Seminar 6- Treatment community interventions and harm reduction
Liverpool John Moores University, May 4th 2016
The 6th event in the ESRC funded seminar series focused on treatment, community interventions and harm reduction approaches to new drugs. The seminar discussed latest guidelines and best practice on the topic, and extended this to take a critical perspective to try and better understand how and why particular approaches are prioritised, and what role evidence plays in development of interventions. Presenters also explored opportunities for users and the marketplace, and how policy environments may facilitate or present barriers to particular intervention actions.
The seminar was chaired by Professor Harry Sumnall (LJMU) and included eight presentations delivered by academics, practitioners, and postgraduate students from a variety of disciplines.
Dr Alessandro Pirona (EMCDDA) – Interventions and drug policy environments in the EU
The first presentation was based on a European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) study which included focus groups with health care professionals, rapid literature reviews, and a survey of the EMCDDA’s national Focal Points. The work provided an overview of NPS use across EU Member States, reported harms, and recommended health intervention responses.
- One of the roles of the EMCDDA is to monitor the drug situation across Europe through a set of standardized data collection instruments that are submitted annually by partners across 28 EU member states, Norway and Turkey.
- In addition, focal points of the EMCDDA Early Warning System (EWS) have been established in each Member State and they collects information and monitor newly identified NPS that are not under United Nations Convention control. Information on manufacture, traffic and use, including supplementary information on possible medical use are collated and disseminated throughout the network and shared with other EU agencies such as Europol.
- In 2015, just under 100 NPS were newly identified in the EU. This was slightly less than the previous year, but represents a substantial increase since the establishment of the EWS in 2006. Cumulatively, as of December 2015, the EWS monitors around 560 NPS, although few of these are in regular street use.
- Across the EU, there are varied legislative responses to NPS, and these range from NPS specific actions within current drug laws (e.g. Austria, Portugal), or general ‘blanket bans’ (e.g. Ireland, Poland, UK) where no individual substances are mentioned but instead are defined by effect.
- Drug laws are partly meant to protect public from the actual and potential health risks associated with use. However as there have been limited investigations of new drugs, evidence is limited, and legislation is often enacted on a pre-cautionary basis or though comparison with similar illegal drugs. This can sometimes undermine the logic of drug laws and classification systems in those countries (e.g. the UK) where drug control has traditional been on the basis of evidence of relative harms.
Prevalence & harms
- Specific NPS can be hard to define for the purpose of research tools such as surveys. General population survey questions regarding NPS might not match with what users call the drug And so often a compromise is reached where generic terms are used, or descriptions of drug effects. However, this can mean that tracking individual substances can be difficult
- The most recent Flash Eurobarometer attitudinal survey carried out by the European Commission (2014) that asked young people (15-24) whether they had ever used NPS generally reported lower levels of use than traditional drugs (3% last year, 8% ever used).
- Analysis of Global Drug Survey data indicate that levels of NPS are higher in party goers than in general population, but are still lower than other traditional club drugs. Other studies have shown that more experienced clubbers have not replaced traditional drugs with NPS, but supplement them leading to a potentially risky pattern of polydrug use.
- Emergency room data from one European study (data from 10 countries over 12 months) examined acute drug toxicities. NPS represented 6% of all intoxications (the majority were associated with traditional drugs e.g. heroin). In NPS cases, polydrug use was the rule rather than the exception. The most common symptoms recorded were agitation, aggression, anxiety, and hallucinations. The support response in the emergency setting is generally not NPS specific, but systematic management, responding to the symptoms rather than the substance.
- Changing pattern of drug use among injectors is particularly worrying to EMCDDA analysts. There is some evidence that in some countries (e.g. Romania and Hungary) IDUs have switched from traditional drugs to NPS. Other studies show that injecting of synthetic cathinones is linked to issues of needle sharing, leading to localised HIV and HCV outbreaks.
- There is low demand for NPS treatment across Europe- only 2% of all drug treatment. Most of this data comes from the UK.
