Author: Nigel Brunsdon

At the time of writing this there have been 7 deaths and 14 people are in hospital with infections related to anthrax in Scotland. The current official advice from Health Protection Scotland’s Dr Colin Ramsey has been:

… I would urge all users to stop using heroin immediately and contact local drug support services for help in stopping.

Which as advice goes has been less than helpful. But what (if any) are the messages that should be given out, and just how worried should we be?

What is anthrax?

Anthrax is an acute disease caused by the bacteria bacillus anthracis that can be fatal. The bacteria can effect you via inhalation (breathing in), ingestion (eating) or, as with the current cases in Scotland – by infecting a wound.

The risk of anthrax infection becoming fatal depends on both the way you become infected and how soon you get treatment. Cutaneous (wound) anthrax is actually the least fatal and responds really well to treatment. The problem though is that you NEED early treatment and as the symptoms of anthrax are almost the same as everyday injecting infections people are unlikely to get the treatment.

Anthrax symptoms

• Cutaneous (wound) anthrax: all the current infections fit into this category. A boil develops about 2-5 days after initial infection which develops into a black necrotic ulcer/scab (eschar). Unlike other bruises and infections this may be painless. Cutaneous anthrax is rarely fatal, but untreated it can cause death in 20% of cases.
• Pulmonary (inhaled) anthrax: Respiratory infection in humans initially presents with cold or flu-like symptoms for several days, followed by severe (and often fatal) respiratory collapse. Even with treatment risk of death can be as high as 45%.
• Gastrointestinal anthrax: commonly comes from eating infected meat and can cause vomiting of blood, severe diarrhoea, acute inflammation of the intestinal tract, and loss of appetite. Sometime lesions have been found in the intestines, mouth and throat. Can be treated, fatality rates are 25% to 60% depending on how soon you get treatment.

Harm reduction

To be perfectly honest I’ve been putting off writing this article for the last couple of weeks. With previous bacterial infections affecting heroin injectors the harm reduction has been obvious; smoke rather than inject. But with anthrax this isn’t as simple, we know a major route of infection is via inhalation, in fact this is the most deadly form. Although only theoretical, the risk from smoking seems likely. Anthrax spores would need to be heated above 90c for a significant time to kill them off (thanks to Tom Ward for this info). Even if your heroin gets hotter than this it doesn’t do so straight away so spores may be inhaled early in the smoking session (and maybe even all through it).

So the usual advice is no good. And neither is swallowing or snorting heroin an option, which brings us back to the ‘stop using heroin’ message. Great, but waiting times in Scotland for substitute prescribing currently range from 8 to 52 weeks. Leaving the only current options as either continue using or self detox.

We need faster scripting

What is needed is rapid prescribing to any and all people that use heroin that want to stop/reduce. There are services in the UK that have same day prescribing and it is possible to do this on a simple basis. I remember talking to workers who had been getting 40ml scripts of methadone to street sex workers on the basis of self declared heroin use and a positive urine sample. Yes full information gathering would be best practice, a series of in depth one to one sessions would be great, but keeping people alive should be the first priority!

Heroin is mobile

And don’t think that just because your service is in Birmingham, London or Devon that none of this applies to you. At the moment police attention on the dealer in the area will be intense, which means one of two things are likely to happen. Either the infected heroin will be vac-packed and buried for a year or so (anthrax spores can survive for decades) or it will be moved and the problem will move with it. We all need to be ready. (At the time of writing there is also an unconfirmed case in Germany, which may be a sign this is a big batch.)

Where did this come from?

We don’t know. Microbiologist, Professor Hugh Pennington has said:

You can’t completely rule out maliciousness as theoretically – people would be able to get hold of anthrax in the UK, although you’d need a specialist microbiological knowledge to do so.

Personally I think you can rule this out; in no way does it make business sense to kill your customers.

The most likely option is that the bacteria got there by accident either somewhere during manufacture/cutting (unlikely as this would probably have resulted in people becoming infected at this stage) or during transportation. Anthrax can be found on animal skins and in the meat of infected animals and it’s possible that the heroin came into contact with these in some way during storage or shipping.

What to look out for.

All workers and injectors should become hyper aware of injecting infections and strongly encourage people to seek medical attention as soon as possible, the longer an anthrax infected wound is left the less likely it is that treatment will be effective. Anyone with flu like symptoms followed by signs of coughing up blood or intestinal problems should also seek medical attention. Although none of the current cases are inhalation or gastrointestinal anthrax we can assume this is a risk factor. The Health Protection agency has produced some anthrax algorithms that should help (cutaneous anthrax, inhalation anthrax).

Why is so little being done?

