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Author: Nigel Brunsdon

Careful Words on Common Ground

Over the last 6-7 years, in my role as a university-based researcher, I have been given privileged access to a number of Needle and Syringe Programmes (NSP) throughout England. Throughout this time, a large number of organisations and individuals have assisted me in carrying out research concerning injecting drug use that takes place in public settings (such as toilets, car parks, green areas, derelict property etc). This assistance has permitted me to carry out observational research within NSP, to make contact with injecting drug users regarding their experiences of public injecting drug use and to identify harms associated with this practice. From this work I have been able to make a number of harm reduction recommendations regarding the harm production effect of public injecting drug use.

During observational work, I have noted that there is often a correlation between ‘the type of equipment request and where drug users inject’. For example, requests for 1ml insulin syringes typically related to injections in superficial veins located in the forearm; requests for shorter needles infer hand/foot injections, whereas requests for 2ml barrels with longer needle attachments typically related to deeper injections into deeper veins (such as the femoral vein in the groin area). This is information is probably well established within NSP-workers on a global scale and will probably come as no great surprise to many readers of this website.

However, from a research perspective, requests for certain paraphernalia not only prove to be an indicator of where injectors inject, but also provides an indicator of where they inject (sic)! More simply, and less ambiguously, I have noted that requests for wider gauge, longer needles, higher volume syringes, in addition to water ampoules often correlates to injecting episodes that take place in outdoor settings. As such, when I note service user making requests for this type of equipment I am particularly interested in learning more of the locations/environments where they may subsequently go to inject.

But, here’s the tricky part! How does a complete stranger introduce this interest to another person who may be reluctant to disclose any details of their injecting drug use in public places? It is now well established in the research literature that public injecting is associated with shame, stigma and negative self-worth. As such, why would somebody volunteer participation in something that they perceive as ‘shameful’ and possibly reinforce a negative self-identity in doing so? The challenge I have faced in all my attachments to NSP sites is how to raise this issue with service users in a manner that is sensitive, non-offensive and ‘relevant’ (as it is entirely possible that requests for 2ml barrels, longer needles and water may be for ‘domestic’ use too).

My initial experiences of this challenge (during a pilot study in 2007) proved useful in ensuring contact with those people that have experience of public injecting. That was because the way in which I raised the topic of public injecting was completely inappropriate and totally the wrong way of asking people about sensitive (almost taboo) topics!!

During the pilot study, after service users made their request for injecting equipment, I would approach the individual, introduce myself (as a researcher based within the NSP) with the question: ‘could I ask you if you have ever injected in a public place?’ After failing to get any positive answers in the first few days – I decided that my question was inappropriate and too ‘in your face’. In research terms, this is called ‘question threat’ and it inadvertently seeks to provide a negative response amongst those asked. After a slight tweak, I amended my question to:

In the last month, have you injected outside at all? Have you used in a toilet, a car park or somewhere similar?

This rephrased question is much more sensitive in its approach and has proved very successful in recruiting research participants to studies that require experience of particular injecting experiences. This is because it omits the ‘taboo’ word of ‘public’. In using a more relevant alternative (‘outside’), that is more neutral and value-free, any judgements, assumptions and associations attached to the word ‘public’ are minimised – if not removed altogether. In addition, this is a question that can be asked that purposely and sensitively excludes those who would not qualify for a particular study – as if they do not have experience of an issue, they can’t talk about it!

When talking to service users about their injecting experiences, there is a great deal of common ground between NSP workers and health researchers. This is especially so when attempting to unpack experiences (and inform intervention, advice and information) regarding the physical spaces and environments in which service users are injecting drugs. Places such as public toilets and the cubicles covered in urine. Places such as ‘safe houses’. Or the kitchen in a squat. The back alley behind the shopping centre.

I would encourage all NSP workers to raise the issue of ‘place’ with all service users during visits for new injecting equipment and during any conversations when doing physical inspections of service users’ veins, injuries, dressings etc. My research (and that of others) demonstrates that a number of already established drug-related harms and hazards are reproduced and made worse in public settings. This may relate to the physical and social environment (causing rushing, sharing, inappropriate technique, recycling discarded equipment, lack of washing facilities, no water, dirty hits, overdose etc etc). If NSP workers can identify the type of setting where service users are actually injecting, they may be able to provide more informed advice and intervention (including any additional paraphernalia to assist safer injecting). But this will largely depend on asking the right questions – and how they are asked.