- Low demand probably reflects low prevalence of use, but structural factors may also be important (e.g. Services are not configured towards, or are attractive to, NPS use)
- Across settings there are three overarching priorities when responding to NPS. Overall priority is to obtain timely and reliable information on harms and substances. This could include three components:
- Risk information. Providing reliable information to users about harms and risks.
- Substance identification. Demand for better technology that can give information on the strength and composition of drug products.
- Competence building – more accessible training material and guidance for health care professionals.
Gaps and challenges
- Most responses for existing interventions can be adapted to NPS settings. However, most drug intervention approaches are under researched.
- Services might not be attractive to new NPS-using populations or there may be limited provision outside of urban areas.
- The Drug market is dynamic and ever changing. The Internet is now playing a crucial role for suppliers, but also for health professionals, and so the Internet could be a threat, but also opportunity to carry out outreach and intervention.
Dr Kathryn Oliver (University of Oxford) – How policy makers use evidence
- This session examined what evidence based policy really is? What counts as evidence? And what are the implications for researchers who seek to inform and influence policy makers
- The policy process has been traditionally defined as though a linear process: problem definition, identification of options, policy selection, implementation, evaluation, awareness raising. However, this process is rarely encountered in the real world and poses a fundamental problem with research that attempts to define policy movement.
- This raises some important questions:
- If we don’t understand the policy process, how are we able to influence it?
- What does evidence use look like? If we don’t know that using evidence in policy making necessary leads to better outcomes, should we be advocating for it?
- What types of knowledge are useful to policy- and other decision maker? Only once we understand this can we as researchers legitimately and effectively intervene in what is a very complex system.
- Dr Oliver presented findings from interviews and observations of conversations about evidence use and policy process and networks, and found that although policy makers used a variety of research evidence, local data was most popular and mostly sourced from people they already know. Personal experience can also come into play during the decision making process.
- Messengers are just as important as messages. The credibility of the person delivering the message of evidence can have an impact on how successful the policy implementation is. This is due to the legitimacy of how knowledge is valued and understood in a political space.
- Democratic credibility is also very important, in both generating knowledge and valuing it and legitimising political decisions.
- Evidence can and does influence policy, but perhaps not in a straight forward way. Evidence can be influential but only when used by the right people who are already imbedded in political institutions and know who to make connections with. This kind of persuasive nature is used as part of a greater toolkit of strategies to create policy and move it forward.
Dr Katinka van de Ven (Birmingham City University) – ‘Blurred lines’: Anti-doping, national policies, and the performance and image enhancing drug (PIED) market in Belgium and the Netherlands
- This presentation focuses do on the supply and production of the PIED market in Belgium and the Netherlands, public Health policy responses, and difficulties associated with policy implementation.
- As a result of the impact upon elite sports, a ‘war on doping’ policy has focused most attention on supply reduction in contrast to harm reduction.
- Responses to PIED use are very different between Belgium and Holland. In Belgium doping in sport is criminalized, and there has been the creation of special police unit to target PIED use. The rationale for doping controls lies in ‘strengthening the fundamental values of sport’.
- Determining prevalence levels is challenging: in Belgian (Flemish) gyms, only men using steroids are typically included in research and therefore other populations such as women are overlooked.
- In Belgium, bodybuilders are smaller which may be the result of PIED testing or using experimental drugs which are not included in testing regimens. As a result, PIED market is being pushed underground which may lead to greater harm and use of other substances or competing elsewhere.
- In Holland, there is little research into PIED but educational campaigns have been introduced by Holland Anti-doping. Research has shown that little attention was paid to the campaigns.
- Again there is a focus on male fitness trainers using or considering steroids and therefore other populations such as police officers or women using weight loss drugs are overlooked. In addition, there is little acknowledgment of the positive effects of PIED use; there is an ‘over-focus’ on the negative health effects.
- A steroid clinic was opened in Holland in 2010 to minimize the harms of steroids but the clinic only treats those with medical issues. In addition, GPs have little or no knowledge or experience with PIEDs.
