submission of articles on the inside back cover of each issue.

Distinctive features of the methadone treatment program of Victoria, Australia

Sir-I wish to provide further comment on methadone treatment programs in Australia which were covered in the article by Gossop & Grant reporting on a six country survey of methadone treatment programs.1 Methadone treatment programs in this country vary, both between and within States, across a number of dimensions including the degree to which they incorporate public versus private sector prescribing and dispensing. Comments in the Gossop & Grant article perhaps best describe programs with a major public sector emphasis.

The methadone treatment program of the State of Victoria, Australia, has developed along different lines, adopting a largely community based approach utilizing generalist health providers. They dispersed program is based on a network of approved private general practitioners (family physicians) and local retail pharmacies. Specialist counseling is optionally available through a network of community based alcohol and drug counseling agencies, most of which are operated by non-government bodies with government support.

The advantages of this community based approach include:

a) greater access to methadone treatment due to local availability;
b) greater ability to maintain/not disrupt employment;
c) lack of stigma in an everyday health settings;
d) ability to expand without building large bureaucratic or treatment empires; and
e) skilling of generalist health providers in drug treatment.

There are few problems with community acceptance as treatment is integrated with existing health services, which also aids in the reintegration and destigmatisation of clients of the program.

Over 85% of the 2270 clients receiving treatment in March 1993 were under the care of private general practitioners (family physicians) and collected their daily oral dose at a local retail pharmacy. Public methadone programs are used for difficult or complex cases, and for the provision of backup, support and training to community based providers. Numbers of clients have increased dramatically since 1985, averaging 15% p.a., the increase occurring almost entirely in community based programs.

Entry is principal on the basis of demonstrable physiological dependence upon opioids and is voluntary. Initial doses are in the 20-40mg range to avoid potential cumulative overdosing in the first week of treatment, and takeaways are restricted. Maximum doses in 1991 were usually in the range 30-50mg, but have recently risen significantly.2 Treatment duration is indefinite but currently averages 18 months. At treatment termination prescribers in 1991 indicated that 20% of clients had completed their program, a further 17% had left prior to completion but on a dose of 10mg or less, 52% left on a higher dose and 11% had treatment interrupted by an external factor (e.g. hospitalization, transfer, imprisonment, death). This suggests that up to 37% of terminations had a relatively good prognosis for not resuming opioid use, although this has yet to be verified by appropriate follow up studies.

The cost of private medical consultations is met under Medicare, a Commonwealth funded universal public health scheme, as is the cost of pathology testing such as urinalysis. Most pharmacies charge a dispensing fee to clients for daily dispensing of methadone syrup in orange juice, cordial or similar drink. The cost of treatment to clients is free except for dispensing fees, which are commonly $25-$35 per week. The State funds the provision of both induction training and continuing education for methadone prescribers, as well as the recent development of a high standard clinical reference manual.3

The current network of more than 100 private general medical practitioners and 120 local community pharmacies represent 3% and 10% respectively of these health providers in Victoria. This represents a significant skilling of generalist health workers in practical drug treatment and has developed a valuable non-institutional alcohol and drug resource.

Methadone treatment in Australia is driven by a harm minimization philosophy and in Victoria the program has been shaped by a community based approach. The Victorian Methadone Program is a low profile, cost effective program providing accessible methadone treatment in generalist health settings.

STANFORD HARRISON
Victorian Drug Strategy Unit,
Department of Health & Community Services,
GPO Box 4057, Melbourne,
Victoria 3000, Australia.

References

1. Gossop, M & Grant, M (1991) A six country survey of the content and structure of heroin treatment programs using methadone, British Journal of Addiction, 86, pp. 1151-1160.
2. McNeill, J.J & Campion, K.J. (1993) Report on Urine Testing in Melbourne Programmes for Victoria (Melbourne, Monash University)
3. GILL, A, PEAD, J. & MELLOR, N. (1992) Methadone Prescribers' Manual for General Practitioners (Melbourne, Drug Services Victoria)

Gender differences in needle sharing behaviour patterns

Sir-We read with interest Barnard's1 recent study in Addiction which showed gender differences in needle sharing behaviour patterns among intravenous drug abusers.

She also indicated that female injectors may be at increased risk of HIV transmission relative to their male counterparts. Stimpson had previously noted poorer uptake from needle exchanges by women.2

From October 1992 to June 1993, at the National Drug Treatment Centre we have had a policy of screening all new and return attenders with a history on intravenous drug abuse for the presence of Antibody to Hepatitis C (using the 2nd generation Eliza method). Hepatitis C can be contracted through sexual, vertical and intrafamilial routes but by far the most efficient mode of transmission is parential. Therefore Hepatitis C Virus (HCV) risk behaviour is very similar to HIV risk behaviour and is a major problem amongst intravenous drug abusers.3 When compared to HIV, HCV is transmitted more efficiently by the parenteral route and less effectively by the sexual route.4 Thus Hepatitis C prevalence can be an indicator of HIV related risk behaviour.

Our results showed gender differences with a significantly greater proportion of females testing positive for anti HCV antibody. From a total of 213 patients, 126 out of 152 males tested positive for anti HCV (82.9%) and 58 out of 61 females tested positive for anti HCV (95.1%) (x2 = 5.612,df = 1, p<0.025). The mean age of the male group was 25.4 years and the female group was 23.1years. The mean duration of intravenous misuse of the male group was 4.9 ears and of the female group was 3.6 years. These results add further evidence to Barnard's conclusions in regard to gender differences intravenous drug abusers and needle sharing. They also indicate that females may be at increased risk of HIV transmission relative to their male counterparts.

