We Can’t Consumption Room Our Way Out of a Drug Deaths Crisis

When the scale of drug-related deaths in Scotland is revealed for 2018 it is expected that over 1000 people will have lost their lives to accidental and preventable overdoses in that year alone. Utterly appalling.

Over Christmas I sent messages to a couple of people who I worked with for many years when I was their ‘Community Addictions Nurse’. I think about them a lot and have no doubt that if they were not in treatment they may be dead and it reminds me of some of the tactics I employed to ensure they remained in treatment…

It’s safe to say they weren’t the most reliable attendees to my NHS style clinic appointments, which often resulted in me texting, phoning, turning up at doorsteps, knocking on windows, shouting through letterboxes, chauffeuring to chemists and doctors appointments and even dog-sitting at one point to encourage one of them to be admitted to hospital who wouldn’t have gone otherwise (probably not allowed but sue me).

This was the type of work I enjoyed. I would have loved if the service was set up with more of an outreach role because it was what helped create solid, trusting relationships with people and had I just continually marked them down as DNA (did not attend) that would have no doubt ended in them being discharged from the service, which in turn would have hugely increased their risk of dying.

Another thing I’m sure of is that neither of them would attend a drug consumption room (DCR). Nor would many of the other people I knew who have now tragically died. The nature of the more rural environment means people are much more likely to be using drugs in their own or someone else’s home. It would be highly unusual for people to be injecting in public places in this area.

There are many areas like this in Scotland but there is also a very obvious need for DCRs, particularly in areas where there are people injecting in public places. But we need to remember what DCRs are primarily for.

It’s fantastic to see such support for them in Scotland but it is wrong to suggest that introducing them without improving existing services will dramatically reduce drug deaths overall, or that this is the only thing missing from a solid drug death prevention strategy.

It’s almost like we’ve got to a situation where we’re saying “yeah, well we would be reducing drug deaths but Westminster won’t let us.” This is of course ridiculous, but frustrating nonetheless. It is also quite dangerous as it shifts the focus away from what we could and should already be doing. Let’s not get distracted while we also continue our efforts to introduce DCRs, it’s a balance.

Indeed, I have also been accused in a public forum of suggesting DCRs alone would prevent wider drug deaths (I wasn’t present so couldn’t defend my position which is the complete opposite to this actually). To say I was irritated by this is a slight understatement.

We all have our things that we get passionate about and I am a huge advocate for DCRs, but they should be part of a wider system of other evidenced based services – which for me would include low threshold prescribing with instant access to opioid replacement therapy (ORT), optimal dosing of ORT for the optimal duration of time (with injectable options), more outreach work including outreach nursing (especially with a focus on physical health), wider provision of naloxone, drug consumption rooms in areas where people inject in public places, a campaign to address stigma… and all of this delivered by the right staff with the right attitudes and values.

I’d like us to pay a lot more attention to preventing overdoses happening in the first place. I especially feel that more emphasis on the physical health needs of people who use drugs is essential, given that the majority of people who die have significant health problems normally associated with people much older.

And while we’re on the subject of age – ‘ageing cohort’ is such a hideous description. Older people who use drugs are classed as people age 35+ which is by no matter of means old (I would like to vouch for that as a 37yr old) but the intention is to highlight the accelerated ageing process seen in people who have perhaps been using drugs for 15-20 years. The average age of someone dying from a drug death in Scotland is 41 – these are still young lives but ‘ageing cohort’ would give the impression of people aged 70 if you didn’t know better.

Anyway, back to DCRs…

The proposal for a Safer Drug Consumption Facility in Glasgow was driven by an HIV outbreak, not rising drug deaths which is also a major issue in the City. I sincerely hope that the legal blockade for this service to operate is removed in the very near future.

Of course, no one has ever died from an overdose in a DCR and there is evidence that they can reduce deaths in the surrounding areas but their main purpose is about connecting with people and reducing the transmission of HIV and Hep C. And lots of other things that I’ve listed previously.

I’ve also spotted a bit of a trend in the UK that people have started referring to them as ‘Overdose Prevention Sites’ – based on the situation in Canada but being used as a way to garner more support for them because of the seemingly more acceptable language. Overdose Prevention Sites, however, have a very specific remit and immediacy to their operation mainly in response to the horrendous situation with Fentanyl. For me, DCRs are way more than overdose prevention so I feel we just need to be careful about that one.

So, can we agree that one DCR is not going to prevent drug deaths in an entire country?

As we go forward in 2019, let’s do everything we can to prevent more disgraceful loss of lives. I’m ready…are you with me?

Join the conversation in the closed Facebook group

The ‘J’ Word: overtly stigmatising or just obliviousness?

Earlier this year I wrote about the importance of language in the drugs arena but wanted to now focus briefly but specifically on the ‘j’ word and some of my experiences with it.

The word itself has been around since the 1920’s but why does it make some of us tense up with disgust whilst others use it freely as though it’s a perfectly acceptable way to describe people who are experiencing problems related to drug use?

I’ve discovered there are three different groups of people who use the ‘j’ word for different reasons.

1. Those using it in a bad way
2. Those using it to describe themselves
3. Those using it without knowing it’s bad

The third group is the one I’m going to focus on but let’s have a look at the others…

1. Those using it in a bad way

This tends to be the media and those who openly stigmatise people who use drugs. This is the worst type of use of the ‘j’ word because it’s done fully in the knowledge that it’s scathing, pejorative and most likely to fuel discrimination.

The use of this word in these circumstances seeks to dehumanise people and further compounds stigma by conveying the message that people who use drugs are unworthy of help, have brought this on themselves, are bad people making bad choices and a drain on society.

Disgraceful.

There’s a risk with this group that we could get people to adopt the correct terminology without changing their core beliefs about people who use drugs but a core part of addressing stigma starts with addressing language.

2. Those using it to describe themselves

There’s a few different elements to this one.

Sometimes the word is used by people experiencing problems related to drugs in a ‘self-stigmatising’ way and can be associated with feelings of hopelessness and worthlessness.

I’ve also seen some people who use drugs refer to themselves with this word by kind of ‘owning’ it and each to their own, but I don’t think it helps the quest to address this among groups one and three, with them often using it as an excuse to continue…

eg. I have a short film in my training where one of the guys refers to himself as a ‘j’ and after watching it, people have in the past used the word followed by “yeah but he said it”. I have a new strategy now that ensures this does not happen…well, not much of a strategy really, I just point out at the start of the training that it should not be used.

