Transcript The Intervention - Exchange Supplies

assessing drug transitions
& developing interventions
to promote safer drug use
A 2 day workshop
[month] [day 1],[day2]
[location]
Developed by Neil Hunt and Andrew Preston
Run by:
[trainer]
[trainer]
[email/contact details]
[email/contact details]
Ethos
• Acknowledge what we don’t know
• Ask when we don’t understand (there’s no such
thing as a silly question!)
• Be generous and confident with our ideas and views
and those of others
• Be open to the literature and evidence…but questioning
• Think creatively
2
Programme structure
• Day 1
– Introductions – ourselves & our services
– Different drugs and routes of administration
– The first hit
• Day 2
– Transition theory and interventions
– Adapting and using the data collection tool to
inform interventions
– Evaluation and close
3
Definitions
• Route transitions
– A temporary or permanent transition in the
way that a drug is administered
• Route transition interventions
– An intervention that either:
a) attempts to prevent the transition to a
more harmful route of drug administration
such as injecting; or
b) promotes the use of a safer route of drug
administration
4
Learning objectives
• Discuss the literature on drug transitions relating to heroin
use and injecting
• Understand route transitions interventions that have
been used elsewhere and the evidence of their effectiveness
• Provisionally evaluate which (if any) interventions may be
most applicable for participants
• Appraise and revise a transitions data collection
instrument to assess local needs
• Assess how best to use the instrument to inform the
development of your own services
5
Health needs and priorities
• What are the health priorities for
injecting drug users in your area?
[needs]
• what services to do you have and what
are your priorities? [responses]
– needle exchange (centre based and/or outreach)
– methadone prescribing (is it low threshold, high
dose?)
– residential rehabilitation
– overdose prevention information
– community detoxification programmes
– prevention of transition to injecting interventions
– basic healthcare, housing, human rights, other…
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Heroin use, injecting
and the ‘first hit’
• Limitations to the evidence-base
• Factors associated with using heroin/injecting
• Reasons people use or avoid heroin/injecting
• Issues associated with the first hit
7
Limitations to the evidence base
• The evidence is largely derived from treatment
populations
• Learning from the literature cannot be
assumed to be entirely transferable to the
regions that concern us
• Heroin use/injecting can be subject to rapid
epidemiological change
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Factors associated with using
heroin/injecting
• Age – a youth phenomenon
– Albania, Bosnia and Herzegovina, Croatia, the Federal Republic of
Yugoslavia and the Former Yugoslav Republic of Macedonia - Mean
age of first injection 17.3 – 19.1yrs (Wong 2002)
– Serbia/Montenegro - Mean age of first injection is 18.2yrs (Cucic
2002)
• Gender – predominantly male
– Tends to be between 3:1 and 4:1
• Socio-economic status
– strongly associated with poverty and urbanisation
• Ethnicity
– associations with membership of a minority population e.g.
Russians in Estonia, Roma.
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Key issues associated with the ‘first
hit’
• Modelling/social exposure
• Peer influence and the desire to try ‘just once’
• The role of alcohol and other drugs on risk
taking
• Type of drug
• Drug buying arrangements
• Risk management
•
•
•
•
Blood borne infections
Bacterial infection
Overdose
Dependence
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Reasons people use or avoid
heroin/injecting
•
•
•
•
•
•
•
•
•
Curiosity
The ‘rush’
Economics
Peer/partner influence
Anomie/self medication
Cultural norms
Availability
Diffusion of innovation
Managing post-stimulant
‘come down’
• Associations of injecting
with modernity/potency
• Glamour and heroin ‘chic’
• Fear of addiction
• Fear of HIV/AIDS
• Lack of
knowledge/technical
proficiency
• Fear of needles
• Stigma of heroin
use/injecting
• But….no evidence that
increased availability of
needles and syringes
increases prevalence of
injecting
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assessing drug transitions
& developing interventions
to promote safer drug use
A 2 day workshop
[month] [day 1],[day2]
[location]
Developed by Neil Hunt and Andrew Preston
Run by:
[trainer]
[trainer]
[email/contact details]
[email/contact details]
Route transitions theory, history and
evidence
• Early 1990s – developments in the
systematic study of transitions
– Griffiths et al 1994
– Darke et al 1994
13
Griffiths et al. 1994
•
•
•
•
408 heroin users (community sample)
54% preferred injecting
44% preferred chasing
More than a third had changed their preferred
route (transition)
“a change in the exclusive or predominant route of
administration lasting one month or more”
• Transitions were
– Usually chasing to injecting
– Multiple transitions uncommon
– But…16% of chasers had previously been regular
injectors
– And…many chasers had not adopted injecting
despite using at high doses for many years
14
Darke et al. 1994
• 301 regular amphetamine users (community
sample)
• Transition defined as “a change in the usual route
of administration lasting four or more occasions
of amphetamine use”
• First route of use:
–
–
–
–
Inject 23%
Snort 58%
Swallow 19%
Smoke 1%
• 40% had made a transition to injecting from
another route of use because of a) the rush b)
more economical c) cleaner
• 9% had made a transition from injecting
– Main reason was concern about vascular damage
15
The road to interventions
• Need to
– “take account of current administration and the
potential for future transitions” (Griffiths et al.
