THE INTERNATIONAL JOURNAL OF DRUG POLICY 1993 4 2
OUTREACH WORK WITH DRUG USERS, AN OVERVIEW
Drawing on his experience as an outreach worker and on time spent at the WHO reviewing outreach work in Europe, Ernst Buning describes some projects, considers the role of outreach in HIV prevention and examines some of the problems inherent in such interventions.
This article is based on a paper presented at a symposium on outreach work in Bergen, Norway, 22-24 February 1993.
Imagine that you are the owner of a delicatessen. You sell the most exquisite products: fresh salmon, Russian caviar, French pat~, ostrich eggs and fresh papaya juice. To your surprise hardly anybody comes to your shop. So you start an advertising campaign. Now, people come into your shop, they look around and leave without buying. By this time you're almost bankrupt. As a last resource you hire some canvassers. They walk up and down the shopping centre telling people about your fantastic products. They even guide people personally into your shop. But still business is slow and finally you have to close down.
This is not very likely to happen. In business, shop owners are dependent on their bank. However, before banks will even consider investing money, they must be convinced about demand, market, selling strategy etc. In our business (the drug field), we have operated differently in the last two decades. We did not listen to drug users, we did not do market research. We decided what was best for drug users and expected them to buy' it.
Clearly, we have followed the wrong path, given the fact that in most countries only 10% of drug users are in touch with drug treatment facilities. AIDS among drug users is rampant in many European countries. There are about 5000 deaths from overdose each year in the European region, and drug users occupy over 50% of prison cells in developed countries.
One of the latest attempts to 'save' the more traditional drug helping system is the establishment of outreach teams. They have to contact the'out ofreach'and try to lure them into the treatment centre. Before giving an overview of 'outreach in the European region', I would like to stress that most of these outreach projects would not have been necessary if a better (i.e. user friendly, client oriented) helping system had been established in the first place.
My first involvement with outreach work was in 1977. As a psychology student, I was doing a placement in an outreach team. In that period, I soon became aware of the discrepancy between the needs of those who are actively involved in the drug scene and the services the drug treatment centres offered. There were many prejudices as well. Some active drug users considered the people in the helping agencies as 'moralistic, badly informed and power-oriented nitwits'. Some of the staff looked at active drug users as'dirty, untrustworthy and
manipulating junkies'. In this field of discrepancies and prejudices, it was not easy to get something done. Nevertheless, I consider this period as extremely valuable. I learned to listen to drug users and realised there is a different world outside the walls of drug treatment centres.
In the summer of 1989, 1 had the privilege of working as a short-term consultant for the Regional Office for Europe of the World Health Organization (WHO).
I was asked to make an inventory of outreach activities for drug users in the light of the AIDS epidemic. In the course of 1990, this activity was prolonged, resulting in apaper 'Outreach work among drug users in the light of the AIDS epidemic' (Buning, 1990c). This paper gavean overview of the situation in the European regionbased on questionnaire responses; it described practical guidelines for setting up outreach projects and, finally,it looked into review mechanisms.
This article is based on my experiences as an outreach worker, the activities I undertook for WHO and the many international contacts I have in my present job.
AIDS-RELATED OUTREACH IN THE EUROPEAN REGION
Most outreach projects consist of a small team of very dedicated and creative workers. If the project is not part ofa larger organisation, outreach workers often work in isolation and they lack support.
The credo of most outreach teams is: 'don't wait for them to come to you, you go to them' and 'make sure that you see and are being seen'. They have an open mind and try to lower thresholds for drug users to seek help. Their attitude is non-judgemental.
The task of outreach workers is fourfold:
1. Reaching the unreached, for example recreational drug users or hard-core addicts who are reluctant to use the existing facilities.
2. 'Survival-help.'This refers to activities which assist drug users in avoiding major health risks (such as HIV infection, overdose), create conditions for avoiding further marginalisation and assist drug users with AIDS. Examples of this type are crisis intervention, counselling and advice, handing out condoms, providing or exchanging clean needles and syringes, referrals and monitoring of the use of (AIDS) medication. AIDS education (apart from this practical assistance) is done through giving information about risks for HIV infection, counselling and referrals to HIV test sites.
3. Outreach projects play an important role in acting as a link to other organisations. Information about other agencies is given and drug users make use of these agencies.
4. Through field observations, outreach projects are able to provide their organisation and policy makers with information about patterns of drug use, prevalence of drug use, AIDS-related risk behaviour and new trends in drug use.
