1 December 2022
Harm reduction interventions were a core focus at the 10th International Conference on Health and Hepatitis in Substance Users – INHSU 2022 – where data and case studies from across the world were presented, and topics such as funding, coverage, and more were put centre stage.
Speakers shared insights and studies into harm reduction interventions including overdose prevention sites (or drug consumption rooms), opioid agonist therapy, naloxone, wound care and more. One thing quickly became clear – that no matter the intervention, decriminalisation needs to be a focus. Please see here for a separate article on safe supply.
Evidence-based approaches for reducing drug-related deaths – What interventions work and what does the future hold?
Andrew McAuley, Public Health Scotland/Glasgow Caledonian University, Scotland
If you take one thing from Andrew McAuley’s presentation make it this — every drug-related death is preventable. So let’s prevent them.
- USA and Scotland have the most drug-related deaths globally
- Vulnerable populations are at even higher risk; in Scotland drug-related deaths are15% more likely in deprived areas
- Drug-related deaths took a year off of Scotland’s life expectancy figures from 2005-2020
- Toxic drug supply must be tackled, with safe supply interventions a key response
- Scaling up Opioid Agonist Therapy (OAT) reduces drug related deaths
- Wide-spread access to naloxone a key intervention (in Scotland, police now carry and use naloxone to save lives)
- Direct Access Antivirals (DAAs) for hepatitis C have been proven to reduce drug-related deaths by up to 75%
- Drug checking services and Drug Consumption Rooms (DCRs — which were the primary topic of Monday’s Policy Day) — also need to form part of the global response
- Gaps in the evidence base when assessing what impacts drug-related deaths include; polydrug use, safer supply, and implementation of DCRs
The impact of disruptions to services for people who inject drugs in Ukraine: Modelling the potential impact of Russia’s invasion
Jack Stone, University of Bristol, UK
People who inject drugs in Ukraine have high HIV and HCV prevalence. This study estimated the impact of likely disruptions to non-governmental organisations (NGO) activities, opioid agonist therapy (OAT) and anti-retroviral therapy (ART) following Russia’s invasion of Ukraine.
The study analysed 1, 10 and 100-year impacts and it’s clear that short-term disruptions can have long-term impacts. For every missed intervention HIV infections (the biggest detrimental impact), HCV infections and drug-related deaths all rise significantly.
We also heard how the illegal invasion of Crimea resulted in 800 people on OAT and/or ART being stopped in just 10 days, leading to a substantial increase in deaths. In the current war, the major impact is in conflict zones (with some access to OAT etc now completely unavailable). The good, and unexpected, news is that interventions like ART and OAT have climbed nationally.
However, using estimates of impact per person-year of intervention missed, this could result in 116 additional HIV infections, 126 additional HCV infections and 30 additional deaths over the next 10 years.
How can we improve data and mobilise funding for harm reduction support globally?
Keith Sabin, UNAIDS, Switzerland
UNAIDS requests countries to report harm reduction indicators each year as part of countries’ commitments to the United Nations Political Declaration on HIV and AIDS. Data on the HIV epidemic and global response among key populations is generally lacking and is particularly sparse for people who inject drugs.
Keith discussed the cyclical impact of this lack of data, or underestimates in data such as an inadequacy of prevention services to slow the HIV epidemic in most settings. This lack of services can be the result of a lack of data, and vice versa.
He also shared approaches to improve data collection and use and how this all might be used to better advocate for increased support, financial and technical, for harm reduction.
How do we address the broader social and health issues among people who inject drugs?
Dame Carol Black, Independent Adviser on Combating Drugs Misuse, UK
Dame Carol was commissioned by the UK Home Office and the Department of Health and Social Care to undertake a two-part independent review of drugs, to inform the government’s thinking on what more can be done to tackle drug-related harms. She presented the findings of the report — which included 32 recommendations — at the conference. Our key takeaways included:
- Urgent investment is needed into the workforce, which is diminished, undervalued and overworked
- There is a desperate need for advocacy for people who use drugs
- There needs to be a holistic approach —with housing, mental health services and more to be incorporated — but departments are currently too siloed to deliver the care that is needed
- Employment opportunities are vital and can help improve treatment outcomes
The session was insightful and while it is positive that the UK government are seeking recommendations to meet the diverse needs of people who use drugs, there is a long way to go to improve a prevention and treatment system that is not fit for purpose. It is noted that more work also needs to be done on nuances of language and the importance of choice in someone’s own drug use journey.
Health benefits and public order improvements after the implementation of DCRs in France. Results from the COSINUS cohort survey
Marie Jauffret-Roustide, Inserm, France
Implementation of drug consumption rooms (DCRs) in France have been delayed due to political controversy. Thanks to activist efforts and alliances with local politicians, two DCRs opened in Paris and Strasbourg in 2016. The COSINUS survey was used to evaluate their effectiveness over 12-months, studying 665 people who inject drugs in France.