In short, choose your words carefully and good luck.

State of the Art Consumption Room in Copenhagen

Last week I had the opportunity to visit the world’s most advanced drug consumption rooms. It’s opened in Copenhagen on Sunday 4th August. I was very impressed; because this is the most modern drug consumption room I’ve ever seen.

The late 1980s and early 1990s saw the early implementation of the first initiatives for Drug consumption rooms (DCR´s) in Switzerland, Germany and the Netherlands.

Although these countries started experimenting with this new harm reduction measure, at the time DCRs were not officially included in national legislations.

From the very beginning, DCRs were regarded as serving two main objectives:

  • To reduce individual health risks associated with drug use
  • to reduce public disturbance.

Meanwhile DCRs were opened in Sydney, Australia and Vancouver, Canada in the early 2000s. Spain, Luxembourg and Norway complete the list of countries that have included these facilities in their drug policy and practice. However, only the Netherlands and Switzerland provide nation-wide coverage of DCRs for people who use drugs.

In many other countries, efforts have been undertaken by service providers, politicians, researchers, grass-roots organisations and drug user advocates to introduce DCRs in their own country, most of them without success.

Denmark the exception

One notable exception is that of Denmark. In 2011, a NGO in Denmark opened a mobile DCR in Copenhagen. For one year, this mobile unit provided services for people who use drugs without interference from the police or any other government authorities.

In June 2012, the Danish parliament passed a law giving municipalities a clear legal mandate to operate DCRs with permission from the Minister of Health.

Two other safer injection rooms (only for iv use) ran since 2012 in Copenhagen and Odense.

Visiting the State of the art DCR in Copenhagen

Last week I had the opportunity to visit the world’s most advanced drug consumption room. It has opened in Copenhagen on Sunday 4th August.

One thing is clear, we have to say goodbye to our dreams of drug consumption rooms which are furnished adorable to invite drug users to linger. No chillout area, no sofas, no smoking rooms where everyone can sit at a round table to talk, smoke, sleep, talk…

…this new Danish drug consumption room does it in a different way. The facility is friendly but functional, washable and hygienic. The interdisciplinary working group inter alia with members of Bruger Foreningen (Danish drug user union) who sat together for more than one year, did a great job, because they realised the different needs of people who’ll use these rooms.

Unique equipment for people who use drugs

Unique are the two ammonia stations which can be used in the ‘Smoker Room’ to change powder cocaine into crack or freebase. These ammonia stations are necessary because in the past drug users have dumped the ammonia bottles they bought in into the faces of employees (this has happened a few times and has been explained as some people becoming erratic and aggressive when using a lot of crack). Rather than prohibit the production of crack, it is possible to get 1ml of ammonia from these stations to produce smokable cocaine.

The employees know that inhaling ammonia is much more harmful and dangerous than using sodium bicarbonate (Natron is the local brand). So they will inform the drug users that Natron is the healthier alternative to ammonia.

To motivate a change in behaviour, smokers will get a glass crack pipe (to help prevent TB, HCV, Herpes and other infections) and a small package of Natron. In my view that’s the right way to change drug user behaviour. If they ban ammonia, there is the risk that the smoking room wouldn’t be used by many people. That’s harm reduction at its best.

There is a fully automatic air conditioner in the smokers room. When the level of vapour is exceed and the oxygen levels fall below a given value the AC cleans the air automatically. This is not only a model for the user who sits several times a day in the room with the high percentage of vapour. In addition it is healthier for the employees working there.

The SKYEN is also equipped for disabled persons. It is good to see that also people who use drugs in wheelchairs can use both rooms. I was very impressed; because this is the most modern drug consumption room I’ve ever seen.

It has become clear to me that we have to say goodbye to our dream of “shooting galleries”. If drug consumption rooms have to focus on issues such as hygiene and safety SKYEN is definitely a good choice.

