Multi-Drug Injecting in Manchester

An assessment of officials statistics revealed that needle-sharing rates and levels of HIV and HCV among IDUs in the North West have recently risen to record levels, and that the North-West has the highest rates of injecting-related HBV and HCV in the UK. In order to investigate the factors underlying these trends, quota-sampling was used to recruit 100 drug injecting clients of Lifeline Needle Exchange Scheme (NES) in Manchester. Respondents were paid £10 to complete a structured questionnaire in February 2006. About nine in ten were male and White, almost all were unemployed, and their mean age was 35 years. Eight in ten were homeless, of whom about half were temporary homeless, and almost half were roofless (rough sleepers). Non-response was almost zero, and the sample was broadly representative of the source population. The average respondent had 36 convictions, and 11 prison sentences totalling about seven years. Half reported long-term health problems (notably HCV), about a quarter reported present physical health problems (notably flesh/vein damage), and a quarter reported mental health problems (notably depression). One in 20 had sold sex, and one in 15 had contracted STIs (notably gonorrhoea). Present drug treatment was reported by just over half, who were prescribed a mean daily dose of 60 mg of methadone.

The mean duration of NES attendance was just over four years, and most respondents attended daily (almost a third) or weekly (almost half), with equipment loans typically lasting five days. In addition to needle exchange, respondents used an average of two of the other 10 services, notably advice/information (a third). Of 10 products available, the mean number utilised was about six - notably filters, swabs, and citric acid powder (nine in ten), followed by water ampoules and sterile cups (eight in ten), with just over half indicating sharps-boxes and needle clippers. The mean number of syringes picked up on an average visit was about 30, including about 25 of the 1-ml ‘diabetic’ syringes. The average estimated return rate was around 70%. Also, four in ten reported recent (past-month) use of other needle exchanges. Nearly all respondents were satisfied with the service, with the ‘things’ they liked most being the friendly, helpful staff.
Tobacco smoking was reported by nine in ten respondents, and alcohol use by just over half. The mean age of first drug use was about 16 years, usually involving cannabis or heroin. The most common forms of past-month non-injecting drug use were smoking crack and smoking cannabis (by two-thirds each), followed by swallowing methadone and smoking heroin (by over half). Total mean weekly spending on drugs was £440, including £213 on heroin and £198 on crack. The main source for funding drug use was state benefits (two-thirds), followed by shoplifting (four in ten), and begging (four in ten).

The main reason for starting to inject was peer influence (over a third), while the main reason for present injecting was dependence (four in ten). Two-thirds indicated that most or all of their friends injected drugs (typically eight friends). Past-month injecting was reported by over nine in ten for heroin, and eight in ten for crack. Almost three-quarters reported regular (daily or near-daily) injecting of heroin, and almost two-thirds for crack. The mean age of first injecting was 21 years, typically heroin (at 23 years) or amphetamine (at 19 years). The mean duration of injecting was about 14 years. The mean number of injections per day was about four overall, and five among daily injectors. The mean amount injected in a typical ‘shot’ was £12 worth of heroin, or £13 worth of crack. Overall, 99% were IV injectors, and just one respondent was a primary ID/IM injector. The main two injecting sites, each mentioned by over four in ten respondents, were the arms and the groin. The mean time taken to inject was five minutes. Respondents were asked if they regularly (usually or always) carried out 18 ‘safer injecting’ (SI) actions across three stages of injecting. Eight in ten reported doing five of them (mostly preparation actions), over two-thirds reported doing another five (mostly preparation actions too), about a third to a half reported six more (mostly administration actions), and less than a fifth reported the remaining two actions. In short, SI actions in the preparation stage were typically carried out by the vast majority of respondents, while half or fewer typically carried out the SI actions in the administration stage. One in five reported having been injected by other people in the past month, and one in eight reported injecting other people (typically about two friends in each case). Almost half admitted to recently re-using their own syringes. Past-month ‘sharing’ of syringe barrels/needles was reported by one in nine, including 9% who injected with other people’s used syringes (averaging six times with two people), and 3% who passed on used syringes to others to inject with – while recent sharing of paraphernalia (spoons/cups, filters, and/or water) was reported by half.

