Author: Nigel Brunsdon

Pregabalin Users Guide

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 and Heroin Assisted Treatment (FAQs)

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.

Includes

  • 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?

Why Should ‘We’ Stop Saying ‘Public Injecting’?

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.

Time For Safer Spaces

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.

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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?

More photos

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.

We Need More Photographs

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.

Embedding Naloxone Into Drug Services

This presentation was delivered to the National Needle Exchange Forum event. It covers some of the things to keep in mind to make sure naloxone is a core intervention in drug services since the Oct 2015 law changes.

You can find other presentations delivered on the same day over at the NNEF website.

Naloxone legal changes (UK)

As a member of the Naloxone Action Group (NAG) England, I have been waiting a year for Regulations to widen the provision of Naloxone, ever since the Department of Health advised that the Medicines and Healthcare Products Regulatory Authority (MHRA) would be drafting these. In truth, the wait has been even longer as in 2012 the Advisory Council on the Misuse of Drugs (ACMD) recommended “actions for government to take to consider naloxone’s role in steps to make an impact on drug-related death rates.”

Last month the Human Medicines (Amendment) (No. 3) Regulations 2015 were laid before Parliament, amending the 2012 Regulations which restrict the supply etc. of medicines, and we got the first glimpse of the changes that are to be introduced from 1st October. The main change is that: “Persons employed or engaged in the provision of drug treatment services”, drugs workers (though a variety of different names apply this role these days) to you and me, will be added to the list of exempted professionals who can supply Naloxone without falling foul of the restrictions. I also think that volunteers working within the drug treatment service will be included within this definition, and so able to give out Naloxone to those accessing the service. The reason for this is that the new exemption is worded exactly the way as the one for “Ampoules of sterile water for injection that contain no more than 2ml of water each”, which volunteers at needle exchanges will distribute as a matter of course. The only difference with Naloxone is that those volunteers supplying it will need to undergo the necessary training to then deliver the training that service users must receive alongside their kits.

Similarly, I would also argue that pharmacists who are providing needle exchange and or supervised consumption of opiate substitution medication will also fit the criteria, and so be able to lawfully supply Naloxone once appropriately trained. I would make a distinction here with pharmacists who aren’t involved in those activities, as they would then not be providing drug treatment services.

You might be reading this thinking ‘I’ve seen Naloxone advertised at drugs services for ages so what will be different?’ You would be right – Naloxone is available at some drug services in England, but this is either prescribed directly by a Doctor or under a Patient Group Directive (PGD) which allows other medical professionals to supply this more generally without having to go back to the Doctor for each individual. PGDs can take a lot of resources to develop and implement as there are a number of legal requirements for them, and they also have to be reviewed every 2 years. So, the amendment is great news in that respect – it removes the need for a PGD and allows those providing drug treatment to supply directly to their clients, without the need for a medical professional to approve it. It is hoped that those services who were put off by the onerous processes surrounding PGDs will now be much more enthusiastic about implementing a programme – there is certainly one less excuse!

But, what is the situation for people who aren’t engaged in drug treatment, and the professionals that they engage with? I’m thinking mainly of hostel workers and those working with homeless people – their clients are just as at risk, or even more so, of overdose. Many of us have been puzzling over whether or not these people will be able to supply Naloxone under the new Regulations. Reading the Impact Assessment (IA) that was conducted before the new legislation was drafted, it would be fair to say that hostel workers are also included. The IA specifically says: “The proposed amendments to the current regulations will mean that organisations, such as homeless hostels, and individuals, such as outreach workers, whose client base includes opiate users, will be able to hold naloxone to use to reverse the effects of an opiate overdose in a client.” However, and it saddens me to say this, I don’t think that the exemption itself can be interpreted in that way. The drug treatment services must be provided by, or on behalf of, or under arrangements made by, one of the following bodies:

  • An NHS body
  • A local authority
  • Public Health England
  • Public Health Agency

Unless hostels and homeless outreach workers are commissioned to provide drug treatment services in this way, they do not meet the necessary criteria, and therefore any supply to individuals would not be “in the course of provisions of lawful drug treatment services”; the condition attached to the exemption. It is this condition which also makes me doubt that drugs workers will be able to supply directly to hostel workers, in order that they can then hold a stock to administer when needed, as that would not necessarily be lawful drug treatment services. Unfortunately the new Regulations do not change who Naloxone can be supplied to, which is someone: currently using illicit opiates, such as heroin; receiving opioid substitution therapy; leaving prison with a history of drug use; who has previously used opiate drugs (to protect in the event of relapse).

