格拉斯哥毒品危機中心提供安全的環境

資料來源：刺胳針愛滋病毒醫學期刊；www.thelancet.com/hiv Vol 5 September 2018；

財團法人台灣紅絲帶基金會編譯

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格拉斯哥毒品危機中心庇護所內提供健身房給尋求照護者使用

現年43歲的斯圖爾特在過去的兩幾十年中一直在為成癮而苦苦掙扎。他由醫院來到格拉斯哥毒品危機中心（GDCC）的居住所。「我已經在橋下睡了一個星期，並在一個老膿瘡旁邊注射了可卡因」。膿瘡重新漬爛開來讓斯圖爾特擔心可能會失去他的腿。幸好，他並沒有。 「我猜我很幸運」，斯圖爾特說。他在20多歲中期開始使用海洛因，最初採煙吸方式但最終則變為注射。「深陷其中就像被棉花包裹起來一樣：很美好、溫柔、蓬鬆。我喜歡它」，他說。但一旦效果消逝，事情就變得很醜陋。 「2到3天后，立即因戒斷症狀全身不適；你上一分鐘是像石頭般冰冷，下一分鐘則如火般燃燒，你覺得你的皮膚都由內往外翻」，斯圖爾特解釋道。 「整體而言，你知道海洛因會立刻把這些不適帶走。我除了尋找一個愉悅的陶醉，但我通常也僅把它當作抵癮功能」。

格拉斯哥毒品危機中心成立於1994年。它由蘇格蘭國家衛生服務部門( NHS ) 和格拉斯哥市議會資助由蘇格蘭慈善機構轉捩點所經營。服務包括針頭交換、個人評估和照護計劃，以及膿瘡和潰瘍之門診。中心24小時全天開放且不需要預約，工作人員大多是社會照護人員；有一名醫務人員隨時待命，在白天亦有兩名護士在中心內。該居住庇護所可供有需要的人士使用，門診亦提供阿片類藥物替代療法。

但這一切都始於一杯茶和聊天。 「你就是走進來，喝一杯熱飲，且你會得到受尊重之治療」，服務經理Patricia Tracey解釋道。「任何人不論是誰，想要解決毒品問題上得到建議或幫助的我們都歡迎； 他們可以按自己的節奏採取行動- – 我們從不向人們施加壓力做任何他們尚未準備好的事情」，標語是「減害」。例如，海洛因使用者如不準備放棄藥物，則可能會鼓勵由注射轉換到採煙吸方式。

進入GDCC居住庇護所大約有一半的人是無家可歸者。他們通常有多重的健康問題。截肢和行動移動性的問題很常見。他們經常經歷一連串的喪親之痛且都有創傷史，無論是源自童年還是因為吸食毒品。大約三分之二是男人，且大多數人年齡超過35歲。「你剛好到了特定的年齡且事情剛好碰上了你，到了30多歲，你就正好到了危機點」，帕特里夏說。一次使用好幾種藥物之情形很普遍。很多人將海洛因和可卡因結合起來，採用注射方式，並佐以苯二氮烯類口服鎮靜劑。

2003年，斯圖爾特被監禁，這是他被監禁的兩次其中之一次。在那裡，他被診斷出麼感染愛滋病毒。他曾經從小巷、類似場所等特定的地方撿拾被丟棄的注射設施。「在格拉斯哥有很多相似的地方」，斯圖爾特說。他會盡力選擇他自己留在那裡的針，或是過去未曾被使用過的，但他卻無法保證能夠記得。他認為在其中的某一個場合，他感染了愛滋病毒。他目前都能跟上他的治療藥物。

Patricia將GDCC描述為一個「安全環境」。斯圖爾特深入了解這實際意味著什麼。「當我睡在橋下時，我抓住了一瓶伏特加酒瓶過著珍視的生活，如此當有人襲擊我時，我可以有一些為自己防禦的方式」，他說。他回憶起在同一座橋下一個粗魯不當心的睡眠者，被一幫暴徒毆打致死之情景。GDCC提供了一些庇護所。 「這裡的人們總是問我近況如何？我會說它是一個真誠的問題」，斯圖爾特說。

Patricia強調建立關係並建立信任的重要性。「這是關於能夠開放和向前」，她說道。「你必須誠實地說明你能做些什麼，而不是承諾你無法提供的東西」。非常強調機構間合作，特別是心理健康上的服務。

GDCC有一項不排除的政策。「我們努力去與人們共同工作，無論他們的行為如何；我不認為我們曾經禁止過任何人」，Patricia說。在過去3個月內尚未接受血源性病毒檢測的藥物使用者，如果他們同意接受測試，會提供5英鎊的優惠券，可以在當地商店消費。「這似乎是有助於我們吸引人們參與的方法」，Patricia說。

