06 September 2015

full circle

As anyone who has come on the KFx Novel Psychoactives course will know, early on we look at the known statistics about some of the newer compounds, and caution against the hype that suggests that we stand before an unstoppable wave of new compounds that have changed the face of drug taking.

Despite the "one new drug a week" type headlines, not all new drugs come to market in significant quantities. And of those that do, not many achieve lasting popularity. And none of the new pretenders come close to the popularity of mephedrone in its heyday.

We also talk a fair bit about Ecstasy on the course. Which of course isn't new or legal. But as the course stresses, it's tempting to chase after the shiny new Novel Psychoactives, whilst failing to recognise that traditional, time honoured substances like MDMA have never gone away and are now enjoying a renaissance.

One of the things asserted in the NPS course is:
"We need to keep abreast of NPCs. But we don’t need to lose sight of some fundamentals here:

• NPC use in part rose and peaked because the “right drug” – 4-MMC – arrived at the right time: pre-austerity, poor quality cocaine and MDMA.

•Some evidence that while a small number of people are dabbling with NPCs, the majority, given a choice, will gravitate back towards the “classics” of cocaine, MDMA, cannabis and speed."

It has been interesting therefore to see the results of the annual research on drug trends in the UK, the Drug Misuse - Findings from the 2014/15 Crime Survey for England and Wales and Smoking, Drinking and Drug Use Among Young People in England - 2014.

Smoking, Drinking and Drug Taking.... covers the age group 11-15. It shows small increases in the use in last year of cocaine, MDMA, LSD and Magic Mushrooms.The increases are very small - a fraction of a percent in each case. Cannabis, it is interesting to note, has dropped, with use in the last year at the lowest levels that the survey has ever recorded.

The Crime Survey covers the age group 16-59 but presents detailed information for 16-25 year olds too.
It shows similar increases in a number of drugs, but with more marked increases than the younger age range.
Use of the following drugs in the past year showed amongst 16-25 year olds increased in the 2014/15 survey.
  • cocaine:        4.8%, up from 4.2% the preceding year
  • Ecstasy:        5.4% up from 3.9% the preceding year
  • LSD:            1.2% up from 0.9%
  • Mushrooms: 1.5% up from 0.8%
Interestingly the Ecstasy and LSD figures means reported use of both drugs is at the highest levels for around ten years. Ecstasy use in last year was reported as 5.5% in 2003/4 and LSD last reached this level at 2001/02.

In order to try and determine if this is a statistical blip or the start of an increase in recreational drug use, we need to try and understand what is driving this modest increase.

The increase in Ecstasy use is likely, at least in part, down to improved availability and quality. Newer synthesis routes have resulted in an increase in production of high quality, strong MDMA pills. And Dark Web successors to the Silk Road, such as Dream Market, have made access to pills easier than ever.

The increase in LSD is marginal, but more of a suprise. Some of it may simply be down to improved access via the Dark Web.
Some media commentators have suggested that this is a retro trend linked to tastes in retro fashion.
It may also be some distortion where people have had used novel psychoactives such as 25i-NBoMe and or 1P-LSD and these have ended up recorded as LSD in the survey. Or if this and the increase in mushroom use are any more than a blip, it could signal a resurgence of interest in psychedelics.
The mushroom example is especially interesting. Now we don't know exactly what sort of mushrooms people are taking, based on the research. But this is one of the only drugs that isn't affected by global production issues. They grow and can be picked (illegally) in the UK. Legitimate commercial sales ended in the UK in July 2005, and resulted in a rapid drop in reported use in the UK that has persisted until this year. It may be again that supply via the Dark Web is playing a role here. But I await with interest the next set of figures to gauge whether this is a blip or something different.

Either way, and importantly, it does rather undermine the Government's repeated claims about the efficacy of drugs policy and the mantra that "drug use is down." Some drug use is clearly, according to the research, up.

My belief that MDMA use was something to focus on, and was probably more of an issue than many NPS, has been borne out by the latest research.

My other key concern has not (yet) come to pass. The levels of heroin use in the Crime Survey are lower than the preceding year, and, at less than 0.1% of 16-24 year olds reporting use in the last year, at their lowest ever levels.

These figures are probably more prone to problems with research than recreational drugs. Those who are most excluded from society, the homeless, vulnerably housed, and those incarcerated are under represented by the research. It may be that those who are most likely to be using heroin are also the most likely to be under-counted.

Other proxy indicators of heroin use, such as seizures and police activity are also affected by a number of other factors. Cuts to police funding have an impact on the policing of drugs, so changes in such indicators are not automatically indicative of reduced use.

Either way, i am not convinced that the downward trend will not sustain, and we will start to see an increase in levels of heroin use again. This is in part because historically heroin has followed a cyclical pattern of use and if the past trends hold true, it will start to increase again.

Other key factors that I fear will contribute to this upsurge are:
  • increased production in Afghanistan. According to the UNODC  production in 2014 was at its highest level ever, a situation liable to worsen with the pull out of western troops and increased instability in the country;
  • increased regional instability maximising opportunities for smuggling and distribution;
  • increasing homelessness and exclusion from wider society in the UK. In this regard, a key risk will be the ending of housing benefit to under 21s, which will increase exclusion of young people
  • increased access to all drugs via the dark web, increasing the prospects of new micro-dealing networks 
  • the banning of synthetic cannabinoids: while some people are using synthetics in place of "normal" cannabis, there is concern that some people who use them will move to (or back to) heroin when these compounds are banned. 
Once, we could have expected  street level drugs agencies to be the first place where any such increase in heroin use would show up. But even this can no longer be taken for granted. As services have been rebranded, it will be interesting to see the extent to which those at the start of their drug using careers access them. But we should watch Needle Exchange statistics very carefully as it is likely to be here that any upsurge in heroin use will show up first.

Although it is gratifying to get it "right" on the MDMA issue, i don't really want to be right about heroin. We are ill prepared for an upsurge in use so I very much hope to be wrong.





18 August 2015

Barriers to NSP Access: Safeguarding and Scripting Issues

This short series of blogs came about after a series of training courses where the issue of Secondary Distribution was discussed. This in turn led to discussion about why people were unable or unwilling to attend Needle and Syringe Programmes (NSP) in person, and strategies for addressing this.

