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Author: Nigel Brunsdon

Avoid Track Marks & Avoid HepC

In 2009 I arrived in London to work on the Staying Safe project at the London School of Hygiene and Tropical Medicine. This international project was originally devised in New York and I had previously been collecting data for it at the Sydney site. Staying Safe is a HCV prevention project which aims to learn from the experts – people who have been injecting for the long term and have not been exposed to HCV. We take a broad approach, conducting two interviews with each participant, the first being a life history interview from which we construct a computer generated timeline. This is then taken back to the second interview and is used to aid recall when discussing injecting practices, environments and social networks over time.

Before I left Sydney I interviewed 13 participants and to date in London I have interviewed 31. I had also worked on other projects talking to people who injected in Sydney and had a decade ‘field experience’ in New Zealand injecting drug user networks. What struck me in coming to London was the profound difference between the Sydney and London participants in regard to the state of their veins. True, the Sydney cohort had, on average, a 10 year shorter injecting history than the London participants (11 years as opposed to 21) but the London participants also described losing the use of their veins much quicker in their injecting histories than I had ever heard of in New Zealand and Sydney. So what are the reasons for this? I surmise that it is due to the difference in the heroin injected in Australia and the UK, the overuse of citric and additional injecting of crack which can numb the injecting site and make it easier to miss. However, us New Zealanders use citric in cooking up our gear and, on the whole, retain venous access for years; also many of the London participants who experienced rapid venous collapse only injected heroin (not crack).

Questions about why aside – what relevance has this got for HCV prevention and harm reduction interventions in general? Well, what has been a major finding of the Staying Safe study to date is that the safe injecting practices and other protective factors that helped people to avoid HCV were not necessarily motivated by BBV avoidance, but by more pragmatic concerns such as avoiding track marks (for those early in their injecting careers – particularly the Sydney participants), maintaining venous access (primarily London participants) and facilitating a pleasurable injecting experience.

Avoiding track marks

Used works = blunt works. Blunt works → scars = stigma

The Sydney participants were aged from 25-37 (average 31) and had been injecting for an average of 11 years. All were HCV antibody negative. Significantly, a primary motivator for participants not to share works, or re-use their own, was in order to avoid track marks (injecting-related scars) and associated stigma. This was especially relevant early in their injecting trajectories before many had heard about HCV or even HIV. For example, Lisa, who started injecting 20 years ago in a Sydney street based drug scene, said: “[I didn’t share] because I didn’t want scars to start off with and blunt needles give you scars … And that was a massive thing to me ’cause I didn’t want to go home and embarrass my family.”

Participants were similarly motivated not to reuse their own works in order to reduce track marks. As Phil says: “[I didn’t reuse because needles] getting blunt mainly and just leaves scars. Also that picture in the clinics and all that. Once, twice, three, five times used and you see it wear down”. Phil refers to a poster depicting magnified pictures of reused needles (see pic). This poster can be seen as an example of health promotion that works, in that it was spontaneously mentioned by a number of participants and appeared to motivate them to reduce the reuse of their needles and syringes. Now, while reusing one’s own needles and syringes does not, in itself, constitute a HCV risk, it can lead to the unintended sharing of syringes if, for example, they get mixed up or misplaced.

Avoiding vein damage

Used works = blunt works. Blunt works →vein damage = difficulty injecting

Now, for the London participants, used works were also conceived of as blunt works, but here the implication of using blunt works was vein damage and associated difficulty injecting. The London participants were aged between 30-53 years (average 41) and had been injecting on average for 21 years. They experienced substantial venous damage and being able to maintain their veins and get a (relatively easy) hit was a strong motivator to use new works. As Andy says: “I’m not going to use a pin more than once, once it’s punctured my skin twice that pin is dead now because it’s blunt, therefore I can’t share anyone else’s because it’s blunt already. That was one of the reasons, that was the main reason.”

Significantly, as in Sydney, participants also spoke of being motivated to use new works early in their injecting careers before they may have heard of HCV or HIV as they wanted to maintain venous access and the ability to get a quick and easy hit. Avoiding vein damage also lessons HCV transmission risk. A common practice among the London participants, when they couldn’t get a vein, was to transfer the mix into another syringe and/or re-cook and filter a mix which has become bloody and congealed. This can lead to increased contamination of spoons, filters and water as well as increase the amount of used works in the injecting environment.