And lastly, we have the adrenaline ‘j’s and the fitness ‘j’s etc. I have an issue with this now purely because of the association.

3. Those using it without knowing it’s bad

I have encountered this so many times and I’m going to share two examples.

First one was a taxi driver.

Within 2 mins… Taxi driver: uses ‘j’ word

Me: “eugh, please don’t use ‘j’ word”

Taxi driver: “you’re absolutely right, I’ve never thought about that before. From now on I’ll make a conscious effort never to say it again”

Ok, so the conversation was slightly longer than that but he really gave it some thought and we had at least a ten minute discussion about it. I genuinely believe that guy won’t use it again. I also gave him a tip to seal the deal.

Second one was a fellow wedding guest.

Wedding guest: uses ‘j’ word

Me: “eugh, please don’t use ‘j’ word. Don’t say it near the bride or my friend on your left either, we all feel the same about it.”

Another wedding guest: uses ‘j’ word

My friend: “eugh, not the ‘j’ word”

Me to first wedding guest: “see, I told you”

He obviously gave it some thought after asking me to explain why we didn’t like it because at the end of the night….

Me: “was nice to meet you”

Wedding guest: “you too, and I promise I’ll never use the ‘j’ word again”

Night made.

 

‘J’ Word Conclusion

So I guess what I’m saying is that there are so many people out there that use this word without giving it a second thought. Not because they are bad, stigmatising people but just because they are oblivious to its negative connotations and they’ve never had anyone point out to them how inappropriate it is to be using that word in this day and age.

So for those of us who want it eradicated, let’s always make sure we pull people up on it and don’t just let it slide. After all, what you permit you promote.

 

Join the conversation in the closed Facebook group

Don’t Be That Person That Just Walks On By

About last night…

Firstly, I am not sharing this story because I want any kind of congratulations or think I deserve any kind of recognition for what was ultimately a very small gesture, it is purely to raise awareness of this kind of situation.

So it was my first girl’s night out in ages. The plan was they were getting the train to Glasgow then coming to my flat for a wee while before heading out.

I insisted on nipping along in the car to pick them up from the station, which is notoriously a place that is a nightmare to get parked anywhere so I pulled up outside the City Chambers.

I sat there waiting flicking through my phone, catching up on some messages, and it wasn’t until around 5 minutes later when I noticed a man lying in a strange position right outside the City Chambers building.

It was a busy Friday evening around 6pm and I watched as lots of people walked past this person, most of them having a good look at him but none stopping. It’s common that people frequently walk past those who are rough sleeping without giving a second glance but the reason so many people were having a look was because of the position he was in. Something just wasn’t right and I didn’t feel I was parked somewhere I could leave my car at this point. 

He was lying flat on his back with a plastic fork balancing in his right hand and a polystyrene plate of half eaten chips on his left side. There were chips scattered around him.

I was getting kind of twitchy at this point but then 3 men went over to him and stood around him but didn’t touch him. I couldn’t see exactly what was going on but they chatted amongst each other then walked off so I assumed the person had spoken to them and they were satisfied he was ok.

My friend then arrived and I said to her to watch the car and that I just wanted to go and check on this guy as I hadn’t seen him move. By this time he’d been lying there at least 15 minutes (and probably a lot longer before). I shouted at him to wake up, tapped his foot then got down and gave him a good shake. He was completely unresponsive. He was breathing but it was raspy so I pulled him on to his side making sure his airway was open and at this point another couple of people joined me. One of them was a Norwegian navy medic and we asked the other man to phone an ambulance.

It was clear to me that it wasn’t an overdose but I imagined he was very intoxicated. There were no obvious signs of overdose and his pupils were slightly dilated if anything.

I opened up his mouth and could see that there was food in the back of his throat blocking his airway.

The emergency call handlers were instructing us to put him on his back, which we did briefly against our better judgement, but I felt there was a risk of the food becoming lodged further back in this position so I got him back on his side while the navy medic ran in to the City Chambers to get some gloves. He returned and scooped out the half chewed chips in the man’s throat and instantly you could hear a difference in his breathing as it became less raspy.

At this point the paramedics arrived and a small crowd had formed. The paramedics tried to get a pain response from him (I think by pinching his ear but I couldn’t quite see) and at this point he coughed and spluttered up the rest of what was in his throat. He then started complaining of the pain being inflicted and they got him sitting up. He was soon assisted to his feet and taken in to the back of the ambulance. He was clearly heavily intoxicated and if I had to make an educated guess I’d say possibly benzodiazepines and alcohol – but I’m purely speculating there.

After he was removed, the City Chambers staff came out to sweep up the chips that were left lying.

The ambulance was still sitting there when we left ten minutes later with him in the back. I hope he’s ok.

So in reflection I have thought about a few things.

Firstly, I’m annoyed at myself for sitting for so long before going over to do something. I’ve been trying to think about why I didn’t go quicker – was it really just because my car was parked somewhere it shouldn’t be? Was it because I was expecting someone else would do something? Was it because I thought he was just asleep? I don’t know, but it was a lesson for me.

Another lesson for me is bloody practice what you preach! I didn’t have my naloxone in the car with me so if it had been an overdose I would have been raging with myself. Carry it wherever you go.

Then I have questioned why over 50 people walked past him, knew something looked odd, but didn’t check on him. Maybe it was because they were thinking some of the same things I did?

Why did none of the City Chambers staff check on him but were very quick to clear up the food that was left behind? Perhaps they hadn’t seen him until the navy medic went in for gloves?

Why did the 3 men who almost helped just walk away? Honestly, I think they must have thought he was asleep because of the snoring sound he was making.

I also wonder how much longer he would have been left there if I hadn’t made the first move. I strongly believe there was a very high chance he would have choked and died if no-one had intervened.

I guess this is a plea more than anything. A plea for looking out for our fellow humans, especially the most vulnerable and marginalised.

If you think something isn’t right, do something. The worst you can do is annoy someone by waking them up! Don’t assume they are snoring – they may be struggling to breathe.

Don’t be that person that just walks on by.

Ten Benefits of Drug Consumption Rooms

Of course there are many more! These are the first ones that came to mind and would fit on one page…

Ten Benefits of DCRs

Join the conversation in the closed facebook group

The frustrations of living in a city in such clear need of a safer drug consumption facility are real

I’ve now been living in Glasgow for almost a whole year and had certainly hoped we’d be closer to the reality of opening a SDCF by now.

