Skip to main content

Author: Nigel Brunsdon

It’s Not What You Say, But Why

I’ve got aTED conference talk for you today, this one is with Simon Sinek talking about “How great leaders inspire action”.

I watched this for the first time a couple of weeks ago and it got me really thinking about how the best drugs workers/activists/services do what they do so well, by communicating effectively.

Watch the TED Talk

Can this translate into advice

If you’re an NSP worker or anyone who spends time supporting people then think about the way you do this. There’s a good chance that the advice you give is heavily focused on ‘What’ people should do, examples would be:

  • Telling people they need to use clean equipment
  • Telling people to not reuse filters
  • Telling people to get tested for blood borne viruses

You might also cover (to a lesser extent) ‘How’ people can do this, examples would be:

  • Suggesting people keep back spare pins for emergencies
  • Keeping all your equipment separate from other peoples when you’re cooking up
  • Checking the angle of injection and orientation of the needle

But as Simon Sinek talks about in his video we should really think about focusing more on ‘Why’ we think people should do the things we suggest if we want to inspire them to change. Of course this is far more difficult as it moves away from the practicalities that we are used to working with, and into the realm of concepts. This takes more time and requires more skills.

I’m sure some of you are already working in this way (pat yourself on the back, seriously treat yourself), in some cases you might not even have realised that there is a difference, but just think about the workers, trainers, teachers and activists that inspire you. My guess is they’re the kind of ‘leaders’ Sinek is talking about.

Simon Sinek

Simon Sinek is the author of the book ‘Start with Why’ and spends his life trying to teach other people how to become inspiring leaders.

Simon’s Website Watch the TED Talk

Raising a Vein: Slapping & Gravity

This is the third and final part of my raising a vein series of articles, previous ones have covered using warmth and using exercise, now I’m going to cover slapping and using gravity.

Slapping (or not)

You see it all the time in the films and on TV don’t you? Someone can’t get access to a vein so they give the arm a few sharp smacks. You’ll also see it in hospitals and doctors surgeries as well, which is unfortunate because it doesn’t work.

Veins like almost everything else in the body have nerves in them, and so they register pain. If you slap them they react the same way you and I do to pain, they move away from it and contract, making them smaller (OK not exactly the way you and I react, you and I might react by punching someone in the face, but veins lack the hands for this and so they contract.)

So why do some nurses and (especially) doctors still slap? Simple, it’s a learnt behaviour. Not during their training, but afterwards. During training nurses are taught to palpate a vein (more on this in a moment), but shortly after they start working on a ward someone will tell them they should ‘slap’ a vein, and so they do. Don’t think too badly of them for falling into this behaviour, peer education isn’t always a good thing. Just think of the amount of people who still lick needles because the person who showed them how to inject licked his. Nurses and doctors are just like the rest of us, only human.

Main thing is though, don’t slap.

Palpation

Instead of slapping you should gently palpate a vein, here’s how:

  • Find the vein,
  • Put a finger on it and keep the finger on it
  • GENTLY start pressing up and down with a slight bouncing action
  • After about 20-30 seconds you should notice the vein has expanded slightly

Gravity

Gravity if your friend, blood like everything else is affected by gravity (one of the reasons injecting in your feet is higher risk). Try lying on a bed or sofa with the arm you want to inject with hanging down over the side. This should increase the amount of blood in that arm, and as a result the veins will appear bigger.

Another way of using gravity is using centrifugal force. The easiest way to do that is to spin your arm around like a windmill. The force on your arm will mean blood still enters but has problems getting back out.

Try first

With these techniques, and any other ways of raising a vein, it’s important to be confident they’ll work. So try them out when you don’t need to inject, it’s a great way to practice so that when you NEED to use them, you’ll know exactly what you’re doing.

And if you are a member of staff in a needle programme or drug service, and you’ve never injected then you should try them as well. It’s so much easier to explain to people how to raise a vein if you KNOW it works (rather than just having read it on a website).

Related links

Raising a vein: Warmth
Raising a vein: Food and exercise

Raising a Vein: Exercise & Diet

This is the second in a series on strategies to help raise a vein. Last time I talked about the importance of keeping warm when trying to find a vein, this time I’d like to talk about exercise and diet. In my opinion not enough needle programme (NSP) workers or people who inject even consider diet issues something to talk about.

Exercise

Exercise is a great was to increase the size of a vein in the short term, when you exercise the body’s nervous system and brain send out messages that will cause all the veins in a body to contract (vasoconstriction). But the process of exercising also makes the muscles release chemicals that prevent this happening there. The result is that during and just after exercising veins in or near muscle carry more blood and so will be bigger (vasodilatation). Working out in some way will also increase your heart rate getting blood pumping better around your body.