In previous articles, we've looked at what Secondary Distribution is, why it may happen, its strengths and limitations and strategies to increase first person attendance.

This final piece looks at the issues of safeguarding and scripting/use on top and how they may deter attendance at the NSP.

Use on top:
To what extent do people on OST who use on top still use NSP effectively? Do we know? I suspect we don't have a robust evidence base for this but annecdotally, both workers and people on OST see the tension between using on top and compliance as a driver to disengage.

The situation has probably got more fraught as more and more agencies work within hub-and-spoke models. The location of multi-disciplinary teams under one roof undoubtely has efficiencies in terms of cost and may well help facillitate access to a range of other services.

It does also, however, mean the walls between NSP and other parts of the service are significantly lowered and in some places removed completely. A person on a script can quite realistically present to get injecting equipment and find themselves speaking to someone directly involved in their prescribing.

This situation has been exacerbated by the increasing political and commissioning pressure to be less tolerant of long term prescribing, the pressure to reduce, not increase peoples doses, and the increasing political unacceptability of people who are on OST also using illicit substances.

The combination of hub models and the pressure on services to get people "off" OST and not have people using illicit substances in turn creates a serious tension between the agency and people attending for NSPs and it's all too easy to see why people disengage.

There are theoretical, practical and idealistic responses to this situation. While in the current climate a "perfect" response may not be possible, improvements can probably be made to most services in this area.

Solutions:
1: Clear policy: the first requirement is that the organisation as a whole develops a clear position on use on top and that this is first communicated internally and communicated clearly to attendees both of prescribing and harm reduction services. Ideally, this position will be one that can work with use on top and injecting. But whatever the position arrived at, it needs to be communicated clearly and in a way that is intelligble.

2:Internal information walls:  We could revert to a model where NSP is separated out from other aspects of service. This ring-fencing of information within the NSP can reassure injectors that confidentiality is located within the NSP rather than the wider organisation.

However it is not always going to be a practical model and there are some significant drawbacks:
  • in practice there is not sufficient demand for NSP in many agencies to space and staff for a dedicated service; workers will invariably be expected to undertake other duties. And there is a very real risk that workers and volunteers who don't see people at other stages of their treatment journeys become less aspirational for the people they do see.
  • even when partial ethical walls are built around NSP, these are largely make believe. Workers may not formally share information but it will still leak between individuals and between teams. Workers may end up playing an unhelpful game where they have to pretend not to know things that they have learned informally. This is neither ethical nor therapeutic.
  • such walls means that essential information such as increased overdose risk, mixing drugs, lapse, social risk factors or under prescribing are not addressed properly.
  • If honesty is a key tennet of successful recovery, a model of NSP based on reinforcing deception is unhealthy and needs to change.
Harm Reduction Interventions: Some of the risks of use on top can be reduced by good harm reduction interventions. Indeed this is one of the reasons why we so want people on OST who do use on top to continue to engage with NSPs. Without this contact we lose the chance to deliver these potentially life saving messages.
  • overdose advice, such as not using alone, or reducing amount used on top
  • route change, including consideration of smoking on top
  • Naloxone training and provision


Proportionate responses:In order for people on OST and workers in NSP to be confident that they can share information about use on top, they need to be confident that this information will be used proportionately and appropriately.
A good starting point therefore is good internal policy, training and assessment tools relating to use on top and the appropriateness (or not) of continued prescribing in the face of use on top.

While there is significant political and commissioning pressure to deliver patients in "abstinent recovery" organisations can and should be confident in asserting that the package of care is client centred and therapeutic, even while working constructively with use on top.
With a clear understanding that it is:
(a) better to acknowledge use on top than ignore it and
(b) better to work with it than drive the person from the service
we can then communicate this to people who are on OST and continue to work with them, whether in prescribing or NSP.

Joint working responses:
Assuming that organisations are able to work pragmatically and proportionately with use on top, then it should become more feasible for prescribers and key workers to explore why it's happening and what the best interventions are. Use on top could be happening for a myriad of reasons including:
  • consistent under prescribing
  • low dose or overly slow titration periods
  • poor explanation about the reality of OST and limitations of a therapeutic dose
  • strong dependency on ritual aspects of injecting
  • use on top as a treat
  • use on top as a way of staying in contact with services
  • preferring to be maintained or reducing too fast
  • using on top at times of stress
  • difficulty in managing triggers.
In order to properly address and respond to use on top we need to acknowledge that it is going on and in a non-punitive way explore why, and solutions.

A range of interventions could be offered including:
  • switching from methadone to subutex
  • increasing dose levels
  • exploring issues around habituation on injecting process or self harming
  • identifying other rewards as a replacement for injecting
  • discontinuing or slowing a reduction programme
  • stress management strategies
Even if such an approach doesn't result in a reduction in use on top immediately, the fall-back position of harm reduction still means the person is retained in service and hopefully engaging honestly. We can still work to reduce harm and, importantly the person can still engage with both parts of the service openly, knowing that their situation will be discussed.


Safeguarding:

The other issue that has come up repeatedly as deterring engagement with NSP is the way questions about safeguarding are approached.

The ACMD report "Hidden Harm" highlighted the need to look in to parental status of what it termed "problem drug users," saying: "in order tocontinue to monitor this important consequence of problem drug use, we consider it essential to re-establish a reliable method of recording if a problem drug user has children and where they are living."

This put the onus on drugs agencies to, as a matter of course, ask about and record if a person attending a service has children, and look out for risks to them. The pressure to look in to this has been significantly increased as the issue of Safeguarding has risen up the agenda. The Statutory Guidance "Working together to Safeguard Children" stresses that "the child’s needs are paramount" and imposes an obligation on organisations saying "local agencies should have in place effective ways to identify emerging problemsand potential unmet needs for individual children and families. This requires all professionals, including those in universal services and thoseproviding services to adults with children, to understand their role in identifying emerging problems and to share information with other professionals to support early identification and assessment."

There's a huge tension between these statutory requirements and the need to offer an accessible service to people who inject drugs. Does the idea of the child's needs being paramount mean that exploring this should be prioritised over getting the person who injecting to engage with services in the first place.

