Charlotte N. E. Tompkins

Barriers to accessing generic health and social care services: a qualitative study of injecting drug users

While research has clearly documented the difficulties injectors encounter in accessing specialist addiction services, there is less evidence of the problems they face when securing general health care and non-substance-misuse-specific support. This paper seeks to fill some of these knowledge gaps. Between January and May 2006, 75 current injectors were recruited and interviewed through three needle exchange programmes located in diverse geographical areas of West Yorkshire. Interview data were transcribed verbatim and analysed using Framework. Findings showed that injectors were often positive about the help they received from generic health and social care services. Nonetheless, they identified a range of barriers relating to inability to access desired assistance, the burden of appointments, travel to services, stigma and negative staff attitudes, personal ill-health, lack of material resources, and anxieties about accessing support. Although some types of barriers were more evident at some services than at others and/or affected particular subgroups of injector more than others, the impact of any barrier was contingent on a range of factors. These included the attitudes of individual professionals, the circumstances and needs of individual injectors, the local availability of suitable alternative services, and the frequency with which a service needed to be accessed. In order to better understand and potentially reduce service barriers, findings are linked to broader conceptual and theoretical debates relating to social exclusion and Foucaults analyses of power and knowledge.While research has clearly documented the difficulties injectors encounter in accessing specialist addiction services, there is less evidence of the problems they face when securing general health care and non-substance-misuse-specific support. This paper seeks to fill some of these knowledge gaps. Between January and May 2006, 75 current injectors were recruited and interviewed through three needle exchange programmes located in diverse geographical areas of West Yorkshire. Interview data were transcribed verbatim and analysed using Framework. Findings showed that injectors were often positive about the help they received from generic health and social care services. Nonetheless, they identified a range of barriers relating to inability to access desired assistance, the burden of appointments, travel to services, stigma and negative staff attitudes, personal ill-health, lack of material resources, and anxieties about accessing support. Although some types of barriers were more evident at some services than at others and/or affected particular subgroups of injector more than others, the impact of any barrier was contingent on a range of factors. These included the attitudes of individual professionals, the circumstances and needs of individual injectors, the local availability of suitable alternative services, and the frequency with which a service needed to be accessed. In order to better understand and potentially reduce service barriers, findings are linked to broader conceptual and theoretical debates relating to social exclusion and Foucaults analyses of power and knowledge.

The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) prisons project: a randomised controlled trial comparing dihydrocodeine and buprenorphine for opiate detoxification

BackgroundMany opiate users entering British prisons require prescribed medication to help them achieve abstinence. This commonly takes the form of a detoxification regime. Previously, a range of detoxification agents have been prescribed without a clear evidence base to recommend a drug of choice. There are few trials and very few in the prison setting. This study compares dihydrocodeine with buprenorphine.MethodsOpen label, pragmatic, randomised controlled trial in a large remand prison in the North of England. Ninety adult male prisoners requesting an opiate detoxification were randomised to receive either daily sublingual buprenorphine or daily oral dihydrocodeine, given in the context of routine care. All participants gave written, informed consent. Reducing regimens were within a standard regimen of not more than 20 days and were at the discretion of the prescribing doctor. Primary outcome was abstinence from illicit opiates as indicated by a urine test at five days post detoxification. Secondary outcomes were collected during the detoxification period and then at one, three and six months post detoxification. Analysis was undertaken using relative risk tests for categorical data and unpaired t-tests for continuous data.Results64% of those approached took part in the study. 63 men (70%) gave a urine sample at five days post detoxification. At the completion of detoxification, by intention to treat analysis, a higher proportion of people allocated to buprenorphine provided a urine sample negative for opiates (abstinent) compared with those who received dihydrocodeine (57% vs 35%, RR 1.61 CI 1.02–2.56). At the 1, 3 and 6 month follow-up points, there were no significant differences for urine samples negative for opiates between the two groups. Follow up rates were low for those participants who had subsequently been released into the community.ConclusionThese findings would suggest that dihydrocodeine should not be routinely used for detoxification from opiates in the prison setting. The high relapse rate amongst those achieving abstinence would suggest the need for an increased emphasis upon opiate maintenance programmes in the prison setting.Trial registrationCurrent Controlled Trials ISRCTN07752728