1994)
– “Address the misconceptions that injecting is more
economical and more healthy, and to emphasise the
vascular problems associated with injecting” (Darke
et al. 1994)
• Renewed interest in circumstances surrounding
initiation into injecting – ‘the first hit’ (Crofts et
al, 1996)
• In the context of epidemic hepatitis C in the
contact Alex Wodak suggested that harm
reductionists should promote Non-Injecting
Routes of Administration – NIROA (1997)
16
Subsequent initiation and transitions
studies
• Australia (John Howard)
• Canada (Elise Roy)
• Ukraine – work in progress (Olga
Balakireva, Cas Berendregt, Jean Paul
Grund et al)
• Young and occasional injectors UNICEF/CEEHRN meeting (Howard,
Hunt and Arcuri 2003)
• PSI 2004!
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Motivation and change
Pre contemplation >
contemplation >
action >
maintenance
> relapse
18
‘Route transitions interventions’
Hunt et al. 1999
• Two main targets for intervention
• Prevent people from beginning to
inject drugs they are using
• Encourage people to switch from
injecting to a safer route
19
Preventing commencement 1
• Working with ‘at risk’ users (Casriel et
al. 1990, Des Jarlais et al 1992)
– Targeted heroin sniffers
– Four part ‘psycho-educational programme’
– Intervention group less significantly less
likely to transition
– Transitions 14/43 controls 6/40
experimental group
– But…hard to contact and recruit
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Preventing commencement 2
• Working with current injectors ‘Break the
cycle’ (Hunt et al. 1998)
– Three month follow up study (73/86 recontacted)
– One-to-one structured intervention to discourage
practises among current IDUs that increase risk of
transition of others
– Uncontrolled trial
– Significant reductions in ‘modelling’ injecting,
willingness to initiate others, initiation requests and
initiations (before and after intervention)
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Preventing commencement 3
• Methadone treatment for noninjecting heroin users (Southwell
et al. 1997)
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Switching (prescribing)
Oral maintenance
• Methadone (Strang et al. 1997)
• Buprenorphine (increasingly and especially
people on lower doses of heroin)
• Dexamphetamine (largely pilot work)
Smokeable maintenance
• Heroin reefers (Marks and Palombella 1991)
• Heroin inhalation (van den Brink et al 2002)
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Social marketing approaches
• Promoting heroin smoking
– The chasing campaign (Healthy Options Team)
– How to chase (Lifeline)
• Promoting rectal administration
– Up Your Bum (Southwell/HIT)
• Promoting sniffing?
• Broad-based, population-wide campaigns that
focus on injecting rather than drug use
• But….no evaluations to date
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Intervening in drug markets?
• Certain formulations of drugs have greater
‘injectability’ than others…compare brown and
white heroin
• Historically, the impact of drug interdiction
efforts has been questionable but…might it be
possible to intervene in a way that favours
less readily injected drugs (where applicable)?
(Strang and King 1997)
25
Route Transition Interventions
overview
• Preventing transition
– Group-based
– Break the cycle
• Switching
– Methadone and other substitutes
– Heroin reefers/prescribing
– Social marketing – How to chase/Up your bum
• Over-arching
– Broad based social marketing re: injecting
– Intervening in drug markets
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Three Key Points
• The intervention is simply a structured
conversation about initiation
• It should never be used coercively
• Work to prevent initiation of others is
secondary to that concerning the immediate
health and well-being of the injector
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Injecting As An Especially Risk-laden Form
Of Drug Use
• Blood-borne viruses and other infections
• Overdose
• Increased dependence
29
The Initiation Process 1
• People don’t generally plan to start injecting
when they start using drugs
• They usually learn about injecting by watching
injectors and talking about it
30
The Initiation Process 2
• They often ask existing injectors to give them
their first hit
• Injectors are often reluctant to do this but
may have difficulty in dealing with such
requests
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The Intervention Aims
• Enable people to think about their attitude to
initiating others
• Develop resistance to initiating others
• Increase awareness of actions that make it
more likely that others will start
• Enhance ability to manage initiation requests
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The Intervention
•
•
•
•
•
Introducing the conversation
Assessment
Their initiation history
Experience of initiating others
Initiation risks
– To them
– To the new injector
• Social learning
• Discuss difficult situations
33
Research results
• Only 7% felt pressure to inject had been
important for them
• 61% felt talking about injecting had influenced
their initiation
• 67% felt seeing others had been important in
their initiation
• 84% had injected in front of a non-injector
(59% in the past 3 months)
• Less than 25% had discussed initiation with a
treatment worker
34
Evaluation Results
• Injecting in front of non-injectors was
halved (97 to 49)
• Disapproval of initiating others was
increased (12 item attitude scale)
• Participants received fewer than half as
many requests to initiate someone (36
to 15)
• The number of people initiated by
participants fell (6 to 2)
35
The ‘Break The Cycle’ Campaign
• The intervention briefing
• An intervention pad – 30 tear off cards
• A leaflet
• A poster
36
Three Key Points
• The intervention is simply a structured
conversation about initiation
• It should never be used coercively
• Work to prevent initiation of others is
secondary to that concerning the immediate
health and well-being of the injector
37
Can BTC be delivered as a using a
higher coverage, peer-delivered
model?
38
Aims
• To test the feasibility of implementing a peerdelivered intervention to reduce initiation into
injecting - the ‘Break the cycle campaign’
– Can it be done?
• Process evaluation
– What happens when you try to do this
– How might it be done better?
• Intermediate outcome data
– What impact, if any, does it have on drug users?
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The main messages
You inject but that doesn’t always mean that you
encourage others to do the same.
But - without meaning to that’s exactly what you
could be doing by:
– Talking about injecting to non-injectors
– Injecting in front of non-injectors
So - giving people their first hit. Consider whether
this is something you are always ok about
doing?
40
Design 1
• All NSP users were seen as potential ‘disseminators’ of
the Break the Cycle (BTC) message
• Those who consented were given
– an explanation of the aims
– a pack of BTC materials
• For each ‘recipient’ in their social network who later
presented back to the service and could successfully
repeat the main campaign messages they were paid £5
(up to a maximum of 5 people - £25)
• When collecting their payment disseminators were asked
to complete a questionnaire
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Design 2
• All recipients who could recite the main
messages of the campaign to a member of the
needle exchange staff were paid £5
• They also completed a research questionnaire
• People who had not used the NSP before also
completed a risk behaviour audit
• Anonymity was maintained throughout by the
use of credit card system that enabled
disseminators and recipients to be linked
42
Results - process
• Duration – Bolton (10 weeks)
– 18 disseminators recruited
– 73 recipients attended service
• Leigh (4 weeks)
– 31 disseminators recruited
– 108 recipients attended service
43
Disseminators
•
•
•
•
Data available for 37/49
30 male (81%)
Mean age 30 (19-43)
Injecting an average of 8 years (but 2 people
less than one year)
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Disseminators
• Number of injectors known locally (median 30,
range 8-300)
• Number known well enough to discuss BTC
with? (median 10, range 2-80)
• Number you spoke to about the BTC campaign?
(median 10, range 3-70)
• Number you gave the BTC leaflet? (median 9.5,
range 0-70)
• Ever asked to give someone first hit (86%)
• Even given someone first hit (43%)
45
Recipients
• Data available for 177/181
• 130 male (75%) slightly fewer than
disseminators
• Age mean 28, median 28, range 18-45
• Injecting an average of 8 years (but 14 people
for one year or less)
• 18 people who were new to the NSP
46
Experience of initiation
• Ever been asked for first hit? 49%
• Ever given first hit? 22%
• Ever talked with drug user about giving
someone first hit? 62%
• Ever talked with drug worker about giving
someone first hit? 27%
47
Risk behaviour audit (%) (new NSP users)
Discussed
Useful
Things I didn’t
know
Expect to do
some things
differently
Sharing needles and syringes
85
91
64
82
Sharing other stuff such as spoons,
filters and water
85
91
68
80
Looking after my veins injection sites
72
84
64
73
Preventing an overdose for myself
62
73
52
63
Dealing with an overdose that
someone else has
48
65
52
58
Getting vaccinated against hepatitis B
77
80
67
72
48
Learning points
•
•
•
•
•
To do this absorbed lots of energy and effort
It is feasible
Non-staff costs were about £2000
The anonymised linking system for payments worked
It got 18 new people through the NSP door (added value
beyond the primary study aim)
• It was crucial to manage demand properly. The service
was swamped at times!
• We should have stipulated that recipients cannot return
sooner than 24 hours after the disseminator is recruited
49
Residual questions and issues
• Data validity?
• Effectiveness/cost effectiveness?
• Ethics of paying people to receive health
messages?
50
Transitions interventions exercise
• Of the interventions that have been
discussed:
– How many seem potentially applicable to
your situation/service?
– Which seems likely to have the best
prospects for adapting within your work?
– Can you think of any alternative, new
route transition interventions that might
work for you?
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What do we know & what do we need
to know to from the route
transmissions assessment tool?
•
•
•
•
•
•
•
•
Who initiates whom?
Pressure/choice
Modelling
Reasons people give others the first hit
Drug types and drug market organisation
Important scenarios/groups
Risk and learning around the first hit
Natural transitions away from injecting
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Route Transmissions Assessment Tool
RTAT
Sections:
A: Personal details / demographics
B: Drug History / main transitions
C: Heroin perceptions /consumption / transitions
D: Transition into injecting
E: Ttopping injecting (reverse transitions)
F: Initiation of others into injecting
G: Problems and consequences of injecting
H: Route perceptions
I: Treatment services / sources of intervention
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