‘A 29-year-old kid dying of sepsis in 2018 in the UK’s second city.’ This was just one drug-related death of many, said National Needle Exchange Forum chair Philippe Bonnet, and reinforced why the focus on harm reduction must not waver and why the work of the NNEF was more vital than ever.
Back after a break in holding its annual event, the NNEF presented a packed conference programme that brought together speakers from health, criminal justice, drug treatment, legal services and policy.
With the first UK drug consumption rooms feeling like a distinct possibility and ever more influential voices and organisations joining the call for decriminalisation, the issues on the programme were bringing back an essential focus on harm reduction.
First speaker to the platform was West Midlands police and crime commissioner David Jamieson, who recently spoke out on the need for treatment over punishment.
‘We’ve got to move away from a polarised binary position – soft or hard on drugs,’ he said. ‘We need new dialogue and thinking.’ Was spending £1.4bn a year in the West Midlands on the ‘war on drugs’ a good use of resources, he asked. Jamieson had launched a strategy to divert people away from the courts and into treatment, through a series of recommendations that recognised drug dependence as a health issue over a criminal justice one.
As a former detective sergeant and undercover drugs operative, Neil Woods had developed an informed perspective of policing the illicit drug market. ‘Locking up nasty people’ was a ‘constant narrative for the public and press’, he said, but the market was so huge that this had a ‘tiny impact’ and ‘the process of policing drugs makes drug dealers more violent’. The growth of ‘county lines’ was involving children in gangs and causing more violence.
His experience had made him evaluate how police operations increased problems for many vulnerable people in society and conclude that the answer was harm reduction.
‘It’s the time to be drastic, the time to be brave,’ he said. ‘Criminalisation of drugs will be looked back on with as much disgust as criminalisation of homosexuality.’
Public Health England’s drugs and alcohol manager, Tony Mercer, had been asked to comment on the arguments of harm reduction versus abstinence – a ‘polarised debate’ that worried him.
‘Ideology can get in the way of interventions,’ he said. ‘We need workers who are happy to provide whatever’s needed at the time.’ Spending energy on a debate that couldn’t be solved meant taking our eye off the ball, he added. ‘It’s a debate that can’t be resolved, so we need to reframe it.’
Referring to William White’s work on the need for different interventions, he said ‘The aim of everything should be to reach and engage people.’
Effective engagement was a central theme for all of the speakers, with the prospect of the first UK drug consumption rooms. They would be a unique part of engaging people, though not a panacea, according to the Scottish Drugs Forum’s Kirsten Horsburgh. ‘We need a whole range of different things,’ she said. Looking at the situation in her Glasgow neighbourhood demonstrated very clearly the difference they would make.
‘You don’t have to go very far from the main shopping areas to find needle litter and discarded injecting equipment,’ she said. ‘We’re already providing sterile injecting equipment but not the rooms to use in.’ People needed to inject in public places – back alleys, toilets, or on the streets. In many cases they would be thrown out of hostels if they were caught injecting on the premises.
The constraints on where people could inject made them do it hurriedly – and the need for speed left them vulnerable to violence, stigma, and dangerous injecting practice, said Dr Magdalena Harris, associate professor at the London School of Hygiene and Tropical Medicine.
Urgent injecting led to venous damage and could easily transition to the groin as this was ‘quicker and easier in a low light’. She shared the experiences of two people involved in her research: Emma had told her about her transition to skin popping (injecting under the skin), which intensified the harms by causing infection. Gary had described injecting while blood was pouring out of his groin – and had seen this as the only viable option to being misunderstood and mistreated at hospital.
Safe injecting spaces would be ‘a place for opportunistic care’, said Harris – a place for food, healthcare, and a shared space for other support services such as benefits and housing. The facilities also made sound financial sense, as people were being hospitalised for preventable conditions such as sepsis and gangrene and not seeking treatment early enough.
‘Soft tissue infections exacerbate social exclusion,’ she added. ‘They give problems with mobility and have a massive impact on people’s lives.’