In 2015 I started properly looking in to the benefits of drug consumption rooms after a travel fellowship culminated in one of the recommendations from my report being that ‘wherever there are significant numbers of people injecting in public places, there is a clear need for supervised injecting facilities’.

This was very timely as it coincided with a health needs assessment taking place in Glasgow City Centre (following the HIV outbreak which is ongoing) that was reviewing the specific needs of people injecting in public places. One of the recommendations from that report published in June 2016 was for a SDCF.

Fast forward almost 2 years and unfortunately, despite an immense amount of time, energy and planning, Glasgow has hit a legal and political nightmare.

Scotland’s Lord Advocate refused to provide a prosecution waiver that would have allowed the centre to operate and advised that amendments were required to the Misuse of Drugs Act via the UK government. The UK government say they have no intention to allow the introduction of drug consumption rooms or to devolve the necessary powers to Scotland.

Meanwhile, the issues in Glasgow have not gone away. HIV among people who inject drugs continues to increase. People continue to inject in horrendous, degrading and unsafe circumstances. And people are dying. Every day.

I walk to work through the proposed area that a SDCF would be situated. Daily I see people in desperate need for such a service.

Near to my office is a lane being frequented by people using drugs, exposed to the elements, surrounded by used injecting equipment and human faeces. Someone died there recently. This is unacceptable.

I watched the other day as someone tried to shelter under the overhang of the building in the lane. It was bitterly cold with sleet falling and a freezing wind. There was a magazine lying on top of one of the bins that was soaking wet but he flicked through a few pages. He pottered around for a while and I wondered where he would go for the next while before he returned to the lane.

It is truly heart-wrenching not to be able to offer someone in these circumstances a warm, clean, safe environment with caring staff and friendly faces.

I’ve walked past several individuals where I’ve had to check they were responsive and not overdosing in the street. I carry my naloxone with me everywhere and feel like it’s only a matter of time before I’ll need to use it.

I talk with local business in the area because I use some of their services and none of them think it’s a bad idea. In fact, they’ve all been hugely supportive of it – some because they are caring individuals and sympathetic to the circumstances of people who inject drugs, others because they see the benefits to the community.

I’ve had various conversations over the last couple of years with all sorts of people about the benefits of a SDCF and tried to dispel many myths whenever I can.

There are huge misconceptions about what this type of service offers and a clear lack of understanding regarding the issues faced by people injecting in public places.

A SDCF would not, in any way, replace or fly in the face of other drug services. It is not an ‘either or’ argument in relation to abstinence-based services.

A SDCF would not undermine treatment goals or encourage people to inject drugs forever.

A SDCF would offer a unique way of engaging with people. A place where you can just turn up as you are and not face any judgement, stigma or discrimination.

The idea that we should be focussing on detox and abstinence is quite frankly a lazy, moral opinion.

It is an unrealistic expectation to think that someone who is currently injecting in a back lane will suddenly feel able, willing and be supported to access a detox centre or residential rehab. Plus they may not want abstinence at that point, or ever.

But given hope, time and the opportunity to engage, which in turn increases self-esteem, people will indeed make positive changes and go on to set goals of their choice.

The evidence is clear that the more times someone accesses a drug consumption facility, the more likely they are to access treatment services.

There’s another misconception that there would be a boundary around the SDCF that police cannot cross. So you’d have people dealing drugs on one side of it sticking their fingers up at police on the other (yes, that has been said to me). This is not the case. A SDCF relies on good working relationships with the police who are able to go about their normal duties but do not specifically target the centre.

Would I want a SDCF next door to me? Absolutely! Because if there’s a need for it in my area it means that drug dealing and drug use is already happening in the vicinity.

So the plan now in Glasgow is to go ahead with heroin-assisted treatment (this was also a recommendation of the health needs assessment) which can be legally provided without any changes to the law required. This will be fantastic – for a small number of people.

In addition to this we still need a SDCF for the reasons described earlier about engagement.

A SDCF will not solve all of the issues related to problematic drug use but it is a critical service that is urgently required. It’s not like there’s no evidence base – there are no less than 150 published research papers detailing the clear benefits of these services with no disadvantages.

We should not be playing politics with people’s lives.

Image credit: unknown but taken from Marilou Gagnon and Greg Scott

Join the conversation with like-minded people in the CWK facebook group

“I didn’t feel protected and I didn’t ever feel safe” – my experience of being stalked.

The recent, tragic story of Molly McLaren really struck a chord with me. Her family have called for more awareness of the dangers of stalking and to encourage people to report any concerns over stalking to the police.

I’ve been thinking of writing about my experience of this for some time now and have had reservations because the person who subjected me to several years of anxiety is no longer alive, having taken his own life.

Molly’s story triggered a lot of memories about how I felt my own story would end and if sharing my experience helps raise awareness and helps the issue to be taken more seriously then that can only be a good thing.

Last year when I moved house I found a USB that contained a file with a timeline of events that followed the break-up of a relationship – some of the things you will read about are things I never thought I would ever go through and hope to never again.

Let me take you back to 2007…

13/08/07

Liam* and I split up after 5 and a half years together. I made the decision to end the relationship due to several months (if not years) of us not getting on and he was devastated about this. In reality I think maybe I subconsciously knew that this wasn’t going to be a straightforward split, which possibly attributed to the time it took me to finally make the break.

I agreed he could stay in the house until he found somewhere else to live because he was so upset. I began helping him organise this move and we remained relatively amicable throughout this time.

09/09/07

Liam moved out following an argument over nothing in particular, other than him struggling to come to terms with the relationship being over.

During the next few weeks we kept in touch at his request. We remained friendly towards each other but I found the contact extremely awkward as it always ended in him becoming tearful and telling me how much he was struggling.

09/10/07

I met with Liam at his house and we both agreed that we would not have any more contact as it was too difficult for both of us. I felt relieved.

12/10/07

I received several calls from Liam but I did not answer as I was asleep having been on night shift. I got up to find he had left a message on my house phone asking for my help as he had “done something stupid”. His speech was slurred. I answered the next call and he told me he had taken sleeping tablets and tried to hang himself but the rope had snapped and he couldn’t get it off his neck. He said he wanted me to go to his flat to take the rope off as he was struggling to breathe. I immediately phoned his friend and asked him to go instead.

