This presentation was delivered to the National Conference on Injecting Drug Use (and later to the Irish Drugs Conference), the focus is why injectors may often ‘choose’ to share even knowing that this is a risk factor for BBVs.
Author: Nigel Brunsdon
A large part of harm reduction work is discussing sharing issues with people who use drugs. Of course this is mainly focused around stopping sharing behaviours. But shouldn’t we be finding out why someone shares first?
Why do people share
Because it’s normal to share… Think back to childhood, your mom always told you “you should share nicely”, Facebook asks you to share articles and photos, in fact in almost every aspect of life sharing is seen as positive. Wikipedia even says:
So, think about it, telling people they shouldn’t share goes against every part of social learning they’ve had. And that’s just the start…
It’s who people share with that decides the reasons
Think about all the possible people someone shares with:
- Many, many more
Each has different possible reasons, for instance in a long term relationship where people are living together sharing food, bed and money, then sharing is just another aspect of life that shows how close you are. However in the same relationship the sharing can also be linked in with someone being injected by another as a form of control (eg “you can’t get yourself so you need me around”).
When someone shares with dealers of course there is a totally new set of pressures. When I was delivering a workshop a couple of years ago one young crack pipe user told me that they didn’t think they’d last long if they refused to share a pipe with a Yardie just in case he had HepC. And this is of course a fair point, part of our role as health educators and harm reduction workers is to equip people with refusal skills for this kind of scenario.
Trust is the big issue
One thing is clear, one of the biggest reasons people share is due to trust issues like the young guy had about Yardies or people have in day to day relationships.
Even when it comes to sharing with strangers it may be that people are fostering new trust relationships that increase their social capital. If I have a needle that I’ve only used once and someone I don’t know wants to use it then they’ll be more likely to do something for me when I need it.
Not “do you share” but “why do you share”
Its clear that just asking people ‘Have you shared in the last 4 weeks’ (standard information required by the NTA in the UK) doesn’t even get people started on addressing the issues around sharing, we need to be talking to people more about the reasons for peoples sharing behaviours rather than blindly focusing on telling people to stop.
We talk to people a lot about how they inject, what they inject and where on their body they inject it.
But how often do we talk to people about their injecting environment? And the effect this has on both their injecting risks and their perception of drug use.
We’ve seen from the previous articles by Dr. Stephen Parkin on ‘Blue Lights‘ and ‘Displacement of Public Injecting‘ that where someone chooses to inject can have a real effect on risk. But how often is this missed out on at the assessment stage? In fact think back over the recent conversations you’ve had with any injectors, has the discussion ever got to the stage where you’ve talked about environment? Different environments of course have different risk factors, here are some examples:
Although they can offer a level of security for people who are homeless these can be quite high risk sites.
- Water sources are normally in public areas, so fear of discovery often stops people accessing them, instead choosing to use water from the toilet cistern.
- There are many public toilets installing blue lights to discourage injectors, however rather than discouraging injecting these lights instead make people move to the higher risk sites like the groin which don’t require seeing the vein.
- The main issue is though that most people injecting in public toilets are likely to be lone injectors, and because of the environment they will have locked themselves into a cubicle with little or no chance of being discovered if they overdose.
This would include areas like alleys, car parks and waste ground.
- Again there is an issue with clean water sources in this kind of environment, both for handwashing and preparation water.
- The fear of discovery can push people to using higher risk factor injecting sites like the groin.
- Poor lighting in outdoor injecting environments can also stop people accessing visible veins on arms and make them move to sites like the groin.
- Preparation of injectable drugs can be a problem in outside areas due to the lack of stable, clean surfaces as well as problems caused by wind and rain.
Communal injecting spaces
By this I of course don’t mean safer injecting sites like the ones provided at services like Insite, but instead the kind all over the country (and around the world) with people who inject grouping together in a shared environment for the perceived safety and community it offers.
- A major risk here is of course either deliberate or accidental sharing of equipment and preparation surfaces. This can lead to increased chances of contacting blood borne viruses, and have also been identified as increasing the risks of contracting tuberculosis.
