With drug-related deaths once again hitting record levels, it\u2019s never been more urgent to make sure we\u2019re properly engaging with so-called \u2018chaotic clients\u2019. DDN reports. \u2018Engagement is always a tough one,\u2019 says Dr Bernadette Hard, GP specialist in addictions with Kaleidoscope. \u2018It\u2019s always problem in services, but that\u2019s the nature of the disease.\u2019 The gamut of engagement can run from highly motivated clients paying for their own treatment, via self-referrers who achieve good levels of stability but may begin to drift away, through to those who struggle to meet appointments and frequently drop out of treatment \u2013 if they engage at all. Much has been written about so-called \u2018chaotic clients\u2019, and a perennial challenge for services has been finding ways to bring more stability to this group, especially as they feature heavily in drug-related death statistics (see news, page 4). Scotland has long wanted to pilot consumption rooms, which have proved effective in other countries, but legal wrangles with Westminster have made this impossible. The closest anyone has come so far has been the establishment of a \u2018safe consumption\u2019 van in Glasgow, which has made national headlines despite technically operating outside the law. Heroin-assisted treatment (HAT) \u2013 widely accessible in the UK until 1967\u2019s Dangerous Drugs Act put paid to it, and available elsewhere in Europe \u2013 is showing signs of making a comeback, however, with a pilot programme launching in Scotland late last year (DDN, December\/January, page 4) and more and more police and crime commissioners coming out in favour of it. The results from the Glasgow HAT pilot, which has been incorporated into the city\u2019s Enhanced Drug Treatment System (EDTS) have been promising, particularly for people who\u2019ve experienced homelessness or been involved in the criminal justice system (DDN, March, page 8). One major benefit of the scheme has been to enable these clients to engage with other services, such as BBV, mental health or housing teams. A number of trials are also taking place to provide long-acting buprenorphine to chaotic clients, which means people no longer need to make regular trips to the pharmacy to collect medication \u2013 or be supervised taking it, something that many find stigmatising and humiliating. Delphi Medical have so far provided around 25 clients with long-acting buprenorphine, starting around ten months ago. \u2018When we first looked at the product it seemed to be aimed towards more stable groups, but the benefits quickly became apparent for the more chaotic group,\u2019 says head of medicines management, Colin Fearns. It was a similar process at Kaleidoscope, says Hard. \u2018Initially the general feeling was that it was the obvious choice for people who were quite stable. I was probably the only voice saying, \u201cLet\u2019s try it on people who are treatment resistant\u201d. It took more than three months to persuade anyone in the chaotic group to try it, she says. \u2018Then the first two did OK, but with the third it was outstanding. This was a lady who\u2019d been in and out of services \u2013 multiple restarts, prison, sex working, domestic violence, living in a night shelter. She\u2019d been in hospital with ulcers on her legs, with infective endocarditis for her heart valves from the bacteria from injecting, massive self-neglect. She was mentally beaten, completely disengaged, very hostile, very suspicious. \u2018I had very low expectations,\u2019 states Hard. \u2018But I thought I can\u2019t make this worse.\u2019 A week after she finally agreed to an injection \u2018I didn\u2019t recognise her\u2019, and a year later she remains drug free and is working and looking after her children. \u2018What she fed back was that having that stable dose turned off the cravings, and combined with that she was able to basically just hunker down.\u2019 Eliminating the need for regular attendance at pharmacies also removes people from potential triggers and from meeting people who might be carrying drugs or who may bully them for their prescription. Unlike sublingual buprenorphine, where it can still be possible to get some effect from heroin, long-acting injections shut this down completely. Incorporating something like long-acting buprenorphine, however, can often require a fundamental readjustment on the part of both service users and services, explains Fearns. \u2018From a psychological point of view for the client, the worker and the service as a whole it was alien,\u2019 he says. \u2018It can be really difficult to grasp that someone doesn\u2019t want to come into service because they don\u2019t feel they have to \u2013 because they\u2019re well. If you\u2019re used to sitting at home, waiting for your drugs, taking drugs, doing nothing, and now all that\u2019s suddenly removed you\u2019ve been launched into recovery, so it\u2019s about what you do with your time.\u2019 As Alex Boyt stressed in October\u2019s DDN (page 8) when it comes to prescriptions the key issue is flexibility. Prescribing needs to be \u2018massively flexible, but sensible as well\u2019, states Mick Webb, coordinator at Community Driven Feedback (CDF) in Bristol. This applies even with something like HAT, he says, with services needing to remember that every prescribing regime should be tailored to individual needs. \u2018It has to be delivered with the right level of independence \u2013 people need to feel that they own what they have.\u2019 Other wider prescribing options could potentially include medicinal cannabis, as recently highlighted by Nick Goldstein (DDN, October, page 12). \u2018Why can\u2019t I go to a drug worker and say \u201cI don\u2019t want these horribly addictive drugs you\u2019ve got me on, but smoking weed really helps with coming off them \u2013 can you prescribe me medicinal cannabis?\u201d\u2019 says Webb. \u2018They\u2019re scared because they don\u2019t have the guidelines, but we can help write those guidelines.\u2019 Prescribing regimes need to be based on thorough and extensive research of what people want, which would also be a key way of starting to build trust with populations seen as chaotic, he believes. \u2018What is there for crack users? Absolutely nothing.\u2019 The obvious way to do this is via peers \u2013 a \u2018massively under-used resource, and they\u2019re often treated abysmally and won\u2019t do anything about it, because they don\u2019t know their rights. The people I\u2019d speak to if I had a problem would not be drug workers, it would be my peers who know me well. At the moment the whole system needs to be broken down and built from the street upwards.\u2019 The major part of any drug worker\u2019s job should always be about how to empathise and understand, he believes. \u2018I\u2019ve seen it from all sides. I\u2019m a service user, I\u2019ve been a prescriber, I\u2019ve worked in management. In some ways since COVID it\u2019s been a good thing \u2013 people on daily supervised consumption suddenly found themselves on weekly, while some people would have preferred to stay on daily because it\u2019s the only contact they might have with a health professional. It should always be about the individual.\u2019 And it\u2019s the peers who should be training drug workers, he stresses, \u2018not other people working in the field \u2013 because there are certain restrictions and things you can\u2019t talk about. With peers there aren\u2019t those barriers \u2013 you can have some fun with the training and start stimulating that passion again.\u2019 But for now, trust remains lacking, he warns. \u2018Sadly, for a lot of people the best option is to not have anything to do with services. People aren\u2019t prepared to take the risks \u2013 they feel drug workers aren\u2019t people that you can be honest with. So I think it\u2019s about training and employing the very people that they\u2019re trying to reach. I don\u2019t think there are many other options. \u2018Start from the street up, just start with a blank canvas,\u2019 he says. \u2018Getting out, doing street work and asking people what\u2019s going on. We\u2019re here, we\u2019re right in front of people. This \u201chard to reach\u201d expression is worn out. If people are being called hard to reach, they\u2019re being made hard to reach.\u2019 This article has been produced with support from an educational grant provided by Camurus, which has not influenced the content in any way.