It seems counterproductive to pursue such a measure if (a) it carries a very real risk that people will disengage from the service and in turn dissuade others from engaging and (b) where people are engaging, asking important questions about family structure and function is less likely to be elicit honest answers if it takes place too early before trust has been established.

So, again balance needs to be achieved to engage and retain people in NSP whilst also creating the opportunity and climate to explore safeguarding issues in an effective and productive way.

1: Joint training: Or for that matter any training. There's still a significant number of people involved in Safeguarding, especially within Social Services, who are inadequately trained around drugs. Most will, hopefully, have had basic drugs awareness training. However, unless there's been a greater exploration of harm redution, safer injecting, attitude awareness and treatment. Without such training, the risk is too many workers will have a knee-jerk reaction to encountering injecting drug use where children are a factor. Without the knowledge, skills and comprehension to assess the situation in a more nuanced way, it will hard for both NSP workers and people who inject to feel confident disclosing and sharing information.

The best way to achieve the desired outcome will be joint training where drugs workers, social workers and other key players can share training around safeguarding and drugs. This provides an opportunity for workers to develop all-important personal relationships and trust, clarify issues, problems and boundaries and look at shared solutions.

2: Policy development and communication: As with the use on top issue discussed earlier, agencies should develop a clear position statement which is understood by all staff and can be shared with NSP attendees in an clear and intelligble way. It cannot and should not offer unrestricted confidentiallity, but should make it more transparent what will and will not need to be shared.

3: Trust worker judgement: Ideally, there should be a recognition that workers can use their judgement, and in the first instance achieving attendance and building trust should be a priority. The worker should be able to assess when sufficient trust and confidence has been established to explore difficult issues such as child welfare. The message to workers should be "you need to assess the situation in relation to children of people who inject, but you should decide when exploring this issue is productive, and should not happen prematurely where there is a significant that to do so would cause the person to disengage from the service. Such disengagement represents a greater risk to both adult and child."

4: Foster idea of benefit not threat: How we frame questions can have a big impact on the answers we get. So if for example we simply ask "do you have any children at home" there's a risk that the question will be seen in a threatening light. Especially if it's been prefixed by a warning that there's a limit to confidentiality and child safety is a "red-line." But let's try and find ways of selling the questions better. So for example if the agency had a contingency fund to buy and fit lockable medicines cabinet for people who inject and have children. The worker could then prefix the questions about children by discussions such as:
"we have sharps boxes with small apertures and non-return mechanisms which are safer if you have children in the house, so let me know if this sort of box would be better for you..."
"there's always a risk that, even if you try and store your equipment safely out of reach, children find it so we encourage everyone to use a lockable medicine cabinet for storing drugs and equipment. if you don't have one at home and need one we can help with this..."
"it can get busy in the needle exchange and it's not the best environment for children, so if you do have children and need to attend with them, it's better if you make an appointment so you can be seen somewhere quiet and as quickly as possible...."

Conclusions and next steps:

NSP sits amidst a nexus of conflicting tensions. Compliance with treatment, returns, child safety, community atttitudes, funding and commissioning all have an impact on how services are delivered and how well they can work. Recent conversations with workers in NSPs have highlighted the extent to which these tensions are having a real deterrent effect on attendance and engagement. Effective engagement with an NSP is valuable, not just because of the life-saving harm reduction benefits that it can offer. The wider engagement that it can lead to is important for the treatment interventions that come with it, and the chance to address wider safety concerns such as the wellbeing of children. It is therefore self-defeating if the requirements to address treatment and child-safety actually have the effect of causing people to disengage from services.

There are solutions to these issues, and it is imperative that these discussions start to take place in a meaningful way within NSPs and wider agencies now.

06 August 2015

NSP: navigating the barriers of Assessment and Confidentiality

This series of articles about NSP started with a consideration of Secondary Distribution and looked at reasons for first-person non-attendance, and the pros and cons of secondary distribution.

As the earlier articles noted, whilst NSPs should acknowledge and work with secondary distribution, we also need to address the barriers to first person attendance and how make access as easy as possible.

Over a number of workshops and discussion, four entangled issues have come to the fore as key barriers,which can and must be addressed to facillitate first-person attendance.

1: Assessment: bloated assessments, imposed too early, seeking repetitve and non-relevant information
2: Confidentiality: confusion over anonymous versus confidential services, and lack of clarity about how information is shared deters engagement. this issues links to:
3: Safeguarding: the drive to assess the well-being and needs of children of injectors may deter attendance by injectors
4: Conflict with scripting: lack of clarity and confusion about use on top deters scripted injectors from attending.

This article will look at the first two issues. We will return to the second two in the last in the series.

Assessment and Record Keeping
Assessment procedures have a habit of developing a life of their own. They start small, and over time bloat and morph in to multi-page assessment documents. Various workers have reported that they are expected to complete mini-epics as a prerequisite to distributing injecting equipment.This is very problematic, because:
  • early on in the relationship, insufficient trust has been built up to make such an assessment a useful process
  • NSPs aren't always clear about information sharing (e.g. in terms of use on top) and this lack of clarity about confidentiality when completing assessment documents is not helpful,
  • too often, questions are not relevant to NSP, or are duplicated from other assessment,
  • information collated isn't always stored or used in any meaningful way - so doesn't get used to deliver a better service, but is merely collected for its own sake.
The need for assessment:
To cover basic dilligence, some assessment is essential. Even workers with significant antipathy to assessing things will acknowledge that (for example) it is important that they assess the age and level of intoxication of someone attending NSP. So if we can accept that some assessment is a prerequisite for safe exchange, we therefore need to establish what we need to asssess to deliver competent NSP.

Having acknowledged this, we then need to record this information in a meaningful, and hopefully useful way.


Minimum assessment:
In order to meet a basic Duty of Care to injectors, workers need to be confident that the person is getting the correct equipment for their needs, and that they know how to use it safely.
We could assume that the person is correct in terms of equipment choice and how to use it. But such an assumption could be erroneous. There are certainly young steroid users who haven't a clue what they are using. Likewise, people injecting NPS could also be unclear about process or technique.But confusion and poor practice isn't the exclusive preserve of these groups. So the safest way forward is to assess rather than assume, especially where people are new attendees at NSP.

