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Author: Nigel Brunsdon

Overdose Bereavement Support

International overdose awareness day was two weeks ago, but I’m still thinking though all the thoughts it’s brought up for me. Every year thousands of people die leaving behind family and friends. But what support do drug services give the people left behind?

When I was 15 years old a friend of mine died, not due to overdose, just because of a tragic accident involving a tree and a power line. I didn’t witness it myself and I didn’t see the aftermath (he lived in different city). But 25 years later it still effects my life. Imagine if instead of it being an accident it was because of some activity we did together three to four times a day, how would this have impacted my life, would I have been able to cope?

In a talk that John Strang gives on overdose he cites UK figures saying that 50% of heroin injectors have witnessed an overdose, and 15% of people have witnessed a fatal overdose. In Austrailia it seems even worse with 78 percent of heroin injectors having witnessed an overdose (he doesn’t cite figures of witnesses of Australian fatal overdose).

Even just looking at the UK figures that means a possible 3 out of every 20 injectors have seen a friend die. But if thats the case why don’t we support people more following an overdose.

Bereavement support

Supporting people though the bereavement process is a specialist skill, and not one that I suspect the bulk of drugs workers have. But if thats the case we are still able to refer to appropriate services, or at the very least point people in the right direction.

Or even better how about working with local bereavement services to develop effective care pathways so people can access effective support. This would of course be a two way process as there are people who seek support for bereavement who may have tried drugs to help them cope with loss. It may also be possible to have a skills exchange where each service offers training to the other.

Why this is important

There are a number of studies linking exposure to overdose to a future personal risk of overdose. So if we want to impact on the number of deaths per year we need to support people far more.

Does your service provide support for bereavement, and if so how effective has it been? Let me know in the comments.

NSP Outcomes Tool

Over the last year or so I’ve come across a lot of people talking about developing tools for monitoring ‘Outcomes’ in needle & syringe programmes (NSP), but I’ve yet to see one that actually manages to work in real life. So I’ve been developing a tool for NSPs that may be a solution.

Firstly

OK I’m hoping that this is stating the obvious, but NSP has always been about running a ‘low threshold’ service. Supply of sterile injecting equipment should never be dependant on completion of this or any other tool, but instead these tools should be something workers encourage people who inject to engage with.

Outcomes tool

The tool itself is a single page based on a mind-map. This includes areas of discussion around the main topics for NSP (overdose, injecting injury etc) as well as other topics that are often discussed in NSP but that workers rarely ever document (education, housing, employment). Recording of these discussion and related outcomes are increasingly important when it comes to talking to commissioners and maintaining funding.

This tool has been written to be easy and intuitive to use, but still be robust enough to enable workers to have in-depth conversations and keep track of outcomes and work done.

What makes this different from other NSP tools I’ve come across is that this doesn’t just record the risk factors someone who injects has, but also keeps track of protective factors.

UPDATE: There is now also a Steroid specific version of the Outcomes tool.

Supporting notes

As with all downloads on the site this has extensive worker notes that explain the whole process. I’ve also included a detailed example of how to ‘score’ the sheet and a tracking tool to monitor each individuals scores.

Needlestick Injury

If you work in drug services the chances are there’s an A4 poster up somewhere telling you what do do if you, as a worker, are accidentally spiked with a used needle. You may even have read it once or twice, but now its going brown at the edges and no one really notices it. But how often do we talk about this with people who inject, after all they’re at a far greater risk of getting spiked than we are.

What should someone do if they get accidentally spiked?

  • Don’t panic: this is the best bit of advice that Douglas Adams ever wrote, panicking won’t help the situation at all. If anything it will speed up the bodies systems. Remember the actual risk of getting HepC or HIV from a single injury is relatively low.
  • Don’t suck the wound: while at first this seems like a no brainer, think back to the last time you cut a finger.
  • Encourage bleeding: the easiest way to do this is to squeeze from behind the wound, easy if its a finger, far more difficult if you’ve sat on a needle. (Have you ever noticed how we always assume a needle injury would be to a finger)
  • Put under running water: This helps wash the blood away that you’re squeezing out, but the water temperature is important. Too hot and the blood will thicken, too cold and the wound will close. I like the term ‘Goldilocks water’.