- 665 participants with 20% women and 80% men. The median age was 38 and 43% were in unstable housing or homeless and only 19% had a paid job
- 67% had injected substances for more than 10 years and 5% were HIV positive with 27% HCV positive
- The cohort showed a 95% satisfaction with the DCRs and a 60% willingness to use the facility
- DCR-exposed participants were less likely to report injection equipment sharing, reducing HIV and HCV risk
- DCR-exposed participants report significantly less injecting mainly in public spaces and were less likely to have committed a crime in the past month
- Non-fatal overdoses, abscesses, emergency unit visits were also all reduced
- 80% of French population are in favour of DCRs (in comparison to 22% 8 years before)
This was the first time at an international level that DCRs effectiveness has been evaluated by using a control group. The findings show that DCRs are a highly effective harm reduction measure as well as an opportunity to enhance civic cohabitation between people who use drugs, local residents and the state.
How can we overcome legal barriers to reduce criminalisation and improve the health of people who use drugs?
Niamh Eastwood, Release, UK
“The War on Drugs has been the most abject failed policy that the world has ever seen” ; a call to arms to stop the war put human rights at the heart of drug policy, and advocate for decriminalisation globally.
Niamh gave examples of how punitive policies and criminalisation of people who use drugs have not only failed to stop drug use, but have done so in the most brutal way, causing a rise in drug-related deaths, an increase in BBVs, and myriad other harms.
- Black people are nine times more likely to be stopped and searched for drugs than white people — showing ingrained racism and the ongoing oppression of black communities during the war on drugs
- People fail to seek the support they need due to fear of criminalisation and even in countries with decriminalisation models, people who use drugs are still being harassed by police and facing stigma and discrimination
- Decriminalisation is not enough on its own though — there must be a push for safe supply
- There are innovative models e.g. in Oregon, the $300 million USD from the taxation of legalised Cannabis has been re-directed to health initiatives for people who use drugs
The impact of opioid agonist treatment on fatal and non-fatal drug overdose among people with a history of opioid dependence in NSW, Australia, 2001-2018: findings from the OATS retrospective linkage study
Nicola Jones, National Drug And Alcohol Research Centre, Australia
Nicola shared a study looking at critical periods of mortality risk during opioid agonist treatment. The study aimed to determine whether non-fatal overdose followed the same pattern as fatal overdose, and also compared opioid and non-opioid overdoses. Analysing 15 years of data from various locations such as hospital admissions and correctional services, the study found:
- Highest incidence of overdose was the first month out of OAT and the lowest was the remaining time in OAT
- The rate of an emergency department drug overdose presentation was highest. It was more than three-fold the rate of opioid non-fatal overdose hospitalisation and 14 times higher than fatal opioid overdose
- It was also twice the rate of non-opioid non-fatal overdose hospitalisation. Fatal overdose was lowest while in treatment
The study raised additional questions such as Why is non-fatal overdose highest the first month of OAT? Should slower rates of methadone be introduced as this does appear to drive the elevation of treatment initiation? And, why is non-fatal opioid overdose elevated early in OAT initiation but not seen in fatal overdose?
A novel contingency management intervention in the context of a syndemic of drug-related harms in Glasgow: First year of the ‘WAND’ initiative
Shanley Smith, Glasgow Caledonian University / Public Health Scotland, UK
To address the high levels of drug-related harms among people who inject drugs in Glasgow, a package of harm reduction measures (referred to as the WAND initiative: Wound care, Assessment of injecting, Naloxone, and Dried blood-spot test) was created. Shanley presented findings from the WAND initiative and the issues that led to its launch, including:
- Scotland has a population of about 5 million, with approximately 18,000-20,000 PWID.
- In Glasgow specifically, there is a population of about 1.7 million, with 4.400-5,400 PWID (approx.)
- In 2021 there were 1,330 drug-related deaths in Scotland, the second-highest annual total on record
- In Glasgow, there are 33.7 drug-related deaths per 100,000, which is the highest of all the health board areas
- The WAND initiative is completely voluntary and comprised of four components, with incentives provided for those who complete all four of the harm reduction interventions included
- 831 individuals engaged with WAND in the first year – 22% Female, 78% male
- WAND ran BBV testing for 632 out of 831 initial engagements in the first year, with an RNA-positive prevalence of 22%
There were some challenges along the way, which included difficulty linking WAND BBV testing data to routine lab testing data to determine the extent of new diagnosis, possible missing data due to errors in manual data entry, COVID-19 restrictions and difficulties in analysing follow-up data.
However, the key outcomes included a high level of engagement despite the pandemic and an indication that the initiative encouraged short-term behaviour change.
Trust and service engagement among people who inject drugs post-release
Lise Lafferty, UNSW Sydney, Australia
Lise presented a study which aimed to understand the ways in which trust was upheld (or breached) during service engagement post prison release. The qualitative study included semi-structured interviews of people released from prison within the previous 12 months, who had a prison term of more than three months, and a history of injecting drug use.
- The majority of people entering prisons have injected drugs and are at risk of systemic discrimination
- In Australia 46% of people released from prison return within two years
- The study utilized Halls Dimensions of Trust (Competence, Honesty, Fidelity, Global Trust)
- There is a lack of trust across the system with the need to recognise transitional support and continuity of care as critical (Competence)
- People released from prison face difficult paradoxes in being honest about circumstances and support needs (Honesty)
- We need models of reintegration that prioritise rehabilitation rather than maintaining punitive approaches (Fidelity)
- Services and service providers should foster encouragement and empathy (Global Trust)