‘Building capacity redressing neglect’

A number of the London participants had transitioned to groin injecting, however many were fearful of making this move and expressed a desire for help and advice about maintaining and finding other veins to use. The inability of the Lambeth based participants to access this help represents valuable missed intervention opportunities. For those who tried, encouragement to cease injecting only caused further alienation and disengagement from services. I asked Tony if he had had any help with vein care or access. He replied “No. You know, for you to ask, no, because they will immediately go, oh well, try smoking. And you know, they don’t get it. Fucking hell, you know, smoking!”

Engaging with pleasure

Sterile works = sharp works. Sharp works = less scarring & a quicker hit

Getting a quick hit is pleasurable, and there is often nothing more desperation inducing than poking around for a vein, ever conscious of the risk of the mix coagulating and losing your hit. The pleasure of injecting and drug use in general seems to be somewhat of the elephant in the room in drug services with all speaking the script of ‘misuse’, ‘harm’ and ‘recovery’. Sure – people who generally come into contact with drug services are often encountering substantial personal, social and economic problems to do with their drug use. This does not negate the pleasurable experience of use for some, and the pragmatic concerns that people who inject have regarding the maintenance of their veins.

This may be controversial, but perhaps it is time for harm reduction interventions to take a leaflet from HIV messages aimed at MSM (men who have sex with men) which actively engage with notions of pleasure in their marketing, and think about the social marketing of syringe use with messages about the capacity for sterile – therefore sharp – works to prolong venous access, minimise unsightly scarring and decrease the need for a transition to groin injecting. These messages have the potential to resonate with injectors who are jaded or confused by HCV prevention messages, and may provide a hook with which to provide other protective interventions.

Yes, using clean works is not completely sufficient in HCV transmission avoidance, as other equipment can be a primary vector of transmission. However, providing non-stigmatising support and advice regarding vein care and venous access can provide an avenue for the dissemination of information about keeping other equipment separate. It was apparent from talking to participants that pragmatic interventions related to facilitating pleasure and ease of injection and avoiding scars and stigma had the potential to be perceived as more appealing and relevant than HCV based messages. For some, HCV was perceived of as inevitable, and/or of little short term consequence. HCV risk could also be difficult to conceptualise when there was no visible evidence of blood or contamination in reused works, for example. This is not to say that the people I spoke to did not care about HCV, however, it was evident that many of their protective practices were motivated by more pragmatic concerns, such as avoiding injecting related scars, and maintaining venous access. By addressing these pragmatic concerns, and not negating the pleasurable aspects of use, harm reduction interventions may engage injectors in a way that a focus on a seemingly nebulous abstract concept as HCV might not.

In this article I’ve provided a brief summary of a paper I presented at the recent IHRA conference in Beirut. I’d like to acknowledge the co-authors of this paper and Chief Investigators of the Staying Safe project from which the findings are drawn: Professors Tim Rhodes, Carla Treloar and Lisa Maher.

Guide to Developing and Managing Syringe Access Programs

In late 2009, harm reduction advocates and drug users in the United State achieved a major victory – the lifting of the federal ban on funding for syringe exchange. The ban, which had been in place for some 20 years, meant that zero federal dollars could be spent on syringe access – forcing syringe access programs (SAPs) to piecemeal together different private and local sources of funding in order to implement one of the simplest and most effective forms of HIV prevention available for drug users. But the federal ban did more than just deny access to money from the country’s largest (and wealthiest) public health, substance use and disease control agencies: it also placed moral and political veils over the issue of drug use and sent a message attempting to delegitimize syringe access programs altogether. Advocates and activists, drug users and their allies, were forced to fight harder for every dollar (and every syringe) while HIV and hepatitis C continued to spread needlessly.

Despite the combined effects of the federal funding ban, the country’s well-known “war on drugs” ideology and the pervasive stigma associated with drugs, people who use drugs and their allies have a long and proud history of providing syringe access services throughout the U.S. From underground programs operating outside the law to small and large non-profit organizations to services run by city and state government health departments, SAPs sprang up across the country as a major component in the landscape of prevention services for drug users.

Following the success of our campaign to lift the federal ban, the Harm Reduction Coalition (HRC) quickly moved to develop pragmatic and comprehensive guidance on developing and managing syringe access programs based on expertise and lessons learned over the years. While there have been similar manuals developed by other health organizations and syringe access providers throughout North America and the rest of the world, HRC began receiving an increased number of requests for technical assistance after the ban was lifted and felt a responsibility to create a document that represented HRC’s perspective on SAP development. We wanted to create a document that would be honest and straightforward in its approach, providing concrete practice suggestions while still encouraging the creativity and flexibility that makes SAPs most successful. HRC also recognized that the U.S. Centers for Disease Control and Prevention (CDC) would be putting forth their own program guidance, and we hoped to have as much influence on that process as possible.