If you work in a project any you get spiked you’ll also have a few extra things to do:

  • Report to your line manager: I’m afraid I have no idea about health and safety law overseas, but in the UK you have to report to a line manager. This of course generates a number of bits of paperwork like incident reports, RIDDOR reporting etc. But most of that can wait until after ….
  • Contacting nominated service: in my experience this has always been the local Accident & Emergency department. You need to tell them that you have a needle injury from a ‘high risk source’ (any used needle injury should be considered a high risk source, see below) you may have to push the point with some nursing staff. You may be asked to give some blood for testing, this isn’t to test to see if the needle injury has exposed you to a virus, but it’s to act as a baseline for a future test (normally 2-3 months). You may also be offered ‘prophylactic medication’ that may help protect you from a virus.

What about people who inject

In all honesty I’m not sure what would happen about preventative treatment if an injector has an accidental needle injury. I’d be really interested to know if any of you have experienced an injector being offered prophylactic medication. I would say that in the UK most NSPs have access to blood borne virus testing either via referral or from a project nurse, and that if you’re concerned you should access this.

Prevention is better than cure

Of course the best thing to do is not get injured with a needle, obvious really. But what steps can people take to avoid one?

  • People who inject: As any regular reader of this site will already know the best first step is to use new sterile equipment for every stage of injection, and as soon as it is used to store it in a good quality sharps container. If you don’t have a sharps container find an alternative like a drinks can or thick sided plastic bottle, most needle programmes should be OK with you returning equipment in these containers if you have nothing else. (If they won’t, point them to this website.)
  • Workers: Never handle used needles, your programme should have large volume bins that people can put used equipment into themselves, normally though a small opening on a fixed lid. But this is one of my regular annoyances, I’ve been in many needle programmes when I’m doing audit or consultations, and in lots of them it seems putting a lid on a bin is some kind of major problem. Large volume bins without lids are a massive injury risk, the obvious on is of course if they’re knocked over, but for me the bigger risk is people putting their hands into the bins to get back something they put in accidentally. I’ve seen this happen too often and its something that just following best practice could easily avoid.

While it may at first glance seem judgemental there’s a term used in healthcare ‘universal precautions’. At it’s basic this means you treat everyone as a risk factor. A needle injury from anyone should be assumed to carry a virus risk, not just from injectors but also from acupuncture needles or any other ‘sharps’ you may come across whether they are from injectors, staff, or the general public. After all the bulk of people with HepC are unaware they have it.

keep this in mind

We always assume something with needle injuries, look at the image for this article, or ANY image you get googling ‘needlestick injury’. Now think … what if the injury isn’t on your fingertip. You might stand on a needle, kneel on one, even sit on one… it’s better to work out now how to get running water onto a wound and have a plan than waiting until it’s urgent.

Talk to people

Talking about needle injury with people who inject, giving advice on how to avoid it and talking about testing if someone gets spiked is not only great harm reduction, but is also treating people as a valuable human being. I think both workers and people injecting often have a habit of just assuming that needle injuries for injectors are par for the course. They’re not, they’re avoidable.

Why I Stopped Recommending The Glute

Over the years the advice I’ve given to injectors has developed and changed. Sometimes this is because of new research, and sometimes it’s just because I realise that there is better advice I could be giving. This article explains why I no longer tell steroid injectors that the glute is the best place to inject.

Continue reading

Blue Lights (Update)

In June 2010 I wrote an article for Injecting Advice concerning fluorescent blue lights (and related harm) in public toilets. That previous article coincided with the publication of an academic paper in the journal Health and Place and both summarised research (from the city of Plymouth, UK) that considered the injecting practices of drug users who had previously accessed toilets lit with blue lights.

In this article, I’d like to provide a brief update of the issue of blue lights following my ongoing interest in this topic. More importantly, this update has been greatly inspired by numerous e-mails and requests I have received over the last few weeks requesting more information on the Health and Place paper cited in the aforementioned Injecting Advice ‘blue light blog’ (June 2010) – most of which have come from harm reduction practitioners located throughout Australia (and I am very thankful to Nigel Brunsdon of Injecting Advice and to Paul Dessauer of WASUA for circulating details of my work on this issue on various websites). However, these requests have come at a time when I have recently completely a study of public injecting drug use in another UK setting and where drug user experiences of fluorescent blue lights was also noted and recorded. Due to this interest, I feel it is vital to maintain the significance of recent research and provide, on-going, up-to-date, information for harm reduction practitioners and services regarding an issue that clearly has international relevance. That is, I aim to keep the issue ‘live’.