We need to know:
  • What is being injected: this will determine should the drug be injected in to a muscle, under the skin or in to a vein. It will also determine should an acid be added, will it need to be heated and will it need filtering.  This will also highlight OD risks.
  • Where - which  sites are being used: this will determine which equipment the person should be using, and highlight key harm reduction information
  • Where - the environment: If the agency is to give practical advice and prioritise resources where needed, it will be important to know who is homeless or injecting in street settings, and who is housed. Swabs, hand wipes and sterile water should be targetted at homeless injectors.
  • When: the frequency of injecting will determine how much equipment the person needs for a sterile needle for each injection
  • Who: is the equipment for the person presenting or someone else? And is the person injecting themselves or someone else? This flags that the other person ideally attends themselves, and the need for specific harm reduction information
  • How: this isn't an exploration of the entire process - just to ensure that the person is familiar with the equipment that you distribute. How to put handles on spoons, what sort of acid you give out, do you supply water and amp crackers. As different exchanges supply different equipment, it is important to explain what you give out.
In terms of staff training, anyone who is delivering NSP should be able to ask these questions, and be able to understand and react appropriately to the answers.

These questions, along with statistical and monitoring information (gender/age/geographical identifier and ideally ethnicity, sexuality) form the basis of an initial assessment.

In order to minimise obstacles to engagement, the aim should be to get such an assessment undertaken at the earliest opportunity BUT the key priority is still to ensure that the person receives sterile injecting equipment. It may be on initial attendances, the person doesn't have time or willingness to engage even for a short assessment. The injector should be supported and encouraged to leave enough time on the next visit to undertake a basic assessment.

Disclaimers: If, after a number of visits, it is apparent that the person doesn't wish to engage with an assessment, a decision should be reached about the appropriateness of continuing NSP to this person. If provision does continue,  the agency should consider asking the person to sign a disclaimer, which acknowledges that the injector does not wish to undertake any assessment process and as such the NSP will not be held liable for any harm arising from distribution of equipment.


Anonymous versus Confidential: Both people attending services and those working within them seem to get the concepts of anonymity tangled up with the issue of confidentiality.

An anonymous service means that the person can engage without any information that links to their identity being used or recorded. So while the person may offer a name, initial, postcode or date of birth to create a unique identifier (for statistical purposes), this doesn't tie in to the person's real identity and as such can't be used to identify them or link to other records.

A confidential service is one where a person's identity may be known, but their identity and how it and information about them is used and shared is restricted.

People attending an NSP are entitled to expect a confidential service. But the term "confidential" is widely used without clarification. No service offers a completely confidential service. There will always be times when NSPs will need to share information - with or without the client's knowledge and consent. Agencies should also be clear where confidentiality lies - at  a team, project or other level.

People who are concerned about their personal privacy or their identity as an injector being exposed may be keen on attending anonymously. However, a wholly anonymous service can have a big drawback -and this relates to advice and record keeping.

Record keeping matters. Again it is something that some workers resist strenuously. But it shouldn't just be a make-work exercise. It can have significant benefits for all parties, and thought should be given as to how to make it work well.

Good record keeping is essential as soon as an organisation is doing more than equipment out/in and "leaflet level" information i.e. verbally presenting stock information such as is found on standard literature/resources.

Where the NSP is delivering more tailored interventions - such as specific advice, referral or signposting to other services, person or situation specific guidance then record keeping is essential.

  • in terms of accountability and professional standards, it ensures that the NSP can demonstrate that it fulfilled its duty of care and, should practice be called in to question, can draw on written records to demonstrate actions taken.
  • in terms of continuity it ensures that, regardless of who the injector next sees at the NSP, there's a record of issues to be followed up. This is useful, not just to ensure that advice or referrals are being actioned. It also demonstrates an ongoing interest in the person's wellbeing.
  • record keeping can help ensure workers focus on current issues that need addressing rather than repeating other messages that may or may not be relevant.
Herein lies the tension between anonymous services and what we could call NSP+ - a programme that delivers more than equipment - offering detailed advice, information and care planning to injectors. A NSP+ service needs to have proper records, and as such can't operate on a truly anonymous basis. Records need to be linkable back to a known, identifiable individual.

One way through the conundrum is to structure the NSP in terms of levels engagement, engagement and record  keeping.

  • At a basic level (NSP) a person can access equipment, and get leaflet-level information. 
  • a minimum assessment as described above should be undertaken
  • such service can operate on anonymous-type identifiers and with minimal record keeping.
The next level of service (NSP+) includes a raft of additional services including tailored harm reduction advice, BBV testing, vaccines and care-planning in relation to injecting health. When engaging with NSP+ the following would be required:
  • additional personal identifiers to allow for record keeping
  • ongoing case notes
  • a more comprehensive assessment of injecting related needs.
In order to make such a proposition acceptable and appealing to people using the service, consider it more as an exercise in offering an "enhanced" service. As an analogy, consider on-line shopping. I can just log on and shop as a "guest" customer. But by registering and signing up I should get an enhanced service, such as special offers, priority service, better customer support and other benefits. What I don't want is just lots of spam.

So in the same way NSP is a basic service, and there's a better, enhanced service that you are encouraged to sign up for - NSP+. It has to have benefits, not merely mean the agency gets a load of information and the client gets the same service.

The limited nature of confidentiality
Organisations should be very clear - both to themselves and to those who use their services - that they can at best offer a limited level of confidentiality.

  • The organisation should determine where confidentiality rests - at a team (e.g. within NSP) or Project, or even at a wider level;
  • the limits of confidentiality should be mapped and clearly explained to service users as early as practical, in a way that is meaningful and understood;
  • wherever possible, workers should try to get the client's informed consent so that information sharing can take place, with the client's knowledge, and where it serves the client's best interest.
Where information sharing has to take place, there are a number of hierarchies of sharing which could be selected. The risks and priorities in each situation will determine the most appropriate. These could include:
  • information sharing with client's knowledge and consent (if not approval)
  • information sharing with client's knowledge but without consent
  • information sharing without client's knowledge or consent.
Where the situation allows for it, it will be preferable that knowledge and consent can be obtained, and the client retains some ownership over the process where possible.