There are many differences between outreach projects. Some use volunteers. The advantage of using volunteers is that many drug users can be contacted with a relatively low budget. The disadvantage is that the training and support of volunteers take up a lot of the paid workers'time.
A number of outreach projects include former and current drug users and/or prostitutes in their team, sometimes as paid staff, sometimes as volunteers. The major advantage of this is the easy access to the drug scene. Projects that have problems with (ex-)users say that ex-users run a major risk of relapsing into drug use or that they are not capable of holding a non-judgemental attitude towards the clients who are still actively involved in using drugs. Another problem is the fact that drug users often don't accept another drug user in the role of'expert'.
Some outreach projects make use of a drop-in centre, where clients come for practical assistance orjust a cup of tea. Although useful, the existence of a drop-in centre may lead to neglect of actual street work if the centre is opened too many hours a day.
Most outreach projects do both detached work and street work. Detached work refers to outreach work which is done in other agencies, such as prisons, police stations, hospitals and/or other agencies. Street work refers to outreach work which is done in the'drug scene' itself. This could either be in areas where drug users hang out, or in private homes where drugs are sold and used.
SOME EXAMPLES OF OUTREACH PROJECTS
Various outreach projects try to reach young recreational drug users with information on drugs and AIDS. In the UK a special project named 'Festival Welfare Services' provided advice and information to young people attending Outdoor music festivals. This includes advice and information on AIDS as wellas drugs. Although the planning of activities was difficult because of the ad hoc nature of outdoor festivals and the reluctance of organisers to allow space on the site, the staff of this project felt that outdoor music festivals were very good locations for outreach work.
The 'Tackle express' (a 16-foot exhibition trailer) visits locations in the UK where young people gather formally and informally. The staff provide information on AIDS/HIV and drugs. They try to build up relationships with prospective clients and raise awareness on counselling, advice and information services.
In the Netherlands, Advies Bureau August de Loor developed a 'safe house' project. A team visits house parties and provides information about various drugs (Ecstasy among others ). They offer a special service of testing of tablets for MDMA content. Although this testing is controversial (Ecstasy is an illegal drug in the Netherlands), the house party-goerg appreciate this service. The major advantage is that users know exactly what they are using and how much. This reduces the risks of overdoses and the unexpected and unwanted effects of the drug. Furthermore, the team provides condoms and talks about safe sex.
In Edinburgh, Scotland, CREW 2000 developed an information campaign aiming at recreational drug users who mainly use 'dance drugs' such as Ecstasy (McDermott et at., 1993). CREW 2000 is a coalition which includes drug workers, youth workers, journalists, artists, designers, club-goers and disc jockeys. Since they work with people from various backgrounds, they are able to contact drug users who don't identify with the 'typical junky'. This kind of service for these new drug users combined with safe,sex campaigns is of the greatest importance, because the Edinburgh area has a high HIV seroprevalence among drug injectors.
Other outreach projects try to provide 'survival help'in combination with AIDS prevention. In Zorich, Switzerland, ZIPP-AIDS carried out various activities for drug users who were hanging out in a park (the Platzspitz). Making use of a former toilet as their base, they provided counselling, needle and syringe exchange (about 5000 aday), condoms, simple medical assistance, health education, tea and fruit. In 1989, resuscitation was carried out on over 1000 drug users who overdosed. In 1992, the park was closed and the drug scene dispersed into different areas of Zorich.
In Belgium, the projet 'Boule de neige' (snowball) started in 1988. Their credo is 'AIDS travels the same route as information, i.e. from friend to friend'. Since the start, over 40 drug users have been trained. They had to attend four sessions of discussions and exchange of information on the risks of H1V infection. Subsequently, the trained drug users were sent into the drug scene with a kit containing written information, condoms and bleach powder and were asked to talk with drug users about AIDS-related risks. They filled in questionnaires to document their contacts. The drug users involved in thisprojectwere very enthusiastic willing to carry on this activity.
In Madrid, Spain, the ISIDRO bus cruises the city with information about treatment facilities and AIDS prevention for drug users. Clients can see a doctor, exchange their needles and syringes and obtain condoms. With this project they hope to attract drug users into one of the 50 centres for drug users.
Another form of outreach work can be found in projects which visit drug users with AIDS. ln Amsterdam, the Netherlands, the Foundation 'de Regenboog' runs a support project for drug users with the HIV disease. Clients are referred to the support project by workers of the hospital project of the Municipal Health Service. Subsequently, volunteers visit the drug users at home and discuss what sort of care is needed. Most of the care provided is practical, i.e. help to do the shopping, going, to the movies, accompanying clients to hospitals or specialists etc.
