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Pizzey R., Hunt N.
Harm Reduction Journal: 2008, 5:24.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Hunt at Neil.Hunt@lshtm.ac.uk.
British needle exchanges which piloted distribution of foil packs for smoking heroin found they were widely used and may have increased attendance and reduced the number of injections, lending weight to calls to legalise such provision.
Summary Though by no means safe, smoking heroin is considerably safer than injecting because it reduces the chances of viral transmission and overdose and eliminates injecting site damage. Commonly foil is used as a container for the heroin while it is heated and the fumes inhaled, known as 'chasing' illustration. The featured study aimed to test whether making high quality, customised foil sheets freely available from needle exchanges (in the form of packs with written material encouraging transition from injecting to smoking and other information) would be acceptable to opiate users visiting the exchanges and what effect this would have on exchange usage and heroin consumption methods.
The packs were developed by Exchange Supplies and piloted at four needle exchange programmes in south west England in 2006 and 2007. Just over half (54%) of the 320 opiate users who visited the exchanges during this period took up the offer of the packs, a proportion which was fairly consistent across the exchanges. Since sometimes they were not offered to visitors, the acceptance rate was actually higher by an unknown amount. Staff tended to prioritise visitors running the greatest injecting-related risks, and found that being able to offer foil provided an opportunity to discuss these risks and the benefits of transition to non-injecting routes of administration. While foil was available, visits to the exchanges increased by a third from 1672 to 2216. To obtain foil, 32 new visitors attended the services who chased heroin but did not inject, drug users who would presumably otherwise not have made contact.
At one of the exchanges 48 injectors who had taken foil were interviewed the first time they did so and again when they next returned to the service, normally within four weeks of the initial visit. All had previously smoked heroin and were familiar with using foil to do so. At the second visit, all but two said they had used the foil and 41 (85%) said that as a result they had smoked when they would otherwise have injected. They universally agreed that foil provision was useful. Several reported that because the foil was provided free, it was available when otherwise it would not have been due to lack of money, the inconvenience of buying it, or because buying it might embarrassingly expose them as heroin users. Some deliberately turned to smoking when they particularly wanted to avoid injecting. Several took foil home for their smoking partners. Among the people who took them, satisfaction with the quality and size of the foil packs was good.
The authors concluded that distributing foil packs can be a useful means of engaging exchange attenders in discussions about ways of reducing injecting risks and can reduce injecting in settings where there is a pre-existing culture of smoking heroin by this method. There is also the potential for wider changes among local networks of injectors in contact with exchange visitors.
commentary As the authors acknowledged, this small study is best considered a test of the feasibility and acceptability of the packs and an indication of their possible impact, which may or may not be replicated in more usual circumstances and at other exchanges. Among the reasons for caution are that it was conducted by enthusiastic practitioners, who themselves sought feedback from service users, obtained it in structured form from only a small and possibly unrepresentative minority, and that the study lacked a comparison set of exchanges not offering foil packs. The authors are also careful to limit their conclusions to areas where smoking heroin is already well established, though in Britain this is not too much of a limitation.
Another report Boid. A., Waldock. D. "The introduction of aluminium foil to Sidney Street Needle Exchange and Sharp Action mobile needle exchange Sheffield." Turning Point, 2008. provided feedback on a trial scheme providing foil from a site-based and a mobile exchange, which indicated that this reduced injecting behaviour and promoted less risky alternatives. An account of its findings says the initiative had many harm reduction benefits. Providing foil enabled workers to engage with injectors about the possibility of smoking. Foil was taken by 85 service users, of whom 72% had injected in the last four weeks, 81% had previously smoked heroin and 12% had not used the service before. A third provided feedback, of which 32 had used the foil, 21 used it daily but eight had either not or rarely used; 27 said their injecting had reduced. Case studies of eight individuals revealed that new clients were seen due to the initiative; most had reduced their injecting and some had replaced injecting entirely with smoking.
If the intervention does prove itself more widely, the benefits could be considerable. Intercepting the transmission of hepatitis C requires greater risk reduction than exchanges can normally achieve; moving away from injecting altogether would be a much bigger step which would substantially reduce transmission. Most people surveyed for the featured study did not go this far, continuing to inject but smoking more often, possibly leaving enough residual unsafe injecting to transmit the virus. A common pattern was to use the foil and smoke when users specially wanted to avoid injecting. If among these occasions they included (or could be persuaded to include) times when injecting meant sharing equipment, risk reduction would be greater and more likely to seriously dent spread of hepatitis C. Overdose deaths are another major concern, particularly in Scotland, but needle exchange on its own can do little to reduce the toll. Here too a move away from injecting would almost certainly make a substantial contribution. In relation to both these major risks, foil provision offers exchanges a potentially important tool.
These were among the reasons which led the Advisory Council on the Misuse of Drugs – an expert body set up under the Misuse of Drugs Act to advise government – to recommend foil be exempted from Misuse of Drugs Act provisions which ban supply of equipment which can be used to prepare or take illegal drugs, in the same way that needles and syringes and other items used in injecting are exempt to enable needle exchanges to operate within the law. Without such a change, needle exchanges can supply equipment to make the most dangerous method of drug use (injecting) somewhat less risky, but are unable legally (though this does happen and is not prosecuted) to supply equipment which might support transition to a far less dangerous method (smoking). This legal barrier may have led the UK's National Institute for Health and Clinical Excellence (NICE) to recommend that needle exchanges "encourage [their users] to ... switch to non-injecting methods", but not to advocate the distribution of equipment to facilitate this transition. Consulted on the guidance, people working with needle exchange programmes were disappointed with this omission. Their comments were in line with the results of a survey conducted in 2008 of UK needle exchange workers. Due mainly to the law, just 15% of the 445 respondents said their services distributed foil, but most supported its provision as a useful harm reduction intervention for both heroin and crack cocaine users.
In the late 2000s attempts were made to remove or amend legal restrictions on supplying foil and other items by medical and drug services when acting in their professional capacity. These were accepted in principle by the government of the time but fell victim to the impending May 2010 election. Apart from illegality, another objection to foil provision may be cost, but in so far as it does reduce the number of injections, it will presumably also reduce the demand for injecting equipment from exchanges, saving money on that front.
Thanks for their comments on this entry in draft to Neil Hunt of the University of Kent and the London School of Hygiene and Tropical Medicine, Andrew Preston of Exchange Supplies, and John Witton of the National Addiction Centre. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 22 January 2013. First uploaded 04 July 2009
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