The result

HRC SAP CoverThe result is our Guide to Developing and Managing Syringe Access Programs now available in both hard copy or as a downloadable PDF. The manual walks the reader through the process of starting a SAP including: Planning and Design, Operational Issues, Organizational Issues, External Issues and Population-Specific Considerations. There is also an extensive appendix with additional information and links to resources. Although the guide is written with a particular attention to the needs of U.S.-based SAPs, we hope the manual can serve as a valuable resource on a global scale. The entire guide can be viewed, downloaded and ordered on HRC’s website.

As we write in the manual, “An SAP is more than a social service or public health intervention. It is a creative social justice project that has the potential to challenge your world-view and take you to new and exciting places.” HRC is anxious to see where it takes you. We welcome your comments and feedback.

In late 2009, harm reduction advocates and drug users in the United State achieved a major victory – the lifting of the federal ban on funding for syringe exchange. The ban, which had been in place for some 20 years, meant that zero federal dollars could be spent on syringe access – forcing syringe access programs (SAPs) to piecemeal together different private and local sources of funding in order to implement one of the simplest and most effective forms of HIV prevention available for drug users.· But the federal ban did more than just deny access to money from the country’s largest (and wealthiest) public health, substance use and disease control agencies: it also placed moral and political veils over the issue of drug use and sent a message attempting to delegitimize syringe access programs altogether. Advocates and activists, drug users and their allies, were forced to fight harder for every dollar (and every syringe) while HIV and hepatitis C continued to spread needlessly.

Despite the combined effects of the federal funding ban, the country’s well-known “war on drugs” ideology and the pervasive stigma associated with drugs, people who use drugs and their allies have a long and proud history of providing syringe access services throughout the U.S. From underground programs operating outside the law to small and large non-profit organizations to services run by city and state government health departments, SAPs sprang up across the country as a major component in the landscape of prevention services for drug users.·

Following the success of our campaign to lift the federal ban, the Harm Reduction Coalition (HRC) quickly moved to develop pragmatic and comprehensive guidance on developing and managing syringe access programs based on expertise and lessons learned over the years. While there have been similar manuals developed by other health organizations and syringe access providers throughout North America and the rest of the world, HRC began receiving an increased number of requests for technical assistance after the ban was lifted and felt a responsibility to create a document that represented HRC’s perspective on SAP development. We wanted to create a document that would be honest and straightforward in its approach, providing concrete practice suggestions while still encouraging the creativity and flexibility that makes SAPs most successful. HRC also recognized that the U.S. Centers for Disease Control and Prevention (CDC) would be putting forth their own program guidance, and we hoped to have as much influence on that process as possible.

As we write in the manual, “An SAP is more than a social service or public health intervention. It is a creative social justice project that has the potential to challenge your world-view and take you to new and exciting places.” HRC is anxious to see where it takes you. We welcome your comments and feedback.

Don’t Forget the Process

Recently I’ve been reading and listening to some interesting talks on the advice that we give alongside syringe delivery. I think that in many Needle Programmes (NSP) workers are overly focused on the equipment an injector chooses to use rather than on the process of injecting.

Of course the equipment used is very important, syringe choice can have a direct impact on risk factors relating to blood borne virus or injecting injury. But having a focus just on this aspect leaves people at a greater risk, and does nothing to challenge existing bad practices that are common in some communities of injectors (just think how often someone mistakenly thinks licking a needle is a good idea).

Change of focus

Well not so much a change of focus, but rather making sure we don’t forget to talk about the rest of the process. While I was following the latest IHRA conference online I saw the presentation that Greg Scott gave which included a lot of talk on processes.

So why should we focus on the process?

Well, mainly because that’s where things go wrong.

Even with a good supply of equipment out there if people aren’t always aware of what they are doing at each step then there will always be a risk of viral or bacterial contamination of equipment. On a recent podcast from the Harm Reduction Coalition Allan Clear spoke to Robert Heimer who was calling for a focus on processes rather than equipment, he spoke about an injecting session where two people batch shared a solution each using their own equipment but using the same ‘cooker’. Although there was a clear risk of contamination both of the people afterwards stated that they hadn’t been at risk because they used their own works.

If clear from the above description that in this situation having identifiable syringes wouldn’t have significantly reduced risk. But having people talk about processes may have highlighted one for them.

Stages of an injection

In Greg Scott’s presentation he goes though the stages of injecting, this is something all drugs workers and peer educators need to think about when discussing injecting risk with people:

  1. Getting stuff ready
  2. Preparing drug for use/cooking
  3. Getting the drug into the syringe
  4. Finding a vein
  5. Getting the skin ready
  6. Puncture
  7. Post puncture

As I’m sure you can see, each of these stages would could be a discussion itself, and each stage has more than ample opportunity for things to go wrong. This is especially the case where people are using with friends/partners. I’d also add to the list above the stage of ‘Clearing up and disposal’.