He refused to let his friend in to his flat, saying he only wanted me to go as he was embarrassed.

His friend phoned the police to assist and Liam became extremely abusive to me via text and phone. He told me it was my fault he had done this and that the next time he tried he would be successful and I would have to live with that.

He left his flat before the police arrived and was found later that evening and taken to A+E for assessment. His abusive messages continued while he was en route to hospital where he was admitted overnight.

13/10/17

Phonecall from Liam having been discharged from hospital. Said he was stuck in Edinburgh but didn’t imagine I’d help as I hadn’t helped yesterday when he needed me. (His words)

During this whole incident it was clear to me that he was completely trying to manipulate me and the situation. He obviously didn’t get the reaction from me that he expected when he allegedly attempted to end his life, which in turn made him incredibly angry and venomous towards me.

Two weeks passed and I hadn’t heard or seen from him. I changed my mobile number during this period to eliminate the possibility of receiving any distressing text messages, which had been pretty horrific and vicious.

27/10/07

I was out locally for a night out with work colleagues. I saw Liam who came over to me and acted like nothing had ever happened. I remember the palpitations and trying to remain composed. He suggested he wanted to contact me to talk about things but I was lost for words and felt physically sick at how much weight he had lost.

28/10/07

I had several missed calls on my house phone and a message asking if I had changed my mobile number and could I phone him.

I did not phone him and went to my friend’s house to visit.

I got home at 7pm and had only been home five minutes when he appeared at my door. I was living on a small country estate with only a few cottages so it wasn’t the kind of place you would just drive past routinely.

He said he wanted to explain about “that night” and when I said I didn’t want to discuss it as it was too upsetting he became very angry. He was verbally abusive and told me he would definitely be attempting suicide again and that he would be successful this time. He told me he had taken sleeping tablets prior to driving to my house. I asked him to leave several times and he finally did without saying anything as he left.

I asked my friend and her partner who lived on the estate to come over as I hadn’t heard a car leave and was worried he was still outside. They arrived and couldn’t see him anywhere. I asked them to check if there was any damage to my car as he had made reference to smashing up my car in anger. There was no damage.

30/10/07

I got in my car to go to work and got along the farm drive before realising I had two flat tyres. They had been slashed. As I live on a remote estate I could only assume it had been Liam in the middle of the night.

I spoke to my work colleagues who were incredibly supportive and at this stage informed the police.

31/10/07

First meeting with police to discuss recent events.

Liam’s car noticed by my friends on the estate to be hanging around my house that night. The owners of the estate very kindly put a note around all of the cottages to look out for the car and to call the police if they saw it.

01/11/07

Noticed a minor cut on my horse which looked like it had been done with a knife. This was so upsetting to even consider that he might have gone to this level to get to me.

02/11/07

Telephone call from Liam using a withheld number. Asked him to stop contacting me. He asked me why I was parking my car in a different place and when I asked him how he knew this he replied “I know everything”. He also menacingly asked how my horse was. When I asked him why he was doing this and trying to worry me he replied – “To make you feel as shit as I do”. He told me he would definitely bump into me soon.

I moved in to my friend’s house for the night and informed the police who again came to see me.

07/11/07

Police came and installed panic alarm equipment. I was going to my bed at night with the panic button next to me, genuinely thinking he was going to break in and murder me. I was also terrified for my dog and my horse now that he had made it clear he’d been responsible for my horse’s wound. The horse’s field was easily accessible from a back road that wasn’t overlooked by any cottages.

09/11/07

I passed Liam in the car in town. When I got home I had a message saying “Hi, I just passed you in town. Was wondering if you could let me know if you are seeing someone as I’ve heard you are.” Incidentally I wasn’t – it was the last thing on my mind.

I phoned BT to change my telephone number.

14/11/07

Liam turned up at my house. He requested a letter that he thought would be at my house and was raging that I had changed my telephone number. I told him I would forward any mail and that he had no need to come to my house again. He said he would come whenever he wanted. He then went on to tell me how much pleasure he had from sticking a knife in my horse and slashing my tyres. He said I had gotten off lightly. He made reference to me losing my life and said he had thought about killing me but was past that. He said the reason he had “lost the plot” was because of me and that things would soon become difficult for me at work but would not elaborate.

I went back into the house and phoned my friend on the farm to come down due to how threatening he was. When they turned up Liam was furious I had involved other people. He had parked his car close to mine so that he could ‘accidentally’ scrape it.

He left in a fury after exchanging words with my friend’s partner. He wheel spun out of the courtyard, lost control of his car and crashed into a wall. Then he drove off.

Police informed. Advised I should have used my panic alarm. Asked them to have a word with him.

My friend rang Liam without me knowing. He was furious saying “I could have pushed her through the door and put a knife to her throat but I never.” Very tearful on the phone and obviously extremely unstable. Reported he was on medication from his GP.

Again moved to my friend’s house and my folk’s for the following two nights to try to get some sleep.

15/11/07

Police unable to get Liam in so they put a note through his door.

17/11/07

Phonecall from police. Liam had been in to the station to speak to them. He denied all of the above and apologised if he had caused me any distress. He was warned not to come anywhere near me or my house.

28/11/07

Handed the above information to managers at my work as he was also employed by the NHS.

30/11/07

On my way home from night shift I met Liam in his car on the back road from my house. He obviously knew I was night shift and that he would meet me on the road. He swerved his car in my direction causing me to swerve to avoid him. Police informed.

23/01/08

On return home from my night shift my horse’s stable door was wide open with her still inside and my haynet at the field had been untied and thrown into the middle of the field. There were car tyre marks next to this and large footprints at the stable.

24/01/08

Car again vandalised overnight. Large, deep scrape on near side wing. Police informed who attended the house and took a statement and later met with Liam who again denied having done anything. Photo taken of damage.

03/03/08

Horse again found to have been wounded on hind quarters. This time it was a deep cut like a stab wound.

Requested police come to see this and they asked for a vet’s opinion of cut and whether it could have been barbed wire. The police who attended this time appeared incredibly sceptical and suggested that because there was horse hair on the barbed wire it was surely more likely to be that. The hair on the fencing was tail hair, not the same thing.

For the first time I felt the police were doubting me.                