Getting the psychological approach right was equally important to tackling exclusion, and Roger Nuttall gave insight from his role as nurse coordinator at Hastings Homeless Service.
He talked about Paul, a 42-year-old man who had gone to his GP surgery with a wound from ‘skin popping’. He had disengaged too early from treatment, but since starting to attend the homeless service he had never missed an appointment.
So what had worked in engaging him? The holistic approach to building trust, using counselling skills, respect and empathy, was just as important as the wound care, said Nuttall. ‘Homelessness and addiction tend to rob people of their identity. By listening to their background and history you can help them rediscover who they are.’
Healthcare environments were often stressful, and raised stress levels (shown through levels of cortisol) had been shown to slow wound healing and impair immunity, he explained. So a little empathy and humility could go a long way in creating the right setting for the transition into treatment.
Another dynamic environment for interaction was the pharmacy, and Kevin Ratcliffe, CGL’s non-medical prescribing lead gave insight into initiatives in Birmingham. Needle and syringe programmes (NSP) were being run out of 88 pharmacies in the city, many with extended hours. Service users were actively involved in providing feedback on the quality of services and a mystery shopper exercise had identified things that the community pharmacies could be doing much better – including harm reduction advice.
The exercise also identified a weak link in the chain of Birmingham’s take-home naloxone programme – that clients had to be already engaged with a drug treatment service to receive kits. After a pilot phase (‘and a lot of learning!’) the kits were given out through pharmacies, ‘reaching people that services weren’t’.
The other valuable role of NSP-commissioned pharmacies was to refer people directly into treatment, and Ratcliffe announced that funding had been secured for hepatitis C testing in the Birmingham pharmacies, with results given within the hour. ‘In the city centre we want to get as many people through as possible and refer them into treatment there and then,’ he said.
Dr Ahmed Elsharkawy, consultant hepatologist at the Queen Elizabeth Hospital in Birmingham, said that community treatment was critical to NHS England’s target of eliminating hepatitis C by 2025. There were no patients now waiting in Birmingham and ‘we’re running out of people to treat’, he said. But the UK needed to be far more proactive in finding people with hep C as there were still more people becoming infected than being cured.
NHS England now needed ‘to put their money where their mouth is and stop the rhetoric’ on eliminating hep C, he said – particularly as the highly effective new oral treatments represented a cure within eight weeks.
While the route map for hep C seemed clear, it was as important as ever for workers to stay informed of the latest drug trends. CGL’s medical director, Dr Prun Bijral, explained some important (yet still widely misunderstood) risks of fentanyl – that potency varied widely, leading to uncertainty around consistency and dosing. When pressed with a bulking agent, ‘hotspots’ could occur, with pills containing dangerous levels of this potent painkiller.
Improving access to medically assisted treatment (MAT) was vital to keeping people safe, in accordance with the Orange Guidelines, he said. The other essential strand of overdose prevention was giving out take-home naloxone kits, as ‘the whole community is at risk, not just those in treatment’.
Dr Loretta Ford of the West Midlands Toxicology Laboratory added to the discussion of changing drug trends and explained that toxicology services had to constantly rise to the challenge of detecting new compounds. The ‘classic’ drugs of misuse had been joined by rising trends in NPS, prescription medication (notably pregabalin and gabapentin), steroids, and over-the-counter meds such as anti-histamines – drugs that had opened up a whole new world of varying potency and uncertainty for the user.
This uncertainty meant that the take-home naloxone programme had an invaluable place in reducing drug-related deaths. Zoe Carre, policy researcher at Release, said that while there had been a significant increase in areas providing naloxone, it was shocking that some local authorities were commissioning drug services without monitoring whether it was being distributed.
Coverage of kits was still not wide enough, and was not reaching the people who needed it. In many areas they were not provided to NSP clients, OST patients or to family, friends and carers of people considered to be at risk. Needless barriers included people having to be assessed or referred before getting a kit, or having to wait for training when the kit contained detailed instructions.
‘We recommend that England implements a take-home naloxone programme as a matter of urgency,’ she said, and Release was setting up a steering group to develop national guidelines to improve coverage and remove barriers. ‘All local authorities should be providing take-home naloxone and every person who uses opiates should be given at least one kit.’