We need to remember that not every injecting episode happens in a nice clear space with plenty of time. The advice we give and the discussions we have should be based in the real world. We need to ensure we talk to people about what they are actually doing from day to day rather than just what equipment they are using to do it with.

The ‘J’ Word & Journalism

I have a confession to make. I’m a Twitter junkie. As soon as I say that people know what I mean. The word, ‘junkie’ is an evocative word, that paints a picture of compulsive behaviour that interferes with other facets of the ‘sufferers’ life. This is why journalists use the word junkie. It provokes and paints a picture with a single word. When used to describe people who inject drugs, the ‘j’ word presents a two dimensional cartoon. An image of an emaciated person prepared to rob his or her mother to get their ‘fix’. It is stereotyping of the worst type. Fortunately I am not the only person to think so.

The excellent publication, The media guide to drugs: key facts and figures for journalists (DrugScope 2011) states:

The world is shaped by the language we use. Consider the confining impact of a word like ‘junkie’. The person is dismissed, written off, blurred into a stereotype of defining a person by their action rather than who they are.

Despite this sage advice, in my homeland of Australia, the Australian Press Council reporting guidelines regarding drugs and drug addiction do no contain a single guidance regarding the use of stigmatising language, instead focussing on the prevention of dissemination of information that may encourage or enable drug use.

In western democracy our news media claim a role enshrined in the term the ‘Fourth Estate’ as guardians of the public interest, but is it really in the public interest to shame and vilify certain groups or individuals within our communities? The use of the word ‘junkie’ creates a sense of otherness, that somehow people who inject drugs are less than other people in the community. I would argue that not only is this not in the interests of the individual who injects drugs, but that it is also not in the interests of our communities.

The ‘j’ word kills people

  1. disparaging + offensive : a person who is addicted to narcotics and especially to heroin
  2. a person who gets an unusual amount of pleasure from or has an unusual amount of interest in something

When the media stigmatises people who inject drugs it reduces the likelihood that they will disclose their drug use to another, whether it be a family member or a service that is trying to reduce drug related harm. If they do disclose to a loved one that they inject drugs, subsequent media reporting only contributes to the distress that a family member may experience. Beyond the very personal experiences of stigma felt by drug users and their families, such reporting can only act as an impediment to meaningful discussion about how we can address drug related harms in our communities, and so people continue to die in often preventable circumstances.

What can we do?

Despite numerous services providing recommendations and information about how to report on alcohol and other drug matters in a responsible and non stigmatising manner there remain news media outlets that continue to stereotype drug users as junkies.

Thankfully, with the advent of increasingly accessible social media platforms, news media is no longer the exclusive domain of journalists and editors keen to sell some advertising space. These new platforms for social news allow us to take control of the message and portray people who inject drugs as well …people. As a sector we need to create news that is balanced and non-stigmatising and engage mainstream media outlets to do the same. We also need to challenge directly misconceptions and stigma by publicly questioning mainstream media representations of people who use drugs. Two great examples of this are the blogs Limit of Shunt and The Australian Heroin Diaries.

Most of all we need to insist that the ‘j’ word be removed from journalism. Search for articles, pick one, write to the media outlet. Ask them to stop using the ‘j’ word.

Stop Saying ‘Clean’

I’ve been thinking of this for awhile, I want to ban the word ‘clean’ from drug services, granted it’s only a word so you might think I’m just being picky, but words like this carry both a lot of power and a wide range of meanings.

Right I’m going to leave the stigma stuff for later on in the article, first lets concentrate on why I’m writing this article in the first place ‘clean needles’.

Clean Needles

We’ve all been guilty of it (yes, me as well) “make sure you’ve got clean needles” or “do you always use clean kit?”. It all seems perfectly fine, after all we know what we mean don’t we.

The only problem is, the word ‘clean’ means many things.

I clean the dishes, I clean my hands, I even (occasionally) clean my car. At no point are these sterile. If we continue to use the term clean when talking about equipment then we are going to have this confusion of language.

Instead we should be using (and getting people to use) terms like ‘new’, ‘unused’, ‘sealed’ or ‘sterile’.

Getting ‘Clean’

It’s rare for me to have a day at work without at least one person telling me that they’re ‘Clean’ or that they want to get ‘Clean’. Although I’m happy for them that they have got to a stage where they are either seeking or entering ‘Recovery’ (another word loaded with it’s own hidden meanings, arguments and history) the fact that they use stigmatising language like this is something that needs challenging.