- Increased chance of vulnerable people being physically or financially abused, this kind of environment is often ‘managed’ in some way often by the home owner and the perceived safety offered normally comes at a price, either financially or with ‘payment in kind’. (Although this isn’t always the case it is an aspect that needs to be discussed.)
Injecting at home
Although at first this may seem one of the lowest risk environments it can in fact have all the risk factors above …. and more. Some things to consider are:
- Do the people living with the injector know about the drug use? If not this can lead to hidden, rushed injecting that can often be in higher risk sites like the groin.
- Does the person inject alone with the awareness of partner (to be away from children etc) if so how long would they be left after an overdose before someone checks on them?
Do they share with a partner, and do they even see this as sharing?
How are they storing their drugs and injecting equipment if there are children in the home?
This is just a short article and it’s only meant to cover the basic of a few locations people inject in, there are far more that will come up but first you have to actually start the conversation with people to raise the issue.
Urban environments provide numerous concealed settings that may be used on a regular and frequent basis for the injection of illicit drugs. In addition to general public amenity (car parks, stairwells, toilets) these places may include derelict buildings, marginal wasteland and squats. Each of these latter examples may be typically used and frequented almost exclusively by injecting drug users who may consider such places as providing temporary safety and sufficient privacy to administer drugs without detection/interruption. When such places are made known to the relevant authorities they are typically subject to some form of sanction (closure, eviction, demolition, clearance, blocked, screened and/or fenced) that prevents further access.
However, such reactive responses may be criticised for failing to consider the needs and rationale of those frequenting such places and the physical consequences of such punitive action. One such outcome is that public injecting continues to take place beyond the site of closure and possibly in yet more marginalised, more concealed and more claustrophobic, unhygienic conditions. Further, those injecting in such places are typically some of our most vulnerable members of society experiencing a wide range of social problems and dependency issues, and consequently have to ‘seek out’ alternative injecting sites. To make matters more complicated, the state’s left hand provides the means to inject (via needle and syringe programmes) whilst the heavy right hand smashes the street-based settings of public injecting (via clearance etc). As such, harm reduction intervention is problematised and made more difficult for vulnerable people to actually apply.
There is perhaps a need to further consider the way in which such concealed sites of injecting are more appropriately ‘managed’ by authorities; in a manner that considers both public health of the community concerned and the individual health concerns of affected injecting drug users. One such consideration may involve a complementary, proactive response to the inevitable reactive response of closure and sanction? For example, following the imminent closure of a given location used for injecting purposes, the following procedures may be considered as exemplars to reduce the harmful effects caused by and/or associated with displacement:
- An organised and structured multi-agency response that is led by the body responsible for the closure/demolition of a given location. This response would focus upon the wider health concerns of injecting drug users as well as consider the immediate health/social concerns of the local population.
- Contact with local Needle and Syringe Programmes (NSP) and/or Harm Reduction Practitioners to notify relevant others of the proposed/imminent closure procedures.
Harm Reduction Practitioners could then disseminate this information to service users – verbally or with an appropriate leaflet. For example:
(Name of site) is now closed. Don’t go there – find somewhere safer. You may be subject to arrest for trespass as the site has been served a clearance order’.
- The above information would provide informed choice, aim to protect liberty (of those possibly involved in the criminal justice system) and essentially encourage service users to seek more suitable, safer injecting locations.
- Prior to immediate closure/demolition, (and where possible) drug related litter bins could be positioned inside, outside and adjacent the relevant settings. This would encourage safer discarding amongst those individuals more determined to access the setting following closure (and possibly less concerned about their liberty in their prioritisation of injecting needs). Such bins should not be regarded as ‘encouraging drug use’ (as injecting pre-existed their presence) and would need to be cleared/emptied on a frequent basis.
- At the risk of appearing to promote the ‘Big Society’ model of ’empowerment’ as advocated by the current UK Coalition government, community residents could play a role in promoting community safety. For example, community activists could provide a rapid response notification role (to police, local authorities or ‘other’) of any injecting sites that may emerge in adjacent settings following the closure of such sites. These may include alleys, parks, gardens, doorways. This aspect of participation would not aim to ‘penalise’, but instead, ‘protect’; in which residents inform authorities who in turn inform practitioners who then respond accordingly (notifying/informing/advising service users). Indeed, a ‘protective chain of socially orientated harm reduction’ may emerge.