But keeping fit can also help keep veins more visible, as your muscle density increases surface veins are pushed up more towards the surface. But how can someone on very limited resources afford to keep fit and exercise? Here are some tips:

  • Walking/running: This has got to be the cheapest option, going for a walk before you’re due to inject can get your blood pumping more.
  • Sit-ups/push-ups: Are also good free ways to exercise, with push-ups you also get the added bonus of greater muscle density on your arms. With both of these though it’s important to start small to avoid injury. Try doing push-ups from a kneeling position, or even by putting your hands on the wall and leaning in (in classic ‘assume the position’ style).
  • Makeshift equipment: There are plenty of household items that can use used, plastic soda bottles make good weights and so do books. Have a look around and see what you can use.

Recently someone asked me about the issue of liability when suggesting to people they exercise because they had been told not to recommend it in case someone injures themselves. Personally I think we should trust in peoples own ability to look after themselves.

What about diet?

When I was thinking of writing this article it was just going to be on exercise, but something made me wonder about the effect diet can have, here’s what I’ve found so far:

  • Caffeine: Foods and drinks that contain caffeine also normally contain theobromine and theophylline (found in cocoa beans and tea), they act as a stimulant for the heart and widen your blood vessels.
  • Bioflavonoids: Long word that one isn’t it. These are found in berries (mainly red and blue ones), soybeans, and in the white part of citrus fruits (don’t peel your oranges too carefully. Bioflavonoids work with vitamin C and can help strengthen the walls of veins, reduce bruising and prevent haemorrhaging.
  • Hot foods: This one could have been included in with the ‘keep warm’ article, having hot food or drinks raises your body temperature, your body then tries to cool itself down by sending blood away from your torso to your arms and legs.
  • Water: Keeping hydrated is always important, remembering to drink can greatly improve both the way you feel and the ease with which you find a vein.

Summary

Of course, having a good diet and keeping fit is important for everyone for long term health, this is something that I think should be talked about more with injectors.

Related links

Raising a vein: Keeping warm
Raising a vein: Slapping and gravity

Raising a Vein: Warmth

Working with people who inject isn’t just about giving out sterile equipment, you should also be aware of some of the more practical issues faced by people on a daily basis. Of course one of the major ones is getting a vein to inject into in the first place, and being warm makes that easier.

This is the first in a short series of articles aimed at increasing access to veins.

I’ve covered issues around raising a vein before on this site (see my article on the best way to use a tourniquet) but this time I’m going to talk about one of the easiest things you can do to help a vein stand up and say hello.

Warmth is your friend

Heat will help dilate veins (dilation is where a vein gets bigger). Keeping warm before injecting will make them easier to find. Remember it’s just as important to warm your body as it is the area you’re injecting. Here are some suggestions to help:

  • Don’t inject the moment you get home on a cold day, give your body some time to warm up first, this will also mean you’re more relaxed
  • Have a warm bath, it’s a great way to warm up your body quickly. But please have some common sense and GET OUT of the bath before injecting, overdosing is already a risk you don’t want to add 20 gallons of water to the mix
  • Invest in a hot water bottle, and give it a big hug for 10 minutes
  • If you’re homeless get in the warm for a while before you try and inject, good drug projects will be happy to talk to you for awhile. Take advantage of this (and ask them if they’ll let you have a warm drink)
  • If you’re out and about on a cold day make sure you wear lots of layers to keep your core body temperature high. If your body is cold it will keep more blood away from your arms/legs to protect your internal organs from the cold
  • If you need to inject when you’re out and about then you might be able to get ‘heat packs’ from local pharmacies, these stay warm for quite a while. You can even get really good ones that can be ‘refreshed’ in boiling water or a microwave

On that last point; it would be difficult for some people who are homeless to afford heat packs, but given how these can help reduce the amount of vein damage then this is really something we should be considering a standard item in the better NSPs.

Related links

Raising a vein: Food and exercise
Raising a vein: Slapping and gravity

Flushing Causes Damage

Anyone who has spent time with people who inject drugs or seen the footage from Avril Taylors study on injecting drug use will know ‘flushing’ is a major issue. But is it something we often talk about? And how can we make people easily understand the issues when we do?

What is ‘flushing’

When someone is injecting they pull back slightly on the plunger to check they are correctly placed in the vein, this is of course a good thing. However the main word in the above sentence is ‘slightly’ what we see happening in a lot of injectors is pulling back a large quantity of blood into the barrel. This is usually done either at the end of injecting and/or part way though the injection.

Why do people ‘flush’

There are three main reasons that people think flushing is necessary:

  • To repeatedly check that the needle in still in a vein
  • To ‘push’ the drug around the body faster
  • To make sure that all the drug is in the vein

All of this is unnecessary, modern syringes are designed to deliver 100% of the drug they contain. Even if these was a small amount of drug still in the barrel/needle it would be minuscule. Blood is constantly on the move in the body so the ‘pushing’ effect will do nothing at all. I do understand the perceived need to check half way though injecting that you are in the vein, but in reality this will just increase the chances of coming out of it.

What’s the problem with flushing

Every time you pull back on the syringe you’re going to cause the needle to move. Of course this means that the needle may come out of the vein you’re using, but it can also make it strike/scratch the other side of the vein itself. This increases scaring on the vein which in turn speeds up the collapse of the vein.