Stigma?

The term ‘Clean’ is of course a wonderfully positive image, however the implication is that anything not clean is ‘dirty’. In this context that means that people on some level are still seeing other drug users as dirty, or if they lapse/relapse they’ll see themselves as dirty. It’s bad enough that tabloid media and a large chunk of the public stigmatise drug users, lets not add to this ourselves.

Is all stigma bad

As I’m sure many of you know there is a body of thought, mainly headed by people like Neil McKegany who seem to think stigma is something that can be a positive influence to change (See Neil McKegany’s article suggesting this in DDN 15 – February 2010, p14). The main points are that stigma may prevent people from starting to use drugs, and that people using them will be more likely to stop if people think they’re scum.

Stigma is something that can lead to hate crimes and assaults on drug users (something I’ve seen in the areas I’ve worked in. But it’s also something that can keep people feeling worthless within society. The UKDCP ‘Getting Serious about Stigma’ states in it’s conclusion:

…society has to look at itself, to begin to challenge the negative attitudes and barriers that can keep those with addictions and drug dependency problems locked into dysfunctional lifestyles. The public needs to understand better the nature of addiction and the routes out of it.

If society is serious about promoting recovery from drug problems it has to get serious about challenging stigma.

Getting Serious about Stigma UKDPC

We need to stop adding to the stigma, we need to stop using the word ‘Clean’.

Related link

Abstract of a randomised study showing there is a difference in the way workers see people depending on the language used.

Cold Weather

The UK in currently in the grip of cold weather. In this article I’m going to look at both the steps services can take to support people during the current cold snap and hopefully some advice for people who are forced to spend time outside in the snow. Plus how this will improve the relationship with visitors and give staff another great set of engagement tools.

It’s all well and good for the media (and some services) to give advice on how to stay safe on the roads during cold weather. But in my opinion there has been a lack of advice on how drug services can respond to low temperatures when supporting people.

For people who are sleeping rough, or for any other reason having to spend lots of time outside getting warm is incredibly important, even for just a short time. So what can a drug service do to help?

Provide some of the following in the service:

  • Give people hot drinks – coffee, hot chocolate etc are great for warming people up (and for warming up hands). I know some services that refuse to give hot drinks to people on ‘health and safety’ grounds, in case someone uses a hot drink as a weapon against staff, simple answer to this is don’t hire staff that make people want to throw coffee at them
  • Instant noodle meals – something as cheap as a 60p dehydrated meal that just needs boiling water added will be a welcome site to someone who is sleeping rough
  • Dry socks – socks, hats and gloves are all easily available from places like the Pound shop (you could even pick up some of the noodle based meals mentioned above) I’d even suggest buying in some ladies tights for people to wear under their clothing during cold weather, something my father used to do when he was night fishing (at least he said he was night fishing)
  • Dry blankets – granted these would cost slightly more money but I’d suggest working in partnership with local homeless charities who are more likely to keep these as standard. (These kind of partnerships are essential to drug services)
  • Clothing – in many places I’ve worked staff bring in spare clothing for people to have if their clothes get wet when sleeping rough
  • Cardboard – why waste the boxes that deliveries of equipment come in, cardboard acts as a great insulator between you and cold ground. In fact if you can find them sleeping on wooden pallets or the plastic crates used for carrying bread (which can often be found dumped behind supermarkets) are great ways to keep off the ground
  • Plastic sheeting/bags – to go under any cardboard and other bedding to avoid moisture coming through. Sealable bags are also great (the sandwich bags) as these can be used to keep important papers etc dry
    Wood – one idea could be to buy a big bag of kindling and split this into smaller bundles to give people to help them get a fire off to a good start, but make sure if you give people wood that you also give them

All these can act as a great set of engagement tools, the time taken to make people a noodle meal or for them to drink a hot drink not only will allow them to get warm, but is also a great chance to talk to people who don’t normally hang around to chat. Which of course leads onto the next important area to think about. Important information staff should give people (and know themselves):

