Early Intervention with Drug Injectors

1. Early Intervention with Drug Injectors Maureen Woods NHS Lanarkshire – Harm Reduction Team Stirling Royal Infirmary 28/11/05

2. What Intervention measures are we providing to drug injectors and are they EARLY enough?

3. The Main Risks Associated with Injecting Drug Use. • Blood Borne Viruses (BBV’s) • Overdose – Fatal and non-fatal. • Injection Site Injuries/Other Bacterial Infections.

4. Blood Borne Virus Prevention

5. Early Intervention – Harm Reduction Measures “1980’s/90’s – evidence that speedy implementation of a range of public health and treatment measures targeted at those who inject can be effective in reducing the number of infections and in some instances has altered the projected course of an epidemic”. The Beckley Foundation Drug Policy Programme 2005

6. The 3 Main Components of Harm Reduction • The widespread dissemination of information on the risks of infection, and advice to drug injectors on how they can avoid that risk. • Accessible provision of clean materials for injection that allows users to avoid re-using infected equipment • Easy access for drug injectors to treatment services that help them move away from the most risky behaviour

7. Hepatitis C Often referred to as the “Silent Killer” because of the chronic nature of the disease and absence of symptoms. • Recent evidence suggests that this is steadily increasing in new injectors in Glasgow. • Among 55 IDUs who had commenced injecting in the previous 2 years, the prevalence rate was 51%; higher than that detected among equivalent IDUs surveyed in 1999 (24% of 126) and 2001 (43% of 120). Shooting Up – HPA Updated Oct 2005

8. Evidence of Good Practice – Lanarkshire Perspective BBV Risk Reduction Outreach Post • Dual funded post – Acute and Primary Care • Initially 3 year funded – now substantive post. • Hep B Vaccination given to over 1100 service users from a range of locations. • Provides Pre and Post Test Counselling for HIV, HBV and HCV - tested over 400 IDU’s and partners. Approx 100 +ve HCV, 1 with HIV. • Provides Fast Track Referral to Treatment Services

9. Evidence of Good Practice – Lanarkshire Perspective • 1-1 Advice and information on transmission and associated risks • Distribution of sterile injecting equipment • Provides Safer Sex Advice and Information/Condom Distribution and testing for STI’s

10. Who needs Vaccination? • Current Injecting Drug Users • Those who inject occasionally • Partners of injecting drug users • Males who have sex with males

11. Needle Exchange

12. Needle Exchange • Evidence suggests that transmission of BBV’s is likely to happen within the first year of injecting drug use: • NSX should be offered from a range of premises from appropriately trained staff: • Pharmacy • Fixed Sites • Outreach • Voluntary Agencies • Addiction Services

13. Pharmacy ExchangeLanarkshire 2004/05 • 17 Pharmacies provide exchange • Total contacts 17,237 • Gender – 13,590 Male: 3647 Female • Total Needles Distributed 262,245 • Return Rates 40-82%

14. Information and advice on how to use the service 1-1 confidential advice and information on drugs and related issues Provision of free needle,syringe and paraphernalia required for drug use Awareness of cleaning techniques of tools Safe disposal for used equipment Assessment of risks associated with drug use Safer injecting advice and information Examination of injecting practices for all injecting drug users BBV Activities Access to treatment/support services Access to overdose training/information Peer education/user involvement/consultation User Perspective on What a NSX should offer.

15. Evidence of Good Practice – Lanarkshire Perspective A73 OUTREACH PROJECT • 2-year funded Project set up in 2002 as a result of DRD’s in the Rural area of Clydesdale. • Needs Assessment Survey using an action research approach • To engage with hard to reach drug users in a rural setting. • Increase referrals to services

16. Evidence of Good Practice – Lanarkshire Perspective • Adopted a Combined approach to accessing the client group • Outreach/drop in facility at our base • Fixed Site Exchange • Pharmacy Exchange • Multi-agency approach • Snowballing Effect within the client group

17. Outreach and Drop In – 2163 contacts Evidence of Secondary distribution of Injecting Equipment Return Rates – 97% 48 Referrals to other services BBV Activities – BBV Counselling – 25 clients, 22 of which were tested for BBV’s – 2 of which were HCV positive HBV – 37 (all 3) 6 (2), 4 (1). Boosters 45. A73 Outreach Activities

18. A73 Outreach Risk Behaviours – BBV’s • 106 Respondents – 83% were currently IDU’s. • Age range for first injection 12-37 years • 63/106 Reported Sharing of Equipment -Needles – 38% -Syringes – 28% -Spoons – 78% -Water – 49% Filters – 36%

19. Comparisons between Outreach NSX and Fixed Sites (3)

20. A73 Outcomes • Proven to be an effective way of engaging with service users. • Model being adopted by the JFIG as a Low Threshold Service in Lanarkshire • Proven to provide early interventions at any stage in the addiction cycle

21. Overdose Awareness

22. Fatal and Non Fatal Overdose • Drug Related Deaths remain high – National Figures for 2003 - 317 • Non-fatal overdose is common amongst injecting drug users. • A73 Needs Assessment – identified that amongst 106 respondents: • 94% (100) reported poly drug use • 38% (40) reported to one or more previous overdose.

23. Fatal and Non Fatal OverdoseRisk Factors • Anyone who takes drugs and or alcohol but in particular injecting drug use (Heroin) • Previous overdose history. • Reduction in tolerance. • Poly drug use • High levels of alcohol use • Poor physical health • Recent detox

24. Fatal and Non Fatal OverdoseInterventions • Importance of obtaining a drug/alcohol history during assessment and at NSX. • 1-1 discussion around risk areas. • Dissemination of factual information. • Overdose Awareness Training which incorporates Life Saving Skills. • Consideration for Retox programmes prior to release from Prison. • Consideration for Naloxone Prescribing

25. Injection Site Injuries And other Bacterial Infections

26. Abscess Vein Damage Citric Burns Leg Ulcers Needle Stick Injuries DVT Hitting an artery Granulomas Localised swelling due to missed hits Botulism Tetanus Septicaemia Endocarditis Gangrene Injection Site Injuries and Other Bacterial Infections

27. Regular checking of injection sites 1-1 advice and information on safer injecting practices Adequate provision of injecting equipment Training on safer injecting techniques Advice on routes of administration for their chosen drug and alternatives Early notification and awareness of potential threats (ie botulism) Poster campaigns in designated areas (ie chemist) Advice on wound care and referral for antibiotic therapy Interventions

28. Why early intervention is important. • Engage with the client group. • So the client can make informed choices. • Prevention/reduction of associated harm. • Reduce/prevent drug related deaths. • Dispel drug related myths and provide accurate and up to date information. • Identify treatment options and priorities

29. For Interventions to be effective Service Users Suggest that: • Services need to be easily accessible. • Offer a drop-in facility. • Non-judgemental • Provide a range of services and treatment options (from Outreach to Aftercare) • Have access to/offer prescribing • Have credibility with the client group. • Short waiting times • Confidentiality User Involvement Survey 2005

30. Lanarkshire’s Service Users Perspective “Recovery does not finish when you finish a detox, this is where the hard work starts” “ A drop-in would be good for people who have finished rehab, just so you can talk to someone who has been through it and get some support”.

31. Pharmacies Needle Exchanges Addiction Services Police Voluntary Organisations User Involvement Groups Health Promotion Housing Social Work Resources Homeless Units Primary Care and Acute Services Education Authorities Peer Education Prison Where are the Opportunities for Providing Early Intervention?

32. Thank you for your attention.