‘ The whole system needs to be broken down and built from the street upwards .’

‘ I was probably the only voice saying let ’ s try it on people who are treatment resistant .’

‘ The benefits quickly became apparent for the more chaotic group .’

MICK WEBB

DR BERNADETTE HARD

COLIN FEARNS

were quite stable . I was probably the only voice saying , “ Let ’ s try it on people who are treatment resistant ”. It took more than three months to persuade anyone in the chaotic group to try it , she says . ‘ Then the first two did OK , but with the third it was outstanding . This was a lady who ’ d been in and out of services – multiple restarts , prison , sex working , domestic violence , living in a night shelter . She ’ d been in hospital with ulcers on her legs , with infective endocarditis for her heart valves from the bacteria from injecting , massive self-neglect . She was mentally beaten , completely disengaged , very hostile , very suspicious .

‘ I had very low expectations ,’ states Hard . ‘ But I thought I can ’ t make this worse .’ A week after she finally agreed to an injection ‘ I didn ’ t recognise her ’, and a year later she remains drug free and is working and looking after her children . ‘ What she fed back was that having that stable dose turned off the cravings , and combined with that she was able to basically just hunker down .’

Eliminating the need for regular attendance at pharmacies also removes people from potential triggers and from meeting people who might be carrying drugs or who may bully them for their prescription . Unlike sublingual buprenorphine , where it can still be possible to get some effect from heroin , long-acting injections shut this down completely .

Incorporating something like long-acting buprenorphine , however , can often require a fundamental readjustment on the part of both service users and services , explains Fearns . ‘ From a psychological point of view for the client , the worker and the service as a whole it was alien ,’ he says . ‘ It can be really difficult to grasp that someone doesn ’ t want to come into service because they don ’ t feel they have to – because they ’ re well . If you ’ re used to sitting at home , waiting for your drugs , taking drugs , doing nothing , and now all that ’ s suddenly removed you ’ ve been launched into recovery , so it ’ s about what you do with your time .’

stressed in October ’ s DDN ( page 8 ) when it comes to prescriptions the key issue is flexibility . Prescribing needs to be ‘ massively flexible , but sensible as well ’, states Mick Webb , coordinator at Community Driven Feedback ( CDF ) in Bristol . This applies even with something like HAT , he says , with services needing to remember that every prescribing regime should be tailored to individual needs . ‘ It has to be delivered with the right level of independence – people need to feel that they own what they have .’

Other wider prescribing options

could potentially include medicinal cannabis , as recently highlighted by Nick Goldstein ( DDN , October , page 12 ). ‘ Why can ’ t I go to a drug worker and say “ I don ’ t want these horribly addictive drugs you ’ ve got me on , but smoking weed really helps with coming off them – can you prescribe me medicinal cannabis ?”’ says Webb . ‘ They ’ re scared because they don ’ t have the guidelines , but we can help write those guidelines .’

Prescribing regimes need to be based on thorough and extensive research of what people want , which would also be a key way of starting to build trust with populations seen as chaotic , he believes . ‘ What is there for crack users ? Absolutely nothing .’ The obvious way to do this is via peers – a ‘ massively underused resource , and they ’ re often treated abysmally and won ’ t do anything about it , because they don ’ t know their rights . The people I ’ d speak to if I had a problem would not be drug workers , it would be my peers who know me well . At the moment the whole system needs to be broken down and built from the street upwards .’

The major part of any drug worker ’ s job should always be about how to empathise and understand , he believes . ‘ I ’ ve seen it from all sides . I ’ m a service user , I ’ ve been a prescriber , I ’ ve worked in management . In some ways since COVID it ’ s been a good thing – people on daily supervised

consumption suddenly found themselves on weekly , while some people would have preferred to stay on daily because it ’ s the only contact they might have with a health professional . It should always be about the individual .’

And it ’ s the peers who should be training drug workers , he stresses , ‘ not other people working in the field – because there are certain restrictions and things you can ’ t talk about . With peers there aren ’ t those barriers – you can have some fun with the training and start stimulating that passion again .’ But for now , trust remains lacking , he warns . ‘ Sadly , for a lot of people the best option is to not have anything to do with services . People aren ’ t prepared to take the risks – they feel drug workers aren ’ t people that you can be honest with . So I think it ’ s about training and employing the very people that they ’ re trying to reach . I don ’ t think there are many other options .

‘ Start from the street up , just start with a blank canvas ,’ he says . ‘ Getting out , doing street work and asking people what ’ s going on . We ’ re here , we ’ re right in front of people . This “ hard to reach ” expression is worn out . If people are being called hard to reach , they ’ re being made hard to reach .’ DDN

This article has been produced with support from an educational grant provided by Camurus , which has not influenced the content in any way .