Harm Reduction International’s flagship publication is the biennial Global State of Harm Reduction report. First published in 2008, it involves a coordinated effort across practitioners, academics, advocates and activists to map global data and responses to HIV and hepatitis C epidemics related to unsafe injecting and non-injecting drug use.
It is the only report to provide an independent analysis of the state of harm reduction in the world and has become the go-to source on global harm reduction developments for researchers and advocates in our sector and beyond.
Latest estimates suggest that in 2015 around 174,000 people (95% credible interval 161,000 to 188,000) in the UK were living with chronic HCV infection, and that this figure has fallen by around one third to 118,000 in 2019.
Injecting drug use continues to be the most important risk factor for HCV infection in the UK, with data from UK surveys of people who inject drugs (PWID) suggesting that in 2019, just over half of PWID tested positive for HCV antibody, and just less than one quarter had evidence of current infection.
Public Health England produce this annual report on HCV in the UK.
Supervised drug consumption facilities, where illicit drugs can be used under the supervision of trained staff, have been operating in Europe for the last three decades.
These facilities primarily aim to reduce the acute risks of disease transmission through unhygienic injecting, prevent drug-related overdose deaths and connect high-risk drug users with drug dependence treatment and other health and social services.
I’ve been fortunate to have been given access to photograph at the two Drug Consumption Rooms in Australia, the Sydney Medically Supervised Injecting Centre (MSIC) which has been running for over 17 years, and the recently opened Melbourne Medically Supervised Injecting Room (MSIR). Most of the photos I’ve been taking are of the staff and the facilities at the projects… but I’d like to describe the photo I didn’t take.
Pregabalin is a medication used for seizures, anxiety and neuropathic pain. It is also known by a brand name Lrica® and various street names. In recent years it’s use has become prolific across Northern Ireland is also seen in other parts of the UK among heroin users and the prison population. It is involved in ever more fatal overdoses in these groups/region.
The Public Health Agency NI tasked me, now with Extern to provide a set of resources on the drug. These include a workers guide, users guide and a poster all intended to raise awareness of the risks and reduce them as far as possible.
The workers guide was produced as a PDF file available to download and print. All too often staff who do not have adequate knowledge about a drug cannot effectively help the people who use it. Worse than that they could fall into the trap of giving poor information and advice which decreases confidence in the worker and can even increase risks to the user.
Once the worker guide became available on both the PHA and Extern websites, I began to receive emails and phone calls about it from professionals and drugs workers all over the UK and Ireland, seeking further information. The feedback received in NI and elsewhere shows that there are increasing issues with pregabalin everywhere.
Used properly this guide can help workers to identify and manage the risks effectively in collaboration with users. There are three pages dedicated to harm reduction tips, many of which have proved very helpful to both users and their workers. I wish you well in it’s use.
Safer drug consumption facilities (SDCFs) are clean, hygienic environments where people can consume drugs, obtained elsewhere, under the supervision of trained health professionals.
They offer a compassionate, person-centred service which focuses on reducing the harms associated with injecting drug use and helps people access appropriate services to meet their needs. By doing so, they are able to reach an extremely vulnerable group who often do not engage with our existing services.
This FAQ document is based on the proposals for the Glasgow project.
What is being proposed in Glasgow?
Why are these services being proposed for Glasgow city centre?
What are the expected benefits of these services?
Will these services increase drug use, drug dealing, and crime in the local area?
What is the legal status of these services?
Can we afford these services?
How will these services help people to stop using drugs?
The latter half of 2016 saw increased interest and positive development with regard to the introduction of Safer Injecting Facilities (SIF) in both Scotland and the Republic of Ireland. Whether or not this interest proves to be yet another false policy promise in the progress of UK harm reduction remains to be seen. However, during this period of potential development, I couldn’t help but notice that advocates of SIF stated that such facilities would aim to reduce local levels of ‘public injecting’ and assist with ‘removing drug-use from the street’.
In addition, I have also noted that since 2016 there have been over a dozen academic publications (in academic journals) that use the term ‘public injecting’ in the title/abstract; or refer to public injecting as an aspect of the paper in question. (This can be easily checked by searching ‘public injecting’ in Google Scholar). Whilst I fully understand the term and what it means (the injecting of illicit substances in public toilets, car parks, park areas etc), I now believe it is an expression that needs to be reviewed and used less frequently! In addition, I recommend that it is time that ‘we’ (academics, service providers, policy makers, harm reduction advocates) completely stop using this term as a result of the ambiguity implicit within the term ‘public injecting’.
This may seem like an unusual, contradictory and/or somewhat hypocritical recommendation from a person who has built a research career on studying/describing the social, physical and environmental circumstances underlying ‘public injecting’ in a variety of English towns and cities during 2006-2014. However, as I explained in a recent guest lecture (at Liverpool John Moores University), when I commenced my doctoral research on this issue in 2006, I was picking-up on an internationally ‘established term’ that had been established several years earlier by leading academics in the field of harm reduction / HIV/AIDS. At that point in time (2006), as a naïve researcher in the actual world of ‘public injecting’, I did not have the confidence to question/dismiss a term that had been established in academic circles by more senior (and internationally renowned) researchers. For these reasons, I blindly and unquestioningly reproduced the term in a large of body of published and unpublished work during 2006-2012 as would be expected of a less senior academic.
Around 2012-2013, I began dropping the term ‘public injecting’ to describe the preparation/injecting of illicit drugs in public or semi-public places. Instead, I began using the term ‘street-based injecting’ to describe the exact same act of preparing / injecting drugs in public / semi-public places. My reasons for this were informed by two recurring themes that had emerged during 3 periods of research in 4 different English towns and cities (2006-2011). These issues related to the way in which ‘public injecting’ was variously (mis)understood by commissioners, practitioners, service providers and people who inject drugs in various locations. It was only after several years of working in the field that I fully recognised that the term ‘public injecting’ was an ambiguous expression and interpreted very differently within different audiences. Indeed, it was only after working in multiple areas throughout England that I fully appreciated that the term is open to subjective interpretation by whoever hears the words ‘public injecting’ – and especially so by those actually working within public health or actually affected by substance use.
