Author: Nigel Brunsdon

Community Management of Opioid Overdose

These guidelines produced by the World Health Organisation aim to reduce the number of deaths from opioid overdose by providing evidence-based recommendations on the availability of naloxone for people likely to witness an opioid overdose along with advice on the resuscitation and post-resuscitation care of opioid overdose in the community.

Specifically, these guidelines seek to:

  • increase the availability of naloxone to people likely to witness an opioid overdose in the pre-hospital setting;
  • increase the preparedness of people likely to witness an opioid overdose to respond safely and effectively by carrying naloxone and being trained in the management of opioid overdose;
  • increase the rate of effective resuscitation and post-resuscitation care by persons witnessing an opioid overdose

Tips For Supplying Foil

So foil is now legal in the UK (since September 5th), needle programmes across the country are now (hopefully) stocking it and offering it as a possible tool for change or early engagement route for people who smoke rather than inject their drug of choice. So here’s a bit of advice for those workers giving it out.

Foil for change

One of the many roles of a needle programme is supporting people to move away from injecting to a safer route of administration, this is of course where foil is most likely to be used as a tool for most of us. But getting someone who injects to just move over to smoking is a pretty hard sell so bear these points in mind:

  • Timing is everything: An ideal time to move over to smoking is when someone is already considering a change in their use, it might be because they are having problems getting a vein, or that they want to reduce the risk of overdose following a personal or witnessed OD. Be aware of these opportunities to positively change behaviours.
  • You don’t have to change all at once: Moving to smoking is a big step for some people. If someone is having problems with their veins then smoking, even just once a day, rather than injecting can help give those veins a bit of much needed rest.
  • If you’re reducing, it’s easier to dose when smoking: Although injecting is perceived as cheaper we have to remember that no matter what the strength of the deal thats injected you are getting it all, with smoking if the drug is stronger you can adapt your use easier. This is especially useful when reducing the amount used as it’s likely people only want to get rid of withdrawals rather than getting high.

Of course, if someone has been injecting for a while then they may be out of practice with smoking, and the worries they have about smoking being more expensive might prevent them from even trying it. The perception has always been that injecting is more cost effective, but bear in mind that if someone is using an acidifier (Citric or VitC) to prep their injection they are probably using too much and destroying some of their drug. That said though, it’s important to make sure we make smoking as cost effective as possible to help encourage the change. The video below shows how to make the foil ‘pipe’ to maximise the amount of drug you can ‘recycle’ from reside. I’d recommend all drugs workers to be familiar with making these.

Burning foil myth

There are a few myths connected with foil, one of the most mentioned ones (this even made it’s way into some leaflets) is that you have to ‘burn’ a residue off the foil before smoking from it as this is ‘poisonous’, for some reason a lot of people think it’s plastic. Think about this for a moment…

… a poisonous coating on something that is put on food, and then in an oven at high temperatures. Doesn’t really make sense when you think it through does it. There is a shiny side and a dull side on foil, but this is because during the process for making foil it goes over a roller at high speed, this polishes one side. On domestic foil there is a slight palm oil residue (again from the rollers) but this is likely harmless. On the foil that Exchange Supplies produce there is no oil residue. Burning foil before using it will actually make it more brittle.

Foil is an important and logical addition to the equipment we use in needle programmes, not everyone will use it, but having a stock of it available can reduce a few peoples instances of injecting.

Buy foil from Exchange Supplies Foil Video

Foil Legal At Last

From the 5th of September foil is going to be legal to distribute from needle programmes in the UK. Another important piece of harm reduction kit that we can now have in our ‘toolbox’ of interventions and engagement. But changes like this still take far too long to happen.

Background

Back in the 1980s the UK government took the decision to begin syringe distribution to injecting drug users as a way to prevent the spread of HIV. This, of course, worked very well (the UK rate of HIV in injecting drug users is far lower than in countries that didn’t support NSP). This involved having an exception to Section 9a of the Misuse of Drugs Act so ANYONE can give someone else a syringe.

In 2001 more items became exempt (citric, swabs, filters, disposable spoons and water ampules under 2ml in volume); this was in response to the spread of Hepatitis C. After a delay of two years Vit C was added. (For more on the history of paraphernalia laws in the UK Click Here).

But all this is responding to people who are already injecting, what we needed was some way of engaging people BEFORE they injected and an option to help people route transition away from it. Almost all NSP workers have tales of people who come in asking for foil, but when we tell them they can’t have it they take needles. Some services distributed foil anyway (with no one prosecuted), but many – including some of the large charities – remained risk averse and in at least one case I know of, a great worker lost their job over promoting foil as a sensible intervention.

A number of organisations including Release and the National Needle Exchange Forum have spent years campaigning for a further law change to allow legal foil provision. This change has taken over a decade to happen, a delay which has not only possibly caused more people to have blood borne virus infections, but also one that’s reduced the likelihood of some of the big services investing in it.

The change

From September the 5th people can legally distribute foil, within certain limitations. In Theresa May’s statement regarding foil last year she said:

…only offered by drug treatment providers as part as part of structured efforts to get individuals into treatment, on the road to recovery and off of drugs.

I really hope we see services adopting this as a tool, it will help reduce the instances of HIV and Hep C infection, prevent some of the risks cause by vein damage and of course greatly reduce the risks of overdose death.