There is nothing radical or subversive in any of these suggestions. Each suggestion listed above currently exists as standard practice within existing local policy and procedures with regard to other issues (which may/not be drug-related). Instead, these suggestions have been ‘resituated’ within the context of public injecting in which the needs of vulnerable people and the potentially harmful effects of displacement have been more ‘considered’.
New research being presented this week at the International AIDS Conference in Vienna has made a strong link between different types of syringe and levels of HIV transmission through sharing.
Every needle-syringe, when the plunger is fully depressed, retains some fluid or blood in what is termed “dead-space”. Some syringe designs have more of this “dead space” than others – especially those with detachable needles (see the diagram below). Depending on the design, some syringes can retain 84 micro-litres of fluid. This is a very, very small amount – but other syringe designs can retain as little as 2 micro-litres.
So the hypothesis is simple: if you share a syringe with higher “dead-space”, then there will be more blood retained in the syringe and you will be more likely to become infected with blood-borne viruses. If you share a low “dead space” syringe, you are still putting yourself at risk – but perhaps less so, as there is less blood retained when the plunger is fully down.
Previous modelling work by Dr William Zule and colleagues in the USA tried to quantify what this could mean in the real world. The results suggested that injection-related HIV epidemics might not occur when most (95% or more) of injectors use syringes with low “dead space”. If everyone uses higher “dead space” syringes, then HIV prevalence can reach 50% among injectors in just seventeen years. When just one in ten sharing events involve high “dead space” syringes, then HIV prevalence can stabilise.
The findings, albeit theoretical, have clear implications for harm reduction programs. However, in Vienna, the research has been taken to the next level. Data from multi-year HIV prevalence studies were gathered from 35 cities in 20 countries, and local needle exchange workers were contacted to find out what types of syringe were mainly used.
In cities where high “dead space” syringes were mainly used, the average HIV prevalence among injectors was 32.6% (and went up as high as 73%). In cities where low “dead space” syringes were mainly used, the average was just 1.4%. When the data were analysed, the type of syringe was the only factor closely associated with this pattern in HIV.
More research needs to be done on this topic, and expect to hear a lot more about this in the future – this is an important finding which could have a big impact on harm reduction and the advice given to injectors. Of course, the biggest message is that ALL needle-syringe sharing is a risk. However, if we could reduce HIV transmission simply by providing one kind of syringe over another, then this is something that must be rolled out as soon as possible. Do you know what kind of syringe your local exchange supplies?
A big thank you to Dr William Zule for sharing this research.
It’s not often you get some totally new equipment in a needle programme and the last thing I expected people to be innovative with was a sharps bin. The new bin from Exchange Supplies is something which could change whole aspects of the way we work with used injecting equipment, not to mention the fact it is (in my opinion at least) a better bin from the point of view of people who inject.
Real innovation is a very rare thing. Even back when Exchange Supplies introduced the Nevershare syringe in response to the findings from Avril Taylor’s study, it was still really ‘just a syringe’ (with a wonderfully thin needle, a detachable end and available in multiple colours to discourage accidental sharing). Or when Frontier released the Filter Syringe; again it’s still basically ‘just a syringe’ (with a great filter built into the cap). So really in both cases it was innovation, but still done by only slightly adapting what is already around.
As most people reading this blog will already know, existing sharps bins are all variations on a theme. Basically a big lockable container for putting all the equipment in, the same as in a hospital setting (in some cases it’s exactly the same bin). Granted some companies have tried to make them more fit for purpose but this is often by either:
- Making the bins slightly smaller to fit in a pocket
- Adding a clear section so paranoid drug services can ‘police’ the contents (I have real issues with the whole concept of clear sided bins)
The new bin
Exchange have done something very few companies do though; they’ve gone back to a totally clean piece of paper and designed something original. In doing this they’ve looked at what is actually ‘needed’, which is of course:
- Something to keep the ‘dangerous sharp’ safely away from the public
- Something lockable (to prevent reuse)
- Portable enough for people to keep with them without it being obvious (even in summer)
The bin they’ve come up with is very small, in fact its only about 1cm high and the whole thing fits in the palm of your hand.
