As a supplier of injecting equipment to needle and syringe programmes (NSPs), Daniels Healthcare wanted to discover more about what appeared to be a significantly changing profile of the injecting drug users who are our end-user clients. For a long time, anecdotally, we had been aware that steroid injectors were accessing needle exchanges for their equipment in ever-greater numbers. So over the course of last year we began to think it would be valuable to learn more about how our provision to this client group could be improved and also see if we could provide further information for commissioners and drugs services to help them understand the needs of a client group that frontline drugs workers often find very hard to engage with, beyond a quick exchange.
We approached Kevin Flemen at KFx to undertake research to use alongside experience gained at his workshops and training sessions, and a simple questionnaire was created and distributed by needle exchange workers to people attending exchanges and who used steroids. Fifty-four completed responses provided some interesting, and at some points surprising, results.
KFx and Daniels were both aware of worryingly wide variations in knowledge among people who use steroids, from the highly knowledgeable and experienced to those with only very basic understanding, so we decided to develop a series of information leaflets. We really liked KFx’s idea of dividing the information into specific knowledge areas and creating resources which could be distributed either with their pharmacy packs, or individually by frontline workers, and eventually free of charge from our websites.
Starting with those who may not have extensive knowledge, it was decided that the following subjects would be the most helpful in offering straightforward harm reduction advice for naive injectors, as well as those who might be interested in exploring potential alternatives to steroid use.
The five leaflets focused on:
• When to start? A leaflet for younger people who either hadn’t started using, or were just thinking about starting to use, performance-enhancing drugs.
• IM injections: a basic leaflet covering intramuscular technique, to be given out with packs for IM injection.
• SC injections: for people using any compounds subcutaneously, describing SC technique and to be given out to people taking packs for subcutaneous injection.
• Melanotan: a specific leaflet for people injecting tanning agents, identified as a group for whom there was little literature about administration.
• Polydrug users: a leaflet for people using steroids in a non-structured way alongside other substances such as alcohol and ecstasy. This group of young polydrug users was considered especially high risk and lacked any targeted literature.
By acknowledging the growing numbers of steroid injectors who were accessing drugs services, we hoped to demonstrate to this group that an exchange could also be part of a tailored intervention.
We wanted to be part of a conversation that acknowledged that NSPs were as much for people who used steroids as any other substance. As part of the same process, we concluded that if sharps boxes were going to carry any messages at all, some of these should also be steroid-specific, so we developed a series of educational messages specific to steroid users, delivered in an engaging way.
The relatively high response rate to the survey allowed us to see some clear trends emerging. However, as the sample group were self-selecting (ie the surveys were conducted in needle exchanges) it provided a poor impression of what went on for people who didn’t use a needle exchange.
We used a simple nomination question to find out if service users felt that most of the people they knew already used needle exchanges. The results indicated that the majority of people attending services felt that most of their peers were also using exchanges, but there was also a significant population that didn’t.
We asked people what aspects of service were important to them, and the results confounded expectations. Despite our preconceptions, a steroid-specific service was the least important aspect and less than a third considered evening or weekend sessions necessary to them. The crucial aspects were friendly, knowledgeable staff delivering the right equipment in a confidential setting.
While the result was biased – completed as it was by people already using needle exchange – the findings were still striking. They highlighted the need for effective staff training rather than a concentration on extended opening or steroid-only sessions.
We found the exercise of focusing on the needs of steroid users informative and enlightening and will use the results to inform how we develop our distribution of equipment to this client group.
James Langton is harm reduction planning officer at Daniels Healthcare, www.daniels.co.uk
To receive a copy of the research, contact Kevin Flemen at www.kfx.org.uk