Another issue is that veins have valves. These valves break the vein down into small sections and when people are pulling back on the plunger these sections of the vein contract slightly again causing the needle to strike/scratch the vein wall.

How to explain this

I personally use many ways to explain this while I’m training or in the NSP eg

Imagine you have a drinking straw and you block up one end while sucking the other, the straw collapses, to some extent this will happen to a vein because of the valves it contains.

I’m also a big fan of the hastily drawn diagram, we even have a whiteboard in the NSP to make it easier. If you draw an image of a a vein with valves, or the build up of scaring leading to collapse it’s easier for people to understand. I think drawing it can even be more useful than having a ready made handout as it makes the intervention more personal and so has a greater impact, although ideally using a sketch to get the point across then a professional leaflet to take away would be ideal.

Complications

Flushing is seen as totally normal and expected by most injectors, so any advice you give will be going up against the advice of people they trust far more than they trust you you.

The risks of damage increase when injecting cocaine/crack because it causes contraction of veins and a has a local aesthetic affect. If someone can’t feel the area they are injecting then they have real problems knowing if they are still in the vein, and so are more likely to want to check. Stimulant injecting is also something that can also lead to more compulsive behaviours and as a result changing flushing habits becomes harder.

But with both these points, just because something is hard to do doesn’t mean we shouldn’t try.

Drug Related Litter: Images that Challenge

As with the discarding of any litter, drug related litter is undoubtedly unsightly, unpleasant, anti-social and a potential hazard to public health (including those involved in clearance, community residents and also individual drug users). However, unlike most other forms of littering, DRL has provoked a number of local, regional and national responses that each aim to minimise needlestick injury (to non-drug users), promote safer communities and encourage appropriate discarding practice by IDU.

Despite his controversial views surrounding substitute prescription and abstinence, I recently found myself applauding and cheering the University of Glasgow’s Professor Neil McKeganey for making the following statement:

…I believe that academia is an honourable profession in which there is a responsibility to raise issues of public concern…

The Scotsman, 25/01/10

In this regard I am in total agreement with Prof. McKeganey. I believe that sociological research is an activity that should, in part, seek to challenge and question established views of issues that may somehow perpetuate inequality, exclusion and/or stigmatisation of minority groups. Qualitative research with injecting drug users (IDU) therefore is an area that provides fertile ground for making such a stance, in which issues of ‘public concern’ may be raised, scrutinised and challenged on a regular basis.

Take the issue of drug-related litter (DRL) in community settings for example; and more specifically discarded injecting equipment. As with the discarding of any litter, DRL is undoubtedly unsightly, unpleasant, anti-social and a potential hazard to public health (including those involved in clearance, community residents and also individual drug users). However, unlike most other forms of littering, DRL has provoked a number of local, regional and national responses that each aim to minimise needlestick injury (to non-drug users), promote safer communities and encourage appropriate discarding practice by IDU. From a more sociological perspective, DRL has also provoked a number of responses that typically inspire fear and loathing within non-IDU populations (of both drugs and drug users); that in turn may justify various sanctions and legitimate continued negative stereotyping of the ‘irresponsible junky addict’.]

My research

During the course of my research into public injecting environments (at the University of Plymouth) I have encountered each and every one of these views and responses to DRL and IDU – by both non-drug users and amongst those that choose to inject illicit drugs. Indeed, the issue of DRL is perhaps one of the most emotional and politically sensitive issues associated with public injecting and associated harms to public health. Similarly, whilst I have encountered countless examples of inappropriately discarded needles and syringes during fieldwork (i.e. used equipment with needles still attached left in places that may injure others), I have also gathered a wide range of qualitative data that may challenge the stereotype of the reckless, anti-social public injector. That is not to say I believe all public injectors are conscientious individuals and are not involved in contributing towards DRL (my research would contradict this!). However I am of the opinion that some public injectors are involved in what may be best described as a street-based harm reduction practice, which serves to minimise risk and hazard to others that may access sites of public injecting.

This latter finding is based upon my study of public injecting environments in which I have visited over 70 sites frequented by IDU for the purposes of drug administration in the local setting; interviewed IDU/non-IDU about their experiences in these settings and collected video / photographic data from within these public and semi-public venues.

syringe in treeDuring interviews with 31 IDU it became (curiously) apparent that none of these individuals were currently involved in any form of reckless or inappropriate discarding. Instead, each described the use of portable sharps containers (from needle exchanges or improvisations such as drink containers); or discarding in situ after snapping off the needle or plunging the syringe barrel into soft surfaces (such as soil) and/or dropping equipment into drains or conventional street-based litter bins.