04/03/08

Vet looked at horse’s wound and in his opinion the wound was created by a sharp implement, more than likely a Stanley blade, definitely not barbed wire. Informed my original contact in the police of this and he said they would get in touch with the vet if need be and would speak to Liam. Unhappy with this outcome, I then rang the vet to request a written statement for my own records. Photo taken of wound.

06/03/08

Visited by the Domestic Abuse Liaison Officer from police. Discussed Liam at length, his past relationships and the risk he potentially posed. A risk assessment was completed. I found this experience completely insensitive and again felt like the female officer did not believe me.

07/03/08

Phonecall from my original police contact to discuss the recent incident. He requested I send a copy of the vet report to him and the liaison officer.

08/03/08

Phonecall from one of the police who attended the horse wound incident. He said he had spoken to Liam at the station who again denied everything. He’d said he was seeking a solicitor’s advice as had heard I was spreading rumours around town that he had been slashing my horse. This was not the case although of course my friends and family knew. The policeman told me that I really shouldn’t be doing this as I have no evidence and could be charged with slander. He also indicated that Liam (who he called by his ‘nickname’ like he was his mate) was helping them with another enquiry.

I felt he was extremely insensitive and unprofessional in his manner and found this very upsetting and infuriating. Discussed this with my mum who phoned the station to complain. Advised that an Inspector would ring me to discuss this.

10/03/08

Discussion with Inspector re above.

12/03/08

Passed Liam on the back road from my house when coming home from work.

13/03/08

Arrived at gym as Liam was leaving. He ignored me. When I left the gym there was no damage to my car but the wing mirror had been pushed in.

14/03/08

Again met him at the gym on the stairs. He said “hello” in an overly friendly manner. I said nothing.

The police questioned why I was going to the gym that he also attended but I was so determined to just get on with my life and I wanted him to see that he wouldn’t stop me.

18/03/08

A friend’s brother who had a CCTV business had very kindly offered to install it at my house. I discovered that Liam was aware of CCTV plans when he told a friend – apparently he was told by the police. I contacted the Inspector and left a message for him to contact me.

20/03/08

Spoke to the Inspector re. CCTV plans being disclosed to Liam.

22/03/08

Phonecall from Inspector re. above. Apparently CCTV was mentioned to Liam but more as a warning.

25/03/08

Finished babysitting for my friend at 0115hrs and when driving home through town I passed Liam on the road. It was 0130hrs. Presumed he had been past my house but no evidence.

07/04/08

I came out of a shop in town and Liam was sitting in his car parked behind mine so close that I was jammed in the space. Every time I attempted to pull away he jammed me in further. I phoned the police and as soon as he saw I was on my phone he reversed and pulled away.

12/04/08

Went out locally. Liam was working on the door at one of the pubs and refused me entry by aggressively saying “no chance” repeatedly until we turned away. Later saw him in a club in town where he was staring at me and smirking.

18/04/08

CCTV installed at house

10/06/08

He followed me through town in a new car. Drove right up behind me, revving engine and smirking. Finally turned away when I reached my grans.

17/06/08

Left work to find him waiting at the bottom of the road in his car. He started following me so I drove back up to my work as I didn’t want him following me all the way home on the back road. Informed two of my colleagues who followed me along the road a bit. Saw him again passing in the opposite direction. I then drove home and didn’t see him again.

08/07/07

Met him on the back road from my house when going to work at 0740hrs. He slowed down as if he was going to turn but he was unable to find anywhere to do this.

Discussed again with original police contact who suggested contacting a lawyer.

11/07/08

Received birthday card from Liam. It read “To Kirsten, hope you’re not miserable anymore, enjoy your birthday, lots of love from Liam x x x “ and a picture of a smiley face winking.

 

Over the next couple of years things were much less intense. He was in a new relationship.

 

31/12/08

Noticed a new scratch on the bonnet of my car approx 4 inches long. Unsure when or where this had been done.

18/08/09

Facebook conversation with a former friend stating that Liam had admitted to her and her husband what he had put me through, including attacking my horse and car.

Early 2011

Liam followed my partner and his friend in his car through town in an aggressive manner, driving very closely, pointing his finger at him and beeping his horn.

07/03/11

My partner was in his car in town with his sister and her partner. Liam followed them on to the local Estate where we lived and was attempting to get him to stop. They eventually lost him.

Email sent to original police contact for advice.

09/03/11

Discussion with police who made me aware that Liam had been to court for similar offences towards another female. He had been released on bail and was due in court to plea 2 weeks later.

June 2012

Liam allegedly took an overdose of sleeping tablets and was found dead.

 

Looking back

I felt emotionally exhausted with this whole situation. I had difficulty getting to sleep at night as I was worried he was going to come to the house and was unsure what he was capable of, imagining the worst. I remember the times I’d fall asleep and wake up struggling to breath imagining he was holding a pillow over my face.

I was angry at him for not getting on with his life and not letting me get on with mine. I felt I was constantly looking over my shoulder and eventually stopped going out in my local town for fear of bumping into him. 

When I look back on this now I cannot believe it went on for so long and I think the only thing that reduced his obsession with me was the fact he got in to new relationships. One of the girls contacted me to tell me he had a photo of me in his wallet and ‘weapons’ in his car that he hinted he’d use on me.

He definitely had a number of people who were good friends of his who thought I’d made up the whole thing. Several of them will be furious at me for sharing all this information, I’m sure.

My experience of the police in this case was only made positive by one individual officer and to him I am truly grateful as without his support I would have completely lost faith. I really hope that there have been improvements in this area and that people are taken seriously when they report their experiences of stalking.

Apart from having an alarm in my home I didn’t feel protected and I didn’t ever feel safe.

A large number of the events listed above were methods of trying to get to me psychologically – the impact of that should never be underestimated. Initially I probably didn’t think of any of this as stalking because so much of it was so subtle.

Whilst I would never have wished him dead, I recognise that there is no way I would be living the life I am now if he was still around. 

Please never hesitate to report anything that makes you feel uneasy or uncomfortable, no matter how insignificant it may seem.

I genuinely feel lucky to have survived this experience as for a long time I truly believed I would not. I thank my friends, family, former work colleagues and ex partner for getting me through it all – you were all amazing ❤️

 

Use, Misuse and Abuse – does language matter?

The issue of language in the drugs arena can often split opinion and is something that I’ve raised in a few different forums, most recently in the CWK Facebook Group.

Perhaps it can seem trivial or controlling to try to assert wording that is respectful rather than just going along with terms that have been widely used for many years. Some of these terms I indeed may have used myself in the past without giving a second thought.