The most common locations for drug injecting were respondents’ own homes/rooms (six in ten) and public places (half), followed by squats/derelict houses (four in ten) and other people’s homes (a third). Use of shooting galleries was reported by almost a quarter, with the typical case visiting an average of four shooting galleries over the past month, on a weekly basis. Poly-drug injecting was reported by almost nine in ten respondents, and multi-drug injecting was reported by eight in ten – all but one of whom were speedballing (injecting heroin and crack together in one shot). Speedballing was carried out daily by two-thirds (55% of sample), and weekly by almost a third (36% of sample). The mean daily number of speedball injections was about three overall, and about four among daily injectors – though the heaviest speedball users were shooting up 8 to 16 each day. The modal amount of drugs put into a speedball injection was one £10 bag of heroin (73%) and one £10 bag of crack (68%). The mean duration of speedballing was about five years - almost nine in ten speedballers reported starting the habit between 1998 and 2005. Overall, over two-thirds of respondents reported that most or all of their injecting friends/associates were presently into speedballing.

Of about five kinds of injecting mistakes/accidents in the past year, over half each reported having a ‘bad hit’ or hitting an artery, about a third reported hitting a major nerve, about one in five reported overdosing, and one in 15 reported seizures – typically with a less than monthly frequency for all five problems. The proportion of respondents reporting that they tested positive for each of three injecting-related viruses was 1% for HIV, HAV and HBV (2% among those tested). By contrast, 32% of respondents were HCV positive (48% among those tested). Vaccination was reported by 56% for HAV, and 73% for HBV. Lifetime rates of bacterial infection were zero for severe systemic sepsis and GAS bacteraemia, around 5% for tetanus and septicaemia, and just 2% for wound botulism. Only two types were reported over the past year - tetanus (4%) and septicaemia (1%) - and none in the last month. Of four types of physical damage, abscesses and collapsed veins were reported by about four in ten, ulcers/sores by a quarter, and gangrene by 5%. Recent experience of the first three types of damage was reported by around one in five in the past year, and by 5-10% in the past month.

Several significant differences were found between respondents with their own homes and homeless respondents – and within the latter group, between temporary-homeless and roofless respondents. Homeless respondents were about 1.5 times more likely than housed respondents to be male and unemployed, and had fewer under–18 children. They were also much less likely to report long-term health problems, and rated themselves as happier. Also, compared with roofless respondents, housed and temporary-homeless respondents reported twice as many treatment episodes, a higher rate of present treatment, and greater satisfaction with treatment. Regarding needle exchange, homeless respondents were more frequent attenders and more regular users of citric powder than respondents with their own homes, with roofless respondents being the most frequent attenders overall. Homeless respondents’ weekly spending on heroin and cocaine was at least two times greater than for housed respondents, and they were also more likely to report drug-related shoplifting - while begging was about twice as common among housed and roofless respondents, compared with temporary-homeless respondents. Also, compared with temporary-homeless respondents, roofless respondents reported higher levels of spending on heroin and drug-related shoplifting.