Furthermore, all concerned were of the belief that most of these strategies were not entirely appropriate, but were adamant that they were genuine attempts to minimise other peoples’ contact with discarded sharps and equipment in relevant settings. Despite this range of views denying participation in any ‘harmful’ littering, I was initially very sceptical of this socially responsible behaviour being described to me during all interviews. In fact, I was convinced that this was an example of the ‘interviewer effect’ in which research respondents attempt to portray a more positive self image of themselves regarding involvement in potentially sensitive issues. However, my visual data (photos and video) of DRL gathered during 18 months of fieldwork provided grounds to reconsider these suspicions and actually validated IDU claims regarding their reported disposal strategies in some settings.

During my visits to those places used, and attended almost exclusively (i.e. hidden places, not known or frequented by the public), by local IDU, there was typically large amounts of DRL present. These were typically places used by numerous IDU throughout the day and night. This provided opportunities to build a substantial database of DRL images that could be subsequently categorised into examples of both irresponsible and responsible discarding practice. Whilst the former is perhaps well established, there is no need to include images of potentially harmful, discarded, equipment. What is perhaps more interesting, more challenging and more provocative are those images that may provide validation of IDU responses initially considered to be biased or influenced by the presence of an interviewer (i.e. those that support IDU claims regarding ‘safer’ discarding practices).

Example

syringe in treeThis photograph clearly shows 5 sets of discarded equipment taken in an outdoor setting that ‘was used on a daily basis by IDU (at a site of which many of the interview sample had direct experience). This particular site was used almost exclusively by drug users and was not a location frequented or attended by members of the general public. What is perhaps most noteworthy about this image is the almost regimental manner in which the 5 items have been placed onto and into the earth. From this image one could assume at least 5 injecting episodes have taken place at this particular spot, and each episode would almost certainly have not involved the same individual due to the frequency with which the site was used. As such, it is feasible to infer that more than one person had injected at this spot and the equipment had been carefully positioned (rather than thrown aside in a random, haphazard manner) in an attempt to maintain some degree of ‘safety’ within this public injecting setting. Further inspection of this image reveals other significant and relevant features of outdoor injecting; features that further illustrate and reflect the interview responses summarised above. Of the insulin syringes pictured, those numbered 1-4 have had the fixed needle removed from the syringe barrel, whereas Syringe 5 is partially submerged into the soil. This image (and others like it) would appear to provide a forensic resource of injecting behaviour previously described by respondents, in which attempts to ‘make safe’ used, discarded equipment may be visualised’ (Parkin and Coomber, 2009; 27-28).

Furthermore, this photograph is not unique and there are many others showing equally ‘neutralised syringes’; others that have been unearthed or placed ‘pin-first’ into surfaces (such as soil, trees), within nearby items (boxes, discarded boots) and/or placed out of reach of unsuspecting hands (on ledges, behind grills, in plant boxes) and on surfaces above eye-level. Whereas, from a non-IDU perspective, each of these strategies may be considered anti-social and/or dangerous, when viewed from an alternative (IDU) perspective a ‘practical logic’ emerges that perhaps prioritises harm reduction within public injecting settings. That is, the application of a limited street based harm reduction by IDU within outdoor settings that does attempt to discard in a manner that is thoughtful and without malice. Whilst this form of harm reduction is not perfect, it should also be contextualised in the social and political circumstances that surround public injecting.

That is, a wide range of explanations were provided regarding the rationale for such alternative forms of ‘littering’ and these typically related to homelessness, hostel residency (that often prohibit paraphernalia possession), involvement in sex work, ‘grafting’, avoiding police searches and a need to evade interruption and/or detection by the public/police/employees when injecting in public settings (i.e. a need to ‘hit and run’). All of which runs parallel with health issues relating to drug dependency and/or avoiding withdrawal symptoms.

Another contributory factor to DRL discarding related to the nature of needle/syringe distribution from community pharmacies. In the present setting this pack typically contained equipment for 10 injections; however, more often than not (and given the unstable lifestyle of my mainly homeless sample) there was only the immediate need for one set of works. As such, the unused equipment was equally discarded as the remaining 9 sets were surplus to immediate need (and considered by IDU as legitimate reasons to justify stop and search by local police).

As I said, I consider academia to be a valid vehicle for questioning prejudice and stigma. I hope I have provided food for thought with this piece that seeks to present an account of images that challenge.

Related links

The DEFRA page containing guidance on drug related litter.
Previous Injecting Advice on increasing returns.

NSPs in a Recovery Orientated System

The UK is moving inexorably towards recovery-orientated treatment for drug and alcohol problems. In February 2010, the National Treatment Agency affirmed its commitment to developing recovery-orientated treatment systems in England, and recently published a twenty-page “Commissioning for Recovery” guide for service commissioners and joint commissioning groups, exemplifying the NTA’s re-visioning of the 2008 drugs strategy within the conceptual idiom of recovery. This is a welcome response to the diverse grass-roots, academic, and political critiques of the UK’s provision.

There can be no question that recovery is now a fixture of mainstream discourse and is set to become a defining and instrumental feature of the policy and treatment landscape in the UK.

