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?

• 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!

Preventing initiation

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 (non-injecting 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 non-injectors 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