As you can see from the images, this bin works with the Nevershare syringe’s removable end and has enough capacity to hold 21 ends. All you have to do is push the end into the bin, click it off and then turn the unit around to the next hole. Of course this means (at least until a version that fits standard loose ends is available) that you’d have to use the Nevershare, but as it’s one of the best syringe sets for people who inject that’s no bad thing.
What about the rest of the syringe
That’s the genius part. The rest of the equipment can just be put in with your normal household waste, it’s not a ‘sharp’ anymore. Yes it may still have blood in, but so does the tissue from the last nosebleed you had, at the end of the day it’s a bit of plastic with a little blood in it.
Drug related litter
OK lets be totally honest though, the rest of the litter is still an issue. Even without a sharp on the end of it an inappropriately discarded syringe will still scare a member of the public. But the kind of person who disposes of needles in public areas was never going to use an old style bin anyway. This new more convenient smaller bin may at least make then take off the end.
We still need to continue promoting good disposal habits to injectors to avoid community fear and anger. After all, that anger gets directed at all injectors even the ones who take great care to safely dispose of their kit.
We also need to educate street cleaners to become aware that, although they still need to report discarded barrels, a distinction can be made between a syringe with a sharp and one without.
The new bins only cost 44p each when you buy 100 of them, which for a bin that holds 21 ends is great. But the other cost to think of is that of disposal. Drug services have to pay for disposal based on volume, with these bins being so small they will be far cheaper to get rid of.
These bins have the potential to change lots of aspects of NSP work and injecting, of course they are not a perfect solution but they do address some big issues. (Workers, ask yourself, would you carry around a standard sharps bin with you in summer?)
It’s a standard question on most assessments in drug services, asked in lots of different ways. “How often do you inject?”, “Number of injections per day?” etc. But, why ask it? And how would a worker react if someone was really honest about the answer?
Why ask it
In some ways we ask because it’s taken as being a marker of how severe someone’s drug habit may be. For instance, someone who injects twice a day is clearly better off than someone who says they inject four times a day. Good NSP workers may also use it as a discussion point for harm reduction interventions like vein care, blood borne virus (BBV) interventions, or talking to people about the amount of equipment they need.
But sadly the usual situation is that very little is done with information once it’s given other than adding a number to a page.
Average injections per day
The average number is thought (in the UK) to be around three per day, at least that’s what we’re told… but is this really the case?
Estimates put the amount of time between someone’s first initiation into injecting to the first time they attend an NSP at around the 2 year mark. By this time there is often significant damage done by poor injecting technique (flushing, not avoiding valves etc), and this has an effect on how successful someone’s injecting may be.
I was talking to one young injector a week or so ago who told me that on a good day it ‘only’ takes him 4 or 5 attempts to inject, another person I spoke to recently said it can sometimes be 2 hours of trying before they get a vein, and in their frustration they often just ‘skin pop’ it (we calculated that they would have pierced the skin up to 60 times in those 2 hours). In both these cases the person had initially stated they inject four times a day.
This is obviously a major issue to the person injecting as the damage from even just the blunting of the needle will help to accelerate vein damage leading to collapse. You also have to take into account that because of the time being taken there is an issue of blood clotting in the needle, both people mentioned above also talked about re-filtering the solution to get rid of these clots, but some people just inject them which can lead to problems like pulmonary embolism.
We have to increase worker and service awareness of this issue, it’s no good just having “Injections per day” on an assessment, we need to delve deeper. I’m currently writing a new assessment tool which asks “Number of successful injections per day” as well as “Average number of attempts per injection”
But how can we better raise awareness, the obvious answer is better staff training, but for me it’s about better communication between the worker and person injecting. If you’re a worker it’s your duty to be asking about his stuff, and even more importantly if you are an injector you need to be telling the workers at the NSP what the real situation is. It’s no good just letting them carry on believing that you just inject three times a day if you are stabbing yourself with a needle 20 to 30 times a day.