Peter, one of the employees said to me:

The word NO we want to say as little as possible. Our main goal is to provide users that equipment and the atmosphere they need to use drugs in a way that minimises harms and the like. If things should not be possible, it is our job to explain this so that users understand the meaning.”


Images by Dirk Schäffer

Naloxone: Stephen Malloy

Stephen Malloy talks about the importance of naloxone as a tool to reduce drug related deaths. This was filmed when naloxone had been made easily available in Scotland but the rest of the UK was still lagging behind in terms of legal access.

Low Deadspace Needles

Although there has been research around the benefits of Low Dead Space (LDS) injecting equipment for a number of years there has been an increasing interest in it recently. Even the New York Times has featured articles on the subject. So it’s clear that now is the ideal time for some innovation in the development of injecting kit.

It should be no surprise, especially to people based in the UK, that this innovation is being led by Exchange Supplies. They have always been leaders in developing high quality harm reduction equipment, with single use sachets of citric and VitC, water, nevershares etc. All developed in response to research, and all developed before other companies even identify a need (although many are quick to try and copy them afterwards).

Last Year Exchange Supplies released a LDS 1ml barrel where the plunger extends all the way up to the needle itself. While this is a great product (and it really is) it doesn’t help people using other barrel sizes. One way around this would be making the needle the part that is LDS.

Which they’ve done

A couple of days ago, with no real announcement, the folks at Exchange Supplies put out a few boxes of LDS orange ends on a conference stand. These needles solve the problem of how to have LDS on any barrel.

As you can see from this image, the needle on the left is a standard orange end which has a high dead space area for blood to collect in, while the needle on the right extends into the tip of the barrel filling up that dead space and reducing the amount of blood that will be contained.

I talked to Andrew Preston (Director of Exchange Supplies) about the new ‘Total Dose’ range and he told me that initially they have developed both long and short orange ends as the costs involved in the ‘tooling’ is quite high, but they intend to expand the range into the rest of the available needles as soon as possible.

This is an important development in reducing the risks of injectors acquiring blood borne virus’s, and something I hope all needle programmes start stocking (and not only stocking but actually explaining to people why they need these).

For more information on LDS you can read Jamie Bridge’s article on William Zule’s previous research, and his latest research that was presented in the Journal of Drug Policy.


Exchange now has a full range of ‘Total Dose’ needles available. They now use the term ‘Reduced Dead Space’ as a more accurate descriptor.

Buy Total Dose Needles

Check Those Warnings

We’re living in a world where we have access to instant communications, couple this with busy workloads and tools to speed up that communication and it’s no great surprise that a warning you receive will often be sent off to others without you checking out the details (or in a lot of cases without it even being read) Someone is always sending out warnings in this world. But this is a problem…

Like pretty much every Facebook user my timeline was recently full of friends reposting something along the lines of:

In response to the new Facebook guidelines I hereby declare that my copyright is attached to all of my personal details, illustrations, comics, paintings, professional photos and videos, etc. (as a result of the Berner Convention). etc etc

If you didn’t already know, this is a hoax. One of the many Facebook and Twitter hoaxes that keep going around and around, for instance how many times have you seen a message saying Facebook is about to start charging etc. But like most hoaxes this is well documented on multiple sites so why do I still get about 5 of these a day.

People are lazy

The reason I get so many of these is the same reason drug services get so many drug warnings (you see what I did there, I started writing about Facebook and then brought it back to drugs, I’m getting good at this stuff) it’s because people are inherently lazy, not you of course, but most people. It’s far easier to hit the share button on Facebook, or the forward button on an email than it is to go and check the accuracy of a warning. But it goes further than that it’s the fact so many warnings are passed on without people even thinking ‘does this make sense?’.