Whilst there is absolutely no suggestion that Needle & Syringe Programmes (NSPs) and other harm reduction initiatives will disappear under recovery-orientated modalities, this article argues that although NSPs are rarely discussed in contextual relationship with recovery, their low-threshold, open-access structure position them as fundamental and critical elements of a recovery orientated treatment system.

Recovery digested

“Recovery” has multiple associations and manifold influences. UK readings of US experience tend to identify “recovery” as synonymous with abstinence and 12-step mutual aid. The embryonic UK recovery movement, although significantly influenced by this account of US experience, is in the process of negotiating the boundaries of its own conceptualisation of “recovery”.

Definitions of recovery are notoriously (and perhaps unavoidably) tendentious. The following formulation utilised by the Department of Behavioural Health, Philadelphia, US, is a usefully inclusive reference point:

Recovery is the process of pursuing a fulfilling and contributing life regardless of the difficulties one has faced. It involves not only the restoration but continued enhancement of a positive identity and personally meaningful connections and roles in one’s community. Recovery is facilitated by relationships and environments that provide hope, empowerment, choices, and opportunities that promote people reaching their full potential as individuals and community members.

What is emerging in the UK is a robust and extensive end-to-end vision of recovery that seeks to consolidate the superabundance of statutory and 3rd sector treatment services with a wider network of reintegration and community provision and independent grass-roots recovery movements.

NSPs and harm reduction

It is impossible to discuss NSPs without considering the ideological driver for their inception and development into a distinct field of professional practice– the harm reduction paradigm. NSPs were the beating-heart of early harm reduction initiatives, which, in a radical discontinuity with past treatment modalities, focused on the attraction and retention of injecting drug users and providing services that promoted safer injecting practices with a view to reducing the risk of HIV/ AIDS (and latterly other viral and bacterial infections) which were seen as a greater harm than drug use itself. Drug dependency was not challenged and abstinence, although a key influence for individuals entering treatment and the gold-standard of harm reduction goals, slowly slipped beyond the horizon of expectations

Catalysed by the HIV/ AIDS crisis of the 80’s, a robust public health approach developed that privileged the minimisation of the multiple harms associated with injecting drug use. Recovery and harm reduction are often polarised as oppositional ideological paradigms. This is neither useful nor accurate. For the purposes of this discussion, I suggest that recovery is best understood as an organisational attitude that seeks to maximise the positive outcomes of harm reduction.

Integration

One of the key principles of a recovery-orientated model is it’s integrated. That is, all of the constituent parts, all the various elements of a local system are co-coordinated, speak the same language, communicate with each other and have a congruous set of values and principles that orbit around the affirmative and empowering possibilities of recovery. Every part of the system is involved in a collaborative effort to increase positive outcomes and take a long-term view with respect to developing the quality of life for individuals who access their services and disrupting negative therapeutic expectations where they occur.

This contrasts markedly with the tiered system of the NTA’s “Models of Care”, which, coupled with a dynamic if bellicose competitive commissioning/ tendering cycle has engendered a fragmented treatment system with individual tiers and their respective providers separated from one another both materially and ideologically. Each tier, sector, and service is compelled to privilege its own interests above the needs of service users, who may not necessarily benefit from being locked into a single service or artificially created strata of provision.

Recovery-orientated treatment systems (which we can expect to replace “Models of Care”) re-situate the individual at the heart of provision and encourage vibrant inter-service partnerships. A local recovery-orientated treatment system allows greater flexibility and non-linear movement between system elements. Thus, it should be possible (where appropriate) for a user to move from NSP engagement to in-patient or community detox, residential or community rehab, supported access to mutual aid groups, and direct referral to reintegration services such as housing, education, employment, training, and welfare.”

Building on strengths developed over 25 years, recovery focused NSPs will ensure responsive, needs-based placement to the most appropriate service from locally available choices. This will depend on apposite and effective assessment, the responsiveness of the local system, and the vision, drive, and leadership of NSP staff.

Low-threshold, high expectations

From the perspective of integration, the principle value of NSP’s in a recovery orientated model is that they offer open-access, low-threshold point of entry into the system for populations with the greatest needs – those with high problem severity and low recovery resources. In a significant number of cases, NSPs are often the only touch-point that members of this drug-using population have with local drug-treatment services.

Although NSP outcomes tend to be framed in a negative discourse of risk minimisation, the real-world benefits of NSPs are overwhelmingly positive. As a corollary of promoting harm reduction goals of safer using, stabilisation, and use-reduction, and without locking service users into restrictive and obstructive disciplinary treatment regimes, NSP engagement:

  • Contributes to a better quality of life.
  • Removes barriers to health care access.
  • Promotes self-control and self-efficacy.
  • Encourage autonomy and personal responsibility.
  • Provides opportunities to increase knowledge and self-awareness.