As a quick reminder, the purpose of fluorescent blue lights in public settings (especially toilets) is to make environments unattractive to injecting drug users by purposely making the process of injecting into superficial veins (those just below the surface of skin, such as those in the forearm) more difficult. This, in turn, is meant to have a ‘dispersal effect’ and prevent drug users from accessing premises that have been purposely modified to prevent injecting from happening. However, my initial ‘blue light blog’, about the Plymouth-based research, described 18/31 injecting drug users that were not deterred by blue lights and their ‘injecting experience’ became one characterised by touch rather than vision. Similarly, Plymouth injectors believed that the lighting did not make groin / neck / peer injecting impossible and these became viable injecting alternatives in blue light areas.

My most recent work on public injecting drug use recently concluded in Southend, (a coastal resort on the east coast of Britain) and was funded by the town’s Drug and Alcohol Action Team (Southend Borough Council). A total of 20 drug users with recent experience of public injecting were interviewed during this study and many similarities were noted with those from the Plymouth cohort. This was especially true about their injecting experiences in public toilets equipped with blue lights. Namely:

  • over half of the research participants (11/20) had ever injected in an environment containing blue lights in a Southend location
  • as such, 11/20 were not deterred by blue light environments and were prepared to inject there
  • as with Plymouth, those that had injected in blue light environments stated that injecting episodes were made more difficult – but not impossible – in blue light settings. For these individuals, the lights merely prolonged the time required to complete injecting episodes
  • others were able to counter the blue light effect by ‘feeling out’ veins or accessing established injecting sites (especially the femoral vein in the groin). For these individuals, injections could be administered ‘blindfolded’, or by locating existing scar tissue near particular injecting sites. These experiences provide wider confirmation that blue light settings influence a sensory (and potentially harmful) shift from sight to touch
  • some of those undeterred by blue lights stated that the severity of individual withdrawal symptoms – or drug cravings – would often increase the preparedness to take greater risks (including within environments designed to prevent injecting drug use)

Why are these findings important?

The above findings from Southend were noted at a time when the issue of blue lights as a form of drug prevention in public places was noted as a sensitive and controversial issue amongst local agencies and organisations. In short, the issue of blue lights tended polarise agency opinion; with some in favour of installation and others against.

However, it is perhaps important to remind ourselves that (over 5 years ago) the UK government’s Department of Environment, Food and Rural Affairs (DEFRA) published guidelines for ‘Tackling Drug Related Litter’. In this, it advised that:

…due to the increased risks to users and lack of evidence as to its efficiency, blue lighting should not be used in public toilets to deter drug use

It is perhaps equally important to remind ourselves that since DEFRA’s report ’empirical’ research (that which has been ‘tested’ and ‘applied’) based in Plymouth (2010) – and now Southend (2011) – demonstrates and confirms the view that blue lights lack evidence of efficiency. Similarly, the common qualitative experiences noted from two injecting drug user cohorts, recruited from two diverse UK settings (geographically and socio-culturally), suggest that blue lights are actually more ineffective in preventing or deterring drug use from occurring (as in both settings, a cumulative total of 29/51 [57%] reported previous injecting experience under blue lights).

From these shared experiences, the following conclusions may be consolidated:

  • blue lights do not completely prevent injecting drug use from occurring in public toilets
  • they do not fully facilitate public safety or public health
  • blue lights are not a panacea for social issues and problems relating to injecting drug use
  • they do make injecting drug use more difficult – and thus more hazardous and potentially harmful

Conclusion

This research update indicates that there is perhaps a greater need for more strategic, multi-agency, approaches to public injecting drug use, in which organisations (including local authorities, police constabularies, drug and alcohol services, harm reduction practitioners and hospital services) attempt to formulate more considered approaches to intervention within specific drug using environments. Whilst prevention and dispersal procedures involving blue lights may be well-intended in design, the actual consequence of these installations may be typically overlooked, understated, or simply ignored. Furthermore, the interest I have received from international harm reduction organisations in this regard suggests that this is an issue not confined to coastal resorts in the UK. Indeed, blue lights appear to be a truly global concern with significant implications for harm reduction. In these times of evidence-based intervention, the continued (often unchallenged) presence of blue lights as an effective measure of drug control almost certainly requires further validation and legitimisation by the appropriate bodies that advocate such intervention.

