Strategies to promote safe disposal of equipment
There is evidence to suggest that needle exchanges do not cause more injecting equipment to be discarded than would be the case if they did not exist129.
Occasionally, used injecting equipment is found lying in the open. When this happens it attracts adverse publicity to exchange schemes and represents a risk of viral transmission if someone has an accidental needlestick injury.
Nourse et al. in Dublin followed up 52 cases of childhood needlestick injury outside hospital in a 15-month period between 1995 and 1996. Most of the cases occurred in inner city areas with a recognised high prevalence of injecting drug use. All received hepatitis B vaccination. Although the number of cases is worrying, it was encouraging that of the nine cases with completed tests for HIV, hepatitis B and hepatitis C, none had seroconverted130.
Injectors should be strongly encouraged to return all used injecting equipment in sharps containers. Ideally this should be to the place it was dispensed from, although this may not always be possible or practical. Measures to promote returns include:
n Verbal encouragement from staff
n Verbal encouragement from peers
n Written encouragement in the form of leaflets
n Written/visual encouragement in the form of posters.
Other measures to promote safe disposal include:
n Examining the appropriateness of exchange locations, e.g. are they too distant from injecting populations?
n Secure disposal points in identified 'hotspot' areas
n Secure disposal points available at exchanges outside opening hours
n Identifying means of safe disposal when none of the above is available.
Strict 'one for one' exchange is impractical and defeats many of the aims of needle exchange. It is more important to ensure that sterile injecting equipment is as widely available as possible, than it is to ensure that all injecting equipment is returned.
The risk of needlestick injury to health care workers is well recognised. The incidence of needlestick injury among injecting drug users is not often considered. Two linked studies of syringe exchange attenders131,132 have included questions about the incidence and subsequent management of needlestick injuries among injectors.
A significant proportion (30.2%) of the 179 questioned had experienced a needlestick injury at some time; 18.3% had experienced one during the past year. Over half of those who had experienced a needlestick injury reported doing nothing about it, some wiped the site with an alcohol swab and a similar number licked it clean. Only one person sought testing.
The risk of a particular viral infection by needlestick injury from an infected needle, varies:
n HIV 0.3%109
n HCV 2.710%109
n HBV 30%133
The recommended management procedure for health care workers includes advice to:
n Wash off splashes on the skin with soap and running water
n Encourage bleeding if the skin has been broken
n Report the accident
n Contact your occupational health
department to obtain post-exposure
n Obtain hepatitis B vaccination.
Similar measures should be encouraged for injectors, including easy access to hepatitis B vaccination and post-exposure prophylaxis.
This also highlights the importance of encouraging safe storage of used equipment to minimise dangers to others.
Drug workers should be aware of the importance of ritual in the injecting process in their work with injectors. The ritualised nature of drug use makes permanent change of behaviour on the basis of reappraisal of the risks a real possibility.
Objects, events or places associated with injecting can become ritualised and serve as triggers for thought processes or feelings associated with the injecting experience. Certainly workers should not be afraid of discussing the detail of a client's injecting ritual and its triggers in order to identify points of risk and potential for change.
Ritual has a strong place within injecting cultures. For an in depth understanding of the subject, the work of Norman Zinberg134 and Jean-Paul Grund66 is recommended.
Just as with legal drugs like alcohol, powerful rituals and social sanctions and values operate throughout the process of acquiring and using drugs amongst the drug using population.
An example of how social sanctions or values amongst injectors can influence messages about safer use, is the crucial understanding that sharing of drugs can be a defining focus of injecting networks. For example it would not be unusual for an opiate user to be expected to provide drugs for another user in withdrawal, with the expectation that the favour would be returned in the future. It is important when communicating messages about the risks of sharing injecting equipment that the power of such reciprocal arrangements is borne in mind.
Helping people change behaviour
Helping people to stop injecting can be extremely difficult. It is important for both worker and client to understand what it is the client wants to achieve. The setting of realistic goals is important to prevent disillusionment and disappointment.
A goal of stopping injecting may not be a sensible first goal and, indeed, may have been proposed by the client because they think it is what the worker will want to hear.
It is much better to have a good relationship with a confirmed injector and accept that many, if not the majority, will want to continue injecting, than to develop relationships based on deception, which will result in disillusionment for both parties.
Many people talk of 'needle fixation', sometimes called 'the draw of the needle', or 'the feel of the steel'. There are many factors operating which make injecting and the events and actions that surround it a powerful experience. Some would say that the ritual of preparation and needle use is a powerful conditional stimulus.Injectors will often rationalise the reason for their continued injecting as 'needle fixation' or that they are 'addicted to the needle'. Although for some people there may be truth in this, for the majority what they are often really saying is that they enjoy using the drug in this way, they like the immediacy of the mental and physical effects.Claims of needle fixation are too often taken at face value. There is nothing wrong in enjoying the effect of injected drugs and it is better to define exactly what is happening for individuals. It is fundamental to establish whether a person has an attraction towards injecting drugs, or the act of injecting itself. Of course for many the attraction is likely to have elements of both and not be limited to a simple 'either/or'.
Motivational interviewing is a directive
client-centred counselling style which aims to allow the client to examine their ambivalence (having conflicting feelings about something) and incorporates concepts such as the cycle of change135.
If an injector has expressed a wish to change their route of administration, motivational interviewing is a useful technique for allowing clients to determine what changes, if any, they want to make. Part of the process would be to assist in conducting a cost benefit analysis of injecting for that person. A similar comparison can be made for the gains and losses of staying the same or of changing.
An example of an individual's cost benefit analysis might look like that shown in Table 8.3.
Table 8.3: Example of a cost-benefit analysis
Good things about injecting Bad things about injecting
The rush Running out of veins
Feeling smashed Risk of catching diseases
Enjoy preparing the injection Groin abscess last year
Friends People always knocking
Better value for money Risk of OD
I get time to myself Partner wants me to stop
Motivational interviewing has many aspects which when applied skilfully can help individuals move towards the goals for change that they have set for themselves. For example, many injectors will know only too well the costs and benefits of injecting, they may want to stop, but not believe that they have the capability to do so. Helping such individuals towards a belief in their own ability to make changes will make those changes all the more likely to occur.
Development of basic skills in motivational interviewing would be useful for exchange staff. Recognising that someone is motivated to change their drug taking behaviour to reduce risk, and providing appropriate support for them to do so, would represent excellent harm reduction practice.
For those that do want to stop injecting there are various practical regimes that may be considered, including:
n Replacing injected illicit drugs with smoked illicit drugs
n Replacing injected illicit drugs with oral prescribed drugs
n Replacing injected prescribed drugs with oral prescribed drugs
n Becoming abstinent.
For those who achieve their desired goal of change, powerful factors often operate for them to return to their previous use. This can take the form of craving triggered by events, objects or places associated with injecting. Preparing people for these eventualities by talking through them and rehearsing coping strategies can be of benefit.
In an Australian randomised controlled trial amongst injectors not in treatment, Baker et al.136 compared the effect of a one-session motivational interviewing brief intervention, against no intervention. At follow-up no significant differences could be found between the groups, but there were significant reductions across both groups in HIV risk-taking injecting behaviour. Baker et al. suggested that it was possible that the subjects who did not receive a formal intervention might be regarded as having received a brief intervention by having their attention directed to their HIV risk-taking behaviour.