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Needles Are Not Enough

In the 1980s, the UK and many other countries started developing needle programmes in an attempt to limit the impact that HIV was having on the injecting community and by extension the general public. Needle programmes have also become early engagement tools to help people get into treatment

The range of equipment provided has gradually increased with (in the UK) minor law changes to allow distribution of citric, filters, spoons and water. 30 years later and these projects are still helping keep HIV levels low and now they’re helping minimise the risks of HepB and HepC.

But this intervention only works with injectors. Injectors are likely to have been using drugs for a number of years already, so surely supplying equipment to people smoking or snorting their drug of choice should be a logical next step in early engagement.

There have been studies into distribution of foil to heroin smokers (Pizzey and Hunt: Distributing foil from needle and syringe programmes (NSPs) to promote transitions from heroin injecting to chasing: An evaluation) These demonstrate that as well as being a good engagement tool the supply of foil can also act as a route transition away from injecting.

In 2008, I presented at the National Needle Exchange Forum meeting about a crack equipment project I’d started that had resulted in an increase in clients to the service, many of whom had never attended before. These new attendees engaged with the HepB vaccination programme and counselling . Both clients and staff said they’d become more confident in delivering and receiving support.

In 2010, the ACMD gave Theresa May a detailed report on foil provision and in November 2012, she wrote to them asking “what evidence [is there] that provision of foil would get people off drugs” (you can see her letter, and the ACMD reply).

Where the provision of smoking equipment has been embraced (like Holland for foil, or some states in the US for pipes) there have been more great successes in engaging with people before they move to injecting. But in the UK, we’re prevented from expanding in this way by Section 9a of the Misuse of Drugs Act, a law that was devised to prevent ‘head shops’ from selling drug paraphernalia. Head shops still sell drug kits, now they just put a sign on them saying ‘novelty use only’, but many drug services have become so risk averse that they are unlikely to give out this equipment, although there has never been a successful conviction under this law and the Crown Prosecution Service state that prosecution of “bona fide operators” of drug services is not in the public interest. (UPDATE: As of September 2014 foil is now legal in the UK, but with strong restrictions).

It’s clear that needle programmes can only do so much, we need pipe programmes and foil projects as well if we want to engage people earlier.

This topic was submitted by Nigel Brunsdon the Community Manager at HIT and owner of the Injecting Advice website. All opinions expressed in this topic are his own. Thanks to Jamie Bridge for assistance in writing this topic.

Overdose, Stigma and the Great Challenge

Last year on the 31st of August 2011, (International Overdose Awareness Day) I posted an image of Jimi Hendrix to Twitter with the following caption; ‘Imagine how much sweeter the world would sound with a little more harm reduction’. (While there are varying reports regarding the nature of Hendrix’s death the official finding was that he asphyxiated on his own vomit after consuming more alcohol than he was able to tolerate – effectively an overdose of alcohol). It was my way of acknowledging that when a fatal overdose occurs it is not just a death that occurs but the loss of an opportunity.

With a little more harm reduction, Jimi Hendrix may have well gone on to record many more revolutionary albums enriching our lives artistically and culturally, but just as important are the many non celebrities who have experienced overdose. They too have lost the myriad and unforeseeable opportunities that a longer future could have entailed. Really, everyone’s world would rock with a little more harm reduction. It is these thoughts I ponder as we approach International Overdose Awareness Day 2012.

I live in Australia, a nation with relatively well developed harm reduction programs. The Medically Supervised Injecting Centre in Sydney has now been operating for over a decade and has saved countless lives, not only intervening when people overdose but also providing a gateway to a myriad of health and treatment services to an all too often marginalised population of injecting drug users. In the Australian Capital Territory a pilot program  designed to widen the availability of naloxone to the peers and families of opiate users is under way with the aim of increasing the speed in which we can respond to opiate overdose. Australia’s well developed needle syringe programs are also playing their part, providing crucial harm reduction information to people who use drugs.

Responding to overdose however is not just about providing a safe physical environment, it’s not just about providing the right medications in a timely manner and it’s not just about getting technique right. While all of these things are vitally important, a crucial ingredient in addressing overdose is overcoming stigmatising attitudes towards people who use drugs. Stigma kills. It drives people who use drugs to the fringes of our community. Stigma has the power to separate people from much needed supports, marginalising them from health services and even their families. People use in secret or fail to let others know when something goes wrong due to fear of the judgement and condemnation.