Overdose Workshop

This presentation is designed for use alongside the Overdose Workshop, it contains a section of the overdose myths quiz, a video on the recovery position and other tools to make running a workshop go smoothly. Using the link below you can also find this presentation on the Prezi website so it can be adapted and used within a workshop setting.

A Trip Down The Silk Road

The front page of Silk Road looks a lot like an Amazon or an Ebay. Goods and services for sale are categorised. Sellers receive ratings from buyers and comments about the quality of their products, how fast they ship, and the level of professionalism and discreteness of the transaction. Trust in sellers is built on reputation.

Much of the research and discussion about drugs and the internet has focused upon either buying drugs online or seeking drug-related information online. News coverage has particularly focused upon the capacity to buy drugs from web vendors (eg, Psychedelic drugs just a click away online).

Yet, evidence from the last decade indicates that most drug transactions still occur in the traditional way.

Popular illegal drugs are not generally available online: unless the product can be marketed as ‘legal’ or ‘not for human consumption’, the legal risk and practical problems associated with selling heroin, MDMA, amphetamines, and cannabis through an online marketplace are just too big, for both buyers and sellers.

It’s not that the demand doesn’t exist for online drug vendors. I interviewed forum moderators for my thesis who prohibited ‘sourcing’ on their message boards and regularly edited, closed or removed discussions they believed were motivated by attracting potential sellers.

An example would be a forum user posting that ‘isn’t it hard to find ecstasy in Perth at the moment’. If anyone in Perth had ecstasy to sell, they could send a private message to the forum user offering their services.

Although this was possible and likely occurred despite swift moderator action to remove those threads, most forum users did not use the internet to buy drugs.

In a paper I presented at the 5th International Conference on Communities & Technologies, forum users discussed their views on talking about drugs in public online forums and their strategies to avoid the risk of incriminating themselves.

One popular strategy was to avoid all discussion of supply or dealing so as not to attract the attention of law enforcement who may be watching the forums. Most believed that law enforcement were after ‘dealers, not users’.

I conducted those interviews 3 years ago in 2008. In 2011, the situation has shifted considerably with the arrival of Silk Road, an anonymous online marketplace where anything*(1) can be bought or sold.

Silk Road is accessible only to people who are using TOR anonymising software. TOR uses encryption to make it impossible for anyone to trace your IP address (the electronic address assigned to each computer on the internet).

Silk RoadThe front page of Silk Road looks a lot like an Amazon or an Ebay. Goods and services for sale are categorised. Sellers receive ratings from buyers and comments about the quality of their products, how fast they ship, and the level of professionalism and discreteness of the transaction. Trust in sellers is built on reputation.

Silk Road traders use the anonymous currency Bitcoin. This decentralised international currency operates through peer-to-peer technologies. It has an exchange and a lively forum of users.

The possibilities of a non-government-controlled anonymous international currency are quite mind-boggling. The obvious possibility is being played out right now on Silk Road: buying and selling illegal products is now possible and may dramatically increase in the near future.

What may stop an exponential increase in the use of anonymous online drug marketplaces is the hurdle of delivery. At the end of the transaction, the physical product still needs to be sent to the buyer.

Sending products between countries allows Customs the opportunity to intercept packages and potentially attempt to arrest the would-be importer. Sending products within the same country may make arrest less likely.

There are also fairly large barriers to entry for most ordinary people who might want to buy drugs online. Installing and using TOR, buying and using Bitcoins in a secure way, and taking the risk of fraud or arrest through package tracing from Customs may deter the majority of would-be users. In a recent example of the volatility of this new system, Bitcoin exchange Mt Gox was hacked, causing the currency to rapidly devalue.