There have been some angry reactions from the community over the lack of any real response to this situation and you can’t help but wonder what the reaction would be if this was hitting any other social group. Remember the panic in America over anthrax a few years ago? Granted this is a normal (although sad) reaction to any stigmatised group (just think back to the early days of HIV). But in this case there is also a misunderstanding of the situation from the general public, clearly the answer is simple as Dr Ramsey said “…stop using heroin immediately”. To Joe Bloggs public it must seem insane that a heroin injector carries on in the face of this.

But people who use heroin also face overdose, hepC, hepB, HIV, septicaemia, tetanus etc etc (the list goes on, and on) as Jolene Crawford, of Transform Drug Policy Foundation Scotland has said:

It is accepted that some heroin will be lethal because by prohibiting it we gift control to criminals. Were opium and heroin to be legally available via regulated pharmacies and doctors’ surgeries, we would not have to see our children, mothers, fathers, brothers and sisters die unnecessarily in this way.

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).

It’s that time again, New Year – a time for resolutions and changes. Like everybody else our people who come to needle programmes resolutions tend to be focused on quitting bad habits. Which is of course something we can really encourage, helping them get the support they need to maintain change. But there are other things to bear in mind as well.

So someone tells you that as it’s New Year they have decided to quit using drugs. Great, you’ll of course either refer them into scripting services (if they are opiate users) or signpost them to appropriate services. Tick that box on ‘referral to scripting’, job done… well, not quite.

How many of your new years resolutions have you ever kept? While in an ideal world anyone wanting to quit will succeed first time, harm reduction is pragmatic and we understand that sometimes this doesn’t happen. (As anyone familiar with the Cycle of Change will understand)

The thing to remember with heroin use is that any break in use will affect tolerance, even spending the day in the local police cells will increase the chance of someone overdosing. So when someone tells you they are intending to quit, or that they are quitting at the moment, make sure to go through advice on how to reduce the risk of tolerance related overdose.

Overdose prevention

So what advice should you give someone who has had or is planning a break from opiates?

• Have friends you can talk to if you feel you need to use.
• Delete dealers’ phone numbers from your mobile.
• If you do intend to use, only use small quantities and not the amounts you used before.
• If you do decide to use again after even the smallest of breaks smoke rather than inject.
• If you do inject, do it in stages, e.g. 1/3rd of the syringe at a time with a 20 second gap. If you start getting a rush then stop the injection.
• Don’t use alone.
• Make sure you trust the people you’re with to call 999.

The Australian state of Victoria government health information site has a great poster campaign that recommends “If you’ve had a break, halve your hit” which I think we would do well to adopt worldwide.

Alcohol withdrawal

As well as increasing the overdose risks of heroin, alcohol has its own problems. Alcohol withdrawal itself can be very risky for dependant users, in some cases alcohol withdraw can even get so bad as to be fatal. If someone who is a daily drinker tells you they are quitting for New Year then you need to advise them to get medical assistance and make them aware of the risks.

Alcohol withdrawal symptoms include: feeling sick, trembling, sweating, craving for alcohol and just feeling awful. Convulsions occur in a small number of cases. As a result, you drink alcohol regularly and ‘depend’ on it to prevent these symptoms. If you do not have any more alcohol the withdrawal symptoms usually last 5-7 days, but a craving for alcohol may persist longer.

Delirium tremens (‘DTs’): is a more severe reaction after stopping alcohol. It occurs in about 1 in 20 people who have alcohol withdrawal symptoms about 2-3 days after their last drink. Symptoms include: marked tremor (the shakes) and delirium (agitation, confusion, and seeing and hearing things that are not there). Some people have convulsions. Complications can develop such as dehydration and other serious physical problems. It can be fatal in some cases.

If you, or someone you’re working with has any of the above symptoms when they stop drinking you should seek medical assistance straight away and normally resuming drinking will also help (but still seek medical help as well).

Supporting people

New Year can be a great time to make changes, it’s important that we support each other in these changes. But it’s also important that we make people aware of the potential risks so we can keep New Year happy.

We need to stay up to date with harm reduction advice, and it’s all well and good being up to date on an individual basis but what about the information we hand out? Are you still giving out that leaflet that was written 5-6 years ago? Of course you are.

We need to learn from the open source software movement, we need to share our advice freely.

Open source

This website is built using ‘open source’ software. The codes that control everything are freely shared so that members of the community can improve them and edit out errors. This means that the site you’re reading will (hopefully) always be stable and continue to grow and adapt to the changing landscape of the internet.

I think this is something we should do we have to do in harm reduction, in fact not just in harm reduction, but in all forms of health promotion.

When a service develops a leaflet/campaign it rarely does so from scratch, but instead looks at everything else available and then attempts to expand on what’s already there while still avoiding at all costs appearing to have used the work of others. This leads to longer development times, greater costs and in the case of health promotion, a delay in information that can save lives!

It doesn’t have to be this way of course.