Thus, NSP’s are directly linked to key recovery-orientated goals in terms of facilitating the accumulation of vital recovery resources, particularly within the domain of personal recovery capital. Recovery success can be directly linked to increases in recovery capital – that is, resources in the personal, social, and communal domains of an individual’s life that can be drawn on to support and sustain long-term recovery. Small incremental gains in the area of physical and mental health, wellbeing, and self-efficacy at this stage are significant as they can act as catalysts and triggers for long-term accrual of capital in other recovery domains.

Self-change: the heart of recovery

Gaining control over one’s injecting practices demonstrates that injecting drug users can be effective agents of self-change. Self-change is the heart of recovery: the notion that an individual can radically transform their relationship with their own selves, others, and the world. From this perspective, NSPs should be considered, and positioned as, recovery outposts; and NSP workers as vanguards on a terrain of recovery choices. Highlighting and celebrating the reality of supported self-change is vital in a recovery-orientated treatment system in order to raise aspirations and create opportunities to further self-change and personal development.

The therapeutic milieu

A recovery focused NSP will be driven by a vision that creates a therapeutic space conducive not only to safer injecting practices, but also to actively promoting and supporting engagement for long-term recovery from problematic substance use. Ideally, this means making visible recovery successes and articulating a robust, realistic narrative of recovery that is meaningful and appropriate to the injecting population. This is not something that can be determined centrally, but requires local dialogue and consultation amongst service users, providers, and recovery mentors.

The therapeutic milieu of a recovery focused NSP would evolve locally and be determined by the quality of:

  • The local service ecology and its commitment to recovery-orientated provision.
  • NSP/ pharmacy teams and their leadership.
  • Local mutual-aid and grass-roots recovery communities.
  • Wider community attitudes and partnerships.
  • Local recovery champions and recovery mentors.
  • The local spirit and ethos of recovery innovation and collaboration.

Making recovery success visible

Those with the most chronic problems often exist in a world of perceived hopelessness and negative self-expectations. Taking advantage of their access to difficult to engage populations, recovery focused NSPs will pro-actively make visible recovery success – for example, through employing workers or volunteers in recovery (the therapeutic power of a positive encounter between a drug user and an ex-drug user should not be underestimated), promoting local recovery champions and mentors, encouraging reciprocal working relationships with other recovery and reintegration services, and providing access to recovery information and resources that demonstrate the reality of long-term recovery from addiction.

Conclusion

The bottom line of recovery can be expressed in three words: recovery is possible. If recovery is possible; that is, if there is an authentic, realistic possibility of recovery then there is arguably an ethical imperative to promote and provide access to services that deliver recovery orientated change. Whilst NSPs have a very specific remit that focuses on the reduction of harm associated with drug use, their services can be delivered in a recovery-aware environment that is engaged with the full range of local recovery and reintegration provision, and firmly, authentically rooted in community. The journey towards a full and meaningful life that is recovery can begin in the most unlikely of places. Why not through the doors of a needle exchange program?

Anthrax Update

As the anthrax situation worsens and we get the first cases appearing in England (London and Blackpool) there is still a lot of confusion over the finer details of the outbreak, especially the lack of details ‘released’ on the routes of drug administration.

This has lead to anger from user groups, as Alan J from the National Users Network said on their Facebook page:

It would be most helpful if the HPA could give a breakdown of those infected by the contaminated heroin according to mode of ingestion…

Well, the information exists but for a number of reasons it’s only being distributed via word of mouth, possibly because Health Protection Scotland (HPS) are worried that the information may make people feel safe using routes that later turn out to also be a risk.

NOTE: As I’ve previously mentioned on this site, it seems that ALL possible routes of administration are risky when dealing with heroin infected anthrax. Please bear that in mind when reading the following information. The best harm reduction advice is still to try to stop using heroin, either via self detox or substitute prescribing.

The following is information is being verbally disseminated to drugs workers in Scotland and was sent to me by a senior worker who wishes to remain anonymous (but who I trust) the worker felt that the information should be made more widely available.

There is no specific profile for the people who most likely to be at risk, the age range is late 20s to mid 50s. The majority (if not all) of those infected have been injectors. There has been one report of smoking from one of the victims, however he was also in receipt of a methadone script and may have minimised his injecting for fear of loosing his script, he had a recent history of injecting and was associating with known injectors, unfortunately no post-mortem was carried out (workers refused to, thinking they were at risk of infection) so there has been no way to confirm whether he was actually injecting.So far the risk from smoking heroin is only theoretical, none of the confirmed cases or those who have died had anthrax via lungs or through inhalation, the anthrax was all through abscesses. There is an increased risk, in theory, if when smoking heroin you start inhaling as it’s candying as you run the risk of inhaling powder rather than smoke. If inhaled the disease progression is very quick and almost always fatal. But this has not been the pattern.

21 out of the 23 people who have died injected into muscle, there is reason to believe one of the other two missed a vein, and the last I’ve already talked about above. There have also been cellulitis, necrotising fasciitis and gut bacteria present in abscesses associated with the anthrax infection, suggesting underlying untreated infection, poor hygiene and poor injecting practice (i.e. licking the needle before injecting). All of this increases the risk of fatality as the immune system is already compromised.

