Workshop goals Briefly review a range of interventions that aim to reduce injecting

route transition interventions encouraging switching from injecting and preventing its adoption

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

Decrease incidence of injecting i.e. things that prevent or delay people from starting

• 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?

Preventing initiation

• 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!

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?

Further opportunities?

• Social marketing aimed at Montreal street youth

• Drug consumption rooms

• ITEP/BTEI

• ‘New recovery’

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