Creative commons

Creative commons (CC) is a way to licence your work (any work at all) but instead of the traditional copyright you assign a level of use that you are happy with. This can mean people are free to take your work, change it, expand on it, improve it etc.

You decide the limits of the licence, for instance the articles on this website have the following creative commons:

Injecting Advice by Nigel Brunsdon is licensed under a Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License.

This means that people are free to adapt my work in any way they choose as long as they attribute the source material to me and they don’t then go on to sell either my work or the work they have made using mine as a source. The licence also says they have to allow their work to have the same licence.

This doesn’t mean someone can’t sell leaflets using my work as a source; it just means if they want to they have to contact me and ask permission (after all this site costs money to run and if someone is making money from my work I’d like some).

Advantages

If we use this way of writing information, we’ll find it far easier to keep up to date and to spot errors in the info we give. Look at Wikipedia – run totally by the public and in tests repeatedly beats other encyclopedias (including Encyclopedia Britania) for accuracy and speed of editing. Granted, at times some teenager comes along and adds something wrong out of mischief, but the wikipedia community spots it and removes it almost straight away.

Things move fast, a leaflet written a year ago on HepC or Legal Highs would be out of date today, but the core info would remain largely unchanged. So why not let people use the information in your great leaflet and add in the latest figures? If they contact you to talk it over (now they know you won’t threaten them for stealing your work) they may even send you the new version and save you doing the update yourself.

Disadvantages

Most of the disadvantages come from groups/people who want to keep hold of information and sell it as a ‘product’, which would be ok if we were talking about anything not connected to saving lives.

And at the end of the day, just because you allow your information to be reused doesn’t mean you can’t make money. The science fiction author Cory Doctorow releases all his books for free as downloadable PDFs at the same time as he releases them in print. He has no problem making money from his books, people still buy them. But they also help him by adapting his work, making plays, putting illustrations to his works etc. This sharing culture means work becomes better known, we should be using that model for harm reduction after all it’s the information being seen that matters the most.

What I’d like

I’d love to see the big name leaflet writers in harm reduction and other health promotion fields adopt CC for all leaflets and information. Let’s stop acting as ‘gatekeepers’ for information that can keep people alive, and let’s stop pretending that people don’t use each others leaflets. If you CC them they can, and will, give you the credit you’re due.

You can find out more about creative commons at creativecommons.org

Creative Commons Creative Commons in education

Do you trust the people you use with? It’s a simple question really, but for a lot of people it’s a lot harder to answer that you’d think.

Every injecting relationship has to have a level of trust. After all in most cases all the people involved are breaking a law, sometimes many laws. Close relationships already have an existing amount of trust and social capital, but not every injecting relationship is considered a close one.

Relationships of convenience

Often an injecting relationship may be just as much to do with increasing the access to a drug as strong bonds of friendship, and in this kind of situation there will be little or no existing trust developed.

So what happens when someone ‘goes over’? We know from research into overdoses that around 50% of the time when someone overdoses there is a second person present. No problem then – ambulance called…

…not always. If you have no existing trust built up the fear connected with calling an ambulance and the resulting circus can be enough to stop someone calling at all. Even calling an ambulance and then doing a runner can mean someone dies before the medics arrive.

What we need is to know the people we choose to inject with will be willing to do the right thing if we OD; that they’ll phone paramedics, put us in the recovery position and stay with us until the medics get there.

Make a promise

The best way to make people understand the need to stay with you if you OD is to let them know you’ll stay with them if they do. Think about the people you use with from day to day and week to week, have you had that kind of conversation with them? Maybe now is the time.

Make a promise to people that if either of you overdose the other one will help.

Life changing

Nothing affects someone as much as knowing they acted to save a life – or by not doing the right thing caused someone to die. Have the conversation with the people you use with, it could save your life.

Every drug worker asks the question “Have you shared injecting equipment?”. It helps us measure risk factors for issues like HepC, we need it for our stats (its one of the questions the National Treatment Agency insists we ask), and it has a lot of associated harm reduction advice.

But let’s be honest the answer given is almost always “No” even though the research that informs the Shooting Up reports says it’s very common. So is there a better way of asking?

I think some of this has, of course, to do with the way you ask the question.

You have to remember that there is a power imbalance from the start and that this is affecting both the injector and the drugs worker. The injector wants to get their equipment with the least amount of fuss but may feel they have to keep the worker ‘happy’ either because of being new to the NSP situation or from possibly having had negative experiences in other NSPs or pharmacies when getting equipment, hence the automatic ‘No’ to the question.

The worker though knows that they have to ask set questions to get the stats that the service needs, even though some of those questions are uncomfortable to ask so early in the ‘relationship’ with the injector, and they themselves may also have had negative experiences when asking some people those questions.