How can we use this
The good news is that from a workers point of view this is a great opportunity for talking about route transitions, after all if someone is spending a frustrating hour trying to find a vein, jabbing this often, and having to re-filter the drug repeatedly, they would have been far better off just to smoke it on the foil in the first place.
Even if it’s only for one of their ‘4’ injections a day.
Blunt needle image taken from the Sharp Needle Blunt Needle card by Exchange Supplies.
In this article, I would like to draw attention to and comment on the potential problems caused by fluorescent blue lights upon the health of injecting drug users.
These lights are perhaps commonplace in many towns and cities throughout the UK (and beyond) and are typically found in public conveniences in settings such as shopping centres/mall, travel stations, cinemas and other socially oriented venues. As many reading this will already be aware these lights have usually been installed with the express purpose of preventing injecting drug use from taking place therein (regardless of any history of such activity) and are considered as a measure for removing the public amenity they provide to injecting drug users by denying access to the temporary sanitation, privacy and semi-protective environments they afford. This is achieved by the electric blue illumination emitted from the lights that problematise vision of all attending such toilets and consequently make the visibility of veins more difficult for injecting drug users (IDU).
However, as many may be less aware, public toilets may provide temporary respite for those experiencing unstable accommodation, long term drug dependency and an urgent need to self-medicate withdrawal symptoms. Accordingly, from a harm reduction perspective, those conveniences fitted with blue lights may be considered as a deliberate attempt to exclude individuals from attending to their immediate health (and hygiene) requirements.
Similarly, during the course of my travels throughout the UK, I have become increasingly aware of limited knowledge amongst the public how these lights are designed to disperse injecting drug users. There is typically recognition that the lights are somehow connected to ‘druggies’ or ‘drugs’ but seemingly little awareness of the way in which they restrict vision of physical injecting sights (i.e. veins).
This is not the case amongst those involved in harm reduction services and especially so amongst service users of needle/syringe programmes. Indeed, there is perhaps widespread acknowledgement amongst both service providers/users regarding the function and design of such lighting.
However, even within these ‘risk-aware’ populations there may also be limited understanding of the way in which IDU may respond to facilities equipped with such lights. In my work on public settings used by IDU, I have considered these particular environments and obtained views and experiences of 31 individuals with knowledge and experience of such settings in one particular UK city. Of these 31 IDU, only 13 stated that blue lights would deter access to such toilets – because they were concerned that they could not see their veins. The majority however (18/31) were not deterred, or only partially deterred, and described various strategies to counter the problematising effect of the blue light intervention. These included:
- Injecting in particular body sites considered more dangerous (eg groin)
- Requesting peer assistance with injection
- Pre-preparing solutes prior to visiting (and complete the process within such toilets)
One individual stated that this was specifically a preferred setting because it was a place where authorities would not expect injecting to take place (and thus felt ‘safer’ from detection and interruption).
It is also interesting to note that those less deterred by blue lights were also IDU with longer injecting careers (typically over 10 years) and felt that they could inject ‘blindfolded’ regardless of the actual environment in which they were placed. This is therefore a ‘skill’ that has been developed as a result of sustained injecting episodes and is skill that can be employed in settings that are designed to minimise, and distort sight and vision. As such, the use of settings equipped with blue lights may be considered as environments that increase particular forms of injecting-related risk taking and those taking such risks are perhaps amplifying the potential for harm and hazard to occur during such episodes.