Levels of daily injecting, crack injecting, and speedball injecting were about 1.5 to two times higher among homeless respondents compared with those with their own homes. Roofless respondents were at least four times more likely than housed and temporary-homeless respondents to have injected drugs in squats/derelict houses and public places, but were almost seven times less likely to have injected drugs in their own residence. Lastly, compared with housed respondents, homeless respondents were almost four times more likely to be HCV-positive, though knew a lower mean number of HIV-positive IDUs. In addition, there were three significant correlations between duration of homelessness (in months) and other variables - including a negative correlation with self-rated happiness, and positive correlations with daily dose of prescribed methadone among those in treatment, and with the number of shooting galleries among those who used them. In short, the longer someone had been homeless, the more unhappy they were, the greater the dose of methadone they were prescribed, and the greater the number of shooting galleries they had visited.
Several significant differences were also found between speedball injectors and heroin-only injectors.
Compared with heroin-only injectors, speedball injectors were four years younger, had almost three times as many convictions, and were around twice as likely to be male, and twice as likely to be homeless (i.e. most compared with about half) - but were three times less likely to report having a regular sexual partner. Also, compared with heroin-only injectors, speedball injectors took almost five times as many needles per visit, notably 1-inch orange needles, and were also more likely to regularly pick up two products (citric acid powder and swabs), but were much less likely to make use of the information/advice service.

Turning to drug use, compared with heroin-only injectors, speedballers were over twice as likely to report recent crack smoking, and spent almost five times as much on drugs (about £500 weekly, compared with £110) – notably heroin and crack. Speedball injectors were also over three times more likely to be daily injectors compared with heroin-only injectors (about two-thirds compared with a fifth), were about five times more likely to re-use their own used syringe needles/barrels, and were much more likely to inject drugs in squats/derelict houses (just over half, compared with no heroin-only injectors). Also, compared with speedball injectors, heroin-only injectors reported knowing more people who were HIV-positive - both overall, and among IDUs. Lastly, the daily number of speedball injections among speedballers was positively correlated with spending on both heroin and crack, the typical dose of crack put into a speedball injection, and the duration of imprisonment.

[ Conclusions ]

Conclusions were presented under three headings: needle exchange, homelessness, and speedballing. It was concluded that the Lifeline NES was generally effective on four evaluation indicators: making contact with up to two-thirds of local IDUs (with six times as many clients as the average NES); achieving acceptable levels of service delivery (including a high rate of needle exchange); reducing levels of many risky injecting behaviours (notably reducing needle-sharing to about 10%); and achieving key harm-reduction objectives (notably keeping HIV around 1%). Compared with other needle exchange services in Britain, the Lifeline NES performed well on all indicators - indeed, almost all respondents indicated satisfaction with the service. However, compared with national trends, Manchester IDUs had much higher rates of public injecting and shooting gallery use, as well as relatively high levels of vein/tissue damage and HCV. But their most distinguishing characteristics involved accommodation status and multi-drug injecting.
About eight in ten Lifeline NES clients were homeless, including over half who were temporary homeless, and almost half who were roofless (rough sleepers). It was estimated that there were about 650 to 1,130 roofless IDUs in Manchester in 2006, including about 230 to 400 roofless NES clients. This contrasted with Manchester City Council’s estimate of seven rough sleepers in 2005. The source of this disparity can be traced to MCC’s invalid and unreliable method for estimating the prevalence of rough sleepers, based on counting roofless people observed in public places on one night of the year and other dubious procedures. British research shows that around a third to two-thirds of homeless people now use drugs, including a quarter to a half who are dependent on opioids and/or cocaine, and around a third who inject drugs. Conversely, the available evidence suggests that about a tenth to a third of drug users are homeless – rising to around half of IDUs. Statistical analysis of the present survey findings suggested that there was a complex relationship between homelessness, drug injecting practices, and various psycho-social factors - notably mental and physical health, offending, imprisonment, and social deprivation/exclusion. Five salient pathways into homelessness were identified from the research evidence: drug use, relationship problems, imprisonment, leaving other institutions, and, being an asylum seeker or refugee.

National policy toward homelessness has undergone considerable development over the past five years, starting with the 2002 Homelessness Act, which required LAs to devise local homelessness strategies by March 2005. The Homelessness & Housing Support Directorate was also set up in 2002, to coordinate national policy on homelessness. By 2006, homelessness prevention was being carried out by almost all LAs, and in March 2007, the government launched its new package of measures to reduce youth homelessness, including a National Youth Homelessness Scheme, an advisory committee of formerly homeless young people, regional centres of excellence, a National Homelessness Advice Service, and a project to transform youth hostels into work-related learning centres. Specific policies to tackle homelessness among drug users have also been developed. It was concluded that if we are to evaluate the effectiveness of these policies and interventions in preventing and tackling homelessness among drug users, then LAs need to develop more valid and reliable methods for estimating the prevalence of local levels of homelessness.