Although, as the phrase ‘lawful drug treatment service’ has not been defined – either within these amendments or elsewhere previously – there may be flexibility. That wider interpretation may well be supported given that the MHRA, in their consultation letter in 2013, stated that:

The amendment is aimed at making stocks of naloxone available in settings which drug users are likely to access, for example, hostels. It will also allow family members or carers to receive direct supplies of naloxone which they can administer in an emergency if needed.

It is worth noting that the amended Regulations do not actually make any specific reference to supply to family members directly, but with the agreement of someone who can be supplied Naloxone, it can also be provided to family members and friends. This was recognised in Public Health England’s (PHE) Guidance issued in February 2015. By supplying multiple kits to each service user, which can be left with family and at other locations the person regularly goes, the aim of ensuring that a wider group of people have the kits can be indirectly achieved. As with any new law where interpretation is unclear, the reality of the situation may not become apparent until the law has been tested. Though I would urge caution as there is the potential for prosecution under the Medicines Act for supply where no exemption applies.

If the intention truly was for homeless and hostel workers to be included within the new Regulations, the MHRA need to clarify this as soon as possible, and certainly before October. Given the time it has taken for this law to be drafted, a redraft might not be a sensible suggestion as it will cause further delay. But perhaps it is possible for a letter of comfort or guidance to be issued, in the same way that the Lord Advocate in Scotland did prior to their national programme being officially rolled out. In fact, I don’t see why this couldn’t be done now for the drug treatment services already specified, in advance of the Regulations formally coming into force, so that there is no further delay.

In the meantime, all is not lost in relation to hostels and homeless organisations though, as I think the way round the potential barriers for is for them to work with drug treatment services to ensure that their clients can access Naloxone. The easiest way for this is perhaps for drug workers to outreach to those groups within those settings, ensuring that those who need Naloxone receive it and also increasing the availability and accessibility within the communities – after all, this is not a medication that will be self-administered. Of course, this doesn’t take into account that additional outreach would need to be funded in some way, but the possibility is definitely there.

In summary, the amended Regulations are a good step forward, but in my opinion they simply don’t go far enough, and definitely do not meet some of the assurances that had been made previously. Ultimately, what we really need is a national programme – as they have in Scotland and Wales – to ensure that everyone at risk of opiate overdose has access to Naloxone.

Ten reasons to distribute ‘take home naloxone’

Naloxone is the opiate antagonist that can prevent overdose. In the US it’s use is increasing and within the UK there are national programmes in Scotland, Wales, and Northern Ireland to distribute it, but not in England, in England it’s left up to local areas to decide if they should distribute it. So, I thought it was time for a top ‘ten reasons to distribute take home naloxone’ article.

1. Conversation Starter

Making naloxone available is a great way to start a conversation about overdose and overdose risks, looking at the myths and the practicalities of what to do when a friend or family member takes too much. Most naloxone programmes include a formal conversation that they require staff to have before distribution, although it has to be pointed out that this doesn’t need to be hours long (there is research showing 5 minutes may be just about the right amount of time).

2. Show that your organisation cares

Distribution of naloxone is a great way to show that your organisation actually cares about the health and wellbeing of people who actively use drugs. If your drug service doesn’t already have an overdose prevention programme than you really have to start one. Just in case you wondered, I also mean Recovery and Rehab services should have naloxone and overdose programmes, after all one of the highest risks for overdose is when someone returns to drug use with no tolerance following a break.