The Hub of the Problem
The issue of confidentiality becomes especially challenging in the move towards hub models where all services including prescribing, key working and harm reduction are all under one roof. Some services have few if any specialist NSP workers. As such a number of workers and volunteers with varying levels of training may end up giving out equipment. There have been numerous accounts of effectively anyone who knows which is the pointy end of a needle "covering" distribution of equipment as required.

Key issues here related to the key issues of confidence, continuity and confidentiality.

Confidence:   Well trained workers and volunteers who understand injecting want to deliver a great service can help even unwilling customers to engage. They can ask the right questions, give helpful advice, and are not afraid to ask questions. Under-confident workers don't want to display their lack of knowledge and risk avoidng questions and discussions. Some under-confident workers will discourage their client from asking questions, and run the risk of viewing their client as unwilling to engage whereas the problem doesn't lie with the client at all.

So whoever is delivering NSP should be properly trained to a high standard otherwise they will be a barrier to good engagement.

Continuity: Even with good record keeping, having an unfamiliar face each time a person goes to the NSP is not helpful. While there may be transfer of relevant information between workers, this doesn't transfer to a transfer of the worker-client relationship. it's not easy to build up a trusting relationship when you rarely see the same worker twice.

Confidentiality: Whilst we can talk about information sharing and informed consent, this goes out the window where the client attends to use the NSP but the worker delivering on that occasion happens to be someone who also plays a role in prescribing, or key working or another area of work. However much we pretend that information is confidential within NSP, when the person using the service sees a person they know in other roles, no amount of reassurance alters the fact that the person's injecting behaviour has been disclosed without them meanting to do so, to a person they wouldn't necessarily have told. All our paper policies are redundant if the person using the service has little control over who they see within the service.

There are a couple of solutions to this problem.

The first is to refocus on a model of NSP where the service is primarily delivered by a cohort of trained workers covering needle exchange duties on a regular, rota basis.

Having dedicated workers, properly trained, and working on a regular basis helps to address the issues of confidence, continuity and confidentiality discussed above. It should also mean that the significance of NSP as a core part of a service is not lost. It isn't a bolt on to a service, to be covered by anyone not doing anything at that moment. And time spent delivering it should be factored in to workload and service delivery, not rushed to get back to the monitored and audited work.

The other solution is to consider how the whole agency works with use on top.And it is to this and the issue of safeguarding that we will return in the next and final instalment.

03 August 2015

Carrots and Sticks and NSPs

[part 2 of a series about Needle and Syringe Provision, exploring practice and ethical issues]

The preceding blog article highlighted some of the legal issues regarding secondary distribution. This one considers reasons why secondary distribution happens, and some of the pros and cons of secondary distribution.

A key function of NSPs is to get sterile equipment in to the hands of injectors when it is needed and hopefully remove used equipment from circulation. Secondary distribution assists this process and as such represents an essential facet of distribution. Although essential, it isn't ideal. For a collection of reasons, some people will be unable or unwilling to attend NSP themselves and so rely on others to attend.

It could simply be that geography, travel costs, work or other commitments make it impractical to attend an NSP in person.

Where the NSP is primarily just distributing equipment and offering little more in terms of advice or other input, getting someone else to collect for you makes a lot of sense. In such settings the perception will be that there's little benefit in attending in person. In order to attend there needs to be some sense of added value, or why bother?

For other people, barriers to attending NSP may be more complex:
  • injectors may have been ASBOd out of area or have other restrictions that make it difficult to attend in person
  • there may be fears around child protection issues, deterring people from attending
  • in hub-style provision, scripted injectors may be wary of attending as it could draw attention to use on top
  • perception may be that the service is not "for me" - not orientated to steroid users, BME or LGBT injectors, young people, those not in recovery.
  • pressure to bring back returns 
  • onerous assessment tools.
So secondary distribution represents an essential access point to sterile equipment for an unknown number of people. As such the NICE guidance on NSPs rightly endorses it. However, it is not without disadvantages. Some of these are significant.


Where injectors take advantage of secondary distribution, this can create another barrier to service access. The distributor can become a gate-keeper. The recipient receives injecting equipment from them. They may also receive advice, information, guidance and other input from the distributor.

As the recipient can access sterile equipment from the distributor (along with additional advice) there is reduced reason for the recipient to attend a NSP. What they receive is therefore limited to what the distributor can offer. A range of interventions such as professional wound care, testing for BBVs, vaccines and access to treatment are therefore less accessible.

In truth we can't be confident that the distributor is distributing the "correct" equipment or accurate information. They may have only collected one or two types of equipment and so can't offer a range of paraphernalia.

And we don't know how it's being distributed. Is it being sold? Distributed pre-filled? Single item distributed with each bag of gear sold? There may be a tacit assumption that the secondary distribution is a benign, philanthropic activity but this may not be the case. We can't even be confident that the equipment distributed is sterile, as the move towards bulk-bagged Insulin syringes increases the risk that used equipment can be passed off as sterile.

The role of distributor as gate-keeper could be especially significant where the recipient is vulnerable, where abuse or exploitation could be an issue or where the recipient is a young person. So far from being an atruistic act, the distributor could be maintaining control and power through the act of distribution.From a Maslowe-esque point of view, the role of distributor can confer status, recognition, respect and status.

Returns is another key issue. Agencies may give out large quantities of injecting equipment for secondary distribution but there isn't always consideration of how it is to be returned. Now in some settings, especially amongst some steroid users, secondary distribution is associated with secondary returns. Here, one person collects and returns used equipment for a number of peers, bringing back large amounts of equipment. Whilst this is to be welcomed, it's probably the exception not the rule so secondary distribution risks contributing to the problem of low returns.

As it will be preferable for people who currently get injecting equipment from peers to attend NSP in person,  in coming articles we'll look in more detail at how to address some of these barriers, especially pressure on returns, assessment, scripting and safeguarding concerns.

