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“Taking Away the Chaos”: the Health Needs of People Who Inject Drugs In

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“Taking Away the Chaos”: the Health Needs of People Who Inject Drugs In “Taking away the chaos” The health needs of people who inject drugs in public places in Glasgow city centre The health needs of people who inject drugs in public places in Glasgow city centre Background 2015 saw a significant HIV outbreak among people who inject drugs in Glasgow, with 47 new diagnoses compared to a previous annual average of 10. New cases continue to occur. Initial investigations suggested a link between the outbreak and injecting in public places in the city centre, with the majority of cases interviewed reporting this risk factor. New HIV diagnoses among people who inject drugs in NHSGGC, 1985-2015. History of public injecting among people diagnosed with outbreak strain of HIV during 2015 for whom structured questionnaires were completed. This is the latest of several outbreaks of serious infectious disease among people who inject drugs in Glasgow, including botulism (2014-15) and anthrax (2009-10). Drug-related deaths in Glasgow have also been a persistent concern: though the rate per 1,000 problem drug users is below the national average, the size of this population locally means that the city experiences a high overall burden of drug-related mortality1, 2. Local residents and businesses have for some years voiced concerns that large amounts of discarded injecting equipment in public places in the city centre and neighbouring areas are negatively impacting on community safety and amenity. There is therefore evidence that people who inject drugs in Glasgow continue to be vulnerable to significant health harms, with those involved in public injecting in the city centre at particular risk. In response, NHS Greater Glasgow and Clyde (NHSGGC) and Glasgow City Alcohol & Drugs Partnership (ADP) initiated this project to review the health needs of people who inject drugs in public places in Glasgow city centre and to make recommendations for services. 2 The health needs of people who inject drugs in public places in Glasgow city centre Methods There are a number of methodological challenges inherent to understanding this marginalised population with complex health and social needs. We therefore used a pragmatic approach, which triangulated information from three key sources. 1. Data from local and national services, including injecting equipment providers, a local Assertive Outreach team, specialist addictions care, the Scottish Ambulance Service, and Community Safety Glasgow. 2. A series of rapid literature reviews on the characteristics and needs of people who inject drugs in public places, and the evidence for potential interventions 3. A consultation exercise with key stakeholders, comprising six interviews with people currently involved in public injecting, a focus group with fifteen individuals in recovery from injecting drug use, and an online consultation with thirty-three staff from health & social services, patient and family organisations, and enforcement agencies. Findings There are few reliable data on the number of individuals who inject drugs in public places in Glasgow city centre. By applying published figures on the prevalence of public injecting to local data from injecting equipment providers, we estimate that approximately 400 to 500 people may be injecting in public places in the city centre on a regular basis: this is consistent with the number of individuals known to a local Assertive Outreach team set up to serve this population. Data from existing services suggest that the majority are male, of Scottish or other British origin, and aged between 30 and 50 years. Many experience the combination of social vulnerabilities commonly referred to as ‘multiple exclusion’ or ‘severe and multiple disadvantage’, including homelessness, recent incarceration, and chronic poverty. A significant proportion continue to inject despite being in structured addictions treatment. The characteristics of individuals involved in the HIV outbreak are very similar to those of individuals known to the Assertive Outreach team and city centre IEP outlets, and a substantial proportion of cases report public injecting. Factors driving public injecting include immediacy and proximity to drug markets, homelessness, and concerns about assistance in the event of an overdose. Public injecting in Glasgow is concentrated in lanes, closes, car parks, and public toilets of the south-east city centre and adjoining areas of the east end. Several informal drug consumption areas have been found in abandoned buildings and makeshift huts. This population experiences multiple barriers to improving their health and to accessing existing services, foremost among which are the severity of their addiction and the precariousness of their social circumstances. Such factors are inextricably linked to health, and must be directly addressed if any response to public injecting is to succeed. Nonetheless, a number of priorities for health service provision can be identified: the risk of blood- borne viruses, of overdose and drug-related death, and of other injecting-related complications, such as abscesses, wounds, and deep vein thrombosis. The link between public injecting and the recent HIV outbreak is particularly concerning, with 83% of cases interviewed reporting this risk factor. From this work, two sets of recommendations emerge: firstly, for the development of existing services, and secondly, for the introduction and evaluation of new services. 3 The health needs of people who inject drugs in public places in Glasgow city centre Recommendations for the development of existing services 1. Develop a strategy for multi-disciplinary co-ordination between the various agencies involved with this population, in order to address the multiple forms of disadvantage they experience and the wider social determinants of public injecting. Public injecting is inextricably linked to the combination of adverse social circumstances often referred to as ‘multiple exclusion’ or ‘severe and multiple disadvantage’. Several stakeholders therefore identified a need for better integration and communication across relevant sectors, including health, social care, housing, and criminal justice. Whilst any such initiative should be mindful of some service users’ concerns about confidentiality and information sharing, a co-ordinated approach is essential to ensuring that services meet the needs of this population. Further work is therefore required locally to develop a multi- disciplinary response to the broader needs of this population, particularly in relation to housing. 2. Support the development of a peer network for harm reduction aimed at current injecting drug users, analogous to – and linked with – successful local peer-led recovery initiatives. Service users and providers alike spoke of stigma as a powerful barrier to accessing much- needed services among this population. Many people with active or former injecting drug use described a need for more person-centred care, and wanting more input into decisions about their care. We were struck by the strength and value of the existing peer network for people in recovery, and by the opportunities for empowerment, engagement, and harm reduction that a similar network could offer for people who inject drugs. 3. Review models of delivery for specialist addiction services to ensure they are able to meet the needs of this population, with particular reference to access, engagement, and harm reduction. While national and international comparisons suggest that the quality of specialist addictions provision in Glasgow is relatively good, these aggregate data may not be representative of the experiences of people who inject drugs, a subgroup of service users with particularly complex needs and at high risk of harm. Though it is anticipated that the novel services recommended below will contribute to greater engagement and harm reduction among people who inject drugs in public places, this project has also identified a number of opportunities to improve the ability of existing services to meet their needs. Staff highlighted a need for more flexible and intensive services, greater specialist outreach, and potentially, a dedicated city centre community addiction team. Both staff and service users also suggested there was scope for a greater focus on harm reduction across all tiers of service. 4. Maximise the capacity of the existing Assertive Outreach service to provide injecting equipment during evenings, and shift existing contracts with city-centre outlets to sites with extended opening hours. Current injecting equipment provision (IEP) in Glasgow city centre is widely acknowledged to be very good. Plans to expand the provision of route transition interventions – such as foil distribution and training – are an important and welcome addition to existing services. However, evidence from our work and that of the HIV Incident Management Team has indicated that there is room for improvement in relation to out-of-hours provision of injecting equipment. Though there is some evidence that vending machines are able to reach the target population, stakeholders generally preferred the option of extending the hours of staffed services, in order to maximise opportunities for harm reduction interventions. While a safer injecting facility in the city centre, as described below, could in future offer out- of-hours injecting equipment provision, there will inevitably be a significant lead time before it becomes fully operational. The most feasible and acceptable approach in the interim is therefore to build on existing services to
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