  • Effects of cold on veins – becoming cold will cause veins to appear deeper and finer, this is because the body in an attempt to get warm will move more blood to the body’s core. This is something I’ve covered previously in the Raising a Vein series
  • Food and shelter – knowing the location of all the homeless shelters, soup kitchens and other places to get free/cheap food, don’t just think of the obvious ones. Places like Sikh Gurdwaras will usually give free food to any who need it
  • Where to sleep – having a good local knowledge of where its best to sleep is really important, you can get this from talking to people who come into the service, but one of the best ways is by getting out there and talking to people, grab a flask of coffee and go out at night on outreach, I can tell you from experience this is a great help for both people sleeping rough and for service engagement. Make sure you tell people to avoid sleeping near water in cold weather, the moisture in the air can make the temperature 2-3 degrees colder, last week 2 people died from exposure sleeping next to a river in Ireland
  • How to keep warm – as mentioned above cardboard is a great insulator when sleeping outside, but things like newspaper pushed in-between layers of clothing is amazing for keeping warmth in. You can also make a long lasting heat by putting bricks around a fire and then wrapping them in a blanket to use as a makeshift hot water bottle (if you’re building a fire be sure to contain it, and never build fires in abandoned buildings)
  • Clothing – clean clothing is warmer than dirty clothing, its also important to keep clothing loose and with plenty of layers, wearing a hat is one of the best ways of keeping the body warm
  • Avoid alcohol – alcohol gives a false sense of warmth while actually lowering body temperature, so under no circumstances drink alcohol or give alcohol in an effort to warm people up

With temperatures dropping below -10 centigrade we are likely to see more serious problems developing though. Please make sure you are aware of the symptoms to look out for.

Hypothermia

Hypothermia can lead to death, it’s caused when the temperature gets so low that the body looses heat faster than it can produce it. Main symptoms of hypothermia are shivering, confusion, lethargy, weakness, apathy and pale skin. There may also be slurred speech and memory loss. Please note how these can easily be mistaken for the normal signs of drug use.

Frostbite

Frostbite is where skin tissue is damaged symptoms include pale/grey, waxy skin that’s cold to the touch, numbness, localised pain, swelling, blistering. In both cases medical attention needs seeking immediately, if you suspect hypothermia then this should be treated as a medical emergency (note: people with frostbite often also have hypothermia).

Finally

Don’t just give this kind of advice to homeless users, but also to people who’s situation may involve them having to be out of the house for long periods during the day (example, one young guy I knew whose parents would lock him out the house to prevent him stealing during the time they where at work).

It’s important to allow people the time they need to get warm at this time of year. It’s a great way to engage with people and provide the time you need to do harm reduction work. But most importantly we should be doing this because it’s the right thing to do, and if we don’t then more people will die this winter.

Accidental Sharing

Accidental sharing risks, those times when in all the confusion of the moment people aren’t quite sure if the needle they intend to use is their own or not.

I recently had an email discussion with Andrew Preston following the sharing workshop I delivered at the NCIDU, he was concerned that from the presentation it looked like I hadn’t talked about sharing accidentally as a ‘reason’ for sharing. Now I’m pretty sure I did cover it in the talk, but the presentation itself was aimed more at reasons ‘choose’ to share.

But I understand Andrews concern, and I think I’m being guilty of something I’m constantly warning others against, that’s looking at the fringe risks and abstracts rather than the basics. We know that accidental sharing is the most common, in Avril Taylor’s study it was shown to be twenty to thirty times more common. This was the reason she advised people find ways to identify their own syringes (hence the development of coloured syringes like Nevershare or Unisharp).

So if you’re a worker in a drug service or an injector, remember that all the talk about not sharing surfaces, about not sharing spoons, not sharing filters is great and very important. But never give this advice at the expense of talking about the basics. For many people the injecting environment is a chaotic one, with preparation areas that have multiple needles and used equipment around, we need to make sure that its’ as easy as possible for people to ALWAYs have a new unused set of works for every hit.

Things that can be done

Here are some suggestions on minimising the risks.

  • If you can manage it NEVER reuse needles or barrels, if you ALWAYS use a new one then you can be sure it’s yours.
  • If you HAVE to reuse then use identifiable syringes like Nevershares/Unisharps, or if you don’t have access to these then use systems like each person in a group having an assigned number and scrubbing this off the side of the barrel.
  • Using reduced ‘dead space’ syringes where possible (for more on the increased risks of high dead space see Jamie’s article about Dr. William Zule’s research).
  • Making sure people take ‘emergency needles‘ to minimise the need to ever re-open a sharps bin to reuse old needles.

Responding to Blue Lights

In this article I would like to provide advice, information and a suggested ‘action plan’ for practitioners who may have concerns about existing/planned blue lights in their particular area/setting.

At the 2010 National Conference on Injecting Drug Use (NCIDU) I organised a workshop session that was concerned with the issue of fluorescent blue lights in public conveniences. In an earlier article on Injecting Advice, I previously outlined the way in which such environments can amplify particular injecting harms and behaviours (such as groin/neck/peer injecting) and emphasised that injecting under these conditions is based almost entirely upon ‘touch’ rather than ‘vision’ (i.e. because injectors, literally, cannot see what they are doing in blue light environments). These conclusions were drawn from empirical research that was conducted in the city of Plymouth (UK) during 2006-2009 (Parkin and Coomber 2010).

