Harm reduction
knife ON A edge
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Acouple of weeks ago I had a call from the BBC , asking if I could speak on their breakfast show about issues faced by a pharmacist in Staffordshire ,’ says Philippe Bonnet , chair of the National Needle Exchange Forum ( NNEF ). ‘ The pharmacist said he was thinking of stopping needle and syringe programmes ( NSP ) because of safety reasons – his staff were being abused regularly . He mentioned a couple of incidents where a service user threatened a member of staff with a used syringe , demanding they give him needles . On another occasion someone came into the dispensary with a knife , demanding their methadone and threatening to kill .’
Bonnet pleaded with the pharmacist to reconsider , asking him ‘ not to punish everyone because of the actions of a couple of individuals ’. He mentioned that NSPs were the reason that HIV prevalence was low in the UK , compared to Europe , and that giving out equipment is so much cheaper than the treatment for blood-borne viruses . He did not get an answer from the pharmacist when he asked him if he was going to stop dispensing methadone .
To the casual listener , the conversation on the radio may sound like discussing sensible precautions on staff protection . But for those working in harm reduction it is another red flag in a public health emergency .
The ease with which people who need these services are being dismissed is being compounded by a crisis in funding and staff morale . ‘ In some services , NSPs are being forgotten about ,’ says Bonnet .
Mark ( not his real name ) works in the harm reduction team of a large treatment agency , and says there has been ‘ a steady erosion of knowledge about harm reduction approaches since 2010 ’. Large cuts to funding have meant ‘ caseloads of increasing complexity ’ and evidence-based practice being replaced by ‘ a mush of dubious interventions ’, including an over-reliance on urine testing .
‘ Significant numbers of drug-related deaths this year , including several believed to be linked to fentanyl ’ have not prompted a relevant response . ‘ The focus appears to be more on data requirements rather than interventions around reducing risk ,’ he says . ‘ There has been no information about fentanyl circulated by the manager or the organisation , in stark contrast to the constant emails related to data needs .’
Furthermore , he sees a slide towards a deskilled workforce . Within increasingly complex caseloads , ‘ much of this work is done by recovery workers who are relatively new to the field but have received little or no training other than shadowing colleagues ’.
Amy ( who also asked for her name to be changed , because she feels she is in a ‘ speak out at your own risk working environment ’) manages a needle exchange and has worked in drug treatment services for the last five years . During this time she has seen ‘ the steady erosion of vital aspects of harm reduction ’.
‘ The stuff we know works – assertive outreach , consistent and persistent support for treatment-resistant individuals – has taken a back seat in favour of assessment , TOPS [ information that needs to be supplied for the Treatment Outcomes Profile ] and group work ,’ she says . ‘ There is so much pressure on “ positive outcomes ” that ultimately very little energy is spent nailing the basics . Ultimately the pressure and expectations we have to impose on our clients is mammoth . The system feels designed for the chaotic to fail – and why wouldn ’ t
Disinvestment in harm reduction is hurting services and failing clients , say those struggling to maintain lifesaving provision . DDN reports
it be ? Fewer chaotic clients in treatment means fewer drop-outs , fewer representations , and all of a sudden your positive outcomes and numbers are on the up .’
While Amy acknowledges some good initiatives – ‘ naloxone has been a gamechanger , as long as you turn up to a service to pick it up ’ – ultimately , she says , ‘ we know that there are so many of our most vulnerable – in the car parks , out camping behind Tesco , sleeping in the underpass – that cannot or will not come into treatment to access such potentially life-saving interventions . What about them ? We are not going to get to them , that ’ s for certain . There ’ s no time , no strategy , and barely enough staff to keep the hubs running . Yet again , these folks fall through the cracks .’
As well as not receiving the immediate help they need , clients are missing out on a much bigger opportunity to engage with healthcare .
‘ NSPs for many people represent the first , and possibly only , engagement with a “ professional ” agency ,’ says Kevin Flemen of KFx training . ‘ This toe-hold in a service opens up routes to so many other interventions – overdose prevention and naloxone , vaccines and BBV testing , wound care and treatment . It can be the first tentative step on a longer treatment journey .’ For many it will also offer the right environment to discuss OST and life-changing options for stabilisation – steps that not only transform the individual ’ s prospects , but also reduce the harm to their families and ultimately to society .
As a trainer he has a fair idea of the level of staff knowledge , and also of the level of priority that harm reduction is getting within services . At the moment he sees that we are devaluing it ‘ by failing to provide space , time , privacy and resources to make needle exchange excellent . All too often , staff with no training dole out equipment with no discussion or further engagement .’ He sees that ‘ some areas have no trained staff or dedicated space for NSP ’. As injectors turn to
6 | drinkanddrugsnews | December / January 2018 www . drinkanddrugsnews . com