Surely we should all be acutely aware of the language we use in order not to add to the stigma and discrimination already faced by people who use drugs?

The most common ones I have an issue with are –

Drug/substance misuse(r), drug/substance abuse(r), clean, dirty, addict (I’ll come back to this one) and a whole host of other derogatory terms including the J word which will not even be afforded the space on this page.

Ultimately we should try wherever possible to use people first language. People who use drugs or people who inject drugs are deemed respectful terms because they do not infer judgement.

Substance ‘misuse’ however, does have a level of judgement attached. Substance use does not. And who are we to say whether a substance is being ‘misused’?

Those of us who are already conscious about this cringe at media articles with sensationalist headlines and content peppered with all of the above terms, but how can we expect or demand that the media use respectful language when we don’t even have it nailed down in services who work with people who use drugs?

I come across this a lot when I’m travelling around Scotland and, like others, try to influence language whenever possible but it’s a difficult task when a lot of services or organisations have substance ‘misuse’ in their titles.

So I tend to start my overdose/naloxone training sessions with a reference to language to try to set the tone and avoid having to call someone out on it. Very often I have substance ‘misuse’ workers on my training. Awkward.

I certainly don’t tell people what they should be saying but just point out the language that I’ll be using during the session and the reason for it. It usually has a very positive effect. Usually.

It may be seen that on the grand scale of things, language is the least of our worries when it comes to addressing stigma however, the language used can often shape beliefs and ideas by negatively stereotyping a person.

Naming someone an ‘addict’ or a ‘drug misuser’ has negative connotations and implies that this is their identity and shapes how a person is viewed (or indeed what care or services they may be offered). They are a person. And they happen to use drugs.

There is more to a person than what they put in their body.

In the research field we often hear about ‘problem drug users’ which makes it sound like the person is the problem, when really what is meant is that the person is experiencing problems related to their drug use.

Now, I said I’d come back to the term ‘addict’. I have to say that I respect that the fellowships use this terminology and that people who are involved in them will use this term respectfully about themselves and others in that context. It’s when it is used out with that setting and without thought, that the problem lies.

If someone wants to respectfully refer to themselves as an addict then that is their choice but we should not be putting labels on other people.

I often hear people say “ah but that’s how they describe themselves” as justification to do the same. A way a person speaks about themselves may come from a place of very low self-esteem and it’s important to be mindful of that.

In training I show a short film of an overdose and the person who overdoses refers to himself as a …(insert J word) and it’s shocked me how many people then start using the term following that and when I point it out the response is as above…”well he said it”.

I don’t know about you but in my own experience feeling strongly about this can be quite exhausting. Particularly when you have adopted a ‘what you permit you promote’ attitude. From family members and friends to participants on training courses and taxi drivers, it’s like a minefield and often words are said without a second thought until it’s pointed out. (Most of my family know the score now although it’s not 100% sinking in for 87 year old Granny Dot)

I wish someone had pointed out the importance of language to me when I first started nursing in this area. Instead I was introduced to a world of ‘clean’ and ‘dirty’ drug tests rather than negative and positive ones. People were given ‘clean’ rather than sterile injecting equipment and people were ‘clean’ from drugs. Lots of cleaning going on.

Please let people know they are not ‘dirty’ if they use drugs.

So what do you think? Does language matter? I happen to think so.

I’d love to hear your thoughts on this one.

 

Involved in Harm Reduction in any way, shape or form? Join the conversation over on facebook in the closed group – the membership is growing and we’d love to see you there!

Projects, Pigeons and Pragmatism: a trip to Paris and the city’s only Drug Consumption Room

My first ever trip to Paris! And it’s to attend a meeting with the advisory and project team working on ‘My first 48 hours out’ comprehensive approaches to pre and post prison release interventions for drug users in the criminal justice service.

My part of the project is to develop guidelines, like a toolkit, for policy makers and practitioners relating to the provision of naloxone-on-release from prison. I’m very happy to be involved in this exciting piece of work.

A few initial observations of Paris – firstly, the pigeon population are a fairly arrogant bunch compared to their Glaswegian counterparts. Their pavements, their paths, don’t even think for a minute they’ll move out of your way politely.

It is also more challenging than expected to get a cuppa. Coffee? Yeah, no worries. Tea? Forget it. Or “non” as I was abruptly informed on several occasions.

On a more serious note, homelessness is very prevalent with large numbers of people begging in the street and rough sleeping. Also, this is the first time I have ever seen people with pet cats on leads…is this an actual thing in other countries?! I’m sure I wasn’t imagining it.

On day 2 of my trip I managed to arrange a visit to the only drug consumption room in the city (my kind of sightseeing) thanks to the fantastic Dr Elisabeth Avril, who accommodated my request at very short notice. It also happens to be exactly one year since the centre opened (October 2016).

I decided to walk the 2.5 miles to burn off some of the food I’d been scoffing and I always think it’s a good way to see more of a place. Particularly since I normally get lost and see more than intended.

The DCR is attached to the main hospital and doesn’t open until 1:30pm so I’m able to see the centre before people are using it. The entrance is actually at the side of the hospital through a security door which I felt was actually placed well and was discreet. Apart from the fact that it is overlooked by the neighbours in very close proximity. Sadly, many of these neighbours are completely against the service and will take pictures of people, posting them online with negative comments. It sounds like this situation has improved slightly over the year and the centre has done a lot of work with the community to try to improve relations. I am unsure whether they had the time necessary prior to the centre opening to do this work, as they had a short time-scale from securing the venue to becoming operational.

A high number of people attending the service have chronic and enduring mental health problems and it’s disappointing that the residents in the vicinity are not more understanding of the difficulties this presents for some individuals.

So as with other DCRs, people require to register with the service (and can do so anonymously) and must be injecting the first time they enter the service. The centre does have a small inhalation room however due to the high numbers of people smoking crack, the centre just does not have the capacity to accommodate the numbers requiring this service. Pet dogs are allowed in as long as they are muzzled (provided by the service) and on a lead or can be tied outside behind the gate if they do not bark.

The main drugs being used are morphine sulphate tablets and crack cocaine, with only a small number using heroin. There are very few overdoses because of this – people know exactly what dose they are using due to the MST coming from diverted prescriptions. If people do overdose, oxygen and intra-nasal naloxone is available on-site to manage this promptly and effectively. The service also has an excellent relationship with the hospital staff who will attend immediately if required to deal with any medical emergencies.