Here are two examples from my experience, one of a hoax, one a bad warning:

  • A previous colleague passed on a warning of HIV infected needles being stuffed down the back of cinema seats locally. This warning went from our local area to most parts of the UK (a peer on the south coast of the UK mentioned to me she’d received it). If however he’d taken the time to check Snopes he would have easily found this is an old hoax designed to demonise drug users.
  • About 2 years ago I was working in a drug service and a warning came though saying that Heroin was being cut with Ketamine. OK thats a strange cut but still not beyond the realms of possibility, but this message then went on to say that the ketamine stopped Naloxone from working (naloxone is the opiate antagonist used to reverse ODs). This had been passed on around the UK without anyone asking ‘how would that work’. Even a basic understanding of the drugs involved would tell you this was wrong.

How to easily check

So, the latest drug warning has come though (or indeed the latest ‘Facebook is planning to steal you children and throw them into vats of acid’ warning) what can you do to check.

  • Have a worker who is tasked with checking facts
  • Check quality news sources
  • Check Snopes
  • Google a part of the text and the word hoax
  • Once you’ve spotted the hoax let other know when you see them spread it, for those facebook ones it’s easy to add into the comments, for drug warnings email around to the same distribution list that sent it
  • Your warnings

    OK so now you’re checking the facts on those alerts coming in, what about the ones you’re sending out? Well in just the same way you can help make them easy to check for others

    • Factual information: is there a supply of drugs that has caused medical problems, then let people know exactly where, and when. Include names of hospitals involved or named workers who collected the initial reports.
    • Avoid stating gossip as fact: if the only reference you have is some guy in the NSP coming in and saying he’s heard that the gear is strong that’s not enough for a warning. However if you get lots of people saying it let people know, but still let them know the source of the info.
    • Date all events and warnings: it may take time for a warning to circulate and even with modern communications the message will be changed over time, I’ve seen the same warning doing the rounds for over 6 months before.


    …don’t automatically think that all strange sounding messages are hoaxes, back when the anthrax outbreak started in Scotland I initially brushed it off as an obvious hoax, I really shouldn’t have of course , I should have checked it out further first.

    So remember check messages before sending them on and make sure your messages are accurate, dated and have useful information.

Peer-Delivered Syringe Exchange Toolkit

This toolkit from the Harm Reduction Coalition in the US is intended to provide examples of policies and practices from current PDSE programs so new and existing programs can think about and incorporate the parts that work for them. It gives an overview of points to consider in starting a PDSE program and is intended to generate new ideas for revising and improving existing PDSE programs.

Each section contains insight and ideas drawn from the experience of various programs and ends with Questions to Consider based on your own program’s needs. Throughout the toolkit, the Harm Reduction Coalition have included quotes from peers currently working at PDSE programs about their experiences and ideas.

Injecting Rituals

This presentation on the psychology of injecting rituals and the ways we can use these within our harm reduction approaches was delivered at the HIT Hot Topics conference in Liverpool and at the Harm Reduction Coalition conference. The video was filmed in Liverpool.

Naloxone Is Childs Play

This short film featuring a simulated overdose and naloxone administration is to show how simple it can be to save a life. No one needs to die of an overdose. Featuring Emily Brunsdon.

Naloxone (also sometimes called narcan) is the life saving medication that reverses opiate overdoses. When this video was filmed in the UK this drug was still prescription only when it comes to supply (since 2015 it’s available via drug projects). It can be legally administered by anyone (in the same way insulin can be to diabetics).

IV Use of Mephedrone

As I’m sure most people who read this site will know Mephedrone has been around for a few years now and it is one of the wide range of new and emerging drugs, some legal, some not that people are experimenting with, using recreationally or in some cases developing a dependency on. One of the questions and fears that has been around has been which of these, if any, will people inject and what will be the consequences and risks if they do.

In the early months of 2012 me and my colleagues who work in the NSP began to hear from service users who had previously mainly injected heroin that they had begun to inject Mephedrone, known variously locally as MCat or Mdog. Within a matter of weeks we had people accessing the NSP whose use of MCat had escalated rapidly and who were injecting large amounts of the drug on a daily basis with little or no awareness about what it was that they were using apart from a vague idea that it was some kind of ‘plant food.’

The speed with which long term heroin users adopted this new drug took them and us by surprise. As harm reduction workers we are faced with the challenge of firstly finding any relevant harm reduction information around the IV use of M Cat to pass onto service users (there is very little of this), of educating people who were injecting about possible risks and consequences and of learning from them about the issues that they were beginning to encounter.

