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.
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.
- 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.
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
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.