In addition to these injecting-related harms and hazards are the seemingly arbitrary decisions made by local authorities and other agencies to have such lights installed on a national and local level; in which choices to install blue lights are apparently based only on assumptions that they are successful in preventing injecting drug use from occurring in relevant environments. However, there is no known publication, report or research that demonstrates fluorescent blue lights as an effective form of drug prevention, yet they continue to be found in settings throughout the UK on a regular basis.

The widespread introduction and popularity of fluorescent blue lights therefore poses particular challenges for harm reduction advocates and practitioners. This challenge relates to:

  • The absence of any ‘proof’ to demonstrate that blue lights do actually prevent injecting drug use from occurring in affected settings.
  • Findings that conclude they actively establish environments for particular forms of harm and hazard to take place.

It was therefore due to this challenge that I organised the workshop session in order to inform a ‘standardised’ harm reduction response to any current/planned fluorescent blue lighting in local settings on a national basis.

In this article I would like to circulate the outcome of this workshop in order to provide advice, information and a suggested ‘action plan’ for practitioners who may have concerns about existing/planned blue lights in their particular area/setting. These suggestions were obtained from an interactive discussion/focus-group session with 7 delegates that attended the workshop – and who each approached the issue from their own particular profession. Although the session had been planned to accommodate a greater number of participants (including service-users), I would like to thank each delegate that contributed to this workshop and for their assistance in the development of the following action plan.

In short, this action plan aims to challenge decisions to install fluorescent blue lights in any setting – and may be utilised as either a reactive, or proactive response to blue light decisions.

Proactive Response (to any installation planned/proposed by local agencies)

  1. Identify the relevant agency responsible for planning blue light installations
  2. Request meeting to discuss proposed installation
  3. At meeting, determine why such lights are to be installed (e.g. increased amounts of drug
  4. related litter?) and request detail on how they are to be evaluated
  5. At meeting, also request any evidence to illustrate the efficacy of blue lights in preventing injecting drug use (from any setting)
  6. Also, request data that illustrates blue lights as an example of ‘evidence-based’ good practice
  7. If there is an evidence base of increased drug use at the proposed site of installation, request consideration for more ‘enabling’ harm reduction focused intervention (for example: discrete placement of drug related litter bins; outreach work with targeted intervention at site concerned)
  8. Provide a summary of the findings relating to the harms associated with injecting drug use in blue light environments (a copy of the paper outlining these can be obtained via email and/or from the summary here on Injecting Advice)
  9. Following any responses to each of the above, refer agency to Department of Environment, Food and Rural Affairs (DEFRA) 2005 report ‘Tackling Drug Related Litter: Guidance and Good Practice’ Report, that clearly recommends (2005, page 36)

    ‘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’.

  10. Ask the relevant agency to consider the annual costs of lighting and if this cost may be used for other more constructive, targeted intervention in the site concerned (e.g. aimed at injecting drug user ‘participation’ rather than displacement/prevention of injecting drug use)

Reactive Response (to any installation already in place)

  1. Identify the relevant agency responsible for installing blue lights
  2. Request meeting to discuss existing installation
  3. At meeting, determine why such lights were installed (e.g. increased amounts of drug related litter?) and request how the situation may have changed. Request information that may demonstrate a ‘prevention effect’ and seek information how others (i.e. non-drug users, members of staff, general public) may have been affected by the lighting
  4. At meeting, request evidence to illustrate the efficacy of blue lights in preventing injecting drug use (from any setting)
  5. Also request data that illustrates blue lights as an example of ‘evidence-based’ good practice
  6. If there is evidence of continued drug use at the site of installation, request consideration for more ‘enabling’ harm reduction focused intervention (for example: discrete placement of drug related litter bins; outreach work with targeted intervention at site concerned as more appropriate harm reduction intervention)
  7. Engage with members of the public attending sites containing blue light installations; obtain their views and attempt to evaluate from their perspective (also include any relevant employees working in such sites)
  8. Provide a summary of the findings relating to the harms associated with injecting drug use in blue light environments (a copy of the paper outlining these can be obtained via email and/or from the summary here on Injecting Advice)
  9. Following any responses to each of the above, refer agency to Department of Environment, Food and Rural Affairs (DEFRA) 2005 report ‘Tackling Drug Related Litter: Guidance and Good Practice’ Report, that clearly recommends (2005, page 36)

    ‘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’.