People can share their drugs providing they are clear that they plan to do this when they enter the facility. There are no restrictions as to where (on their body) they inject.

There are only 5 staff on shift which can be problematic at times when the centre is very busy, with up to 250 visits per day, 7 days a week. A diverse range of people attend the service and there can often be major language barrier issues. The staff team also includes peer volunteers, some of whom go on to gain employment with the service.

Views en route to the DCR

Rude pigeons

Hospital grounds

Chill out area

Inside the entrance – note close proximity of residents

Entrance with take-away injecting equipment provision

This note advises that crack pipes are no longer available for take away from this site – can be obtained nearby

Registration desk

Take away IEP

Waiting area

No alcohol allowed inside but can be stored in reception with space to charge phones

Ticket operation waiting service

Crafts made by guests

Injecting booths

IEP in supervised injecting area

All available equipment

Inhalation room

Crack pipe

Hand washing area

Quieter booth can be used to provide safer injecting advice

Counselling room

Exit to right (route is like a u-turn)

Tobacco smoking room

Light indicates when toilet in use to alert staff

Nasal naloxone

Indivior nasal naloxone

Tweet me @cuppawithK if you know what these lamps are made from!

Crafts room

Comments from guests

Would you notice there is a DCR in this picture?

 

In addition to the services provided on-site, people can be referred for opiate replacement therapy after completing a short assessment. Following this, they can then attend the nearby low-threshold clinic and receive a prescription the same day. Something we should all aspire to achieve in our treatment services.

When I asked Dr Avril what she would do differently (or advice for Glasgow) if she were able to start again, she said she’d have multiple smaller sites rather than one large site to accommodate the needs of more people. Unfortunately in Glasgow it has been a challenge to find one site, never mind three or four.

The visit was incredibly useful and will be helpful to inform some of the discussions in the planning for the first safer drug consumption facility in Scotland.

Join the conversation – Cuppa With Kirsten Closed Group

‘These conversations wouldn’t happen without conferences like this’ – My thoughts from HIT Hot Topics 2017

I’m just travelling home on the train from a fantastic few days in Liverpool. Since 2012 I’ve been going every year for the HIT Hot Topics conference and it’s something I really look forward to for many reasons which I’ll attempt to highlight here.

This year it got me thinking about what a privileged position I’m in to be able to attend such events on a regular basis and since starting the Facebook group it’s reminded me about how important networking in the harm reduction field is.

In 2012 I’d only just left the NHS to work for Scottish Drugs Forum, so getting to attend a conference like Hot Topics was a bit of a novelty after years of hardly being allowed to attend anything. I’d started using social media for work purposes towards the end of my NHS career when we began distributing naloxone and was using twitter more frequently to start making connections with some really great people – it was at my first HIT conference where I met most of them in person.

Since then I’ve been back every year and have managed to get myself a ‘job’ most years too, whether that be presenting on naloxone or drug consumption rooms, or chairing one of the sessions. This year I was attending as a delegate and took some time to consider what the conference means to me and why I’m drawn back year on year.

The conference actually starts the night before at the Harm Reduction Cafe. The cafe details are provided to delegates in advance and rather than it being a formal educational event, it’s a completely relaxed atmosphere in a bar where people can just get together and catch up or meet and be introduced to new people. The HIT O’Hare family make a real effort to ensure everyone is warmly welcomed whether you’ve known them for years or are meeting them for the first time. I feel privileged to call them friends.

This year was no exception and I caught up with old friends, colleagues and met others I’d been liaising with by email for different projects or sharing information. I also got a chance to chat to some of the speakers and hear a bit about what their presentations would cover. It’s a place where you know you’ll be able to offload some of the issues going on in your own area with many a conversation starting with ‘aw, wait ti’ a tell ye about this…’ (insert your own accent version).

The following day is the conference itself and this year was held at the stunning Lutyens Crypt.

There’s nothing quite like the feeling of walking in to an environment where you know that every single person there is on the same page with a mutual understanding and a real sense of belonging (without sounding too dramatic). There’s lots of hugging (something I’ve gotten much better at over the years…I am no longer an ironing board) and a genuine warmth and friendliness from everyone there.

The programme is, as usual, packed with all kinds of talks by speakers travelling from far and wide to share their knowledge, experience and expertise.

It’s the type of conference where people spontaneously clap at statements made by speakers that reinforce the rights of people who use drugs. The things we all know and believe in but somehow when they’re stated in this environment people feel empowered, inspired and hopeful. Hopeful for positive changes in times where the negativity surrounding harm reduction can feel all consuming. It’s almost like people feel the weight of all the harmful practice, poor decisions and stigma witnessed being lifted from their shoulders. It’s certainly how I feel anyway, like I’m calling upon all the naysayers and people who’ve become ingrained in punitive practices to say ‘See! This is what I’m talking about!’.

I enjoyed all the talks this year and particularly liked the running theme through many of them about language. So important that people are mindful of the words they use and how they can contribute to the enormity of the existing issue of stigma and discrimination.

The breaks offer time to connect with people and exchange details. This year it was great for me when people who are members of the Facebook group came to say hello – I loved that. I also met some incredible new people, one of whom gave me a huge boost and probably didn’t realise the impact of her words. I won’t name her but she’ll know who she is if she reads this…she said (about the FB group I set up) “I think it’s an excellent idea. I’ve just been on a leadership course and it’s so great to see a female leading in this way.”

Such a nice comment and one I’ll refer back to in moments of self doubt. These are the kind of conversations that build people up and make them powerful in what they can achieve. These conversations wouldn’t happen without conferences like this.

As the conference comes to a close, people leave with a real buzz, feeling inspired and like their batteries have been re-charged, ready to take on the world. Despite the landscape appearing bleak at times, there is strength in numbers and that solidarity can only lead to positive change.

And the event does not end there. At night, there is a chance to celebrate, party and enjoy an awesome charity gig at the famous Cavern Club with live music. A perfect way to keep that conference high going on until the early hours (very early hours for some).

It’s so important that service providers see the value in allowing their staff to attend conferences like this and fund places for people who use drugs. The benefit not only to the individual but to the wider team and in turn the clients of the service is enormous. I don’t think the benefits of this investment can be underestimated.