I’ve known many, many people who have used drugs throughout my life. Some have been mad, some have been sad and some have been bad, but if I looked hard enough I could always find something positive about them. With the vast majority I haven’t had to look very hard at all. The reality is that people who use drugs are mothers and fathers, policemen and poets, sons and daughters – in short they are just people like you and me.

While I’ve known many people who use drugs, I’ve also met many people over the years who have held very strong negative opinions about people who use drugs. Possibly the most callous opinion I have heard uttered was the idea that we should ‘put buckets of the shit out in the street and let them all kill themselves.’ Many in our communities have dehumanised people who use drugs and fail to recognise the loss that lives cut short by overdose entails.

This loss may be best encapsulated not in my words but by the words of Kat Daley who recently published a stunningly honest account of her own experience of the overdose of a loved one.

There are so many assumptions that come with drug related deaths. People assume an overdose is a heroin overdose. And that heroin overdoses happen in laneways somewhere. They assume the person was a ‘junkie’ and had probably caused their loved ones much angst and heartache, having stolen from them and abused them and all of those other things that drug addicts do.”

“Sometimes all of that is true. But a lot of the time it’s not. Either way, it doesn’t matter. Losing a child who stole from you is still losing a child. Only a parent who has been through this can understand that losing your child means losing part of you. The day I lost my brother part of my mother went with him.

The great challenge in addressing overdose is not which programs we can put into place. The harm reduction sector has demonstrated time and again that through a combination of effective advocacy and the systematic collection and analysis of evidence, we can implement effective harm reduction programs (even highly contentious ones like drug consumption rooms) that prevent or reduce the likelihood of overdose. The greater challenge is how to address stigma in our communities. How can we convince the wider community that people who use drugs are human beings not that much different from anyone else? How can we convince our communities that reducing drug related deaths provides opportunities so broad and so large that the potential loss is unimaginable? Saving even one life from overdose may result in the greatest rock and roll album ever made or it might result in tender moments shared between a parent and a child that otherwise might not have been.

Matt Gleeson is an Educator, Blogger and Harm Reduction Advocate. He is currently employed by UnitingCare ReGen and in his spare time writes the blog, Stonetree Harm Reduction. All opinions expressed are his own.

Russell Brand on Newsnight

Last week, Newsnight hosted a discussion on drug policy, starring that well-known expert on drugs, Russell Brand. The BBC have decided that Russell Brand can make a documentary film in which he will tell us what we should be doing about drugs, or rather what we should be doing to people who use drugs.

He was interviewed by a star-struck Stephanie Flanders, a (normally excellent) economics expert, who let him spout his views unchallenged, although she did ask him how he was qualified to offer a blueprint for the future. His answer was that he used to take drugs, which itself went unchallenged. For the only time in my life, I yearned for Jeremy Paxman. (For a discussion on whether that qualifies him to tell us all what we should be doing, read this excellent article by Yasmin Alibhai-Brown in the Independent, in which she argues, successfully in my view, that experience is not the same as expertise.)

My Way, The Only Way

For Brand, the government is doing the wrong thing in giving people methadone, and the only way is abstinence-based recovery. He believes that we shouldn’t give people methadone because it is a drug, and they shouldn’t be taking drugs. I take three drugs a day and they deal with a medical condition that I have. Presumably Russell Brand thinks I shouldn’t be taking them because they are drugs. However, if he believes that drug “addiction” is a disease, should that not lead him to believe that the correct medication, or drug, one of which is methadone, should be prescribed?

His “empirical understanding” leads him to believe that drug users are people of “deep sadness and malady” who have a disease or disorder and who spend their lives doing silly and irrational things over which they have no control because they are using drugs. They are not themselves.

While not wanting to make light of the problems which can face some people who use drugs, legal and illegal, I have always believed that people take drugs, not the other way round. Most of the heroin users I have known have spent most of their lives doing very rational and well thought out things in order to have the money to buy their drugs.

This really is the cult of celebrity gone mad. While I believe that everyone has the right to express their point to view, for the BBC to give Brand such a platform could have serious implications for policy, which is supposed to be for the many, not the few, and will further contribute to the marginalization and stigmatization of people who choose not to be abstinent.

This Hot Topic is by HIT’s Director Pat O’Hare who has been involved in the development and promotion of drug services since the 1980s, Pat is also on the board of Harm Reduction International (HRI) and the Middle East & North Africa Harm Reduction Association (MENAHRA).

Young People’s Outcomes

On January 17th 2012 Mark Johnson wrote an article in the Guardian entitled “It’s time to treat drug-addicted children as adults” although the article was itself about young people’s rehab, the title does raise the issue of how we treat our young people when they access services. As those working in young people’s drug treatment know, the outcomes the government look for are already those of adults. But, is it reasonable or even achievable to use same outcome measures for young people and adults in the UK?