To illustrate, when I raised the issue of ‘public injecting’ with some commissioners, service providers, frontline staff and drug/alcohol commissioner groups, a typical response was that ‘we don’t have public injecting in (insert name of town here)’. In return, I regarded such responses with some degree of scepticism and/or incredulity as I found it hard to believe that ‘public injecting’ did not take place in the towns/cities concerned. However, during a conversation with a Director of Public Health in May 2012, it suddenly dawned on me that all those previous denials of ‘public injecting’ were possibly premised upon a misunderstanding of ‘public injecting’ itself. More accurately, this misunderstanding was possibly connected to an (incorrect) assumption that I had been asking questions about the type of open, communal injecting drug use once associated with places such as Platzspitz Park (the so-called ‘Needle Park’ in Zurich during the 1980s-90s). From the perspective of those completely detached from, or only partially connected to, frontline services, it is perhaps reasonable to see why ‘public’ in the term ‘public injecting’ was regarded in such spatial terms (namely, with a view that prioritises social location). While this may seem as a somewhat frivolous point, it does have important consequences. For example, those wishing to develop harm reduction services (or seek finances from commissioner groups) on the topic of ‘public injecting’ may face immediate obstacles if the term is viewed as irrelevant to the local setting. To discuss the topic with such groups more in terms of ‘street-based injecting’ perhaps diminishes this ambiguity and perhaps makes more explicit an activity that will almost certainly take place in any town/city where substances can be acquired for injection!
In addition to the above, I also opted to use the term ‘street-based injecting’ following my experiences in recruiting PWID during the initial stages of my work on this topic. I submitted a full account of this matter to this website sometime in 2013 (see Careful Words on Common Ground; link here?). In short, I quickly noted that using the term ‘public injecting’ with service users and PWID was a form of expression that was loaded with ‘stigma’ and ‘shame’. In making the term less explicit by emphasising an interest in places of injecting drug use (rather than the public nature of these same places) I found it much easier for research participants to describe their (often harmful) experiences of street-based injecting. Accordingly, for PWID and drug/alcohol service users, it is possible that the term ‘public injecting’ is one that emphasises the activity more in relational terms (a view that prioritises contact with other people; the general public). As such, to discuss harms and hazards associated with the more explicit ‘street-based injecting’ is more likely to produce meaningful conversations with this group than a term that is loaded with stigma and shame (‘public injecting’).
For the above reasons, since 2012-13, I have preferred to use the term ‘street-based injecting’ to describe what is widely known as ‘public injecting’. I believe that in using this preferred term, I am being overt and explicit to all audiences that read/hear the word. In addition, I suggest that street-based injecting is a less ambiguous term to certain audiences and less shameful to yet other audiences. I believe that the term ‘street-based injecting’, (with its overt emphasis upon ‘place’), removes the potential for misunderstanding by competing audiences (who may confuse spatial and/or relational understandings attached to the ‘public’ within ‘public injecting’). It is thus for these reasons that I suggest we (within the field of harm reduction) should stop using the term ‘public injecting’ in debates of harm and hazard associated with street-based injecting drug use. …. And especially with regard to disseminating understandings of Safer Injecting Facilities that have been proven to save so many lives in other international settings.
I’m writing a conference presentation at the moment, the topic is the need for safer spaces to use drugs in the UK. As part of the research for it I spent a day this week walking around Birmingham with my camera. I think it’s very easy for drug workers to lose sight of the situations people are forced into when using drugs. Seeing where some people are injecting really makes it clear that we need a real push to get drug consumption rooms started.
Drug consumption rooms (DCRs) are not a new thing, in 2015 there were 92 facilities operating in 62 countries around the world, with more opening every year. The most famous of these is Insite in Canada which is possibly the most researched medical unit in the world. These sites provide a safe place to use drugs (there have been no overdose deaths in DCRs) as well as a first point of contact for people to get into treatment, housing, healthcare and support services. But nothing in the UK, and with a few minor exceptions, no real calls from drug services to start one.
During my photo walk around Birmingham I visited three known areas that people are publicly injecting. Two of these are waste-grounds next to car parks but one was a main walkway in the centre of town. The walkway is actually overlooked by one of the local drug services, this has resulted in situations where drug workers can see people going into the injecting space and effectively start timing them to check they are not there too long and overdosing.
To me, that alone is a sign that something needs to change, if that service included a DCR space either supervised or semi supervised (eg a room with a timer and an intercom) there would be far less risk of people dying of overdoses.
No place to inject
As you can see from some of the images these are no places where it’s possible to inject in a sterile or even semi sterile way, in many of the sites I saw used needles alongside human excrement. Add to that poor lighting, the fear of being seen by the public/police and in the case of the waste-grounds the chance that an overdose could go undiscovered and you realise that this cannot be allowed to continue.
But it IS continuing, I spoke to an ex-worker from Birmingham who took a similar set of photos 15 years ago. So the big question for me is why are the major drugs support charities not calling out for DCRs, will we ever see one take the leap to making a safer space for the people in greatest need of support?
I’ve posted a selection of the photos here, but if you want to see the full set they are over on my photography site.
This presentation was delivered to the DDN Conference in 2016, the conference topic was “Get the picture” and they had asked me to present on using photography. This doesn’t contain any drug information or advice on harm reduction, it does however have basic photography advice and some good portraits from the harm reduction movement.