B.SMYTH,E.KEENAN,A.DORMAN & J.J. O'CONNOR
The Drug Treatment Centre Board,
McCarthy Centre,
30/31 Pearse Street,
Dublin 2, Eire

References

1. Barnard, M. (1993) Needle sharing in context. Patterns of sharing among men and women injectors and HIV risks, Addiction, 88, pp. 837-840.
2. Stimpson, G.V., Dolan, K.A., Donohue, M.C. & Lart, R. (1989). The first syringe exchange project in England and Scotland a summary of the evaluation, British Journal of Addiction, 84, pp. 1283-1284.
3. VON DE HOCK, J.A & VAN HASSTRECHT, M. J. (1990) Prevalence, incidence and risk factors of Hepatitis C virus infection among drug users in Amsterdam, Journal of Infectious Diseases, 162 pp. 823-826.
4. LAU, J.Y.N. & Dowis, G.L. (1993) Managing Chronic Hepatitis C virus infection, British Medical Journal, 306, pp. 469-470.

Do Female injectors under-utilize needle exchanges?

Sir-In a recent article about gender and sharing of injecting equipment, Barnard argues that female drug injectors are more socially inhibited than males in securing independent access to sterile needles and syringes.1 It is claimed they are less willing to use facilities like needle exchanges because of a greater sense of stigma or embarrassment associated with injecting drug use, and greater fear of notification to the authorities.

It is true that most clients attending needle exchanges are male, but this does not necessarily mean that females are under-represented. In a study cited by Barnard and carried out in Glasgow during 1989, women were found to represent 27% of the estimated 9500 injectors in the city.2 Our own records, for the same time period, show that females accounted for 30% of the 700 new needle exchange clients, and 30% of 8030 visits made to two needle exchanges in Glasgow.3 In 1992 women accounted for 25% of the 781 new clients, 33% of all 2600 clients and 32% of all 27,990 attendances at the city's eight needle exchanges. Needle exchanges also offer a wide range of services such as primary health care, advice on safer injecting and safer sex, HIV counselling. In 1992, the first full year when the uptake of these services was monitored, women accounted for 34% of the 15,480 visits at which these were received. To these figures can be added the 300 women attending the needle exchange within a Drop-in Centre for street prostitutes in the center of Glasgow, which is not open to men. The hypothesis that female injectors are less likely than their male counterparts to attend needle exchanges is therefore not supported by our data.

It can still be argued, however, that needle exchanges should attract more injectors of both sexes. During 1992, under one third of the total estimated injector population of Glasgow visited needle exchanges. Whilst this is higher than uptake rates reported by other exchanges, it is still inadequate.4 Thus; we believe that efforts are needed to make independent access to clean needles and syringes easier for all drug injectors, regardless of their sex.

LAWRENCE ELLIOTT, LAWRENCE GRUER,
KATHRYN FARROW & JOHN CAMERON
HIV & Addictions Resource Centre,
Ruchill Hospital,
520 Bilsland Drive,
Glasgow G20 9NB, UK

References

1. BARNARD, M.A. (1993) Needle sharing in context: patterns in sharing among men and women injectors and HIV risks, Addiction, 88, pp. 805-812.
2. FRISCHER, M., BLOOR, M. & FINLAY, A. (1991). A new method of estimating prevalence of injecting drug use in an urban population: results from a Scottish city, International Journal of Epidemiology, 20, pp. 997-1000.
3. GRUER, L., CAMERON, J., & ELLIOTT, L. (1993) Building a city wide service for exchanging needles and syringes, British Medical Journal, 306, pp. 1394-1397.
4. GUYDISH, J.,BUCARDO, J., YOUNG M. et al. (1993) Evaluating needle exchange: are there negative effects? AIDS, 7, pp. 871-876.

Why less women than men injectors attend needle exchanges services. A reply to Elliott et al.

SIR-In the letter by Elliott and colleagues, the suggestion appears to be that because an estimated one third of drug injectors are female and one third of needle exchange attenders are female, so gender has no discernible influence on attendance at needle exchange services. It would be comforting if the influence of gender could be so easily dispensed with, however I suspect it would be premature to do so.

The statistics cited by Elliott and colleagues refer only to needle exchange attenders. On their own estimates, two thirds of Glasgow injectors (male and female) do not attend these services. Surely the import point is not the relative proportions of attenders but the reasons why the remaining two thirds do not choose to use needle exchanges. My argument referred to women who did not use these services and suggested that gender was a factor influencing their non-utilization. As I indicated in my paper, greater stigma attaches to women injectors than to their male counterparts which leads some women to keep their drug habit as invisible as possible. So too are there women who fear official notification of drug use in case it leads to loss of children. These were real concerns which had a bearing on these women's access to clean needles and syringes.

We urgently need to look at the various factors influencing access to sterile injecting equipment. In particular we should pay attention to the specific experience of women injectors. Further support for this contention is contained the letter by Smyth and colleagues. Elliott et al. conclude their letter by saying that all drug injectors should have easy access to needle exchange services 'regardless of their sex'. On the contrary, the challenge is to design services which recognize, and respond to, the different needs and experiences of male and female injectors.

MARINA A. BARNARD
University of Glasgow
Glasgow, Scotland

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