Things to avoid when injecting;

  • Injecting under skin
  • Injecting into muscle
  • Missing a vein or experiencing leakage is a risk factor in many of the confirmed cases
  • Excessive use of citric causes extra tissue and vein damage, increasing likelihood of infection
  • Injecting contaminated heroin into a vein increases the risk of systemic infection

Filters are unlikely to stop anthrax spores, there is a better chance of filtering out spores using the purpose made filters as they may be able to filter particulate matter to a small enough size. Anthrax spores will last a long time in a filter and can survive extremes of heat and cold, so dispose of filters after a single use.

There is minimal risk through intimate or sexual contact. Although there is a potential risk from touching skin lesions, especially open wounds. Avoid contact with leaking or dried out wounds of abscesses, keep them covered, clean up spillages with bleach or other suitable diluted disinfectant.

I think some of this information is not already out there and I hope it proves useful.

Again I would like to make it clear, as also mentioned in this text, that this does not mean smoking is a safe route of use for anthrax infected heroin. Inhalation anthrax leads to death in a far higher percentage of users than wound anthrax.

Update

The Scottish Drugs Forum as released guidance for workers on how to deal with the Anthrax outbreak, this is essential reading for all workers (and users).

Not All Syringes Are The Same

As you’ll know if you’ve spent any time either working in a needle programme or injecting there are many different kinds of needle available.

The assumption is normally that the needle you’ve used in the past is always the best one for the job and most NSP workers will just go along with this, but at the end of the day not all needles are equal. This article will compare some of the main equipment you can get.

NOTE: This article is only covering injecting into surface veins and not meant for advice on equipment for deeper veins (like the groin).

Standard 1m insulin syringe

This is by far the most popular syringe supplied by needle programmes, available from a number of different companies. This is usually the first needle that people use when injecting and as a result it’s usually the one they’ll use until they either stop, or progress to a higher risk injecting site.

The only problem though, is that this needle was never originally designed for injecting into a vein (IV) but was instead meant for injecting just under the skin (subcutaneous).

It was pointed out during the Avril Taylor study into injecting practices that it’s very difficult to tell whose needle is whose. Although you can still tell the difference by scratching off a number on the side or burning the plunger. (The best bet is of course to never run out of equipment.)

On a plus point though, a recent study into HepC transmission found that this kind of needle keeps back far less blood post injection. This then reduces the risk of passing on the HepC virus via a reused syringe. (NOTE: in reality this isn’t that much less of a risk as most needles that are reused are within a short time of initial use, this makes HepC transmission risk from one of these fixed units only very slightly less than from a separates system.)

Nevershare syringes

I’ve never made it a secret that I’m a big fan of this kind of syringe. The Nevershare was developed by Exchange Supplies in response to the Avril Taylor study as a way of identifying each persons syringe by the colour of the plunger (5 colours available).

This doesn’t mean that these syringes are designed to be reused (no syringe is), but it is a pragmatic response to the unfortunate reality that people do occasionally reuse either deliberately or out of desperation.

As well as being different colours, these also have Nevershare written along the side. Now you might think that this is pointless, but it is in reality called a ‘nudge’ (for more information on the psychology of nudges read Thaler & Sunstein’s great book Nudge).

The needle on the Nevershare is also thinner than most 1ml insulin syringes; this means less damage to the vein. Plus, the needle can be removed from the barrel (although this is not mentioned in the guidance notes for this syringe). Removing the needle allows you to use a filter far more effectively than with a standard insulin syringe.

I have only two problems with this syringe; the first is that the green ones are more difficult to see if they have been inappropriately disposed of (e.g. in grassland or woods). But the second problem is the biggest one for me. Although the needle (including cap) can be removed, it’s not colour coded. The colour coding is only on the plunger, so if the needle is removed it’s still possible to get confused over which needle belongs to you. It’s also worth thinking about where the end is kept while removed (I’ve even caught myself putting one towards my mouth a couple of times when delivering training).

Filter Syringe

One of the newest needles available is the Filter Syringe from Frontier Medical. This syringe is made in a single fixed system like the insulin syringe. However, the cap includes a tiny filter allowing you to not have to use makeshift filters. And when I say tiny I really mean it; the filter is less than 2mm wide. The good thing about this is that it doesn’t retain any significant quantity of drug. Because a makeshift filter is usually larger it can hold up to 10% of the drug solution, which of course gives it a reuse value which the filter in this syringe doesn’t have.

Frontier have a different approach to syringe identification. They’ve included a number of scratch off sections on the side so people can mark them themselves (although you can also do this with any other syringe). The needle on the Filter Syringe is a 29 guage so slightly thicker than the Nevershare.

Brand loyalty

As I mentioned previously, once people start using a brand of syringe they tend to stick with the same one for years. I can remember working in one NSP that changed from BD syringes to Terumo and, although both essentially the same thing, we got lots of people complaining that the new syringes where blunt. I spoke to another worker I know in a different area and she told me she had exactly the same complaint from people when they changed from Terumo to BD.