Supervised injecting centres

Medically supervised injecting centres are “legally sanctioned and supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use.”1 Their purpose is to enable the consumption of pre-obtained drugs under hygienic, low risk conditions (box).1 They differ from illegal “shooting galleries,” where users pay to inject on site.2 Worldwide, medically supervised injecting centres (also referred to as health rooms, supervised injecting rooms, drug consumption rooms, and safer injecting rooms or facilities) are receiving renewed attention. In 2001, the first medically supervised injecting centre in recent times was opened in Sydney, Australia. By 2002, there were 16 centres in five German cities,3 over 20 in the Netherlands, and some in Switzerland and Spain.4 The UK Home Affairs Select Committee recently recommended “that an evaluated pilot programme of safe injecting houses for heroin users is established without delay and that if this is successful, the programme is extended across the country.”5 However, the Home Secretary rejected this recommendation, stating that medically supervised injecting centres would be supported only as part of a heroin prescribing programme.5 We argue that this decision should be overturned. ![][1] Supervised injecting centres enable the use of pre-obtained drugs under hygenic, low risk conditions Credit: SHANEY BALCOMBE/NEWSPIX ### Functions of medically supervised injecting centres [1]: /embed/graphic-1.gif

Exchange, deceit, risk and harm: The consequences for women of receiving injections from other drug users

Aims: To explore the consequences for women of being injected with illicit drugs. Methods: In-depth interviews with 45 women injecting drug users who have been injected by other people. Findings: Womens reliance on others to administer injections meant they had less control over their drug use. Exchanging drugs as currency for being injected was common and women had little choice but to provide the injector with drugs. Being injected by others often caused the recipient physical harm. Previous experience of deception and harm meant women became more knowledgeable about their injectors intentions and subsequently tried to reduce future damage when being injected. Women appeared to be confused about the risks associated with being injected and the perceived risks were often complex and polarized. Understanding the context and nature of being injected is important for services when working with injection recipients. Conclusions: This work uncovered ideas about a complex area and highlights the importance for those working with drug users to pay attention to this. Increased training and awareness for drug-service staff about factors influencing being injected and the potential associated risks is recommended. Reinforcing current harm-reduction messages and providing related advice to injection recipients is also important. In improving the knowledge and awareness about being injected, women recipients may gain increased choice and agency in the injection process.

Experiences of prison among injecting drug users in England: A qualitative study

Imprisonment is common among drug users. However, historically healthcare for injecting drug users in prison in England and Wales has not been equivalent to that offered in community settings. Fiftyone injecting drug users who had a history of imprisonment were interviewed. Interviews focused on the experiences of drug‐related care and treatment in prison. The interviews were analysed using the Framework method. Accounts of prison drug treatment experiences provided valuable insights into drug treatment in the English prison. The participants’ accounts provided a historical perspective, many of which reflected the different practices of different prisons and prison staff and the changes in policy and practice that have occurred in prison healthcare over recent decades. Positive and negative experiences of healthcare and drug treatment in prison were discussed. Issues that affected levels of drug use inside prisons and their receipt of care, support and treatment in prison included prescribing policies, illicit drug availability and prison staff and doctor attitudes. Whilst negative experiences of prison and drug treatment prevailed, users identified that recent policy and practice changes had positively influenced healthcare provision for drug users in prison, particularly the provision of opiate maintenance therapy. Drug users often saw prison as an opportunity to detoxify and contemplate their drug use. Further work needs to build on the positive experiences identified to ensure that prison drug treatment in England and Wales is consistent, effective and efficient in the future.

Is peer injecting a form of intimate partner abuse? A qualitative study of the experiences of women drug users

Women are over-represented as the recipients of injections of illicit drugs and are often injected by their intimate partners. This study used qualitative research to explore women drug users’ experiences of abuse from intimate partners when being injected with illicit drugs. In-depth interviews were conducted with 45 women drug users in the city of Leeds and the area of North Nottinghamshire, UK. The practice of peer injecting illicit drugs places women recipients at risk of physical, economic and emotional abuse from their male intimate partner injectors. However, this was not a universal feature. In trusting, supportive intimate partner relationships peer injecting took place through reciprocal arrangements. Moving away from peer injecting was technically and emotionally difficult for women and rarely straightforward. The implications of the work are discussed as clinicians and wider drug service staff should be aware of the possibility of abuse and enquire about peer injecting when consulting with women injecting drug users. However, clinicians should avoid working within a simplistic clinical framework that views all peer injecting as intrinsically abusive. More research is needed to provide evidence for best practice. Until then, generic principles of best practice management of intimate partner abuse could apply, including enhancing womens motivation to effect change in an abusive situation.