  10. Consider the annual costs of lighting and if this cost may be used for other more constructive, targeted intervention in the site concerned (e.g. aimed at injecting drug user ‘participation’ rather than displacement/prevention of injecting drug use)

Advice to people who inject drugs

  1. Provide as much information as possible relating to the potentially harmful effect of blue lights upon injecting practice (again, these are described in the above paper available via email and/or from the summary on Injecting Advice)
  2. This could be assisted with an ‘in-house’ leaflet designed by local harm reduction agencies and circulated with injecting paraphernalia that addresses specific settings (i.e. a locally relevant information sheet)
  3. Alert service-users of all blue lights in area/planned and explain why they may have been installed
  4. Request service users find alternative, safer places to inject and to avoid visiting blue light areas where possible
  5. The best advice here is not to inject under blue lights; regardless of individual injecting ability or length of injecting career
  6. If decisions to install blue lights relate to increased amounts of drug related litter, engage with service users about the issue of safer discarding practice

Finally, I would be very interested in any feedback from any practitioners/ service-users that use this guidance in responding to blue light installations and particularly interested in how harm reduction challenges were received by the relevant agencies.

Injection by Others

Usually this topic would be more about the increased risk of vein injury, or the fact that injection can often be used as a control mechanism. But this time I’m going to focus more of the way I see injecting another person as a type of sharing behaviour, especially within trust relationships.

Who injects who

Normally we of course think of this as being an issue with a male partner injecting a girlfriend or wife, but remember that this can often be reversed with the woman injecting her partner. We even see this in other trust relationships like friends injecting each other, or more experienced injectors showing someone how to inject.

Another time we often see this is with steroid injectors who lack either the knowledge on injecting, or who have been advised to inject in the glute, but lack the flexibility to rotate their body enough to get this site, although I’m not going to specifically discuss the issues around this in todays article I will return to this at a later date.

Control or need?

We know that injection can often be used as a form of control (ie “you need me because I’m the only one who can find your vein”) but this can still be in the environment of a trust/loving relationship. It may not even be perceived by either person as a form of control.

But you also have to understand that injecting another person may be seen as helping, if a friend or partner can’t get a vein, it may be that there will be less vein damage caused by a more experienced or ‘calmer’ person performing the injection. Of course from a worker point of view this is something we can never recommend because of the legal issues raised if someone then dies following an injection by someone else.

BBV risk

Part of the reason I still see this as a ‘sharing issue’ even when its not the actual equipment being shared (tourniquets, needles etc) is because there will always be a quantity of blood involved. If you’ve see the footage from Avril Taylor’s research into injectors in Scotland then you’ll know that fingers are often used to wipe away blood from injecting sites. Add to this that hand washing is still often all too rare and we have a possible route for blood borne virus transmission.

The bigger problem

For me though there is a far larger problem. What happens when the relationship ends. This could be because of a breakup, a partner overdosing, going to prison or even rehab. At this point we are left with a vulnerable person whose route of choice is injecting, but who doesn’t have the technique to inject themselves. I’ve seen far too many young women who have arms full of abscesses in this situation, or people who start having inappropriate abusive relationships based only on the fact the other person is willing to inject them.

It’s at these times that we need to do ALL of the following:

  • Rapid access to treatment – traditionally we have prioritised people injecting in their neck, pregnant women etc when it comes to substitute scripting. I feel that we need to see people who have been injected by others in the same risk group and need to be able to get scripted or into rehab fast.
  • Route transition interventions – we have to have access to foil within NSPs, in the UK this is still of course illegal under Section 9a of the Misuse of Drugs Act but it needs to change. Some services have letters from police stating it not a policing priority, and some are supplying foil without these. But we all need to push for a law change. However learning to use foil can take a while.
  • Teach people how to better inject – unless we have VERY rapid scripting or someone already has a good smoking technique then they are likely to inject at the very least a few more times, services need to make sure their staff are competent enough to show people better injecting technique.
  • Self-detox advice – as with rapid access to treatment, we should also see this as an opportunity to shorten someones drug use career.

Conclusion

Injecting someone else or being injected by someone should be seen as a sharing behaviour, but we need to be aware of both the risks of BBV and the risks to someone when the relationship ends. At the very least we need to be giving people advice around handwashing and the legal issues. But we have to be ready to do so much more.

Sharing Workshop

This presentation was delivered to the National Conference on Injecting Drug Use (and later to the Irish Drugs Conference), the focus is why injectors may often ‘choose’ to share even knowing that this is a risk factor for BBVs.