LGBT drug support

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London Friend chief executive Monty Moncrieff talks to David Gilliver about the treatment needs of the LGBT community and the challenge posed by the ‘chemsex’ scene

Established more than 40 years ago, London Friend is the country’s oldest LGBT support charity and also operates what is still the only LGBT-specific drug and alcohol treatment service, Antidote. ‘There are pockets of LGBT work, and workers within local services, but it’s the only one that offers such a comprehensive range of support,’ says chief executive Monty Moncrieff. ‘Although we’re a non-medical service – it’s psychosocial.’

He’s been at London Friend for three and a half years, moving to the top spot in 2012 from his role as head of services. But it was during his nine years at Turning Point that that he originally set up Antidote, in 2002.

‘The Turning Point project I was working for, the Hungerford Drug Project, had propped up an older piece of work, Project LSD, which had been doing LGBT outreach in clubs in the ‘90s,’ he says. ‘That had essentially run out of funding but Hungerford saw the need for work with LGBT people – that they didn’t have anywhere specific to be referred to – and wanted to develop a service. They got a 12-month piece of funding and that’s when I came in.’

Around the same time Brixton-based alcohol project ACAPS also came under the management of Turning Point, he explains. ‘They ran a lesbian, gay and bisexual alcohol counselling service, and we already did some joint work between Project LSD and their counselling service so we decided it was a good idea to merge the two and develop something with a little bit more structure.’ The counselling and walk-in services were brought together, with psychosocial treatment and structured key working groups added, and the project was re-branded as Antidote. ‘That’s where it really started,’ he says.

He went on to other roles within Turning Point while always keeping ‘a toe in the door of Antidote’, but it was after the national programme for LGBT equality he’d left to manage at the Department of Health fell victim to funding cuts that he made the move to London Friend. His interest in drug and alcohol treatment came about ‘almost by chance’, however.

‘I didn’t really have any experience of doing drug and alcohol work – I’d managed a pub, so having spent five years getting people pissed I was then helping them to get sober, which was a bit of an interesting shift,’ he laughs. ‘It was really the LGBT angle that brought me in, although I found quite quickly that it was an interesting sector to be working in. We were noticing some different trends – even over a decade ago – in the drugs being used by LGBT people compared to those that mainstream services typically worked with, and also to work with organisations around their LGBT competence is a really interesting strand of the work that we do.’

Obviously, one of the most high profile issues of the moment is the ‘chemsex’ scene, with people getting into real problems with mephedrone, crystal meth and GHB/GBL. Does he feel this is something that mainstream services are now properly equipped to deal with?

‘I think it’s starting to improve,’ he says. ‘We were getting a lot of feedback from our service users that, with local services, they didn’t always feel that they really had any experience of working with the drugs they were using and also, very often, the cultural issues as well. It’s that feeling of “how can I go in and talk to a mainstream drugs worker about the fact that I was involved in quite extreme sexual behaviour at the weekend?” Those sort of feelings of shame and guilt and embarrassment, which are all very closely tied to people’s sense of self and identity. So it’s that ability to come into a service and feel safe and understood and not judged.’

Many Antidote service users prefer to work with LGBT staff for precisely those reasons of empathy and understanding, he says. ‘I know that’s a tricky area when you’re talking about therapeutic services – whether sometimes you should match like for like – but we’ve got a very strong sense that our service users are opting to come to us because an LGBT service is going to be the best one to meet their needs. It’s really about trying to remove those barriers.’

Nonetheless his organisation has done a good deal of training with mainstream services over the past decade, and more so recently as chemsex has started to ‘become more widely understood and people have started to present at services’, he says. ‘There’s definitely not a lack of willing from services – they’re really keen for training, keen to try to be meeting that need, and there’s some really good pieces of work developing. There’s still a way to go, but I think progress is being made.’

Last year London Friend published Out of your mind, a report on the treatment needs of the LGBT community, which recommended that commissioners and providers should be carrying out LGBT audits, addressing LGBT need in service specifications and introducing mandatory monitoring of sexual orientation data. Is any of that starting to happen?

‘We work with a couple of services that are putting those in place – either at a local level or, sometimes if they’re a larger provider, across their services –and we are working with a couple of commissioners who are interested in implementing aspects of that report. And what’s really good for us is that Public Health England have launched their action plan, Promoting the health and wellbeing of gay, bisexual and other men who have sex with men (DDN, March, page 4), which contains some commitments that match some of the recommendations in Out of your mind. It’s really nice to feel we’ve got a bit of traction with those recommendations and it’s the first time that an action plan like that has been done for a minority group by a government agency, so we very much welcome that.’

Even predating the issues around chemsex, levels of substance use in the LGBT community tended to be higher, for a range of reasons – the more central role of the bar and club scene, or people self-medicating to deal with things like anxiety or depression. Are mainstream treatment services getting better at responding to those wider issues?

