Healthy exchange

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DDN reports from the 2013 NNEF annual meeting in Bournemouth, which has become a keenly anticipated fixture for information and ideas. 

ex1Keeping harm reduction at the heart of drug strategy was a key concern of the National Needle Exchange Forum (NNEF)’s annual meeting. This year it was held in Bournemouth and drew enthusiastic attendance from needle exchange workers from all over the country.

The forum’s chair Jamie Bridge reiterated the NNEF’s aim of promoting, supporting and protecting good quality needle exchange in England, and invited Steve Taylor from Public Health England to give an update on how PHE related to this agenda. 

‘Harm reduction and public health interests align in a way that they didn’t when the NTA had to be seen to be aligning with the government’s recovery strategy,’ said Taylor, outlining work on newer psychoactive substances, men who have sex with men (MSM), improving access to hep C treatment, adding to recovery resources and collecting evidence on the effect of recent legislation relating to the use of foil.

His colleague Vivian Hope, previously of the Health Protection Agency, gave an update on injecting drug use and infections from PHE’s injecting drug use team. Patterns of injecting were changing, he said, with an increase in psychoactive and club drugs as well as performance drugs – primarily anabolic steroids.

Hepatitis B and C had declined markedly over time, thanks to ‘harm reduction approaches supported by good drug treatment’. Levels of HIV infection were stable, although four times higher in London than elsewhere in England and Wales, and there had been spikes in transmission of HIV, probably related to crack cocaine and increased risk behaviour. Needle and syringe sharing had declined overall, but the changing patterns could increase risk among different populations, so it was important to respond quickly to any changing

‘Changes will be positive’

Blenheim’s chief executive, John Jolly, was asked to give an update on commissioning and policy in England, and could not find much to be optimistic about in the new localism agenda, with the impact likely to be that ‘the needs of the many outweigh the needs of the few’. Despite politicians telling us ‘changes will be positive’, the drug and alcohol sector needed to realise that ‘we are no longer the priority’, he said. ‘The priorities for public health are at local level.’

Ring-fenced drug money had gone into ring-fenced public health money, ‘but it gets worse,’ he said. ‘The ring-fence comes off in 2015 and we’ll have to compete with everything else. In London it feels a bit like the Wild West – the last man standing.’

Niamh Eastwood, chief executive of Release, underlined the need to be ready with legal challenges in this changing climate, and offered Release’s practical help.

‘If any of your clients are being harassed by police, let us know,’ she said. Release was challenging such ‘incredibly humiliating’ experiences as strip search before arrest and the practice of forcing clients to reduce their methadone script, where it was linked to an organisation’s policy decisions. They were also keen to challenge services that attempted to discharge clients on the grounds of bad behaviour, reminding them of their duty to provide alternative support. 

Frontline action

Next the spotlight fell on local services for a look at experiences on the front line.  Tim White from DHUFT (the local NHS foundation trust) credited a multi-agency approach with bringing drug deaths down.

‘We’re doing what we can to bring services to the community,’ he said, with the help of a thriving working relationship with the Big Issue and great support from Bournemouth DAT. 

Simon Chilcott of the Big Issue Foundation said that about half of the 81 Big Issue vendors in Bournemouth had substance issues and that the needle exchange was successful in attracting repeat visitors, including steroid users.

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‘We see street users, people who are falling through services – it would be nice to catch them before they go down that far,’ he added.

Richard James, a blood-borne virus specialist said the BBV project had become successful through working with other agencies, using dry blood spot testing instead of needles, and training more workers to do the testing. With the percentage of people needing hep C testing higher than normal in this client group, it was a good idea to partner with a BBV project, he said. Needle exchanges represented a good opportunity to make contact with clients that didn’t present to other agencies.

The meeting brought in expertise from frontline workers in other areas of the country. Philippe Bonnet, an outreach drug worker in Birmingham talked about his work with chaotic clients – people who had become regarded as ‘problem people’ rather than ‘people with problems’.

Working in pharmacies in the centre of Birmingham had convinced him of the need for drug consumption rooms (DCRs) in the city, he said. Injecting in cold dark conditions often led to hurried injecting into cold veins, resulting in a high incidence of venous ulcers and abscesses.

