|Addiction, Opiates, heroin & methadone|
|Written by Teresa Jankowska|
|Tuesday, 02 December 1997 00:00|
Benefits of Heroin Chasing Campaign as a Harm Reduction Tool
This is a descriptive paper of the opportunities, challenges and dilemmas in developing the concept of promoting heroin chasing as a harm reduction strategy. The advent of hepatitis C gave added impetus to this approach and in 1996 a model campaign was presented to the 7th International Conference on the Reduction of Drug Related Harm. This paper considers the continued development towards one of the first specific professional interventions to stimulate transitions to chasing heroin injectors.
The paper will consider three primary areas:
(i) the community development approach applied to developing and implementing the campaign which embraced user involvement;
(ii) the management approach to creating the organisational, political, and legal environment within which the campaign could thrive;
(iii) lessons from early work described through three case studies of injecting drug users who considered a transfer to chasing.
In 1990 the Healthy Options Team (HOT) was established as an experimental project in response to the advent of HIV infection within the drug using community. The team's main objective was to target the unmet needs of the "hard to reach" and hidden population of illicit drug users, the vast majority of whom were injecting. Harm reduction initiatives targeted at this population were promoted and developed.
A year later, William and I came to London from Holland. We brought with us life experience as chasers from a scene where chasing was prevalent and had relatively high status. It came as quite a shock that we were turned away because we were not injectors and as chasers our problems were seen as not significant enough to merit any serious intervention. We had fallen into a drugs culture (shaped by both professionals and users) which felt alien. 1 It was as if the pinnacle of one's drug using career had been reached at the point of transition to injecting. Services and harm reduction strategies were all designed with the injector in mind.
In 1993 I was appointed as Volunteer Co-ordinator for the Healthy Options Team. There followed a three year period of actively encouraging contemplation about chasing within the agency and the local using community. Exploration with users revealed myths and misconceptions about chasing. Roadblocks to transition were openly discussed. The process of influencing change within the community was slowly taking place. Skilled chasers were called upon by their peers to contribute to and inform the lively debate. This work was reinforced by research that confirmed that spontaneous transitions do take place in the UK between different routes of drug taking. 2
This early work informed the design and development of the pilot chasing campaign presented at the 7th International Conference on the Reduction of Drug Related Harm. s The potential role of promoting transitions from injecting to heroin chasing had been discussed. a The 1996 Rankin Lecture promoted a broader vision of drug transitions as a response to HCV. I The presentation of non-injecting routes of administration (NIROA) as deliverance from HCV provoked widespread reaction from user groups with fears that injecting was being stigmatised. This created tensions around the Chasing Campaign with an approach from a community development agency being seen to collude with messages that were perceived as being hostile to injecting drug users. User groups within the Australian context had not rejected outright the concept of drug transitions but rather the language and spirit in which it was delivered. 6 The philosophy of HOT's work is that stigmatisation of injectors serves no purpose other than to decrease an individual's self-esteem and selfefficacy, two crucial components to change.
Reflecting on the experience of the reaction to the 1996 Rankin Lecture it is clear that there is strong attachment to routes of administration and that supporting rather than imposing change is essential. To this end HOT's development model was that work around drugs transition must be informed by and actively involve users and user self-organisations. Discussions with Respect Users Union (self-organisation of drug users), following its formation in 1996, caused to other revisions in the original approach. Firstly, the separation of work around heroin and crack and secondly, the framing of drugs transitions work within a wider HCV prevention strategy which gave a primary prominence to a safer injecting campaign (the Viral Protection Campaign). 8
3. Aims Of Heroin Chasing Campaign:
The campaign retained the strong leadership of those with histories of chasing but sought to improve the dialogue with injectors. This approach sought to protect the ability to deliver messages that would provoke internal conflict as an agent of change among injectors while taking advice on supporting the self-esteem of injectors within the campaign. To this end the campaign had six aims:
(i) to challenge the status of chasers as an inferior population of users;
(ii) to challenge misconceptions of chasing among injectors;
(iii) to question a belief among workers that chasing is an automatic precursor to injecting;
(iv) to highlight positive benefits of chasing as a harm reduction tool among injectors;
(v) to value patterns of chasing among new users and other key populations within the using community;
(vi) to reinforce spontaneous trends towards chasing from within the injecting community.
