The Word on the Streets This year\u2019s Hit Hot Topics asked, how can we give harm reduction most impact on the frontline? DDN reports, pics by Nigel Brunsdon. \u2018What the heck are we doing, criminalising people for what they do to themselves?\u2019 Nanna Gotfredson is the founder of Gadejuristen, the \u2018Street Lawyers\u2019 of Denmark. She brings legal outreach to homeless people and witnesses the \u2018constant war on drug users \u2013 the constant fight between doves and hawks\u2019. Nanna Gotfredson: 'harm reduction, outreach, legal aid - and hugs, because we also need love.' \u2018Denmark is a welfare country \u2013 but the welfare system is designed for middle class people,\u2019 she told the HIT Hot Topics Conference. With her team, she brought harm reduction, outreach and legal aid services \u2013 \u2018and hugs, because we also need love\u2019 \u2013 to people on the streets. It brought her into confrontation, and then \u2018a critical dialogue\u2019, with the police \u2013 but it also brought progress. Denmark now has five heroin clinics and has had drug consumption rooms since 2012, all with vein scanners. \u2018You can get so well within a month,\u2019 she said, adding, \u2018We can\u2019t have a situation where people choose between HIV and a penalty.\u2019 Sue McCutcheon is all too familiar with these issues \u2013 and the gap between poor engagement with services and the potential for radically improved health. Working as a nurse with the Homeless Primary Care Team in Birmingham, she looks for the substance users who need help but are not coming forward. Her job is about \u2018taking the service out to them, so they have healthcare\u2019, working for four hours a day on the street. Sue McCutcheon: 'Imagine managing illness when you are homeless on the street.' \u2018Rough sleepers generally have multiple healthcare concerns,\u2019 she said, \u2018and many present late in the pattern of illness. Health concerns will have gone on for weeks and months, until it becomes a health emergency.\u2019 Many will have had a history of very poor engagement with services and poor care or treatment, which often colour the way they use services. Homeless people suffered the same illnesses and challenging conditions as the rest of us, she pointed out. \u2018But imagine managing diabetes when you are homeless on the street, dependent on soup kitchens and without benefits.\u2019 Within the last 18 months she had noticed skin lesions that looked like impetigo. When swabbed they turned out to be group A strep, potentially serious for those whose immune systems are poor, and PHE Birmingham confirmed there had been outbreaks. Sharing spliffs and bottles and sleeping next to someone infected made such conditions easy to spread and hard to contain, but information in drop-in centres and \u2018simple things like hand washing and hand gels in hostels\u2019 were effective in stopping the spread of disease. Another simple and effective measure had been the widespread introduction of take-home naloxone, equipping people with the skills to manage resuscitation from overdose and minimise harm. \u2018I can\u2019t talk about homelessness without talking about NPS,\u2019 she added. \u2018In Birmingham, it\u2019s \u201cmamba\u201d \u2013 what we\u2019ve seen in the last six to 12 months is shocking. One day last week we dealt with four people who were unconscious, vomit in their mouth.\u2019 Others suffered cardiac arrest in the street. \u2018And people say, \u201cit\u2019s just mamba\u201d.\u2019 Most people that McCutcheon saw and supported were groin or neck injectors \u2013 people who tended to say \u2018I\u2019m alright\u2019 when they weren\u2019t. \u2018It\u2019s your role to make sure they\u2019re alright,\u2019 she said. \u2018It\u2019s about being vigilant around healthcare issues.\u2019 The reality for many was grim, living and using out in the cold, surrounded by faeces and vomit. \u2018We have to look at all possible options to make a difference, including consumption rooms,\u2019 she said. \u2018I have a duty as a nurse to minimise harm. We need to look at every option that might produce a better outcome for people. It\u2019s about building relationships\u2026 finding ways to deliver healthcare.\u2019 Does language matter? Different perspectives drew a very visible line between language and stigma. Speakers at Hit Hot Topics covered many areas of harm reduction, drug use and outreach, and their experience came from different countries and contexts. But there was a common theme that ran through each of their talks \u2013 the \u2018dehumanising language\u2019 that perpetuated stigma. Professor Susanne MacGregor of the London School of Hygiene and Tropical Medicine charted 30 years of drug interventions. Throughout \u2018many contextual changes, during which harm reduction has had to struggle\u2019, language had been adapted and new terms introduced. The New Labour era, \u2018tough on crime and the causes of crime\u2019, gave way to \u2018the language of recovery\u2019. Gaps grew between those who provided services and the people that used them. \u2018Let\u2019s stop using derogatory descriptions of people and move to a society where rights and evidence prevail,\u2019 said Naomi Burke-Shyne, Harm Reduction International\u2019s deputy director, in her talk about the oppressive impact of drug policy on science. \u2018We can\u2019t afford to abandon evidence, and language is a big part of that,\u2019 she said. \u2018We can\u2019t use stigmatising language. Let\u2019s stop talking about abuse \u2013 it implies all use is abuse.