policies on client confidentiality and systems to keep the exchange separate from
the domain of client case workers/prescribers. Ideally, this would be
accompanied by the widespread introduction of injecting equipment vending
machines for after-hours access.
The current UK policy emphasis on ‘recovery’ – often interpreted as
abstinence-based – creates additional barriers for people who inject drugs to fully
engage with services. Participants demonstrated a need for non-stigmatising
practical advice about vein care, venous access and caring for soft tissue
infections. This is important for reducing transitions to groin injecting and
associated problems such as unresolved ulcers and limb amputation. Concerns
about confidentiality and punitive OST policies can inhibit people from disclosing
current injecting and receiving the help they need.
Participants were only able to self-regulate and keep methadone back as a
safeguard for themselves and others if they were receiving take-home doses. This
important harm reduction resource can only be facilitated by less punitive and
restrictive methadone dosing protocols.
While this is a controversial recommendation in the current policy environment,
it is backed by research demonstrating that the adoption of more flexible dosing
regimens has better outcomes than supervised consumption – resulting in
improved treatment retention rates, increased involvement and trust in services,
improved reported quality of life and no
demonstrated increases in criminal activity or
illicit drug use.
The fear of losing children to social
services, coupled with concerns about
confidentiality, can inhibit people who use
drugs, particularly women, from accessing
services, and the trauma of having children
removed often exacerbates risky practices.
There is a need for service provision to be responsive to these issues;
COUNTERfit, a Toronto harm reduction programme, provides an example of how
this could be put into practice.
For couples who use together, there is a need for straightforward information
on the relative risks of unprotected sex and sharing injecting equipment.
Hepatitis C prevention materials which ‘add on’ safe sex information can do more
harm than good, perpetuating ‘risk equivalence’ beliefs. Couple-based
interventions can include practical tips such as strategies to keep equipment
separate and distinctive.
INNOVATIVE MESSAGES
Getting a quick hit is pleasurable, and there is often nothing more
desperation-inducing for a person who injects than poking around for a vein,
ever conscious of the risk of the mix coagulating and becoming unusable. The
pleasure of injecting and drug use in general seems to be the elephant in the
room in drug services, where the preferred rhetoric is one of ‘misuse’, ‘harm’
and ‘recovery’. While people accessing drug services are often experiencing
substantial personal, social and/or economic problems to do with their drug
use, this does not negate the pleasurable experience of use for some, and
the pragmatic concerns that people who inject have regarding the
maintenance of their veins.
Hepatitis C prevention could learn from the success of HIV prevention
messages aimed at MSM (men who have sex with men), which actively engage
with notions of pleasure. This would involve a move away from an emphasis on
risk (
ie
‘do not share’) to one emphasising the pleasure and utility of using new
works (
ie
getting a quicker hit, less vein damage and scarring).
It has been a highlight for us to see this suggestion taken up in harm
reduction workforce training and by organisations such as the Irish Needle
Exchange Forum, who produced a series of harm reduction posters based on
these messages. While using new works is not completely sufficient
in HCV transmission avoidance, these messages have the potential
to resonate with people who inject and who are jaded or confused by
HCV prevention messages, and may provide a hook for other
protective interventions.
We believe that harm reduction initiatives which acknowledge the
pleasures and pragmatics of drug use are more likely to reach long-
term users than those that frame drug use as ‘problematic’ and
imbued with risk. This can be a challenge in the current policy
environment where services face pressure to provide ‘results’ in
regard to transitions away from drug injecting, and ultimately
transitions off OST.
Innovative service provision and harm reduction messaging are
particularly important in an environment where people who inject are
increasingly facing challenges not only in regard to their drug use, but
also benefit and accommodation provision. Responsive service
provision can not only help to prevent drug-related harms, but help to
address the trauma faced by people who have had their children
taken and the destructive patterns of drug use that can result.
Magdalena Harris and Tim Rhodes are based at the Centre for
Research on Drugs and Health Behaviour, London School of Hygiene
and Tropical Medicine. To find out more about the Staying Safe
project, email magdalena.harris@lshtm.ac.uk. Here she talks about the
Staying Safe project in an Exchange Supplies video:
www.youtube.com/watch?v=PsWn0_gOT4Q. For a fully referenced
version of this article, with case studies, visit
www.drinkanddrugsnews.com
May 2014 |
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Harm reduction |
Communication
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