Drug consumption rooms reduced deaths, as well as saving money for the NHS and reducing needle litter – apart from which, he pointed out, human beings should not be injecting in such circumstances. There were now 90 DCRs around the world, with the 91st opening in Paris next month. ‘The drug strategy says we are committed to learning from what works in other countries and an evidence-based approach,’ he said. ‘So how much evidence do you need?’

Practical knowledge sharing

Next up to talk about frontline action, Nigel Brunsdon of HIT and the NNEF explored the potential of harm reduction cafes in sharing ideas. 

‘It’s a return to the grassroots idea of small stuff that led to bigger action,’ he said. The internet offered a way to share resources and ideas: ‘Use the tools and adapt them, even if you’re in the recovery movement.’ Get active, piggyback events, choose the right venue and time (late afternoon or early evening) and think about involving speakers – ‘but above all, don’t wait for others to do it,’ he said. 

Moving on to the key developments for needle exchange, trainer and consultant Stephen Molloy wanted to know why all commissioners were not fully aware of the benefits of supplying naloxone.

‘How can we prevent people from standing beside the graves of their loved ones who have died needlessly?’ he asked, before giving a detailed reminder of the world’s first licensed kit. Although recommended by the ACMD’s naloxone report, it was still batted away by many politicians who said the decision lay with local areas. 

‘We know kits are used and we know lives are saved – so why wait?’ asked Molloy. ‘There are more than 1,700 deaths every year in the UK from accidental overdose. Why is this allowed to happen when naloxone works?’

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Changing behaviour would mean having to talk to people about the potential of death – not a comfortable subject, he said. ‘But we need to change attitudes – an opiate-related overdose death doesn’t have to happen.’

The practical knowledge-sharing continued with Andrew Preston of Exchange Supplies explaining latest developments with low ‘dead space’ syringes – a design shown to have a much lower viral burden of HIV.  Exchange were now working with Bath University to see if they could further improve the dead space measurement without compromising the fit of the needle. 

The meeting then moved on to review changing trends, starting with trainer Danny Morris’s look at mephedrone (MCAT) and methamphetamine (crystal meth). ‘There have been changing trends in drug use that suggest progress in the work we do,’ he said, but the rise in MCAT and crystal meth use among some groups – primarily MSM – bucked this trend. With the former drug massively cheaper than the latter, ‘if gay men can’t get hold of meth, MCAT will do,’ he said. 

The resulting extreme behaviour, which could include sex sessions of up to four days with different partners, meant the need for greater knowledge and understanding among drug workers, as well as expertise relating to possible complications including mental health problems. 

As well as ‘getting kit out there’ it was important to engage and work in partnership with services including sexual health clinics, who were ‘ill-equipped to give any advice’, said Morris. He also advised the drug and alcohol field to ‘de-emphasise recovery’ in this context. ‘If you have a recovery service, the door’s not going to be open to them,’ he said. 

Unknown population

Josie Smith of the Welsh Needle Exchange Forum, added her knowledge from the 2013 Steroids and image enhancing drugs survey (SIEDs) – an online survey from harm reduction databases in Wales.

It was found that many needle exchange workers felt ill-equipped to deal with the problem of steroids, which were distributed by coaches and increasingly used in bodybuilding. The majority of steroid injectors were between 18 and 22 years old – ‘an age where you shouldn’t be injecting these, as they interfere with natural hormones. A lot of younger users think you don’t have to train or eat properly – you just bang the steroids in,’ she added.

Needle sharing had increased as this population did not see itself as at risk, so they needed to be offered hepatitis B vaccinations and warned about the dangers. There were many risks and complications from a public health point of view, ‘because we know so little about this population,’ she said. 

An online survey (at www.siedsinfo.co.uk) would help workers and pharmacists to learn more about this population, she added. Another initiative in Wales was to go out to gyms – ‘the ones who are providing the gear’ – but it was a constant battle to distribute information and posters, as gyms did not want to be associated with it.

With so much information-sharing taking place throughout the day, it was up to Mat Southwell of Coact to comment on the value of needle exchange in the past, present and future. Telling the story of one of the early drug user activists from the Italian drug using community in London, he highlighted the need to protect harm reduction, while emphasising how far we had come from the early dark days of the HIV response. ‘This field has to be commended for its positive progress and culture of collaboration,’ he said.