Much of the Harm reduction advice that we as workers can offer around the use of Mephedrone is similar to other stimulant type drugs that we have worked with but we also began to hear alarming reports from our service users about the impact that their use was having on themselves and people around them.

Many reported an increase in incidents of violence and aggression amongst the using community, as one long term heroin injector said to me, ‘people do more for this than they ever did for heroin’. Stories of assaults and robbery of other people who use drugs became common place. Many people reported that they felt aggressive when using and that they and others were resorting to violence to settle disputes and differences far more quickly than they would have done in the past. As workers we saw a marked change in the way in which people were behaving in and around the project with individuals acting in erratic and aggressive ways towards staff and other service users.

This aggressive behaviour came alongside a reported increase in paranoia and anxiety, particularly after using for several days. Stories of people feeling that they were being watched or followed, strangers in vans, voices from the TV etc are commonplace amongst people injecting large quantities of the drug . One woman who was using about 5 Grams daily at that point remarked to me that ‘its wrecking everyone’s heads..’

A visible effect of injecting M Cat has been the rapid and significant weight loss that people are experiencing. Most people I have spoken with have been concerned by this but there have been a few female injectors who have identified this as a positive side effect.

One of the most concerning side effects that users have discussed has been the slow healing process of wounds. As with other stimulants people under the influence of M Cat may pick at their skin. These spots do not seem to be healing and are then picked at again , slowing the healing process. People have told me that other cuts and wounds on their body are also healing very slowly or not at all. This would appear to be related to a vasoconstriction effect where the blood in the veins is flowing far more slowly but I can find little solid information or research to support this particular reported side effect of Mephedrone.

There have also been several reports from people who have suffered fits after injecting, this has generally occurred after extended use of larger amounts, in the region of 3 Grams or more over the course of a session and would appear to be a stimulant type overdose.

It appears that the rise in tolerance that people experience with Mephedrone is rapid. It is not uncommon for people to be injecting in the region of 3 – 5 G on a daily basis. There have also been reports of almost compulsive injecting episodes. I spoke to one person , a long term heroin user who claimed that he had injected approximately 40 times in a 24 hour period, he based this on the number of used filters that he counted afterwards. The potential vein damage and trauma associated with this number of injections is clear and he himself was deeply concerned about how much Mephedrone he was using and the compulsive nature of his binges.

What is puzzling is why so many in the heroin using community have adopted Mephedrone as their main drug of choice, in some cases ceasing to use heroin completely. I have spoken with people about their motivations for using Mephedrone and there have been a few different explanations that have been offered.

For some older heroin users the buzz and rush of injecting could only be likened to one thing, that of early 90’s ecstasy. ‘its like old school pills’ has been enthusiastically stated on several occasions. Many people have also stated that while they enjoy the initial rush it is the come down afterwards that they really enjoy, describing it as being opiate like and ‘better than the gear that’s around.’

The most common explanation offered is based on the fact that the quality of heroin and Crack has been steadily decreasing and Mephedrone is seen by users as being a cleaner, higher quality drug. Up until a few months ago there were people selling Mephedrone in the original ‘plant food’ packaging that it was sold in when legal. This has changed over the last few weeks and there are now complaints that the quality has declined and people who are using claim that it is now being cut with a wide range of substances including salt, sugar or amphetamine. People who are using back this up with their descriptions of the drug which has changed from being rice sized crystals to a more powder form. There has been a recent Police seizure in the area where a large amount of crystal type Mephedrone was discovered ( 9 Kilogram’s) alongside 24 Kilos of Monosodium glutamate (MSG) a flavouring used in Chinese cooking which the police stated was to be used as a cutting agent.

The above is really only a snapshot of some of the issues that people injecting Mephedrone have discussed with workers. None of these people have injected it for any longer than 6 months. What the consequences of longer term IV use will be is hard to say and this is the message that we are giving to our service users. What is clear is that as workers we need to listen to everything that they are reporting to us and work with them to develop effective and relevant strategies to reduce the harm of a drug that one person likened to ‘A nightmare, this drug has got a hold of me quicker than any other.’