4. Benefits of heroin chasing as a harm reduction tool:
In light of the debate around the presentation of drugs transitions that arose from the 1996 Rankine Lecture, it is important to restate the benefits of promoting heroin chasing as a harm reduction strategy with injectors:
4.1 Enhanced HIV prevention messages:
While safer injecting messages have to be conditional in relation to HIV infection, chasing offers totally safe practice in this area.
4.2 Viral prevention strategy:
Chasing provides one more response to all blood borne viruses at a time when hepatitis C has maximised the risks associated with injecting.
4.3 Reduced overdose risk:
There are reported incidents of overdoses involving heroin chasing. However, these isolated incidents need to be set against over 500 opiate related overdoses among injectors per year in the UK.
4.4 Reduce primary health care risks:
There are less associated health care risks linked to chasing. Chasing may act as a tool for those who have problems finding injecting sites, as a method of resting veins or for those who have reached the end of their injecting careers.
4.5 Using on top of methadone:
Chasing offers a safer option for those using on top of methadone programmes. It may also help break association with chaotic using by leaving behind rituals of using that may, in an individuals experience, have been historically associated with chaotic use. This is not to say that injecting correlates automatically with chaotic use.
4.6 Controlled street use:
For those not wanting to go on a methadone programme, chasing offers a viable alternative for reducing dosage or gaining more control over street drug use.
While the positive benefits of chasing are noted, it is equally important to reflect and advise on the potential health risks associated with chasing. While this approach argues that there is an overall cost/benefit in favour of injecting it would be inappropriate to mask risks associated with heroin chasing. 9 '0
5. Validation process for the campaign:
Promoting chasing as a harm reduction tool could be a potentially controversial approach. The Heroin Chasing Campaign is a radical harm reduction approach with high in built risks for the partners in the campaign. A clear strategy to identify and manage ethical, legal and public relations issues has had to be a core element in moving from an informal process of consultation within the using community to a fonnalised campaign. 11 This was reinforced by HOT's management within Tower Hamlets Healthcare NHS Trust part of the UK's national health service. This paper will not describe in detail this process (see Appendix A) but a number of key lessons can be learnt from this experience:
5.1 Legal Issues:
The legal review of the campaign identified that the greatest risk legally was a charge of incitement to heroin use. Every effort in the campaign therefore was made to stress that the audience was existing heroin injectors and that the campaign was promoting a technique rather than heroin use itself.
5.2 Integrated approach:
It was essential that the validation process was integrated into the development process to allow for the marketing and design of the campaign to be re-orientated in light of professional and public concern.
5.3 Links to Up Your Bum Campaign: 12
Presenting both the Heroin Chasing Campaign and the Up Your Bum Campaign alongside one other in joint planning forums took pressure off the Heroin Chasing Campaign due to shock with the UYB campaign!
5.4 Links to community development process:
The development of the formal campaign and the subsequent validation process built on a pre-existing two to three year development process. This validated any risk and exposure taken by the organisation as users had supported the purpose of the campaign and managers were able to feel confident in the "product".
5.5 Ethical Issues
Formal ethical frames have been used to assess this work. An externally facilitated ethical review will be undertaken prior to launching the campaign.
6. Theoretical foundation of campaign:
The design of the campaign has been guided by the theory of motivational interviewing which sees motivation to change as a behavioural process that can be influenced. 13 The core thrust of motivational interviewing is the enhancement of cognitive dissonance (ie: the working of the internal conflict in the individual between what they are presently doing and what they wish to achieve). Motivational interviewing particularly targets those who might be seen as pre-contemplative (ie: with no problem self-identified with target behaviour) or contemplative (ie: ambivalent about changing a target behaviour). In seeking to motivate change with these two populations motivational interviewing identifies five key areas of self-motivation which need to be enhanced to raise self-motivation towards a wise decision making process in relation to change.