The Drugscope document ‘Young Peoples Drug and Alcohol Treatment at the Crossroads‘ recognised that over the last 10 to 12 years young people’s drug treatment services have evolved from the adult style system that provided drug specific treatment, prescribing and health services to a wider system that better recognises the diverse needs of young people and their modes and developing patterns of drug use.

Most young people’s services now offer services that are provided within multi-disciplinary teams, are not drug specific and recognise (and incorporate) emotional well being, mental health, family functioning systems, social inclusion, sexual health/relationships and knowledge of developmental stages of young people.

Outcome Tools

These adult treatment measuring tools used in the UK (NDTMS/TOP) do not reflect the diversity of work done in young people’s services or the achievements or multiple changes achieved by young people within these services.

They also don’t reflect the nature of young people’s drug use, which is often a fluctuating series of episodes that range from stable, chaotic, problematic, to episodes of reduced use, no use, back to chaotic etc, including a variety of drugs. Often this is as a result of the other issues going on for young people. Such as periods of sofa surfing, exam stresses, temporary family dysfunction etc. Whilst clearly this is the case with adults too, for young people these ‘episodes’ are often more regular and persistent, because, in part, it’s a part of growing up.

Practitioners working with young people understood and were working with the emerging ACCE (Alcohol, Cannabis, Cocaine & Ecstasy) profile and the legal high phenomenon long before commissioners realised, and because of the already diverse way in which they were working were usually able to respond appropriately. Which in a sense renders the statistical data, published a year after the episodes as irrelevant, as the trends will develop and change again before they’re even released.

…EXPECT SUBSTANCE MISUSE PROBLEMS TO INCREASE DURING A PERIODS OF HIGH RECESSION AND HIGH YOUTH UNEMPLOYMENT.

“Young people’s drug and alcohol treatment at the crossroads” – Drugscope 2010

These statistics are useful though, when viewed against the politics and economics. Currently, young people’s services are gearing up for the possibility of a radical change in current trends due to the recession and unprecedented youth unemployment (and the persistent presence of cheap booze and cheaper drugs).

Therefore in recognition of the enormous changes in young people’s services, is it time that we looked at a more reflective outcome measuring tool, than the inherited adult system of NDTMS and TOPS? What should it measure and how could it work to help young people?

This Hot Topic was suggested and contributed to by Melody Treasure.

Drug Consumption Rooms

Earlier on this year in September the Canadian Supreme Court ruled that the Harper government couldn’t close the Insite safer injection facility in Vancouver. Insite, which in 2009 had over 250,000 visits from people using its facilities, opened in 2003. In the time it has been operating it has received strong local support especially from the Mayors of Vancouver who irrespective of their party have always fought to keep it open.

In 2009, almost 500 people overdosed on the premises but because of the medical staff on hand none of these people died. Staff at Insite (and other facilities like it around the world) provide advice on safer injecting, sterile equipment, wound care and a safe warm place to use rather than injecting in public areas of the city. Insite also helps people access treatment services and rehabs directly.

UK Situation

In the UK there have been previous calls to pilot drug consumption rooms, not only from organisations like the Joseph Rowntree Foundation (paper Apaper B) but also from David Cameron who in 2002 voted in favour of supervised injecting rooms being launched in the UK.

However, there are also many people who suggest that opening drug consumption rooms sends out the wrong message to people using drugs, and that providing injectors with somewhere that removes many of the risks of injecting may give them a false sense of security.

Martin Chandler

Martin Chandler (BSc, MSc, PGCE) is currently completing a PhD at the University of Birmingham, exploring the use of Image and Performance Enhancing Drugs (IPEDs) in athletes, having previously worked there as a Research Fellow in Performance Enhancing Drugs.

Prior to joining the University of Birmingham, Martin was a Research Fellow in Human Enhancement Drugs, based at Liverpool John Moores University and has been studying the use of IPEDs since 2006, as well as providing consultation around injecting drug use. He was also Co-Chair of the National Needle Exchange Forum (NNEF) from 2009-2012 and Chair from 2012-2013.

He has presented at both national and international conferences on a range of issues around IPED use and contributed to local and national government guidance on the provision of services for IPED clients. He provides training around anabolic steroid use to healthcare and other professionals, with a focus on service provision for this client group. He has also provided expert witness testimony in a number of high profile cases involving anabolic steroids.