But for the minority who master these concerns and are willing to take the risk, Silk Road and its successors have forever changed how the internet can be used to source drugs. After all, buying drugs in the real world also involves considerable risk. For some, the online equivalent may prove more secure than trying to arrange a standard deal.

From one angle, buying drugs from Silk Road could be understood as a harm reduction strategy. On Silk Road, action can be taken if someone rips you off by providing sub-quality product: the buyer can rate the seller poorly and give a scathing review. Sellers with negative feedback are less likely to attract more buyers. While similar warnings can be provided through social networks in real-world drug markets, sellers can simply find new buyers without that knowledge of their dodgy deals. Silk Road provides a public reviewing system that could help people avoid adulterated or sub-quality product. The quality controls inherent in this publicly reviewed marketplace may also increase the purity of drugs that make their way into offline drug markets.

Silk Road FeedbackI also observed that some sellers provided harm reduction information alongside their product advertisements. This screenshot shows a seller offering established harm reduction websites to buyers. In another exchange, I read that one seller would divide the research chemical they were selling into single doses as a free service to buyers, they just had to be prepared to wait an extra day or two to allow time for these divisions. With research chemicals which require only micro doses, this service could enable buyers who do not own their own set of scales to avoid overdose.

There are a lot of unanswered questions about Silk Road. The extent to which law enforcement can bring down a site like this is yet to be seen. Equally, the extent to which ordinary drug users will use this new technology is also unknown. Needless to say, if anonymous online drug markets do end up expanding into mainstream drug markets, they will pose a real challenge to existing drug laws and policies. Maybe this technology will be the catalyst for drug law reform if it becomes impossible to effectively police anonymous online drug markets?

How Will Supervised Injecting Facilities Affect You

What will supervised injecting facilities do to people who don’t use them?

Nothing.

But, you probably want a more convincing argument because:

You’re convinced that a SIF will spread disease and addiction and encourage drug use, or you say that a SIF will benefit you as it will prevent you from being exposed to injecting drug users. (I am working from the assumption that if you don’t care either way about SIFs then you probably won’t be reading this article – at the least, you’re probably not going to be offended that I’ve excluded you.)

So here’s why neither of these schools of thought have much nous.

“Supervised injecting facilities encourage drug use”

Premier Baillieu said in parliament today, ‘I don’t want to be in the business of sending messages to kids … that it’s okay to dabble in drugs’. Baillieu is opposed to SIF ‘based on observation and a detailed look at all of these issues’. Now, I’m not sure what he’s had a detailed look at but it isn’t the evidence.

I’m not going to regurgitate all of the statistics which show that SIFs are good on pretty much every measure. Because if after all of the years of these figures being made public you still have such an absurd view, you obviously don’t respond too well to evidence. So I’ll tell you a story, an example:

Supervised injecting facilities look like the image above. Do you think this environment looks attractive to kids? Do you think that they would look at this and think, ‘Hey, I wanna go shoot some smack?’. No, I didn’t think so. And this is when the place is empty! Imagine it with five or so smelly, homeless, sad-faced individuals sitting on those chairs – do you think it would become more or less appealing? Do you think that this image glamorises injecting drug use?

But not all injecting drug users are homeless and smelly you say. I KNOW. But the ones who aren’t homeless are really unlikely to stroll down to the supervised injecting facility to hang out in this clinical environment when they can shoot in the comfort of their own home. That’s the point – the people who access SIFs aren’t just drug users, they’re typically homeless individuals with nowhere else to use. So why use at all? Well, as one welfare worker I’ve interviewed put it, ‘… I would far rather be sleeping on the streets stoned than sleeping on the streets straight’.

And while we’re on this point, think about the homeless people you’ve seen in your time – do they glamorise injecting drug use? Do you think young kids see them and think ‘that’s what I want to do when I grow up?’. I doubt it. But you know what, even if you think that this is what happens – that kids see drug users and are influenced to become a drug user – irrespective of the failure in your logic, it’s another reason why you should support supervised injecting facilities – it keeps the drug use behind closed doors.

And here’s some other points – most people are scared of needles. The idea of injecting anything is not appealing. Facilities like that shown above won’t change that. And there’s that other issue – people who don’t use the facility are unlikely to know what it is, or where it is, or why it is.

