In 1987 the south of England was hit by one of the worst storms in history when hurricane force winds ripped up trees and tore off roofs. In Manchester we were creating our own little storm by producing harm reduction comics with, and for, people with opioid use disorders. I spent much of late 1986 and early 1987 ‘in the field’ with people who were injecting and smoking heroin on a daily basis (people with Opioid Use Disorders – OUD). The method I used is called participant observation. The idea was to get alongside people who were using brown powder heroin and, with them, produce harm reduction information in a format that would be read, shared and discussed.
The characters in the first edition of Smack In The Eye (SITE) were based on real people and the jokes were reflections on real life. In the same year we (Lifeline) opened our first Needle and Syringe Programmes (NSPs). By 1988 we had a team of Outreach Workers working across the North West of England. Our friends and colleagues in Merseyside were engaged in similar activities and had, let the record show, blazed the trail for us at least a year earlier. Looking back at this time our harm reduction work did not have direct, formal links with treatment services. Many of us worked in treatment services but our harm reduction work was truly independent of treatment. For example, the first editions of SITE were distributed by people selling heroin. Some early NSPs were supported by people selling heroin. Those who were selling from houses and flats gave out our comics and our injecting equipment and provided sharps boxes for the return of used equipment.
Fast forward to today and harm reduction in the UK is either nonexistent or provided by professionals inside treatment services. Pharmacies operate most NSPs and those NSPs located within or alongside treatment services are compromised. Opioid Substitution Treatment (OST) is the primary service provided to people with OUD by treatment services. The primary purpose of OST is to reduce ‘use on top’ of the prescribed opioid. The use of other drugs (street heroin, crack cocaine, pregabalin, benzodiazepines and alcohol) ‘on top’ of the prescribed opioid is endemic in the UK and several reviews are underway to try and reduce ‘use on top’.
Naloxone is a life saving medication that can reverse life threatening opioid overdoses. The idea is that Naloxone (“Narcan” in the US) is distributed as widely as possible to users and their families and all first line response professionals (ambulance staff, police, fire service etc, etc). It seems obvious to me that Naloxone should be like rats in London – never more than six feet away from everyone. So, I was taken aback to hear a seasoned OUD treatment expert say that ‘naloxone is a response to failing OST systems’. This was a throw away comment made in the margins of a conference some time ago but it has been haunting me ever since.
If we had Naloxone in 1987 it would have been distributed by everyone we knew in the heroin distribution retail scene. The point is that back then; harm reduction was linked to treatment but was not part of treatment. In the mid 1990s, health authority officials in Manchester initiated a plan to get thousands of people into OST. They were successful and Manchester (like Wirral and Liverpool) soon had a high treatment penetration rate. Most people with OUD in Manchester were enrolled in OST. This same scenario was played out across the whole of England. Today, we are rightly proud to say that the English OUD treatment system has one of the highest treatment penetration rates in the world. Yet, we have worryingly high rates of Drug Related Deaths (DRDs) among people with OUD and ‘use on top’ remains the norm.
In this context, the distribution of Naloxone is a critical harm reduction intervention. However, is the need for Naloxone an indicator of a failing OST system in England and the UK? Personally, I do not agree that it is. However, the failure to distribute Naloxone throughout our system does say something important. I suspect that the failure to get Naloxone out is linked to the decline in discrete and bespoke harm reduction services. I know that some treatment providers are making great efforts to distribute Naloxone and provide NSPs to their service users. It is a real challenge to provide harm reduction services from today’s treatment services.
In recent years these services have been driven by notions of abstinence based recovery and measured by the number of people with OUD who exit treatment via a successful completion and do not return (“represent”) in the next reporting period (six months). People in abstinence based recovery have been recruited to these treatment services as volunteers and workers and are influencing treatment practice and ethos. Whilst this is a positive development in terms of equity and social inclusion it can have a negative side effect in terms of harm reduction.
Back in 1987 our community connections were with people using illicit opioids on a daily basis. Our outreach workers either had personal experience of opioid use, were well trained in harm reduction or both. Many could give direct advice on the intricacies of safer injecting and safer drug use per se. Until the mid-90s push there was no pressure to get these people into OST in Manchester. Harm Reduction was provided to them on their terms with the sole aim of making their own drug use safer. The situation today is that harm reduction, if it is offered, is often provided by people who know little about safer, continued drug use. There is an inbuilt reluctance to engage in harm reduction services provided by these treatment providers if you are also on OST with them. After all, the primary purpose of OST is to reduce ‘use on top’. Attending a NSP means, by definition, that you are ‘using on top’ of your OST prescription. Your key worker may be a staunch advocate of abstinence based recovery and take the attitude of “I did it (abstinence based recovery) so can you”. In recent years progress has been made in treating HCV amongst people with OUD in treatment. If these people continue to ‘use on top’ and do not access NSPs provided by treatment providers there is a risk of re-infection amongst those who have successfully cleared HCV.
So, in summary, is the need for Naloxone an indication of failing OST systems in England and the UK? In my opinion no, it isn’t but the failure to get Naloxone within six feet of everyone who might need it is a critique of the state of harm reduction in the UK. Budgets are falling and treatment contracts are being let and awarded with every decreasing financial settlement. Harm reduction, independent of treatment, is a casualty of public service cuts and a performance management system unable to recognise the importance of keeping people alive. Perhaps the ultimate irony is that people who leave treatment and die can be chalked up as a success in a system measured by the numbers of people leaving treatment and not returning. Grandpa Smackhead Jones will be turning in his grave.