Everyone should be afforded the opportunity to attend this type of conference, especially HIT Hot Topics. Hope to see you next year!

Meantime, please pop over and join the group 😉

How Might Drug Treatment Services be Impeding the Process of Reducing Drug-Related Deaths?

I talked recently about my experiences of being a new nurse working in drug services and I was not surprised to have feedback from several people commenting on how it echoed their own experiences.

I’d like to now talk through some of the concerns I have about our drug treatment services in general and how some of the practices and processes in places could, indeed, be increasing or causing more harm rather than reducing it.

This is not intended to be a scathing review of how horrendous our services are or that everyone working in them is on a mission to increase the harms towards people who use drugs. That would be ridiculous, and is not the case. However, we cannot deny that there are some deep rooted problems that need to be addressed.

Let’s start at the beginning of the treatment journey for someone trying to access prescribing services.

 

WAITING TIMES

A HEAT target was introduced in Scotland to ensure that people were ‘in treatment’ within 3 weeks of their referral date. This was a great step forward given the hideous situation prior to that where people could be waiting up to an incredible 18 months for an initial appointment.

I remember the introduction of this well as I was working in a community addiction team at the time.

Sounds decent until we start to unpick it. So…a person decides they want to make some changes and consider opiate replacement therapy (ORT). At the point of this decision they are motivated and this is when we should be able to act, immediately, and there are examples from other countries of people accessing ORT on the day they present. However, what now happens is that their referral is processed by the service and the ‘clock starts’ at the service’s end, indicating the 3 week countdown.

The person will receive an initial appointment within this 3 weeks and be seen for an assessment. Unbeknown to most, their first treatment is ‘preparatory and motivational work’ – one of several treatment code options. And voila, they are in ‘treatment’ within 3 weeks.

What we should really be measuring is the time between this ‘treatment’ and the actual ORT, which may be several additional weeks.

If you miss your initial appointment, the clock can be adjusted to give the service additional time to send out another appointment. Or, if you haven’t made contact or you miss two initial appointments you may be removed from the system altogether – depending on the procedures of that particular service.

So, in order to best engage with people we need to get creative and be providing ORT services that can be accessed on the day that people make that decision to attend for treatment.

 

WE’RE IN!

Ok, we’ve made it through the waiting times process, provided several weeks worth of drug diaries and urine samples and attended all of our appointments – and we’ve now been titrated on to a methadone or buprenorphine prescription.

Now, let’s bear in mind that before this person was receiving treatment, there’s a high chance that their life was fairly hectic, they were using multiple substances and spending a large part of their day focussed around the activities of getting money together, sourcing their drugs and then using them. This made attending appointments and maintaining a routine tricky at the best of times.

So why then, do we assume that providing a methadone prescription will instantly enable a person to stop using all additional substances and suddenly become able to maintain a routine and attend all appointments? And if they don’t then they can be discharged for the very reasons they attended the service in the first place? The prescription surely can’t be expected to have solved all the housing, benefits and multiple other things going on that might be more of a priority for the individual.

Over the years I’ve seen many instances of people being sanctioned or discharged for not complying with the service’s expectations. I have seen first hand countless letters to people either informing them of reductions to their prescription if they fail to attend, or having increased supervision of their prescription should they provide a positive drug test. (note I’m saying positive rather than ‘dirty’ – language in this field is for another day)

People have also been sent letters when they are discharged and told to go and ‘work on their motivation’ for 3 months before they attend again. Yeah, no bother, I’m sure their motivation will be through the roof now! Also, if they are lucky enough to survive this 3 month period, which is effectively a ‘ban’ from the service. When did this type of exclusion start becoming acceptable practice and where is the accountability for the increased risks this person now faces?

 

WHY THE DISCHARGE?

If someone is not attending their appointments, what is the real reason behind that? Are we sure these appointments are providing value to the person or are they just coming to provide a urine test which, if positive, may result in negative consequences? I’m pretty sure I wouldn’t bother attending either.

A question I often get back when I raise this in training is ‘yeah but how do I know if they’re ok if they are not attending?’ – which is a fair question and one that comes from a caring perspective. But we need to be creative and make sure we are communicating with other services, like the pharmacy who have no doubt seen the person most regularly, if not every day. And let’s not forget the very basics of picking up the phone or texting to show people we’re genuinely concerned about their wellbeing.

In relation to people using ‘on top’ of prescriptions, a question that comes up is ‘but how do I justify my practice if I knew they were using, I continued to prescribe them methadone and then they overdosed and died?’ I would say that firstly, we know that people are much safer when they are on ORT and that it is a protective factor against overdose. If necessary, the reverse should happen and the dose should be increased rather than removed altogether. Taking away the prescription massively increases the risks.

If it was me, I’d be considering all of the above, discussing harm reduction strategies and the risks of overdose with the person, making sure they had naloxone and reminding them to tell others they were carrying it. And if I was ever questioned I’d say that I was doing everything I could to keep the person in service as I knew from the evidence that it was the most protective thing I could do.

These reasons for discharge can all remarkably be interpreted in different ways in to ‘planned, unplanned or disciplinary’ discharges. Incidentally I know of no other health service that has ‘disciplinary’ discharges but I’m happy to be enlightened.

In Scotland, the majority of people who die from an overdose are not in treatment at the time of their death but have been in treatment or in contact with services within the previous 6 months. The small percentage of those who were in treatment were mostly not on optimal doses of methadone. So people who die with methadone in their systems are, on most occassions, not prescribed that methadone.

It is so important that managers have this discussion with their staff and create a supportive culture where every possible step is taken to retain people in treatment when they need it. Discharge should NOT be the norm.

 

MY IDEAL SERVICE

If I could design my own ORT service it would be low-threshold, so with no expectations of ceasing all other substances as a condition of prescribing.

It would be provided on the day people presented by compassionate, non-judgemental, altruistic staff who were fully supported and adequately resourced.

There would be no mandatory drug testing so that there was instead an emphasis on trust and respect.

It would be flexible and involve assertive outreach to firstly engage people and then follow them up if they appeared to be disengaging.

The service would also have paid peer workers.

Of course, if people wished to reduce/detox they would be supported to do so.

Ultimately, the service would be designed to meet the needs of the people attending, not the needs of the service.

 

None of this should be seen as controversial or completely outwith our capabilities. We can all do better – the biggest change required is the culture.

 

Thanks for reading and please join us in the closed Facebook group to continue the discussion.