About eight in ten NES clients were into speedballing - the simultaneous injection of heroin with crack- cocaine. The main reason for speedballing appears to be the massive surge in dopamine produced by injecting the two drugs together, a synergistic effect which raises dopamine in the brain to ten times normal levels – compared with nearly double when heroin is injected alone, and quadruple when crack/cocaine is injected alone. The present wave of illicit speedballing began around 1990, distinguished by a switch to injecting crack, instead of cocaine powder, with heroin. Rates of speedballing among British IDUs climbed from less than 1% prior to 1990, to around 20%-40% by 2006 (an estimated 40-80,000 people). Research also suggests that the highest regional prevalence of speedballing among IDUs is in the North-West, with estimates ranging from about a quarter in some areas to three-quarters in Manchester. Indeed, it was estimated that 615 to 750 of the 854 NES clients in the first quarter of 2006 were speedballers, and that there was a total community prevalence of about 1,600 speedballers in Manchester in 2005. The typical speedballer had started the habit about five years earlier, and, compared with heroin-only injectors, was more likely to be male, single and homeless. Recent research also confirmed the present survey’s findings that speedballing is associated with significantly higher levels of risky behaviour - including heavier drug consumption, frequent injecting, groin injecting, public injecting, using excess citric acid, re-using syringes, and poor injecting techniques – and drug-related harm, notably higher rates of infectious diseases and greater vein/tissue damage. It was concluded that drugs research has neglected the growth of speedballing, and therefore that multi-drug use needs to become a core variable in researchers’ data-collection instruments and drug agencies’ monitoring systems if our knowledge of the nature and extent of speedballing is to be improved.

[ Recommendations ]

Recommendations were organised into six groups, with four focused on needle exchange schemes, and one each on treatment and research. First, needle exchange purchasers and providers should continue to develop the accessibility and availability of services, by providing a range of generic and specialist agencies, and by continuing the ‘user-friendly’ style of service delivery. Second, NESs and other drug agencies should provide information on safer injecting to IDU clients through multiple delivery channels, with a particular focus on 12 issues: safe locations, washing hands, clean space, injecting technique, vein-raising, dissolving agents, equipment cleaning, choosing sites, syringe flushing, site hygiene, managing health problems, and non-injectable methods of drug use. Third, NESs should consider providing additional products, notably sterile wipes/gels, injecting mats/boards, syringe markers, butane lighters, tourniquets, and wound-care materials (plasters, ointments, etc.). Consideration should also be given to providing multi-item injecting kits and pro-smoking/sniffing devices. Fourth, NESs should consider a range of service improvements, including appropriate medical technology (eg. Vein Finder), drug consumption rooms, drug product quality-control facilities, and overdose prevention measures (notably take-home naloxone). It was also recommended that treatment agencies should consider offering a wider range of prescribing options, including diamorphine maintenance for heroin addicts and substitute stimulants for crack users – in oral, injectable and smokable forms. The final recommendation was for more research to be conducted into the aetiology, epidemiology, and social psychology of injecting drug use – as well as related harm-reduction interventions. Urgent tasks include disentangling the multiple variables associated with drug injecting and homelessness, in order to identify common cause-effect pathways; producing valid and reliable estimates of the prevalence of various injecting behaviours and homelessness; carrying out more ethnographic research into drug injecting practices and lifestyles, notably speedballing, public injecting, and groin injecting; improving routine monitoring of clients’ characteristics and service uptake, particularly multi-injecting and accommodation status; and establishing a consensual framework for evaluating the effectiveness of needle exchange and other harm-reduction interventions.