In the meantime, looking at the issue from a broad perspective, organisations need to:
  • acknowledge and accept that secondary distribution is a component of comprehensive NSP
  • make proactive efforts to encourage recipients of secondary distribution attend in person:
    • stressing to distributors the benefits of attending in person
    • exploring reasons why they can't/won't attend in person
    • weighing up "greater harm" principle - does withholding the secondary distribution increase or reduce risk?
    • working with distributors to ensure they give out the correct equipment and 'right' advice - especially those who are distributing significant amounts of equipment to a number of peers
  • address barriers to attending in person
    • outreach where geography is an issue
    • addressing fears around confidentiality and scripting
    • streamlining assessment processes
  • maximise and stress benefits of attending service in person - informed, compassionate, caring staff offering a confidential, non-judgemental service including but not limited to needle distribution.
  • identify and challenge situations where secondary distribution increases rather than reducing risk, such as the sale of pre-filled syringes, incorrect equipment distribution, lack of disposal options and inadequate amounts supplied.



29 July 2015

Needle and Syringe Programmes: challenges old and new

The last few Safer Injecting and NSP courses have highlighted a resurgence of concerns about key areas of policy and practice. At the heart of this is the ongoing tension between the provision of a low-threshold harm reduction service whilst simultaneously trying to negotiate the needs of injectors, commissioners and the wider public.

As we've navigated these discussions in training, there seemed to be some merit in writing up the key issues not least to open up broader discussions and explore possible solutions.

Secondary Distribution: a starting point

Secondary distribution represents a useful starting point for this discussion. Primary distribution is the 'formal' distribution of syringes and needles via NSPs. It is widely aknowledged that some of this equipment will then be redistributed amongst peers - secondary distribution. In some settings this may be partially formalised where peer advocates undertake such distribution with the explicit knowledge and 'blessing' of the service. More frequently it is undertaken informally where additional equipment is requested for the distribution to family, partners, friends and peers. There is also wholly informal and unplanned distribution where those with equipment will give equipment to those without in emergency or social situations.

We don't really know how much secondary distribution goes on. The explicit, intentional secondary distribution is easier to map as customers directly request additional equipment for distribution. The level and extent of wholly informal secondary distribution is probably widespread but hard to estimate.

Secondary distribution is an essential component of getting sterile equipment in to the hands of an injector at the point where it is needed.

The NICE Guidance on NSP is explicit on the subject stating NSPs should "not discourage people from taking equipment for others (secondary distribution), but rather ask them to encourage those people to use the service themselves."

Despite this, some agencies remain wary of engaging with secondary distribution, with a range of responses on offer ranging from an outright refusal to allow it, allowing it on a one-off basis, through to unrestricted, large quantities being given out.

The Law:
In practice some aspects of secondary distribution are slightly more nuanced than the NICE guidance would suggest.

The distribution of paraphernalia is covered by Section 9a of the Misuse of Drugs Act 1971 (as ammended in 2005).  Section 9a made it an offence to distribute items for the administering or preparing a controlled drug but explicitly exempted syringes from the legislation, meaning they remain legal for distribution. Importantly the exemption did not specify who could undertake this distribution making the secondary distribution of needles and syringes wholly lawful.

After much lobbying and campaigning, the law on other paraphernalia was gradually relaxed and in 2003 the law was amended to allow distribution of other specified items:

"the following articles are exempt if they are dispensed by a doctor, a pharmacist or someone working lawfully within drug treatment services:

  • Swabs
  • Utensils for the preparation of a controlled drug
  • Citric acid
  • Filters
  • Ascorbic acid
  • Water ampoules of up to 2ml"
 
However, as the text above makes clear, while the revision added some specific paraphernalia to the list of exempt equipment it also specified who could distribute it - certain professionals and "someone working lawfully within drug treatment services." This is a curious wording. Can someone be working lawfully or unlawfully in a drug treatment service? But either way it does mean that secondary distribution of the items listed is generally not lawful. It remains legal for the secondary distribution of needles and syringes to take place but not these other items.If an agency were giving out pre-packaged equipment for secondary distribution, some of the contents of the pack would be unlawful for secondary distribution.

Now in truth, we shouldn't get too hung up about this legal issue. There have been no prosecutions against any services for secondary distribution, nor are there likely to be any. This does not mean that an organisation should be cavalier in terms of secondary distribution.

There is a clear need for thought as to what is distributed, how and why, so an organisation can be clear that (a) secondary distribution is essential in the context and (b) there is a public interest and (c) the organisation has endeavoured to minimise the risks associated with secondary distribution.

The next part of this blog (hopefully next week) will look at barriers to service access and ways to improve access.



 

31 May 2015

The Psychoactive Substances Bill – a fundamental shift in drugs legislation and state control.



Part 1: Commentary
Every now and then, a piece of legislation emerges which fundamentally changes the way that the State seeks to regulate how people choose to get intoxicated. The Misuse of Drugs Act was one such piece of legislation. If it becomes law, the Psychoactive Substances Bill will represent another such seismic shift.

It is essential to recognise that, whilst the Bill emerges against a backdrop of concern about Novel Psychoactive Substances (NPS), its breadth and reach far exceeds newly emergent drugs. It represents a step change in how substances are and will be regulated. 

Up until now, substances were lawful to produce and supply provided that they were not currently regulated either by the MDA or the Medicines Act. The Psychoactive Substances Bill reverses this position and says that all psychoactive substances will be illegal to produce or supply unless specifically exempted. 

This fundamentally changes the way that the State manages the risk of substances. Until now the onus has been on the State (via the ACMD) to demonstrate that any specific substance was so dangerous that it needed to be “controlled” under the MDA. Now any substance, old or new, will be automatically prohibited for production, importation or supply unless specifically exempted. It’s all too dangerous for us to access unless the state determines otherwise.

The Act to a large extent nullifies the role of the Advisory Council on the Misuse of Drugs (ACMD) as any new emergent Psychoactive Compounds are automatically covered by this Act. Their only role in relation to new drugs would be (presumably) to determine if they should also be controlled under the MDA, and if so in which Class. 