3. Allows people who use drugs to support themselves and each other

Rather than telling people that they are powerless in the face of the drugs they use, naloxone shows people that they can be in control of their own health promotion, and the promotion of their peers. Given access to naloxone drug users will (and do) support each other.

4. Engagement tool for treatment

Services are under continuing pressure in the UK to ‘attract’ more people into treatment. What better way of attracting people who actively use drugs than to provide naloxone. Show people that just because they are continuing to use that this is no barrier to using your services, and once they get to know that the attitude of the project is one that supports people and doesn’t judge them they may be interested in using your other services.

5. Gives people a second chance

Or a third, fourth or even tenth chance. I’m not a fan of the “there is no recovery in a graveyard” type hyperbole, but there is a truth to the fact that NOT allowing people a second chance at life isn’t something that any caring society should do.

6. It saves money

A drug related death investigation costs thousands of pounds, but the Welsh naloxone projects found that even taking training and distribution costs into account naloxone costs around £400 per life saved. You can add to this though, someone who overdoses and doesn’t get help fast runs the risk of long term health issues caused by a prolonged lack of oxygen, earlier intervention of a peer that is there when someone overdoses could prevent this.

7. Support for families and carers

There is increasing pressure both in the UK and the US to make access to naloxone easier for families and carers (watch the ‘Reach for Me‘ film that highlights the story of Denise Cullen who now fights for naloxone access following the death of her son Jeff). Having carer access to naloxone can help remove the feeling of powerlessness that some family members face when thinking about overdose. UK law does allow for carer access to naloxone as long as the person at risk holds a prescription.

8. Protects against future ‘strong’ batches

Public Health, the police and many drug organisations often put out warnings about strong batches of heroin causing overdoses of course that is all it amounts to, a warning, and human psychology being what it is a warning that says “drugs here are stronger” often just leads to increased drug sales. Isn’t it far better to also have an antidote in place in the community already that protects people who overdose, after all as Jennifer Vanderschaeghe of the Alberta AIDS Network Society says:

The best time to start an overdose program was many, many years ago. The second best time is today.

Jennifer Vanderschaeghe

9. Not just heroin users

While heroin use is an obvious focus of most readers of this website, we need to remember that opiates are in many prescribed pain medications, and that these medications are an increasing cause of accidental overdose deaths. Providing an antidote for accidental OD along with any prescriptions for these pain medications seems only logical (I’m looking at the Doctors out there on this one).

10. Brings other groups in

Naloxone provision brings other groups to the discussion, for instance in the US there are now many police forces that carry naloxone to allow them to respond effectively to overdoses (after all they are often first at the scene). This changes the narrative of the police being someone a drug user feels scared of to one where police are actively promoting life and wellbeing.

Ohh I promised you ten reasons and I seem to have ten already… so please consider this a special bonus reason:

NALOXONE SAVES LIVES

Related

The website of the Naloxone Action Group campaigning for wider access to naloxone in England.
Film with Greg Scott talking about having naloxone in a family situation.
A HIT Hot Topics film with Dan Bigg talking about the rising cost of naloxone in the US.
The Naloxone.org.uk website.

Special thanks to Eliza Wheeler, Meghan Ralston and Stephen Malloy for help in putting this article together.

Alternatives to Public Injecting

Harm Reduction Coalition invited experts from several countries to share their various SIF models, planning and policy development process, implementation challenges, and evaluation results. This report is a summary of the proceedings of the consultation.

Conclusions

At the risk of ‘spoilers’ here are the conclusions of the report:

  • People who use SIFs take better care of themselves, reduce or eliminate their needle sharing, use their drugs more safely, and ultimately reduce their drug use;
  • SIF participants gain access to other medical and social services and entry into drug treatment;
  • There has not been a single overdose death in any of these programs over many years of operation and many thousands supervised of injections;
  • SIFs do not increase drug use in the area, nor do they encourage young people to initiate drug use;
  • Crime and public nuisance decrease in the areas around these programs.

Images and content © Nigel Brunsdon unless stated otherwise, all rights reserved.

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