‘I think there’s still a long way to go there as well,’ he says. ‘With almost all of the clients we’ve worked with – whatever the trigger for them coming into the service – when we’ve started to look at the issues behind their using it’s so closely linked to their identity, their self-esteem, and how good they feel about themselves. That’s still a very difficult thing for mainstream services to do. That’s not to say that mainstream services can’t do that, but I think there is a limitation sometimes to that kind of empathy. 

Just how surprised was he when the anecdotal evidence started to come though about people injecting drugs like crystal meth? ‘Very,’ he states. ‘Injecting hadn’t really been part of this community before – there was a real taboo about it. There was a small group injecting steroids and image-enhancing drugs, but not injecting drugs recreationally. So it was a real surprise when we started to hear about people injecting crystal, and after that, mephedrone.’

One attempt to tackle these issues has been through Code, a pilot project with the 56 Dean Street sexual health clinic in Soho, which offers specific help for people using drugs in a sexual setting. ‘People come into Antidote or mainstream drug services when their drug use becomes problematic or reaches crisis point. But people access sexual health services much earlier on – when they need an STI treated, or as part of their regular check-ups that a lot of gay men do, or they might come because they’ve got an urgent need for PEP [post-exposure prophylaxis] after an HIV risk. That’s actually how it came about – we noticed how many people were coming in after a bank holiday requiring PEP and saying that drugs had been involved, so we thought this might be the ideal opportunity to get to speak to people who wouldn’t necessarily come into a drugs service.’

By improving screening to see if drug use was an issue and being on hand to deliver brief advice or refer to Antidote or another treatment agency, it became apparent that there was a real opportunity to get to people ‘much earlier in their cycle of drug use’, he says. ‘We can give some harm reduction advice, maybe some motivational interviewing sessions to look at behavioural change, but in the context of their sexual behaviour and their drug use together, which I think is unique. It’s tended to be two segregated areas before, but as we’ve seen use become so much more sexualised through the chemsex scene it’s really been imperative for us to look at sexual behaviour and drug use interventions together.’

It’s not just physical health that can be at risk with chemsex, of course – there are major potential mental health issues as well. ‘There’s things like poor self-esteem,’ he says. ‘But we’re also seeing more drug-induced psychosis, a higher number of clients who’ve been detained under the Mental Health Act and those sort of issues around paranoia and delusions that come from heavy stimulant use – using drugs for three or four days, perhaps even longer.

‘The impact of that sleeplessness mixed with strong stimulants like crystal and mephedrone does seem to be kind of a perfect storm,’ he continues. ‘Once people stop the comedown’s so intense. We’re getting more and more calls on a Monday and Tuesday from people who are experiencing really quite horrific comedowns and just wanting reassurance and somebody to help talk them through it. There does seem to be a disproportionate amount of harm happening with the chemsex drugs.

A typical user profile may be someone who’s taken drugs recreationally for years and whose drug use has previously been ‘relatively well contained’, he says. ‘They’ve taken ecstasy, cocaine, maybe some ketamine, but in the context of going out clubbing and maybe chilling out the next day – not this sort of days-on-end use. There does seem to be a real shift.’

It’s quite a wide age range, isn’t it, with people in their 40s and 50s? ‘Absolutely. We’re seeing some late initiations as well, with people only starting to use at that age, but also people using much, much younger than that, where it’s their first forays into sexual identity and intrinsically linked with their first sexual encounters.’

So, more broadly, what else could services and commissioners be doing to support LGBT service users? ‘I think what we want is that acknowledgement of a community with different needs, to see that better represented within a local needs assessment,’ he says. ‘We did some needs analysis of London-based JSNAs as part of the Out of your mind report and it was very poor in consideration of LGBT issues anyway, but when you drilled down into LGBT issues in relation to specific health areas it was even poorer. That’s the experience of several of our LGBT colleague organisations across the country as well, so we’d like to see better inclusion of LGBT issues in that assessment of needs. But we’d also love to see more collaborative commissioning across areas. Localism isn’t an agenda that serves LGBT people particularly well, because they’re a community of identity, not a community of geography.’

While localism can ‘work brilliantly’ for specific health inequalities within a borough, it ‘just doesn’t lend itself to that natural division’ in a city like London, he says. ‘There are some boroughs with a high percentage of LGBT people, some with less, but there’s not necessarily that economy of scale for local commissioners to be identifying and committing great deals of money to pockets of LGBT work just within local authorities. So we’d like to see greater collaboration, that bigger picture.’

‘Actually, if there was a mechanism to pool relatively small amounts of money, you could have a very sizeable pot across London that could be directed at meeting the needs of this community very efficiently indeed.’