[trainer] [email/contact details]

1. A 2 day workshop[month] [day 1],[day2][location]Developed by Neil Hunt and Andrew PrestonRun by: assessing drug transitions & developing interventionsto promote safer drug use [trainer] [email/contact details] [trainer] [email/contact details]

2. 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

3. 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

4. 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

5. 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

6. 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…

7. 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

8. Limitations to the evidence base • The evidence is largely derived from treatmentpopulations • 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

9. 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.

10. 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

11. Reasons people use or avoid heroin/injecting • 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 • 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’

12. A 2 day workshop[month] [day 1],[day2][location]Developed by Neil Hunt and Andrew PrestonRun by: assessing drug transitions & developing interventionsto promote safer drug use [trainer] [email/contact details] [trainer] [email/contact details]

13. Route transitions theory, history and evidence • Early 1990s – developments in the systematic study of transitions • Griffiths et al 1994 • Darke et al 1994

14. 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

15. 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

16. 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)

17. 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!

18. Motivation and change Pre contemplation > contemplation > action > maintenance > relapse

19. ‘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

20. 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

21. 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)

22. Preventing commencement 3 • Methadone treatment for non-injecting heroin users (Southwell et al. 1997)

23. 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)

24. 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

25. 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)

26. 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

28. 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

29. Injecting As An Especially Risk-laden Form Of Drug Use • Blood-borne viruses and other infections • Overdose • Increased dependence

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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)

36. The ‘Break The Cycle’ Campaign • The intervention briefing • An intervention pad – 30 tear off cards • A leaflet • A poster

37. 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

38. Can BTC be delivered as a using a higher coverage, peer-delivered model?

39. Aims • To test the feasibility of implementing a peer-delivered 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?

40. 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?

41. 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

42. 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

43. Results - process • Duration – Bolton (10 weeks) • 18 disseminators recruited • 73 recipients attended service • Leigh (4 weeks) • 31 disseminators recruited • 108 recipients attended service

44. 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)

45. 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%)

46. 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

47. 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%

48. Risk behaviour audit (%) (new NSP users)

49. 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

50. Residual questions and issues • Data validity? • Effectiveness/cost effectiveness? • Ethics of paying people to receive health messages?