A 2 day workshop[month] [day 1],[day2]

[location]Developed by Neil Hunt and Andrew Preston

Run by:

[trainer][email/contact details]

[trainer][email/contact details]

assessing drug transitions & developing interventionsto promote safer drug use

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 treatment

populations

• 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

• 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’

• 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

A 2 day workshop[month] [day 1],[day2]

[location]Developed by Neil Hunt and Andrew Preston

Run by:

[trainer][email/contact details]

[trainer][email/contact details]

assessing drug transitions & developing interventionsto promote safer drug use

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

27

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

• 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

The Initiation Process 2

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

Discussed Useful Things I didn’t know

Expect to do some things differently

Sharing needles and syringes 85 91 64 82

Sharing other stuff such as spoons, filters and water

85 91 68 80

Looking after my veins injection sites 72 84 64 73

Preventing an overdose for myself 62 73 52 63

Dealing with an overdose that someone else has

48 65 52 58

Getting vaccinated against hepatitis B 77 80 67 72

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?

51

Transitions interventions exercise

• Of the interventions that have been discussed:– How many seem potentially applicable to

your situation/service?– Which seems likely to have the best

prospects for adapting within your work?– Can you think of any alternative, new

route transition interventions that might work for you?

52

What do we know & what do we need to know to from the route

transmissions assessment tool?

• Who initiates whom?• Pressure/choice• Modelling• Reasons people give others the first hit• Drug types and drug market organisation• Important scenarios/groups• Risk and learning around the first hit• Natural transitions away from injecting

53

Route Transmissions Assessment Tool

RTATSections:

A: Personal details / demographicsB: Drug History / main transitionsC: Heroin perceptions /consumption / transitionsD: Transition into injecting E: Ttopping injecting (reverse transitions) F: Initiation of others into injecting G: Problems and consequences of injectingH: Route perceptionsI: Treatment services / sources of intervention