We can never be certain what the future will hold but in my opinion we are seeing a fundamental and seismic shift in the pattern of opioid use in the UK . This isn ’ t going to be a temporary drought with business as usual soon .
DO THE RIGHT THING
1 : PULL TOGETHER HYPER- LOCAL FOCUS GROUPS – located within drug services , pulling in people who use , workers , housing , emergency services . Drill in to both fatalities and near misses . Detailed granular information , the way people are using and experiencing the drugs , how people responded to naloxone , duration of effect . Encourage people to send samples for testing .
2 : TESTING – in lieu of having an English testing service we must continue to impose on WEDINOS but we need to get greater random testing of samples , not just in response to ‘ bad batches ’. Support people and encourage people to send in samples so we get a proper picture of the distribution of novel opioids .
3 : CONSOLIDATE OUR KNOWLEDGE BASE – there ’ s a lot of information we don ’ t have that will inform harm reduction . How many fatalities or near misses related to smoking ? We say ‘ start low , go slow ’ but with isotonitazene ( for example ) forming long-acting potent metabolites , what does this mean in practice ? To what extent are the nitazenes rewarding and reinforcing redosing ? Our focus groups are essential to build this knowledge .
4 : AGREE AND STANDARDISE KEY MESSAGES – there ’ s literature going out about fentanyls that doesn ’ t mention naloxone , and some where there ’ s no mention of calling an ambulance . I ’ ve been in services where there are no posters , others where there ’ s a sea of them and the message is lost . Communication – posters , leaflets , verbal input from reception staff , key workers , groups is imperative .
5 : THERE NEEDS TO BE RAPID AND PROACTIVE EXAMINATION of the pros and cons of nasal v injectable naloxone , and while the primary message has been to ‘ get naloxone to people ’, in some areas this has seen nasal formulations being the more acceptable option . But if the lower number of doses this affords could be a risk , it needs to be reviewed . What would the gold standard look like ? We urgently need an evidence base for this – or a nasal preparation with more doses .
6 : HOSTEL POLICY – there ’ s an ongoing clamour for drug consumption centres but with the best will in the world these will take time and significant cost to deliver . In the meantime hostel policy work developing high tolerance policies and effective in-house overdose responses can have a real impact immediately .
Their effectiveness in areas where they are established is well developed and needs to be expanded without prevarication .
7 : TRAINING ! Well , while you would expect this from a trainer , recent courses have highlighted some significant issues that need to be urgently addressed . This has included people excluded from OST as they ’ re testing negative for opiates , with clinicians unaware that some ‘ brown ’ heroin may contain no diamorphine and that nitazenes won ’ t show up on an OPI screen . There is a colossal training need – for drugs services , wider healthcare and other related services including housing , mental health and criminal justice .
8 : WIDENING THE MESSAGE – as novel opioids are being found in a growing range of substances – benzos , fake Oxys and vapes , we need to widen awareness and harm reduction beyond heroin users based on evidence . Benzo users need to be a key target , many of whom may not be in touch with drug services . Given the growing prevalence of bromazolam / nitazene benzos , consideration needs to be given to refining messages (‘ don ’ t mix ’ isn ’ t useful when the pills are effectively ‘ pre-mixed ’). Messaging needs to be via channels other than drug services – chemists , mental health services , GPs – to reach people using grey-market benzos but not in touch with drugs agencies .
9 : BENZO TREATMENT – we ’ ve been talking about this for too long and the unwillingness to offer effective benzo substitute prescribing has been an issue for a long time . The idea of directing people to wean themselves off illicit benzos has always been less than ideal , but now that we know those benzos could contain novel opioids to offer such a message is unconscionable . But not only do we need effective prescribing options for people using street benzos , we need to recognise that such patients may have developed opiate / benzo habits due to mixed pills and will need treatment options for both .
10 : TRAUMA SUPPORT – even with our best efforts people will die and this has a huge impact both on those endeavouring not to use and those still using , as well as people working in support services . Bereavement , grief , helplessness , survivor guilt – we need to ensure that we bake in the support all affected parties will need to cope when people die . On a recent training course we were looking at one small catchment area where the worker was describing seven people being acutely unwell or dying in December . The impact on them and the people they were supporting was colossal .
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