And really Baillieu, you don’t want to send off the message to kids that it’s okay to dabble in drugs? Then make all government events alcohol-free and ban alcohol sponsoring and advertising.

Then there’s those of you who support SIF and really push the ‘it improves the community’ point.

Well, yeah. But, er, no.

Yes, certainly, it’s better people use in supervised facilities than in public toilets, and it’s certainly good to prevent the public from stumbling upon the body of a person who has overdosed in such circumstance. But, given how infrequent it is that a member of the public stumbles upon a body it’s probably not the best selling point, it’s not an experience most members of the electorate can relate to.

But I don’t think a SIF needs to have benefits given that it poses no harms. I also don’t think that we need to see people reducing their drug use to measure the success of SIFs. We can’t expect a reduction in drug use while we are not addressing the issues that have lead to the drug use. The role of the SIF is first and foremost to provide a space, with medical supervision, where injecting drug users can avoid death, overdose and blood borne viruses.

The role of the SIF is first and foremost to provide a space, with medical supervision, where injecting drug users can avoid death, overdose and blood borne viruses.

I also don’t think that SIFs will eliminate public drug use entirely, but I think it will reduce the number of people using alone in public. And given that accidental overdose is far more likely to happen when one is alone, this is a good thing. But, it may not benefit you. For instance, a group of people who hang out in a public housing estate on weekends and sneak behind the cars to use before returning to the communal area to friends are probably going to keep on using like that. You see, they feel safe. They have friends there to monitor for overdose and keep an eye out for police, so they don’t have to go anywhere. So, if you’re a tenant in those flats who feels uncomfortable walking through this area, that’s unlikely to change. On the upside, these people are very conscientious about safe disposal so you needn’t worry about standing on dirty syringes. And given that there’s a group of them, you won’t be left to find a dead body.

Another reason that we will keep on seeing ‘drug users’ on the street is that, as I’ve pointed out, the minority of injecting drug users who would access a SIF are those people who are homeless. So while their drug use may be moved indoors – they are not. Homeless people will still be homeless and you will still have to reconcile how we live in a country that is so inequitable (oh, you don’t think that when you see homeless people? Cold hearted person you are.).

Conclusion

So while I am not here telling you how you will personally benefit from supervised injecting facilities, here’s the facts:

  • They won’t harm you either
  • They won’t encourage drug use
  • They save other people lives
  • They prevent police telling a mother that her child’s dead body was found in a public toilet
  • They prevent the spread of disease through provision of clean equipment and advice on safer using
  • Ambulances are limited. Less ambulances attending street overdoses means more ambulances able to respond to you.

If they don’t affect you, but they might help someone else, then why not support them?

What Works

One of the questions I’m often asked when delivering training to drugs workers is “What are all the different needles for, and which is the best one to use”. Although in a perfect world there would be a clear answer this is rarely the case as each person and each injecting site is unique, the best answer I normally manage is to give loose guidelines.

Exchange Supplies in an attempt to make things a little clearer have produced a small guide to needles and syringes called “What Works”. The information included in this is incredibly robust, filling 50 pages. The guide starts with the usual advice around injecting being a dangerous activity and trying to convince people to smoke or snort their drug instead.

Each needle type is given two pages with a visual guide showing you needle length and gauge. This also covers the main uses for that needle and suggested alternatives that are colour coded to show the hierarchy of risk.

If you are injecting, the best needle to use is the shortest, thinnest one that will reach the site and enable you to inject without it breaking

For me the most useful pages are the ones explaining needle length, gauge (outer thickness) and bore (inner diameter). We’re also given a simple clear explanation of the risks of high ‘dead space‘ syringes. The guide also has a ‘flip out’ panel with all the needle lengths and gauges on to allow easy comparison.

Conclusion

I really like this guide and think that at the very least every needle programme should have one available, better still every drugs worker, activist and health educator should have them.

However this doesn’t appear to be the target audience. It’s clearly written as a guide to be given to injectors, but because of the high quality of the publication the price of the guide (£2.53 each when ordering 100) in my opinion is likely to be seen as too high for many services to consider this with current budgets the way they are. Although I’d happily recommend those services with good budgets supply them.