- Conducting medical studies in this area is challenging because of the moral and ethical issues which are linked to doping.
- In conclusion, there is too much focus on sport groups. There needs to be a rethink in terms of interventions to local policies which are focused on public health.
Joe Kean (Nine Zero Five, Bradford) – Tailoring harm reduction services for anabolic steroid users
This presentation addressed the following questions: What are our motivations for delivering different types of services for anabolic steroid (AS)? What type of services should be developed for AS users? Do AS users belong in treatment services or needle exchanges?
The needs for specific AS services was outlined:
- There are (conservative estimate) 60,000-70,000 steroid users in the UK.
- Risk are varied and relate to injecting practices, such as sharing needles. Accordingly, there is as much risk in injecting steroid use as other drugs.
- HIV rates are equivalent to that if the injecting drug user population
- Different types of users, different types of populations that may require different interventions.
- Knowledge gap in AS users, service providers, and other professionals.
Where should services be delivered?
- Most current services are delivered in needle exchange, gyms, treatment centres, pharmacy based services, clinics
- However, it can be difficult to attract AS users into these services.
What type of services should be offered?
- Basic e.g. needle exchange
- Harm reduction assessment in addition to needle exchange
- Blood taking and advice
What difficulties do practitioners working with AS users face?
- Variation in staff knowledge on AS, and lack of consistency in screening and assessment
- Local agenda and priorities might not support work that needs to be undertaken with AS users
- There is not enough national guidance to support service development, and there’s no ‘one size fits all’ intervention model
What are some solutions to these barriers?
- Sharing good practice-there is often an insular way of working due to protection of expertise and an environment of competitive tendering.
- Utilising different forms of expertise
- Contributing to the discussion
- Contributing to the evidence through participation in research
- Fostering committing to the service by commissioners, professionals, and potential service users
- Need to get steroid users engaged and involved in service development; service user involvement is critical.
Dr Rebecca Askew (MMU) – Drug Dealers Can Advertise: How Drug Cryptomarket Vendors incorporate harm reduction into the sale of illicit substances
- This work was an analysis of online vendor descriptions from Silk Road, an online marketplace for the purchase and sale of illicit substances. So far, researchers had analysed over 3000 listings of different drugs. One of the most important features of such crypto market sites is the anonymity in buying and selling, and (perceived) trust between consumers and vendors.
- Silk Road was the first and largest dark net market place, and the researchers managed to collect data from the site before it was closed down in 2013.
- The aim of the work was to analyse how vendors listed their products, and to look at whether harm reduction messages were included when vendors describe their products. Although NPS might be sold on the Clear Web (pre Psychoactive Substances Act in the UK) they are typically listed as ‘not for human consumption’; therefore harm reduction messages weren’t available.
- The researchers were interested to know if there was potential for advice and harm reduction messages on the Dark Web due to anonymity and availability of space for vendors to describe their product.
- A discourse analysis was undertaken on vendor product descriptions. Dr Askew described a pilot study and focused on three drugs: heroin, cocaine and DMT. The analysis looked beyond the content for not only what was said, but why it was said and how it was said.
- Findings: information provided about products seemed to be connected to broader cultural knowledge around substances, and vendors assumed a certain amount of customer knowledge.. Main findings across drugs were good customer service and encouraged communication between consumer and vendor.
Harm reduction discourse analysis for different drugs
- Cocaine- less description/ more assumed knowledge. Mainly dosing advice in terms of harm reduction, but possibly advertisement masked as harm reduction, more about purity and quality of product.
- Heroin- vendor write about IV injection. Offers other methods of ingestion- other users advice etc. Could be harm reduction but more about getting more for your money.
- DMT- ‘expert knowledge’- chemist/ synthesizer
Dosing/ prep/ storage
Aimed at new users- how to use it
Integrated harm reduction
Less assumed cultural understanding
- Harm reduction by proxy?