In applying this theoretical foundation to the design of the campaign a number of principles can be identified:
7. Key issues arising from practical experience of facilitating transitions to chasing among injecting heroin users in east London:
In addition to the theoretical modelling, the formal campaign drew on the community development work of the Healthy Options Team. Following the debates around chasing in the agency, individual injectors asked for support in seeking to transfer to chasing to either extend their range of using techniques, to improve control or reduce health risks. From this work a number of key issues can be identified both in terms of developing the harm reduction campaign itself but in following up who decide to try switching to chasing (see Appendix B - Three case studies of injecting drug users who considered a transfer to injecting):
7.1 Chasing and injecting are different:
Chasing should not be viewed as a substitute for injecting but as an alternative way of enjoying heroin. Acknowledgement should be made at the beginning that the effect does not offer the same intensity as injecting but that it does offer a gentler and less risky form of use with the added benefit of extending using episodes.
7.2 The learning environment is an important factor:
How an individual is introduced to chasing and the social environment in which this takes place is of major significance. Care must be taken not to decrease or attack an individual's sense of self-esteem and competence. The role of chasers, or injectors with experience of chasing, is vital in the process of change. Most people new to chasing are coached by experienced chasers adopting one element of the process at a time.
7.3 Cultural issues should not be ignored:
We need to consider the needs of those who are contemplating change towards chasing but come from cultural communities or national settings where chasing is alien and totally unfamiliar. The experience in Spain shows that in such settings transitions can still occur, however, the individual will not be reinforced in their change by their immediate peers thus heightening the chances of relapse. Some form of peer mentoring may be a future strategy.
7.4 Individuals' reasons for transition are unique:
We cannot be prescriptive in the outcomes of transition. People decide to change for many differing reasons. We can outline the health benefits associated with chasing including greater self-control but there needs to be acknowledgement that processes and motivation for change remain unique. Therefore, techniques to target those in pre-contemplation or contemplation can operate at a mass level seeking to mobilise community norms. However, support for those who make a decision to change requires a more personalised approach. This may require work with individuals or guidance of smaller peer groups. This may be either professionally facilitated approaches or spontaneous or formalised peer support approaches.
It is recognised that chasing has historically held lower status within some sections the using community and among drugs professionals in the UK. Heroin chasing has positive health benefits over injecting and some heroin injectors have spontaneously transferred to chasing. The Healthy Options Team. has provided a forum for a debate among injectors and chasers about the benefits of promoting chasing as a harm reduction strategy. Work has now developed in partnership with Respect Users Union to a formal facilitation campaign targeted at injectors. This campaign is founded on the theories of motivational interviewing and practical experience gathered from work with drug users in east London to date. This campaign will be launched as a demonstration project in the summer of 1997.
1. Griffiths, P., Gossop, M. Powis, B. and Strang, J. Extent and nature of transitions of route among heroin addicts in treatment - preliminary date from Drug Transitions Study - Addiction (1992).
2. Griffiths, P., Gossop, M., Powis, B., and Strang, J. Transitions in patterns of heroin administration: a study of heroin chasers and heroin injectors. Addiction (1994).
3. Southwell, M. and Jankowska, T. Promoting heroin and crack/cocaine chasing as harm reduction tools in the late 1990s - 7th International Conference on the Reduction of Drug Related Harm (1996).
4. Strang, J., Des Jarlais, D., Griffiths, P. and Gossop, M. The study of transitions in the route of drug use: the route from one route to another - Addiction (1992).
5. Wodak, A. Jim Rankin Lecture - 7th International Conference on the Reduction of Drug Related Harm (1996).
6. Wood, C. Demonising the needle - Connections (1996)
7. Miller, W. and Rollnick, S. Motivational Interviewing - preparing people to change addictive behaviour. Guildford Press - New York (1991).
8. Southwell, M. and Kennedy, D. From theory to practice: developing a practical harm reduction strategy in response to HCV -- Drug News (1997).
9. Brandsma, R. and Southwell, M. Toxic heroin induced leuko-encephalopathy: a threat to heroin chasers - 8th International Conference on the Reduction of Drug Related Harm (1997).
