In an effort to reduce the record number of drug-related deaths in the UK, there have been repeated calls for the introduction of supervised injection facilities (SIFs), but are we any closer to actualising them?
Kaleidoscope CEO Martin Blakebrough makes the case for establishing a peer-led SIF in Wales, considering the hurdles previous models failed to overcome, and why a peer-driven paradigm could better engage people who use drugs, offering a neutral place to discuss treatment while reducing public harms. Most importantly though, he highlights why it is entirely possible to set this model in motion right now.
A clinical SIF, operated by healthcare professionals in white coats, has not progressed thus far, and I would suggest that its weakness is two-fold. On the one hand, it is not altogether attractive to the community it aims to protect, on the other it is too costly and legally difficult to gather sufficient political momentum. So how can we better set the scene for dynamic engagement whilst remaining realistic? I believe a model led by salaried peer mentors has the potential to strengthen relations between drug users and the public health and third sector organisations that support them, and that a safe and sterile environment needn’t cost a fortune.
This is an empowering model, not an exploitative one, and there is significant learning we can draw from on the merit of peer driven initiatives. On the world stage, we can look at how other cities, most specifically Vancouver, have approached this DCR model without measured negative consequences. And closer to home we can observe how the peer-led roll out of Naloxone, spearheaded by ‘Naloxone Champions’ like George Charlton, has been so successful in the north-east of England. I anticipate the pilot of a non-medical SIF will be met with a measure of risk aversion, however we must accept that every clinical attempt to get a UK SIF established has not come to fruition. Alarmingly there were 2,917 deaths from illicit drugs in England and Wales in 2018 – a rise of 17% – and so we must consider all of the options based on what is most effective to reduce harm
The legality of establishing a SIF within the UK has proven to be a huge stumbling block. I believe many SIF models we have seen globally are too clinically focused, and are not created in co-production with service users. Nurses assisting someone to inject potentially dangerous substances into their bodies is extremely problematic, and so a peer-led model would not jeopardise the licenses of those healthcare professionals. With the right support peer mentors can assist people to inject more safely and give reliable health advice. There is little doubt that the success of Naloxone is not wholly down to established drug agencies, it is the innovation and passion we see from peer communities in its distribution. I also believe that the establishment of clear governance to protect the employed peer mentors already working within agencies such as Kaleidoscope is very achievable. If one links with agencies commissioned to provide drug services they should also be able to support clinical governance, and indeed clinical assistance for any concerns a peer mentor may have.
One of the critical issues to kick start such an approach is a letter of comfort. To take this model forward in Wales, Kaleidoscope has the support of North Wales Police and Crime Commissioner, Arfon Jones, who is willing to issue a letter of comfort allowing a SIFs to operate in North Wales. With this legal protection, Kaleidoscope aims to work with peer mentor activists to establish a pilot, one that we can later mirror in Cardiff, Newport and Swansea. Areas where we can most easily mobilise our teams while achieving the biggest community impact.
Security will be a significant priority, and in cities where SIFs have been effective, a partnership with the police has proved vital. Kaleidoscope’s frontline drug worker, Elwyn Thomas, when visiting a SIF in Hamburg reported that if police were called to deal with an incident, the client would be escorted off the premises with respect and in some cases banned from using that particular SIF for 24 hours. The SIF staff and local police worked collaboratively with a common sense approach. In Vancouver a dedicated team of DCR patrollers are responsible for security and incident response, with the added support of a team of outreach workers whose role it is to encourage vulnerable people in the community to visit the facility. The case for SIFs is in many ways analogous to the government’s response to sex work, in that condensing the activity over a smaller area limits social harm and allows public and third sector organisations to better engage with that community and keep them safe.
Glasgow’s clinical model –a facility hosting a maximum of 12 individual injecting booths, and a small drug inhalation room at the estimated operating cost of £2.36 million per year– would take too much capital from our treatment budget, and the more people who are in treatment, the more lives we save. Of course SIFs alone will not solve the UK’s drug related death crisis, but I believe they will, as they have in other countries, reduce harms and facilitate engagement with the vulnerable drug using community. Use of SIFs is associated with reductions in syringe sharing and BBV risk behaviours like syringe sharing and assisted injecting. Reports have also shown a high willingness to use drug consumption rooms among intravenous drug users in Scotland*, while uptake in Vancouver is high as sites cover a small area with a high population of street homeless and IDUs who will not be required to travel. Evaluations have also looked at drug related crime, and the presence of SIFs had a positive impact on this. Overall, evidence suggests that SIFs deliver better impacts on public and social harms than individual harms*, including a significant decrease in discarded drug paraphernalia.
Service user involvement will be critical to the design of this model, and we are currently assembling a focus group to consult on this. The aim is that the peer led aspect encourages people to come and positions the facility as a safe and non-judgmental space where patrons who may not feel full ready to enter treatment have the opportunity to take away health information, harm reduction advice and signposting materials to all kinds of help, from housing to mental health services. It is key that it is presented in an informal, non-clinical environment by those with lived experience, and research* supports that people who use drugs feel a level of safety using drugs in front of peer workers due to their shared experience. Peer workers have been described as favorable compared to non-peer staff because of nominal power dynamics and past negative experiences with non-peer staff.
In addition to service users, we are collaborating with academics from University of South Wales (USW) and our consortium partner Barod to push a peer-led model forward. Ultimately, our service users have become so fatigued by the debate that many have voiced a readiness to establish a SIF on their own terms. Be it a mobile premise or pop-up, it’s really only a matter of time.
Martin will present this model in a public webinar on 4th June, 2020 at 2:00pm.
The webinar, organised by Professor in Criminal Justice at University of Kent Alex Stevens, will enable participants to discuss and plan progress towards opening supervised injecting facilities. It will feature short presentations on legal, policing, clinical, user involvement and research aspects, followed by discussions of the steps to take to open SIFs.
Presenters and discussants will include Niamh Eastwood (Release), Mat Southwell (drug user activist), Martin Blakebrough (Kaleidoscope), Jason Kew (Thames Valley Police), Megan Jones (Office of the West Midlands Police and Crime Commissioner), Rudi Fortson QC, and Alex Stevens (University of Kent).
Book your place here: https://www.smmgp-fdap.org.uk/Event/webinar-planning-for-supervised-injecting-facilities
References:
* International Journal of Drug Policy, High willingness to use drug consumption rooms among people who inject drugs in Scotland: findings from a national bio-behavioural survey among people who inject drugs
* THE SCIENCE OF PREVENTION (JD STEKLER AND J BAETEN, SECTION EDITORS), Public Health and Public Order Outcomes Associated with Supervised Drug Consumption Facilities: a Systematic Review
*HHS Public Access Author manuscript Drug Alcohol Depend. Characterizing peer roles in an overdose crisis: preferences for peer workers in overdose response programs in emergency shelters