Injecting drug use in prison: prevalence and implications for needle exchange policy

PURPOSE The purpose of this paper is to explore prison drug injecting prevalence, identify any changes in injecting prevalence and practice during imprisonment and explore views on prison needle exchange. DESIGN/METHODOLOGY/APPROACH An empirical prospective cohort survey conducted between 2006 and 2008. The study involved a random sample of 267 remand and sentenced prisoners from a large male category B prison in England where no prison needle exchange operates. Questionnaires were administered with prisoners on reception and, where possible, at one, three and six months during their sentence. FINDINGS In total, 64 per cent were injecting until admission into prison. The majority intended to stop injecting in prison (93 per cent), almost a quarter due to the lack of needle exchange (23 per cent). Yet when hypothetically asked if they would continue injecting in prison if needle exchange was freely available, a third of participants (33 per cent) believed that they would. Injecting cessation happened on prison entry and appeared to be maintained during the sentence. RESEARCH LIMITATIONS/IMPLICATIONS Not providing sterile needles may increase risks associated with injecting for prisoners who continue to inject. However, providing such equipment may prolong injecting for other prisoners who currently cease injecting on account of needle exchange programmes (NEPs) not being provided in the UK prison setting. Practical implications - Not providing sterile needles may increase risks associated with injecting for prisoners who continue to inject. However, providing such equipment may prolong injecting for other prisoners who currently cease injecting on account of NEPs not being provided in the UK prison setting. ORIGINALITY/VALUE This survey is the first to question specifically regarding the timing of injecting cessation amongst male prisoners and explore alongside intention to inject should needle exchange facilities be provided in prison.

Do women with complex alcohol and other drug use histories want women-only residential treatment?

Abstract Background Women‐only addiction services tend to be provided on a poorly evidenced assumption that women want single‐sex treatment. We draw upon womens expectations and experiences of women‐only residential rehabilitation to stimulate debate on this issue. Methods Semi‐structured interviews were undertaken with 19 women aged 25–44 years [currently in treatment (n = 9), successfully completed treatment (n = 5), left treatment prematurely (n = 5)]. All had histories of physical or sexual abuse, and relapses linked to relationships with men. Interviews were audio‐recorded, transcribed verbatim, coded and analysed inductively following Iterative Categorization. Findings Women reported routinely that they had been concerned, anxious or scared about entering women‐only treatment. They attributed these feelings to previous poor relationships with women, being more accustomed to male company and negative experiences of other women‐only residential settings. Few women said that they had wanted women‐only treatment, although many became more positive after entering the women‐only service. Once in treatment, women often explained that they felt safe, supported, relaxed, understood and able to open up and develop relationships with other female residents. However, they also described tensions, conflicts, mistrust and social distancing that undermined their treatment experiences. Conclusions Women who have complex histories of alcohol and other drug use do not necessarily want or perceive benefit in women‐only residential treatment.

“There's that many people selling it”: Exploring the nature, organisation and maintenance of prison drug markets in England

Abstract Aims: To explore the nature, organisation and maintenance of drug markets within male prisons in England from the perspective of drug users, considering the role of policy and practice in shaping the markets. Methods: Thirty in-depth qualitative interviews with former male prisoners were analysed using a Framework approach. Findings: Prison drug markets traditionally operated through “Established Enterprises,” sophisticated and business like ventures run by community drug dealers. Prisoners maintained the market by selling or delivering drugs or collecting payments and enforcing violence towards debtors. They were reimbursed for their “work” with money or drugs. Market competition was increasingly created by the concurrent existence of less formalised, more spontaneous markets through “Separate Suppliers,” where individual prisoners opportunistically sold illicit drugs, directly benefitting from the profit. Irrespective of provider, illicit drugs were commonly available within male prisons, although they were expensive, of poor quality and small deal sizes. Drugs had a pervasive and powerful influence on prison environments and were strongly linked to the threat and experience of violence. Conclusions: Two main types of drug markets operated alongside one another in male prisons in England. They operated flexibly, as prices, supply routes and payment methods quickly responded to changes in prison policy, prison drug prescribing, drug availability and prisoner demand.

Paying participants in addiction research: is cash king?

ABSTRACT I know there’s some real scary, hardcore stories of people selling vouchers, but I’ve never experienced anything like that. If I got a voucher, I would often see it as a bonus. If it was for a shop I didn’t use, I would sell it to someone I knew for the same amount of money – them just doing me a favour really. I wouldn’t sell a voucher for less than its value.