10. see reference 3
11. Southwell, M. The implementation of the Healthy Options Team Chasing Campaign - Briefing Paper to Tower Hamlets Healthcare NHS Trust Management Team (1996).
12. Southwell, M. "Up Your Bum" - A Simple Safer route of drug taking or a squirt too far? - 8th International Conference on the Reduction of Drug Related Harm (1997).
13. see reference 7
VALIDATION PROCESS FORM THE FORMAL CAMPAIGN
Discussion with east London using community.
Discussion within Healthy Options Team and ELCDS Management Team.
Peer Review - 7th International Conference on the Reduction of Drug Related Harm.
Presentation to THHT Management Team for in principle support for the development process.
Discussion with Respect Users Union and formal agreement to develop a partnership approach.
Legal advice - Release (legal drugs charity) and local police.
Discussion through local joint planning forums.
Identification of research partner.
Peer review of final campaign - 8th International Conference on the Reduction of Drug Related Harm.
Ethical review facilitated by THHT Medical Director.
Legal audit of final campaign.
Final approval by THHT Management Team.
Final approval by THHT Board of Directors.
Campaign formally launched.
THREE CASE STUDIES OF INJECTING DRUG USERS WHO CONSIDERED A TRANSFER TO INJECTING
CASE STUDY ONE - MARY:
Mary lives with her partner who injects. Chased for several years before injecting. Her partner taught her how to chase. At present Mary injects and chases.
"I found that when I chased I had more of a buzz through chasing than I do when I inject and I can't figure that out. "
"A nicer thing with chasing I think is when you do boot, chase .... I think you can sort of look for a gouch (nod) and come round and know that you have still got gear on the foil. "
At present Mary continues to enjoy the benefits of both injecting and chasing. Her choice of route of administration is influenced by concerns and needs which fluctuate. Her two main concerns were controlling her tolerance growth and maintaining healthy veins. What she wanted from her use was an effect that was longer lasting and controllable, rather than an immediate gouch (nod). Mary found that her times of injecting were influenced by the quality of the heroin and the fact that her boyfriend injects all the time.
CASE STUDY TWO - ROSA:
Rosa an Italian user living in London. Rosa has been injecting for 12 years. She is now experiencing health problems. She was taught how to chase by friends. Rosa has decided to continue injecting.
"I was looking for another option which would give me the same thing. "
"The difference for me between injecting and chasing is that injecting is like wine and chasing is like water. "
Rosa first sniffed heroin before starting to inject. Rosa came from a drug using culture which did not include chasing. She approached the idea of chasing with caution and saw it as a very complicated technique to have to master.. Rosa found that the effect of chasing was different and said that she "could not feel anything" and needed to "top up" with a fix, to get any effect. Despite experiencing continuing health problems associated with injecting Rosa has decided to stay with it. The benefits she receives from injecting far outweigh the health concerns and continuing to explore appropriate safer injecting methods would be the better option.
CASE STUDY THREE - TIM:
Tim started injecting at 16 years of age and had been injecting for 10 years. He is a polydrug user. Tim was introduced to chasing via "chasing gallery". Describes himself as a lone user. He has stayed with chasing as his preferred option.
"I just felt like I was making friends more .... it wasn't like, in you go, have a boot, out you go .... apart from keep running to the shop to get bloody lighters all the time! "
"I'm very surprised at myself that I can have a wrap and it'll be there the next day .... what I found myself doing, I'd be chasing and I'd still have it a few hours later."
Tim has described himself as very much a lone user. Injecting for him was a private and quick affair, which gave him instant rewards. Although he found injecting very attractive he did not engage in it at a social level. Tim describes his visit to a chasing gallery with a group of friends as a "turning point". He found the relaxed and friendly atmosphere very engaging and was taken by the sharing of heroin that was happening. This environment encouraged Tim to "have a go"and the users present were more than happy to teach him. Tim has stated that it is this "social" factor which has encouraged him to stay with chasing. He likens the effect of chasing as, "like sinking into a warm blanket slowly enveloping you". Tim considers the fact that he has gained more control over his use as an added bonus.