Unfortunately this can, for some staff, result in them flying through the ‘set’ questions and just blindly accepting even the most obvious dodges to questions.

Better way to ask

I’ve started asking a different question, instead of asking “have you shared injecting equipment?” I now ask “When was the last time you re-used injecting equipment?” with the follow up question of “Whose equipment was it?”

I feel that this question still gets the information workers need for ‘stats’, but will also give extra information that we need to help people reduce their risk factors for blood borne viruses AND abscesses from reused kit. Asking the question this way won’t come across as judgemental, unlike the way it’s normally asked.

Everybody shares?

No of course not. But sharing is more widespread than most services report. According to the latest Shooting Up report one in five injectors admit to sharing syringes in the last year and the figures are higher for spoons and filters. Then take into account that the figures may be even higher with people who have no/limited access to services or are using in a way that it doesn’t seem to them that they are sharing.

Sharing relationships

For most people you need to remember that sharing may be a normal part of their relationships, either with a good friend or partner, possibly even with a good social dealer. While writing this article I had a discussion with someone who pointed out that:

…sharing is pretty much accepted amongst the community. It’s not ok and it’s not right but hey, if you’ve got drugs and no works then sharing is ok. Not by me, I hasten to add but that’s the perception, isn’t it.

And for most workers this is a hard thing to talk about without coming across as preachy or judgemental.

Peer networks

I’m often told by people they only share with a partner and that both of them have previously tested clear for HepC, and to some extent this is fine; we know that small closed networks are only at a minimal risk of transmission. But those networks have to remain closed; as soon as a network starts expanding the risk factors increase dramatically. You have to ask yourself how much can you really trust the people you share with not to share with others? And remember – nobody really expects partners to do anything behind their back, but relationships break down every day for just that reason.

We also need to take into account that some sharing is done without any conscious thought, as Avril Taylor showed in her study of Injecting Practices Scotland there may often be times in a chaotic injecting situation that people lose track of equipment, this may not seem like sharing to someone but the outcomes are the same.

What we need to do

We need to start dealing with the sharing issue in a new way, just asking “Have you shared?” at assessment is not enough. We need to start understanding better how sharing habits change from day to day and relationship to relationship. What may be an unacceptable risk to someone one day, may become an option if it’s the only way to get the hit they need. We have to understand that sharing risks are a mixture of drug effects, peer networks, environment and economics. Only then can we start to develop better approaches to harm reduction.

But first, we need to learn to ask the questions in a better way.

At a conference I was recently at there was lots of talk about peer supply of injecting equipment and it’s clear that engaging networks of injecting drug users to help with self distribution of equipment is a great way to increase the quantity of sterile equipment available. However for some people (it seemed mainly to be some service managers) the concept seemed full of problems. Hopefully this article might help with at least one of them.

Peer supply

For some people the whole idea of injecting drug users giving sterile equipment to their peers seemed to be a new idea, and one that would need to be micro managed. One person even talked about the possible audit trail that would come from a drug death resulting from a needle that they had knowingly allowed to be peer supplied.

But peer supply of equipment has always happened; often it’ll be something that organically develops between people, one week Jon will need some needles, the next week it’s his friend Julie that needs some. People have always sorted each other out. The real issue is what happens when there are no sterile needles to help out a friend, as people will still be tempted to give them a needle, only now it may be a used one.

Social capital

Another question which came up was about what happens if people sell on needles we supply, and yes, this sometimes happens. (I’d just like to quickly point out that the thing that gives any item cash value is scarcity, so if we do increase supply this problem becomes a non-issue.)

But for me the bigger issue is one of social capital. If someone you know needs a few fresh needles and you choose to sell them then yes, you’ll get a small amount of cash which will be gone in no time. But the friend will probably resent you for it, and when you’re in need you may well have to pay as well.

However if you give the person some of your spares freely then you earn a ‘favour’ and good will. This is social capital, and it’s far more valuable than any cash you’d earn from selling equipment. It’s social capital that makes you the person people answer the phone to after midnight, and social capital that gets your friends to support you when things are going wrong.

Think about it – who would you go out of your way to help? The friend/dealer that sells you needles? Or the one that sorts you with equipment for free? We need to start thinking about the things we do in terms of social capital, everyone is in this together and we need to help each other out.

Social capital for drugs workers

Don’t think that this doesn’t apply to you, every time you give good advice, every time you treat your clients well, and every time you take time to understand the issues, you increase your social capital with your clients. I personally think that high social capital is something that will make more people come to a service/worker.

But remember that it works both ways, the attitude that you approach people with can also lose you social capital and in turn lose you and your service any of the good reputation that you may have built up in the community.

Related Links

Wikipedia entry on Social Capital.
There’s a great site called the Social Capital Gateway that collects together articles relating to social capital concepts.