The Act contains provision to exempt specific psychoactive substances and the Secretary of State has the power to add to this list via Statutory Instrument. There is no formal or independent mechanism for such reviews to take place beyond a loose requirement that the “Secretary of State must consult such persons  as the Secretary of State considers appropriate.
The list of exemptions includes:

  • ·         Controlled Drugs and Medicines,
  • ·         Alcohol,
  • ·         Tobacco and Nicotine,
  • ·         Caffeine,
  • ·         Food.

Aside from the obvious inherent contradiction in restricting some very low-risk compounds (e.g. Nitrous Oxide) while not acting on others (e.g. alcohol, tobacco) the legislation in its current form makes prohibits supply of a number of lawful substances, such as Areca Nut (betel, paan).

This is however not the key issue. It will be relatively easy for such substances to be exempted prior to the Act coming in to force. It’s the idea that from this point on the relative risk or safety of a substance is irrelevant. If it’s psychoactive and not exempt, it is forbidden.

Because the legislation is coming at a time of ill-informed moral panic about NPS, the odds are that the legislation will be passed without significant changes to it. It’s a bad time for the sector to lose voices such as Drugscope, however muted they had become over time. The voices that have got the Government’s ear are more likely to be those who will endorse such a blanket ban.

But, ideological objections aside, will this legislation work? That in part depends on how one measures success. If the experience of the Irish Republic is anything to go by, then it will have a significant impact on so-called Head-Shops. The vast majority of Irish Head-shops closed down when similar legislation was introduced. The trade and use of NPS has not, however ceased. It’s still goes on, but more underground, akin to more traditional drug markets.

The other potential development will be the relocation of key suppliers outside of the UK. The legislation creates offences around importation, and includes requirements that can be imposed on internet service companies. However it seems likely that suppliers with websites and storage outside of the UK, and especially outside of the EU will be able to supply NPS with a low level of risk to purchasers in the UK.

In the longer term, as successors to the Silk Road emerge and stabilise, on-line sale of both old and new psychoactive substances will continue and grow via virtual markets. Ultimately, a future Government will have to recognise and accept that prohibitive responses are and will become increasingly obsolete. Sadly this Government is intellectually too myopic and ideologically opposed to any such insight and instead will leave us a terrible legacy: a piece of legislation that views all possible psychoactive substances as equally dangerous and a single response to them – ban them all.

Part 2: The legislation.

The main provisions of the proposed legislation restrict production, supply and importation of Psychoactive Substances.
 A Psychoactive Substance is defined as “is capable of producing a psychoactive effect in a person who consumes it, and is not an exempted substance.” A psychoactive effect is “a substance produces a psychoactive effect in a person if, by stimulating or depressing the person’s central  nervous system, it affects the person’s mental functioning or emotional state.”
In its current form the Bill creates key offences of production, supply, importation and exportation. It doesn’t make possession for personal use an offence BUT the Bill creates the power for the Police to stop and search for suspected offences under the Act, to seize substances and to destroy them.
There is also provision for the searching of vehicles, buildings etc.
The offences are:

Producing a psychoactive substance


(1) A person commits an offence if—
(a) the person intentionally produces a psychoactive substance,
(b) the person knows or suspects that the substance is a psychoactive substance, and
(c) the person— (i) intends to consume the psychoactive substance for its psychoactive effects, or (ii) knows, or is reckless as to whether, the psychoactive substance is likely to be consumed by some other person for its psychoactive effects.
Production here means “producing it by manufacture, cultivation or any other method.

Supply, a psychoactive substance


(1) A person commits an offence if—
(a) the person intentionally supplies a substance to another person,
(b) the substance is a psychoactive substance,
(c) the person knows or suspects, or ought to know or suspect, that the substance is a psychoactive substance, and (d) the person knows, or is reckless as to whether, the psychoactive substance is likely to be consumed by the person to whom it is supplied, or by some other person, for its psychoactive effect.
Additional clauses cover Possession with Intent to Supply and Offer to Supply.

Importing or exporting a psychoactive substance

(1) A person commits an offence if—(a) the person intentionally imports a substance,
(b) the substance is a psychoactive substance,
(c) the person knows or suspects, or ought to know or suspect, that the substance is a psychoactive substance, and (d) the person—(i) intends to consume the psychoactive substance for its psychoactive effects, or (ii) knows, or is reckless as to whether, the psychoactive substance is likely to be consumed by some other person for its psychoactive effects.
(2) A person commits an offence if—
(a) the person intentionally exports a substance,
(b) the substance is a psychoactive substance,
(c) the person knows or suspects, or ought to know or suspect, that the substance is a psychoactive substance, and (d) the person— (i) intends to consume the psychoactive substance for its psychoactive effects, or (ii) knows, or is reckless as to whether, the psychoactive substance is likely to be consumed by some other person for its psychoactive effects.

Commentary: 

One of the key challenges in drafting this legislation will have been to ensure that labelling products as “plant food” or “not for Human Consumption.”
The key wording in the proposed legislation to address this is “knows, or is reckless as to whether, the psychoactive substance is likely to be consumed”
The expectation is that a court could determine that a person was acting in a reckless way by the production or supply of compounds which a reasonable person could assume were for the purposes of intoxication, irrespective of how they were packaged.

Enforcement Powers:

In addition to the criminal sanctions of fines, imprisonment or action under the Proceeds of Crime Act, the Bill introduces new powers to prohibit activity or close premises.
Prohibition Notices could be served against individuals who are believed to be carrying out prohibited activities such as production or supply of prohibited activities, requiring them to stop any such activity.
Premises notices can be issued to people who own, manage or lease premises where there is a belief that prohibited activities in relation to Psychoactive Substances are taking place, requiring that any such activity ceases.
In situations where such notices have been breached or in other circumstances, Prohibition or Premises Orders can be issues by a court. The standard of proof for these is on balance of probability, though they could be issued as part of a sentence for an offence under the Act.

Commentary:

 If the experience of Eire is anything to go by, the Prohibition and Premises orders will be a key tool to act against shops and other retail outlets. As there is no requirement to prove to criminal standards that the any criminal breach has taken place, it will be relatively easy to enforce and effectively stop sale via shops. 