Messages weren’t always about reducing harm but about how users can get the best buzz for their buck?
- For NPS- potential for using online vendor websites for harm reduction/ education.
Jamie Tully (LJMU PhD student) – Cognitive enhancers and learning technologies in University students
- Cognitive enhancers’ definition: improve an individual’s cognitive capacity. Usually stimulants: ‘Soft enhancers’ include caffeine pills, coffee, energy drinks; whereas ‘pharmacological enhancers’ include modafinil, Adderall and methylphenidate.
- ‘Smart drugs’ are a media label and don’t really reflect the psychopharmacology cal effects of these classes of drugs
- The majority of research in this area has been conducted in the United States, although there have also been a European studies. The majority of UK research is anecdotal or ‘media driven’ and there have been only two peer reviewed UK studies examining prevalence of use. One studied prescription drug use more broadly, but included cognition enhancement drugs.
- The PhD is exploring motivations for cognitive enhancers use whether these are used as study aids by University students. A secondary research question examines student welfare concerns and long term consequences of use. The proposed work also examines who uses these substances? Is there an element of academic competition between students that encourages cognitive enhancers?
- The Cognitive Enhancement survey has been launched at three universities, including Liverpool John Moores University, looking at prevalence, learning styles, academic self-efficacy, morality, risks/benefits and ease of accessibility.
- Next stages of the work include: long term use and acute administration of a pharmacological enhancer and effects on cerebral blood oxygenation and cognition.
Rick Bradley (Addaction) – Young People and NPS in Practice: Changing Perceptions and Calculated Risks
- This presentations provided an overview of NPS use from a local service perspective (Kent). The service is Interestingly placed given its proximity to London and ports. Across the county, over the previous few years there have been an Increase in NPS use and the highest number of head shops in the UK.
- Interest in NPS stimulant pills and powders first emerged around 2009. There was a low purity of traditional stimulants and the arrival of new products which were legally available, better purity and more consistent effects. There was also an occasional cannabis ‘drought’ due to law enforcement activity. NPS offered something new and exciting to young users.
- In a focus group of young experimental drug users convened by practitioners, participants provided a long list of drugs that they thought they could get hold of.
- Impact of local trading standards actions (pre-PSAct) anecdotally led to a reduction in NPS use.
- Reduced prevalence was believed to be due to young people struggling to get hold of drugs or no longer wanted to NPS (linked to purity).
- There were confusing media reports which tended to equate the harms of all NPS. This was believed to dilute health care messages and makes it difficult for the service to get accurate information to the public.
- Overall, very few people have accessed services in relation to NPS drug use and far more presenters not using than are taking. When perceptions of NPS risk have been explored, young people felt that newer substances were far riskier. Older cohorts also thought they were risky, not as a result of media reports but from their own experiences.
- Vulnerable groups have been identified by the service as requiring special attention These include (but are not limited to): homeless, opiate users, prison populations, and social excluded teens.
- These are the groups that are taking even though they know they are risky, possibly because they know they are risky (‘risk-seeking’ behaviour). If they are having issues around self-worth and self-identify then taking risky drugs could be a sensible decision for them
Emma Begley (CPH, LJMU) – Social rituals and sanctions informing online harm reduction
- This research examined social rituals and social sanctions and how these are employed within social groups in order to explain control against more harmful patterns of use.
- Moderate or controlled use of drugs often overlooked in harm reduction as there is often a focus on more harmful and extreme use patterns of illicit drugs.
- Online drug forums can provide a useful source of drug-related information.
- Advantages of researching forums:
Access hard to reach groups
Anonymised data collection
Can tap into existing networks
Information cannot be validated
Is it representative?
- Studies have found that there is a often ethical practice within online communities and despite there frequently being a pro-drug tone, they often carry strong harm reduction approaches. Previous research has suggested that online users feel a responsibility for other’s awareness and safety around drugs.
- By exploring how messages are responded to online, we could understand better how harm reduction messages could be shared across these forums.