My stance on these lights are that they are a public health/community safety nuisance – as they not only affect IDU – but also make such public conveniences for all visitors an unpleasant and uncomfortable experience especially for:
- People with epilepsy (or sensitive to strobe-like lighting)
- Those that may be physically disabled
- The elderly and the infirm
- People who already have impaired vision
From a harm reduction perspective, they are perhaps slightly more sinister! In a society that considers itself equitable, ‘fair for all’ and sensitive to the needs of vulnerability, why such lighting that purposefully discriminates and promotes health inequality amongst marginalised populations is considered ‘legitimate’ confounds me. Such lighting also serves to disrupt the harm reduction intervention provided by NSP in simultaneously establishing particular ‘no-go’ and ‘high-risk’ areas for service users that may be experiencing socio-economic hardship and exclusion. That is, in the context of injecting drug use, blue light areas purposely create ‘disabling’ and ‘risk-taking’ environments, and this may be consolidated by the view that they are not necessarily effective amongst longer-term injectors. A more cynical (or possibly sociological) way of considering these lights is to equate them with garlic and holy water! That is, they are perhaps a curious 20th /21st century talisman designed to keep the ‘vampire’ from crossing your door – a way of maintaining social division and keeping the ‘unacceptable/unclean’ body from the more (self-proclaimed) righteous!
*Apologies to Paul Weller and The Style Council for such a shameful mis-appropriation of this song title.
Steroid use and the use of other performance & image enhancing drugs (PIEDs) have been on the rise in the UK for a number of years now. We even have services reporting that over 50% of new injectors visiting their needle programmes come from these groups.
But in most services workers are being given very little guidance on the types of advice they should give, and most paperwork used is the standard paperwork that is used for opiate injectors. This has resulted in both steroid users and workers having very little confidence in the quality of the harm reduction advice being given.
To help try and address this I’ve developed a PIED assessment tool.
This tool has already been trailed in a busy needle programme that has a high proportion of steroid use, and both workers and injectors have said how much of an improvement it is to have an assessment written specifically for PIED use. (Please note that as well as this tool I have also developed a PIED Outcomes Tool, have a look at both and see which one you think fits your service better).
What’s in it
As with all downloads on Injecting Advice.com this assessment comes with extensive worker guidance notes that help you understand how it should be completed and what associated advice you should think of giving.
The main categories in the assessment are:
- Cycle details
- Goals of use
- Diet & exercise
- Injecting sites & physical health
- Disposal & storage
- Side effects
- Vaccination & testing
- Other substance use
As well as the assessment itself there is also a steroid specific case note sheet for each time someone visits to allow you to work well with changing goals and use. I’ve also included links though to more resources that workers will find of help when working with this group.
This assessment has taken months of work and testing to develop so I’m really looking forward to hearing what people think of it. If you have comments or even if you are just thinking of using it in your service please let me know.
I’ve talked before about the importance of coming up with new and novel ways of giving people advice. But his idea came from a conversation I was having with a co-worker.
Like most ideas I get this is a relatively simple solution to a problem.
Emma, one of my co-workers, was talking to me about someone she’d just completed an assessment on. He hit all the alarm bells for overdose, he injected, he used benzos, he drank, he occasionally used crack etc etc.
But she said that when she raised the issue of overdose with him he was adamant that it wasn’t a problem because he’s used for years and never overdosed.
This is of course something that happens for most people working with people who live with risk. You’ll get someone who feels that they are immune to those risks because they haven’t directly experienced the related problem. In fact it’s not just with drug use, think about the amount of people who drive fast cars without seatbelts, or who never use a condom. People tend to feel they are immortal, especially when they are younger.
A possible solution
My first thought when Emma was talking was that it may be pure chance rather than good judgement that has stopped him overdosing so far. The chance aspect of this made me think of gambling and the phrase “a crapshoot”.
So, I suggested one idea would be to carry a pair of dice around and the next time someone says this kind of thing ask them to role the dice, then roll them again, (and keep doing this for as long as you think you can get away with) then point out that the person hasn’t rolled a double six yet. So, by their own logic they’ll never roll a double six. (if they have rolled a double six, you can of course make it a double one etc).
Back it up
It’s important when you’re using this kind of ‘flippant approach’ to be able to back it up with real facts:
- Make yourself aware of the number of overdoses that year in your neighbourhood
- Use risk awareness tools like the ‘Know your score’ from my Overdose Workshop
- Remember that the annual mortality rate of people using heroin in the UK is between 1% and 2% per year
We now keep a pair of dice in the NSP.