‘Naloxone is only part of the solution, but a vital part of the puzzle,’ she added. ‘There needs to be adequate access to harm reduction advice and information.’
At the end of a full and informative day, it was Dr Judith Yates’ job to spell out ‘how to reduce harm and save money’. The clearest message was that ‘we should be ending the war on people who use drugs,’ she said. Decriminalisation was the only model that made sense, ‘and we should do this first’.
Secondly, the harm reduction measures that the conference had considered were highly cost effective: ‘DCRs don’t have to be posh expensive places – just a roof and a kettle,’ she said.
The take-home naloxone programme was proving to be extremely effective and was only challenged by stigma and ignorance: ‘There isn’t another drug that can save a life for £15 in a few minutes,’ she said.
Her work in recording drug-related deaths reinforced time and again that these deaths were preventable and showed that 78 per cent of people were not in treatment at the time of death.
‘There is huge scope for getting these people in treatment,’ she said, calling for an end to re-commissioning and funding cuts. ‘Stop wasting money on the drug war and stop treating people who use drugs as criminals.’
Kasey Elmore visited the conference from Australia to share learning points from developing and building Australia’s second drug consumption room.
‘I wanted to design the best DCR in the world, with no risk. But lesson number one is to accept that this isn’t possible,’ she said. You had to acknowledge that the service that you want to run, and others in the sector want you to run – your clients, the government, the wider community – all look incredibly different.
‘Our model had to be located at our workplace and be medically supervised – an integrated model with nurses, doctors and registered drug and alcohol workers,’ she explained. ‘It’s in a residential area, located on a large public housing estate, and runs a needle and syringe programme giving out 90,000 syringes a month.’
Consulting with the client group was essential, but she felt there wasn’t enough time to do it properly. As they designed the layout of facilities, they came up with a three-stage model with zones for registration, injecting and aftercare, which seemed logical but already posed a problem – that people had to inject to get access to the aftercare services. So it became necessary to discuss a stage four, where people could access mental health services etc, if they didn’t inject.
There were also some conditions imposed by their licence that they had to adhere to, such as not allowing pregnant women or under-18s to use the facility.
An important part of design was to get the toilets right, with needle disposal, and their location in zones three and four. Would pets be allowed in a health facility, and could a dog get in the way of medical staff? Should there be secure pet parking on site so they were not stolen?
Liaising with key stakeholders on the project meant working with people who had never worked with this client group, so ‘pick your battles and build an external consultancy team’, Elmore advised, adding ‘we’re lucky we have an awesome police liaison officer’.
Clients were keen to know the ‘house rules’, such as the amount of drugs they could take in, and it was important to work out the protocol for supervision, the amount of people allowed in a booth, how to prevent people from stealing each other’s drugs, how to stop someone from operating a vehicle afterwards – and would staff be able to inject out of their working hours?
Do not underestimate the time and money needed for staffing, she advised. Finding the right people could be a ‘nightmare’ and ‘training costs a fortune’, but it was important to build a team that reacted in the right way to witnessing injecting and responding to an overdose, and weren’t bothered by a backlash from residents or the media.
The law in the UK was used as an excuse but there was no real barrier to DCRs, Release’s head of legal services Kirstie Douse told the conference.
Home Office statements on DCRs ignored public health elements, such as reducing blood-borne viruses and getting people into treatment, and focused on points of the law, such as possession being an offence.
‘But is this really insurmountable?’ she asked. The legal issues cited related to offences under the Misuse of Drugs Act 1971, other related criminal offences, and civil legal issues. However, she said, ‘there are things we’re already doing in relation to NSPs that we can do in relation to DCRs.’ The focus of the initiative would be on preventing crime and limiting harm.
‘Let’s step back, take a breath and not get bogged down in the law, but remember that drug-related deaths are the highest since records began,’ she said. ‘These are not just statistics but real people, and we want to save lives.
‘It’s up to local areas to take a stand. The law is not as significant an obstacle as people would like you to believe.’