In San Francisco, USA, the Health Outreach Team operates in the Tenderloin. Their attitude is very much the same as that of doctors working in developing countries. They visit shelters and try to organise proper medical and social care for AIDS patients, patients who have dropped out of psychiatric hospitals, the homeless and drug users. Part of their work is to ensure that homeless drug users take their AIDS medication daily. They also negotiate with hospitals and clinics about treatment options for their clients.
In many countries, mobile units (vans and buses) are used to provide services to drug users. The rationale behind these mobile interventions is: 'if they don't come to us, we wil I go to them'. Furthermore, a mobile unit helps to encounter problems with neighbourhoods adequately.
In the late 1970s, the Netherlands started to provide methadone through mobile clinics Cmethadone buses'). In 1986, health workers in London and Liverpool started to exchange needles and syringes using mobile units (vans). In Bremen (Germany), Utrecht (Netherlands) and Oslo (Norway), vans are used to contact street prostitutes.
PROBLEMS RELATING TO OUTREACH WORK
One of the major problems encountered by outreach projects is funding. In many European countries, governments stimulate AIDS prevention among drug users by making extra funds available. However, this is often short-term funding. The experience from most outreach teams is that they need at least a year to get to know the drug scene, build Lip a network of clients and develop a rapport with other agencies. If the workers have to start worrying about their funding after the first nine monthsl this will undoubtedly have negative effects on the output of the project. It should therefore be stressed that funds must be secured for a period of at least three years, before setting up an outreach activity.
If an outreach project is too small and not part of a larger organisation, the workers may feel isolated and may lack support in carrying out their work. A prerequisite for funding outreach projects may thercfore he that the project is part of a larger organisation. '
Some outreach projects encounter problems in referring clients, owing to a lack of agencies in their area. The outreach workers feel obliged to do all the work themselves. They are faced with a limited number of clients who need all their attention, leaving no time to get a broader scope of the drug problem in their area. Sometimes outreach workers have to deal with agencies who are reluctant to provide services to drug users, for example, pharmacists who refuse to sell clean needles to drug users or general helping agencies who feel that drug users do not 'fit the profile of their client≤'. Outreach workers sometimes feel helpless in influencing these reluctant agencies, and need optimal negotiation skills in dealing with this.
Most outreach projects have difficulties in relating to the police. The police have an independent responsibility towards public order. This sometimes results in actions by the police which are counterproductive to outreach work. Sometimes this results in the temporary dispersal of the drug scene which can make it difficult for outreach workers to contact drug users. An example of such a situation was an incident in which the police were using the possession of condoms as evidence of illegal prostitution!
Outreach teams sometimes face problems of staff turnover. They have built up their network of clients and are not able to transfer their knowledge to new workers. One project described a situation in which they were very successful in involving one of their clients in peer group education on AIDS. Halfway through the project the client was arrested by the police and had to go to prison. Subsequently, the peer group education project fell apart. Another problem related to staff turnover is the lack of career possibilities for outreach workers.
Many outreach teams who want to operate adrop-in centre are faced with neighbourhood resistance in accepting such a facility in their community. The neighbourhood anticipates extra public orderproblems caused by drug users and dealers who hang out around the centre. As these problems are not imaginary, it is important to develop good liaisons with the neighb ) rhood and make concrete arrangements concerning opening hours, house rules etc.
SUMMARY AND CONCLUSION
I . Outreach projects play an important role in con tacting drug users who are not in touch with the existing facilities. This can range from young recreational drug users to hard-core addicts.
2. Once in contact with drug users, outreach teams provide information about safer drug use and safe sex, offer 'survival help' and assist drug users with AIDS.
3. Outreach workers inform drug users about treatment facilities and refer them to such agencies. Inso doing, they are an important link between active drug users and drug helping agencies.
4. Outreach workers have an important intelligence role. They are in a good position to find out what is going on in the drug scene, such as new trends in drug use, new groups of drug users and/or a lack of facilities.
In conclusion it can be said that there is an important place for outreach work in the drug scene, especially, in relation to AIDS prevention and the promotion of safer sex and safer drug use. Since they observe what is going on in the drug scene, they are able to provide very valuable information, Furthermore, they can report on what drug users think of the existing helping system. This intelligence-gathering role of outreachwork should be recognised by policy makers.
Ernst Buning, Bureau International Contacts Drugs and Aids GG&GD, Amsterdam, The Netherlands
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