這是斯圖爾特第七次入住庇護所，但這是他第一次依自己的意志入住 – 以前他的父親會哄騙或賄賂他參加。斯圖爾特是一個合格的細木工匠;他希望重回職場，也許是通過大學的進修課程。「停止吸毒是一回事，但是對我來說，持績不使用對我來說很難」，他承認。但相對應的情況令人恐懼。「這個危險的實體存於那裡。不管怎樣，我的大多數同伴都已經離開了，這嚇壞了我的生活」，斯圖爾特說。

刺胳針愛滋病毒醫學期刊

塔爾.巴布基

Glasgow Drugs Crisis Centre providing a safe environment

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The GDCC gym is open to people seeking care in the residential facility

Stewart has struggled with addiction for the past two decades. Now 43 years old, he came to the residential unit at the Glasgow Drugs Crisis Centre (GDCC) from hospital. “I had been sleeping under a bridge for a week and injecting cocaine next to an old abscess.” The abscess reopened and Stewart feared that he might lose his leg. Fortunately, he did not. “I was just lucky, I guess”, said Stewart. He got into heroin in his mid-20s, smoking at first but eventually injecting. “It is like being wrapped up in cotton wool: nice and gentle and fluffy. I loved it”, he said. But once the effects wear off, things become ugly. “After 2 or 3 days, you go cold turkey; you are stone cold 1 minute, burning up the next, you feel that your skin is inside out”, explains Stewart. “All the time, you know that heroin will take that away instantly. I was looking for a buzz but I also took it just to function.” 

The GDCC was established in 1994. It is funded by NHS Scotland and Glasgow City Council and run by the charity Turning Point Scotland. Services include a needle exchange, individual assessment and care plans, and an abscess and ulcer clinic. There is no need for an appointment and the centre is open 24 hours a day. The staff are mostly social care workers. A medical officer is permanently on call, and there are two nurses in the building during the day. The residential unit is available for those in serious need and an outpatient clinic provides opioid substitution therapy. 

But it all starts with a cup of tea and a chat. “You come in and you are given a hot drink and you are treated with respect”, explains service manager Patricia Tracey. “Anyone who wants advice or help with a drug problem is welcome; they can take it at their own pace—we never pressure people to do anything they are not ready for.” The watchword is harm reduction. For example, a heroin user who is not prepared to give up the drug may be encouraged to switch from injecting it to smoking it. 

Roughly half of those who access the GDCC residential unit are homeless. They typically have multiple health issues. Amputations and mobility issues are common. They have often gone through a succession of bereavements and have a history of trauma, both from childhood and from their drug use. Around two-thirds are men, and the majority are older than 35 years. “You get to a certain age and things just catch up to you; by your mid-30s, you are at crisis point”, notes Patricia. The use of several drugs at once is widespread. A lot of people combine heroin and cocaine, which are injected, with benzodiazepene, an oral sedative. 

In 2003, Stewart was imprisoned, one of his two stints inside. There, he was diagnosed with HIV. He used to retrieve discarded injecting equipment from particular spots, alleyways and suchlike. “There are lots of places like that in Glasgow”, said Stewart. He would try to choose a needle that he had left there himself, but there was no guarantee he could remember, or that it had not been used since. He believes that on one of those occasions, he contracted HIV. He is keeping up with his medication.

 Patricia describes the GDCC as a “safe environment”. Stewart offers an insight into what this actually means. “When I slept under the bridge, I held onto a bottle of vodka for dear life, so if someone attacked me, I could have some way to defend myself”, he said. He recalls a rough sleeper under the same bridge who was beaten to death by a gang of thugs. The GDCC offers something of a sanctuary. “People here always ask how I am doing, and I can tell it is a genuine question”, said Stewart. 

Patricia stresses the importance of building relationships and establishing trust. “It is about being open and up front”, she said. “You have to be honest about what you can do for people, and not promise things that you cannot deliver”. There is a strong emphasis on interagency collaboration, particularly with mental health services. 

The GDCC has a non-exclusion policy. “We try to work with people no matter what their behaviour is; I do not think we have ever banned anyone”, said Patricia. Drug users who have not been tested for blood-borne viruses within the previous 3 months are offered a £5 voucher, which can be spent at local shops, if they agree to testing. “That seems to be something that is helping us to engage with people”, said Patricia. 

This is Stewart’s seventh stay in the residential unit. But it is the first time he has come of his own volition—previously his father would cajole or bribe him into attending. Stewart is a qualified joiner; he hopes to get back into work, perhaps via a refresher course at college. “Stopping drugs is one thing, but staying off is the hard part for me”, he admits. But the alternative is frightening. “It is a dangerous existence out there. One way or another most of my mates have gone, and that scares the life out of me”, Stewart told

The Lancet HIV.

Talha Burki

www.thelancet.com/hiv Vol 5 September 2018