The full text of the bill can be viewed and downloaded here:
http://www.publications.parliament.uk/pa/bills/lbill/2015-2016/0002/16002.pdf

07 September 2014

The Language of New Drugs - From Education to Assessment


The KFx Cats, Bees and Dragonflies course explores the subject of newer, emerging drugs. One of the issues we address very early in this course is terms of reference. This inevitably brings up the vexed question of what collective terms to use about newer compounds.

For well rehearsed reasons we should eschew the phrase “Legal Highs.” Many of the compounds are no longer legal, and not all are stimulants. There is debate as to whether or not people construe legality to equate with safety. I am of the mind that ‘legal’ has connotations of being sanctioned or approved. It suggests legality via permission. As this is not the case with our newer compounds, I prefer “unregulated” as opposed to “legal.”
The phrase that has become de rigeur amongst academics and policy experts is Novel Psychoactive Compounds (or substances). It’s the phrase of choice for the EU, and the EMCDDA defines it thus:
a new narcotic or psychotropic drug, in pure form or in preparation, that is not controlled by the United Nations drug conventions, but which may pose a public health threat comparable to that posed by substances listed in these conventions.”

There are a number of problems with this definition, not least some of the compounds are not that new: Nitrous Oxide has been around since the latter half of the 19th Century, 4-mmc was first synthesised in 1929 and a lot of the benzo-type drugs doing the rounds at the moment were first synthesised in the 1960s.
It also creates the small problem that as soon as the drug is controlled by the UN drug conventions it ceases to be a Novel Psychoactive Compound (NPC).
Most problematically for me it has little or no relevance as a term to end users. A resource, service or awareness session entitled referring to Novel Psychoactive Compounds will not register with key target groups. Asking people “what NPCs have you used in the last month” won’t elicit the information that I am looking for. It’s akin to when the language switched from talking about “glue sniffing” to “volatile substance abuse.” The language may be more accurate but what it gains in accuracy it loses in comprehension.
The other thing that is interesting about all the widely used phrases: “Novel Psychoactive Compounds,” “Legal Highs,” and “Research Chemicals” is that the word Drugs is absent. According to Rick Bradley at KCA, presenting at a seminar in 2014, about 85% of NPS users do not recognise themselves as drug users.
The language we have all adopted contributes to the sense that these are somehow distinct from other drugs.

In turn, this linguistic sleight of hand has, to my mind, disempowered drugs workers. The recurrent theme from training sessions is a sense of not understanding this new world of NPS. These are often experienced workers who can deal with the full spectrum of “traditional” drugs. Reminding these workers that these are still drugs, much like ones they can and have worked with, does much to overcome this sense of disempowerment.

So over time I have tried to find a language that works to address these problems. I ended up finding that the phrase “Newer Unregulated Drugs” worked reasonably well. Except when the law changes. But it’s largely immaterial as I am not egotistical enough to think the phrase will ever catch on. What’s more important is that we have the discussion and explore the role language and terminology plays in constructing paradigms.
Language of Assessment:
What we call our emerging drugs also has a bearing on the assessment process. If we don’t ask and prompt about newer drugs, we may not get this information volunteered. And when it comes to newer drugs this brings with some very specific challenges.

1: Not perceiving substances to be drugs:
As highlighted earlier, there’s some evidence that some people may not consider their “legal” substances to be drugs, so if they are asked about other drugs may not volunteer emergent drugs.
2: Unfamiliar with collective terms:
We want to try and avoid the term “legal highs” for reasons mentioned and use of phrases such as Novel Psychoactive Compounds may not have a high recognition factor with young people.
3: May not be familiar with drug families or link drugs to families
Routinely we would ask people about (for example) their benzodiazepine use. But asking this doesn’t automatically mean that the respondent will link their Etizolam use to the use of benzos, and volunteer this as a response. Similarly, although we ask about cannabis use, the respondent may not volunteer that they are smoking synthetic cannabinoids.
4: May not know what they have used or have misidentified it:
The emergence of generic slang such as “legals” could cover a wide range of drugs. Regionally, slang such as “Monkey Dust” or “Bubble” could refer to a specific compound such as mephedrone or any unknown white powder.  In turn “mephedrone,” once referring to 4-mmc, could now be used interchangeably for other white powder drugs. So assumptions both by user and worker as to what a person is actually using could be both misleading and dangerous.
5: We don’t want to give people a shopping list:
Especially when working with younger, na├»ve users, it is important that the assessment process doesn’t end up introducing the client to a whole list of substances with which they were unfamiliar. So while initially tempting, an assessment form which either lists or illustrates a wide range of different products is risky. It is still unlikely to be comprehensive – there are SO many brands on the market now. But it also risks introducing substances to a client who was hitherto unaware of that compound of family of drugs. We need to prompt, but without exposing the respondent to still more compounds.

Assessment to Prompt, not Promote:
After a numerous training sessions and a number of false starts, a screening process emerged which addressed all my key concerns. It sits alongside an existing standard screen and looks specifically at newer drugs. Rather than exploring specific substances it looks at types of compound and routes. So for example by asking about smoked substances it can elicit synthetic cannabinoids, kratom, or salvia without naming the substances. Even vague references to “I smoked something, I’m not sure what it was…” can be incorporated.
 
Likewise, by asking about “white powders” we can explore all the different brands and unbranded substances, again without having to give names. Using the same format, the tool asks about Pills and Pellets, and Other Substances (swallowed, inhaled etc) to cover other drug groups.

In training we use the Drug Map to explore the relative location of different drugs. We can use it to explore
potency, duration and effects. In the context of assessment it is left blank, so the respondent can describe how the substance affected them – strong stimulant effect, very hallucinogenic, drowsy and so on. This is useful, not least because it ensures that the client can articulate their experience of the substance. It can also highlight where there’s a high chance they have used something other than their names substance – where the effects described are at variance with typical reports of that drug.
The assessment tool goes on to explore key issues stemming from use and develop an action plan. Sample pages are shown below.

As with other KFx resources this Assessment Tool can be downloaded from the KFx website here. It is free to download and use. If you have any feedback I would be keen to hear it and will revise the tool as feedback is received.
Ideally use of the tool will be combined with staff training to increase awareness and confidence of responding to Newer Unregulated Drugs. Such training is of course available via KFx.


LINKS: