Transcript Neil Hunt
route transition interventions encouraging switching from injecting and preventing its adoption welsh needle exchange forum, national conference cardiff 20th april, 2010 neil hunt Workshop goals • Briefly review a range of interventions that aim to reduce injecting • Reflect on the ethics of intervention in this area of practice • Discuss opportunities to develop services in Wales that: – Draw on our existing evidence and understanding – Are relevant to the needs of people in Wales – Might realistically be adopted within your service What are our intervention points? • Decrease incidence of injecting i.e. things that prevent or delay people from starting • Increase outcidence i.e. increase the rate at which people wholly or partially stop injecting Are our interventions right and proper? Ethical considerations • Are our interventions based on the goals and concerns of: –people who inject/those at risk of starting to or… –someone else’s agenda? • Will our programmes increase stigma and discrimination? • Does a focus on transitions interventions divert attention, energy & resources from more important work? • Other unintended consequences? Preventing initiation • Psycho-educational programmes e.g. Casriel et al 1990, 1992, Roy et al in progress • Break the Cycle e.g. Hunt et al 1998; PSI Uzbekistan, Kyrgyzstan, Viet Nam; “One shot” New South Wales; UNICEF/Aksion Plus/Stop AIDS, Albania; Scottish HCV strategy (in progress); “BTC/CTC (Change The Cycle)” Canada (in progress) • Opioid substitution treatment – Timely OST for heroin dependent chasers/sniffers can prevent escalation to injecting • • Unintended consequences? OST can also be used to promote injecting if you make injecting an eligibility criterion for treatment! Promoting switching • Social marketing e.g. “It’s good to chase” HOT, East London; “Smoking Brown”, Lifeline • Foil distribution e.g. Pizzey and Hunt 2008 • Opioid Substitution Treatment…again OST and reductions in injecting • In first month of methadone treatment 25% stop injecting and a further 70% inject less often (Strang et al 1997) • Higher doses are associated with stopping injecting (Capelhorn et al 1993) • Effectiveness depends on the nature and intensity of other non-pharmacological treatment factors (Ball and Ross 1991) • Methadone maintenance reduces injecting in prisons (Stallwitz and Stöver 2007) • Do we currently provide our services in a way that optimises these outcomes? Foil distribution • Not for everyone and not all of the time, but foil distribution has been clearly shown to promote both full or partial switching from injecting • Foil provision enables earlier engagement of non-injecting heroin users • All police forces in Wales have now provided ‘letters of comfort’ regarding foil distribution and S9a of MDA • Just giving out foil isn’t enough. How might foil distribution programmes be implemented in your service to get best results? Further opportunities? • Social marketing aimed at Montreal street youth • Drug consumption rooms • ITEP/BTEI • ‘New recovery’ Social marketing campaign targeting street youth Elise Roy et al., Evaluation of a Media Campaign Aimed at Preventing Initiation Into Drug Injection Among Street Youth. Drugs: Education, Prevention and Policy (2007) 14, 5,401- 414 •Lighters •Pre paid calling cards •Chocolate •Water Results • Powerful, positive impact with the target population (noninjecting street youth) • Unintended consequence – Some injectors also found the campaign useful because it caused them to reflect on their injecting • Some injectors felt that the fear-based messages and images are too harsh and confrontational and expressed concerns that the campaign could be stigmatizing Drug Consumption Rooms • Shortened injecting careers? • Weekly use of safe injecting facility roughly doubles likelihood of entering detox. • ‘Quarantine’ effect • Can DCRs reduce mixing of people who inject with noninjectors and decrease the social transmission of injecting? • Wood et al 2006, Attendance at safer injecting facilities and use of detoxification services. New England Journal of Medicine ITEP/BTEI • A “non pharmacological treatment factor”? • ‘Nodal Link Mapping’ - potential maps (guided/free/hybrid) –Injecting pros and cons –Injecting alternatives –Injecting lapse/relapse New Recovery: new opportunities to reduce injecting? • New context and new zeal – We’ve never had this proportion of people who inject engaged in treatment – We’ve never had this level of service coverage before – We’ve never had a treatment workforce this size before – Recovery is now central to our national strategies – A recovery renaissance with a more mature engagement between harm reductionists and the recovery movement – No-one has ever been here before • Are there new opportunities that a recovery orientation overlaying a harm reduction based treatment system can now bring? Recovery Walk, Cardiff 10th September, 2011 Small groups Which, if any, interventions seem to have most potential for: • Improving the health and well-being of drug users in your service or locality • Actually being implemented Thank you