Submitted by Action on Hepatitis C
In the late 1980s British drug policy was led
by an individual and public health approach to contain the spread
of HIV. The reduction of harm through needle exchange and other
measures took precedence in development plans1. Although this
effectively contained HIV transmission via injecting drug use,
the UK now has a much larger epidemic of another blood borne virus,
hepatitis C (HCV) with huge anticipated costs. Yet current UK
drug policy sidelines this. Issues of control and criminal justice
are promoted to the detriment of individual and public health.
Our current policy will increase drug-related deaths and other
harm to individuals and society. It should be replaced by one
where harm reduction is central to our approach.
The following are examples of recent/anticipated
national drug policy changes and omissions which will increase
New UK criminal justice initiatives will increase
drug-related deaths from hepatitis C.
Prisons are multipliers of blood borne viruses.
Many people become infected with hepatitis C while in prison through
the sharing of injecting equipment with other prisoners and will
later die of their infection. Harsh UK drug laws with high custodial
sentencing are out of step with other European countries and will
increase drug related deaths in the UK.
Recent changes in UK legislation have worsened
the risk of BBV infection in prison and drug-related deaths:
(a) There is widespread anecdotal evidence
of a switch from cannabis to heroin use in UK prisons since the
introduction of mandatory drug testing. Unlike cannabis heroin
is commonly injected, increasing the risk of BBV transmission
and drug-related death.
(b) Abstinence Orders are expected to increase
the number of drug users in prison when those sentenced fail to
maintain abstinence, because dependent drug use is a relapsing
disorder. Studies in France, Italy and Australia show that 54-64
per cent of IDUs in prison are already infected with HCV. The
total numbers of HCV infected prisoners will increase with a heightened
risk of infection of other prison inmates.
(c) As investigation and treatment of hepatitis
C is almost impossible to obtain in prison, overall circulating
virus levels remain high with an increased risk of HCV transmission,
and anticipated future high morbidity and mortality.
The treatment of injecting drug users who have
chronic hepatitis C
British drug policy and national policy on BBV
infection are intimately related through drug-related deaths.
Deaths from hepatitis C can be prevented by treatment. Although
current IDUs with HIV can access treatment, UK guidelines 2,3,4
on the treatment of hepatitis C exclude current IDUs. This is
a major concern because drug users form the greatest number of
those who are infected with HCV. It ignores the human right to
life and will considerably increase the morbidity and mortality
of drug users.
This exclusion on the grounds of presumed future
lack of compliance and presumed high reinfection rates is ill-founded
as shown by two articles in the medical press in July 2001. The
first by seven authors from the University of California in San
Francisco (UCSF)5 lays out all the evidence why drug users should
not be denied treatment for HCV. The second is a paper in Hepatology
from a group in Germany6 showing that current IDUs can be treated
successfully for HCV.
Current clinical guidelines recommend that almost
all new patients should have supervised consumption of their prescribed
drugs for at least three months, subject to compliance. Supervised
consumption has a small role but should not be universally applied.
The management of drug users should be sensitive to individual
health care needs.
In rural areas most supervised consumption occurs
at community pharmacies where drug users can be seen swallowing
the green liquid by their neighbours. The BMA believes this to
be unethical7. It will also deter drug users from accessing treatment
for other reasons, such as distance to travel in rural areas,
potential loss of employment, etc. This deterrence to help-seeking
will increase overdose deaths, increase deaths from BBVs both
in drug users and the general population, and increase crime.
Proposed licensing of doctors treating drug users
An almost identical proposal to license doctors
was rejected in 1984 because it would deter GPs from treating
drug users. Senior doctors in the drug field have recently stated
the current proposals on licensing will also deter GPs from treating
drug users8,9,10, and that clinical governance is a better way
of ensuring good quality care9,10. Specialist drug services are
small, but there are 36,000 UK GPs. Even a small percentage of
GPs pulling out will have a major impact. We anticipate that specialist
drug services, already stretched beyond capacity, will become
overwhelmed with drug users seeking help they cannot obtain from
their GP or elsewhere, and waiting lists for treatment (already
up to six months in places) will grow progressively longer.
It is well established that treatment reduced
drug-related deaths, drug-related crime and injecting risk behaviour
leading to blood borne virus (BBV) transmission. Failure to access
treatment will result in:
more overdose deaths and a rise in
blood borne virus infection rates. We already have a national
disaster from the hepatitis C epidemic. This will worsen with
more delayed deaths from liver failure and cancer of the liver.
more crimes on the streets perpetrated
by those unable to access treatment.
The absence of an alcohol treatment strategy
and the exclusion of alcohol from advice and funding within current
drug strategy will increase drug-related deaths. Alcohol use
increases the risk of death from liver failure and cancer of the
liver of the estimated 400,000 people in the UK who have been
infected with HCV (in 80 per cent the virus has been transmitted
through shared injecting drug use).
Prison needle exchange has been shown
to work in Europe and should be piloted in the UK.
Harm reduction should be central to UK drug
policy, as it is in Australia, where policy makers ensure that
potentially harmful new polices are not enacted and harmful policy
omissions are corrected.
1. Report of the Advisory Council on the
Misuse of Drugs. (1988) AIDS and Drug Misuse Part 1. London: HMSO.
2. Report of the National Institute for
Clinical Excellence (2000). Guidance on the Use of Ribavirin and
Interferon Alpha for Hepatitis C. www.nice.org.uk.
3. British Society of Gastroenterology (2001)
Clinical Guidelines on the management of hepatitis C. http://www.bsg.org.uk/guidelines/clinguidehepc.html.
4. EASL International Consensus Conference
on Hepatitis C. Consensus Statement. (1999) Journal of Hepatology,
5. Edlin, B.R., Seal, K.H., Lorvick, J.,
et al (2001) Is it Justifiable to Withold Treatment for
Hepatitis C from Illicit Drug Users? New England Journal of Medicine,
Vol 345, No 3, pp.211-214.
6. Backmund, M., Meyer, K., Von Zielonka,
M., & Eichenlaub, D. (2001) Treatment of hepatitis C infection
in injecting drug users. Hepatology, 34, (1), pp.188-193.
7. Personal communication to Dr Waller from
Anne Somerville, ethical adviser BMA. (2000).
8. Beaumont, B., Carnwath, T., Clee, W.,
Ford, C., Gabbay, M., Robertson, R., Rumball, D., Waller, T. (2000)
Licensing doctors counters the national strategy, Druglink, 15
9. Beaumont, B., Carnwath, T., Clee, W.,
Ford, C., Gabbay, M., Robertson, R., Rumball, D., Waller, T. (2001)
Alternatives to licensing doctors, Druglink, 16 (1), p.9.
10. Gabbay, M.B., Carnwath, T., Ford, C.,
& Zador, D.A. (2001) reducing deaths among drug misusers,
British Medical Journal, 322, pp.749-750.