\u2019 There were words that were formerly used about the LGBT community that were \u2018unspeakable today\u2019, she pointed out, adding \u2018we need to move the same way\u2019. Prof Craig Reinarman of the University of California talked about drug policy reform and the \u2018slow motion shift\u2019 in the way we think about people who use drugs. Back in the 1980s, as initiatives spread from Liverpool like a \u2018crack in the stone wall of punitive prohibition\u2019, the very words harm reduction were \u2018blasphemy, giving the stamp of control to addiction\u2019. Similarly, in the US, scientists \u2018couldn\u2019t even use harm reduction in the title of a paper\u2019 for it to be accepted. Drug terminology became the language of fear: \u2018Crack cocaine is the principle cause of urban ghettos\u2019, President Reagan\u2019s drug czar William Bennett had said in the 1980s. Even now, 40 years later, discussions take place \u2018in a different register\u2019 for different parts of the population. White people find treatment beds waiting, not prison cells, said Reinarman. Delon Human of Health Diplomats, Switzerland, found dialogue missing where tobacco harm reduction was concerned. Of the earth\u2019s 7bn population, 1.4bn were smokers and one out of two smokers would have a condition that would limit their life. In the UK e-cigs were resulting in the number of smokers being \u2018the lowest it\u2019s ever been\u2019, with the \u2018biggest gains in the shortest time\u2019, yet public health seemed unwilling to talk frankly about the benefits. \u2018We can all accept seatbelts, but for some reason they\u2019re not accepted in drugs and alcohol,\u2019 he said. \u2018We need to find new language to frame the debate\u2019. Stephen Malloy of the European Network of People Who Use Drugs (EuroNPUD) called for plain language to galvanise the pace of a harm reduction response to drugs such as fentanyl, whose dangers were well known and documented. This was an example of direct action needing to be accompanied by straight talking, he said, quoting the Canadian activists\u2019 slogan \u2018they talk, we die\u2019. For Patriic Gayle of the Gay Men\u2019s Health Collective, harm reduction was being compromised because the conversation between gay men and drug workers was \u2018conspicuous by its absence\u2019. Back in the \u201980s, the LGBT community and substance misuse field came together to make sure Aids campaigning was as hard-hitting as it could be, but the dialogue had disappeared. Gay men \u2018need to be engaged and wooed a bit to trust services,\u2019 he said, and his organisation had had to resort to distributing resources and information that spoke honestly and openly to peers. In a similar context, Joseph Kean, visiting research fellow at LJMU, looked at the language and culture of image and performance enhancing drugs (IPEDs) and asked, do we have relatable ways of reaching the \u2018massively underestimated\u2019 70,000 people using these drugs? DrugWise\u2019s director Harry Shapiro felt that disconnection was abetted by the terminology we chose, and that drug workers must take a share of responsibility for perpetuating stigma through using \u2018a language of hate\u2019, which made people who use drugs feel \u2018expendable\u2019. \u2018It resides within the community and the drug sector to challenge it,\u2019 he said. \u2018I don\u2019t use addict, clean, drug abuse or misuse.\u2019 Teaching a university course on personal and professional development, Dr Jennifer Randall had had the opportunity of exploring the triggers to attitude change. Introducing students to the Support, Don\u2019t Punish campaign, she witnessed how they embraced a Gabor Mat\u00e9 approach \u2013 \u2018think of people with love\u2019 and had insight into creating the right language to change culture. Using Dr Carl Hart\u2019s book, High Price, she encouraged \u2018slow critical conversations\u2019 that were effective in changing students\u2019 attitudes and preconceptions. The final speaker, Emma Roberts, demonstrated the value of making grassroots user-led initiatives the mouthpiece, putting them at the forefront of commissioning and capacity building. Through describing her work with the Harm Reduction Coalition in the US, she explained that the voice of people who used drugs was vital, not just in leading advocacy, but in choosing the right language and setting the tone. Working with different drug user alliances she was able to challenge stigma and redefine recovery, demonstrating that \u2018it is not the opposite of harm reduction\u2019, but all part of the same necessary conversation.