However funding towards harm reduction focused interventions is being stretched very thin, some areas are moving to a pharmacy only delivery (which would be difficult to class as ‘structured’) and we have some large charities that are desperate to show how ‘recovery orientated’ they are by dis-investing in their existing NSP spending (which ignores NSPs place within ‘Recovery’).

Foil is something we should invest in

As an early intervention and engagement tool foil is a great piece of kit to have. And added to that foil can be used as a discussion point with injectors about changing their risk levels and it becomes obvious that any organisation working with active drug users should have packs available.

World Health Organisation Calls For The Decriminalisation Of Drug Use

This month, the World Health Organisation (WHO) – the UN agency that coordinates international health responses – launched a new set of guidelines for HIV prevention, diagnosis, treatment and care for key populations. The new document is the culmination of months of consultation and review, and pulls together existing guidance for five groups: men who have sex with men, people in prisons and other closed settings, sex workers, transgender people, and people who inject drugs.

These key populations are the most-at-risk of HIV, yet the least likely to access services – a fact that “threatens global progress on the HIV response” according to WHO. By consolidating previous guidance, the document is able to highlight common barriers and needs – including recommendations for legal reforms to support service delivery.

The guidance puts forward a “comprehensive” package of interventions that governments should provide:

a) Essential health sector interventions:

  1. Comprehensive condom and lubricant programming
  2. Harm reduction interventions for substance use, in particular needle and syringe programmes and opioid substitution therapy
  3. Behavioural interventions
  4. HIV testing and counselling
  5. HIV treatment and care
  6. Prevention and management of co-infections and other comorbidities, including viral hepatitis, TB and mental health conditions
  7. Sexual and reproductive health interventions

b) Essential strategies for an enabling environment

  1. Supportive legislation, policy and financial commitment, including decriminalization of behaviours of key populations
  2. Addressing stigma and discrimination
  3. Community empowerment
  4. Addressing violence against people from key populations

As well as reaffirming the previous WHO, UNODC and UNAIDS guidance on harm reduction (and particularly the importance of needle and syringe programmes and opioid substitution therapy), the new WHO Guidance goes further to explicitly recommend, for the first time, that people who use drugs should have access to naloxone – the WHO Essential Medicine designed to reverse opioid overdose. This endorsement is a major step forward by WHO, and hundreds of thousands of lives will be saved if this recommendation is followed by governments.

Crucially, the WHO Guidance also recommends that “Laws, policies and practices should be reviewed and, where necessary, revised by policymakers and government leaders, with meaningful engagement of stakeholders from key population groups”. Within this so-called ‘critical enabler’ (see graphic) is an explicit calls for the decriminalisation of drug use in order to reduce incarceration – as well as calls to reform laws and policies that block harm reduction services, and the end of compulsory treatment for people who use drugs. The Guidance also cites the experience of Portugal in terms of decriminalisation – citing successes such as the increase in people accessing treatment, the fall in HIV cases among people who use drugs (from 907 cases in 2000 to 267 in 2008), reductions in drug use and less overcrowding within the criminal justice system. According to the press release accompanying the Guidance, “Bold policies can deliver bold results”.

The new WHO Guidance therefore represents the latest high-level, evidence-based call for the end of criminal sanctions for people who use drugs – and one of the most prominent calls from within the United Nations itself. The Guidance will be launched and disseminated at the International AIDS Conference 2014 in Melbourne, calling on governments to strengthen their HIV responses so that all key populations are included.

This article first appeared on the IDPC website and is shared here with permission

Low Dead Space Syringes

Robert Heimer, William Zule and Andrew Preston talk about the importance of low dead space syringes for blood borne virus prevention.

Safer Injecting Basics for New Psychoactive Substances

Scottish Drugs Forum in conjunction with NHS Greater Glasgow & Clyde and Frontier Medical have created a new advice booklet for people injecting New Psychoative Substances (NPS). The guide is intended to inform people of the risks associated with injecting NPS, drugs commonly called legal highs, or any unidentified white powders.

Printed copies of the booklets are free to access in Greater Glasgow and Clyde, please contact katy@sdf.org.uk for more information.

Examining the injecting practices of injecting drug users in Scotland

Avril Taylors “Examining the injecting practices of injecting drug users in Scotland” report details the results of her work looking at HCV risk factors in injectors.

The aim of the study was to examine the injecting practices of Scottish injecting drug users to a degree of detail not previously achieved in the UK. The specific focus was practices that could potentially facilitate the transmission of HCV infection. Risk practices other than the direct sharing of needles and syringes were of special interest as these are not so well understood.

NICE: Needle and Syringe Programmes

This guidance makes recommendations on needle and syringe programmes, including those provided by pharmacies and drugs services for adults and young people (including those under 16) who inject drugs, including image- and performance-enhancing drugs.

The main aim of needle and syringe programmes is to reduce the transmission of blood-borne viruses and other infections caused by sharing injecting equipment, such as HIV, hepatitis B and C. In turn, this will reduce the prevalence of blood-borne viruses and bacterial infections, so benefiting wider society. Many needle and syringe programmes also aim to reduce the other harms caused by drug use.

The guidance is for directors of public health, commissioners, providers of needle and syringe programmes and related services, and those with a remit for infectious disease prevention. In addition, it may be of interest to members of the public.


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

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