This is why it’s important with introducing these new syringes that people are shown exactly how they are different. Personally, I always take them out of the packaging and physically show people. Frontier Medical have even produced a film showing people how they should use their filter syringe, and Exchange Supplies have supporting guidance notes for the Nevershare.

Availability

If your local needle programme doesn’t stock these syringes, and you think they should, then ask them. Both of the companies that produce the syringes are usually happy to send out free samples to NSPs to trial, in many cases they’ll even come and show the staff how to use them. If your service says they can’t get them then you may need to approach your local drug action team (who fund the NSPs) or the local user group (who can advocate for you). In both cases the workers in the NSP should be able to put you in contact with them.

Retractable syringes

Just a quick note on ‘difficult to reuse’ syringes. I’ve been asked before if I would endorse these in any way, and I won’t. Both the National Needle Exchange Forum (NNEF) and the UK Harm Reduction Alliance have said that these are unsuitable for drug users and that they promote hoarding behaviours of non-retractable equipment. Because of this and the extra costs they incur I personally feel they should be avoided.

Summary

There is no perfect syringe for injecting street drugs. Both Exchange Supplies and Frontier Medical have developed good ideas into really innovative equipment, but in reality we need these two syringes to be merged into one.

Update 2021

Since writing this article there have been some changes, Exchange Supplies no longer produce the 1ml Nevershare, but they now produce a fixed needle unisharp in both 29 and 30 gauge and a range of colours. Frontier Medical are now ‘Vernacare’.

Pharmacy and Attitudes

I’ve had a couple of conversations this week about the way some people feel they are treated in pharmacies when they collect needles. This is something that comes up from time to time, both when I’m talking to people who inject and also when I’m talking to pharmacy staff.

It’s even something I cover when I’m training pharmacy staff, and I think it comes from a lack of understanding by some people on both sides.

Pharmacies are an incredibly important aspect of needle distribution in the UK. And they have been ever since needle programmes started back in the 80’s. One of the first was Boots the Chemist in Sheffield which started distributing free needles in 1986.

There are now around 2000 pharmacy programmes, they outnumber formal NSPs by about 3 to 1, and without them we wouldn’t have even a fraction of the coverage we need to get clean equipment out there.

Attitudes

So what is the whole issue with attitudes? Well, from conversations I’d had with injectors they often complain that they are treated with suspicion, mistrust, fear or even disgust by some pharmacy staff. But on the flip side I’ve also spoken to pharmacy staff who say they are treated with aggression and anger by injectors.
As I’ve said, this is something I talk about when training pharmacy staff and when talking to injectors in NSP. Both sides have the following expectations and attitudes:

Pharmacy staff People who inject drugs
Fear (of aggression) Fear (of aggression)
Mistrust (shoplifting, lying) Mistrust (who will they tell)
Lack of confidence in their own knowledge Lack of confidence in staff knowledge
  Expecting to be questioned/challenged

As you can see the expectations on both sides are mostly the same and these expectations colour the way people react to each other. If you go into a situation expecting a fight then you are going to be hyper defensive. Previous studies have shown that heroin users are more likely to be able to identify signs of disgust and anger in others, so is it any surprise that they are defensive when they enter a pharmacy? Of course there may be many reasons for the reaction they are getting; the worker may just be having a bad day, be tired, be busy, or they could be reacting because of a bad experience they have had in the past. What both sides actually want from the situation is the following:

Pharmacy staff People who inject drugs
Respectful/polite Respectful/polite
Positive/friendly Positive/friendly
Open and honest Open and honest
Confident (in their own knowledge) Confident (in the workers ability)

Again it’s clear that both groups want the same thing. So, how can we achieve it?

I think when it comes to the confidence issues that this is a training need for pharmacy staff. Pharmacies tend to have a quite high turnover of staff and it’s usual for some of the bigger chains to have locum pharmacists who will only spend a short time in each branch, so training needs to be regularly repeated. It’s also important for all training to have a strong focus on attitudes as well as knowledge.

But most of it can be changed by people in both groups taking time to think what it is like for the other person and to realise that even if someone appears to be in a mood with them then it’s even more important to be polite, friendly and open.

Everyone is different

Of course in the same way that it’s not every heroin injector that shoplifts and gets aggressive in a pharmacy, not every pharmacy worker treats injectors with mistrust and suspicion. If anything the bulk of them are doing their best in a busy job, and in some cases they are fantastically supportive. Those pharmacies that are the most supportive also seem to be the ones who have very few problems with shoplifting and aggression – cause and effect?

Related links

For any pharmacy staff who feel they need more support running a needle programme can join the needle exchange discussion list, which is managed by the National Needle Exchange Forum.

The recent NICE NSP guidance which talks about the need to move focus away from strict one to one exchange, which was historically one of the biggest causes of conflict in pharmacy provision.