October 2021

Setting the pace: ‘We were the first NSP to be state-funded anywhere in the world’

Q&A with Philippa Jones

Approaching the first anniversary of her appointment as National Operations Manager of the Needle Exchange Services Trust in New Zealand, Philippa Jones draws on experience amassed in the social services and health sectors and during her tenure as Chief Operating Officer of Lincoln University. Based in Christchurch, she liaises with five individual needle exchange trusts spread across the North and South islands.

You’re relatively new to your role, and to this field as well, I think?

When I saw this job come up – there’s not many national roles in Christchurch – I knew a teeny bit about the Needle and Syringe Programme (NSP) and I thought “Really interesting: it’s an opportunity to do something that has more direct impact and is a bit more purposeful”. That was the attraction for me. And, I suppose, it brought me back to one of my areas of interest around human behaviour and people in vulnerable positions and the counselling I’d done early in my career. Not that I’m doing that now in any way, shape or form, but I have an empathy and an interest in it.

I joined in November 2020, and I’ve been learning a lot about drugs and other things and connecting with all the people in the sector in New Zealand. Actually, I thought, “We have this iconic little organisation – the first to be state-funded anywhere in the world, as I understand it – and it’s just too far below the radar. We’re doing great work but we’re not shouting about it.”

The first state-funded NSP?

According to the research and what I’ve been told, NZ had the first state-funded NSP in the world.

When was that?

It was in 1988. I Googled it, because I wondered too, and I did find a reference to what I’d been told when I arrived here. I found it on the International Drug Policy Consortium website. On May 16 1988 the world’s first legal nationwide needle exchange program opened in NZ.

What’s the role of the organisation and what do you do in it?

We still have that old-fashioned title “needle exchange programme” but we’re an NSP, and we’re nationwide. We’re made up of six trusts, including five regional trusts. I’m in the national office, which is the sixth trust. I report to a board made up of the chairs of the other trusts and some independent trustees.

We have 20 dedicated needle exchanges across those trusts and two mobile services: one down the west coast of the South Island and one in the lower half of the North Island.

We have 195 pharmacies and we have an online shop. Some of our equipment is free: 27 different needles and one syringe, which happens to be a 3ml. It’s been like that since 2004; it’s never been updated even though drug use has changed dramatically in that time. We’re advocating for updating the list of free equipment at the moment. Everything else has to be purchased: wheel filters, cigarette filters, sterile water, cups, all the other syringes – butterfly syringes, 1ml syringes.

We distributed 3.9 million needles just this past year.

You said the drug market’s changed since 2004 – in what way?

We don’t have imported heroin; we have mostly methadone, methamphetamine and pharmaceutical morphine as the predominant categories.

We have a growing steroid use, which I think is similar to what they have in Queensland.

Methadone and morphine are still 42 per cent of what our clients are using and methamphetamine is 30 per cent, and we have 14 per cent methylphenidate, and then steroids and others. It’s evolved over that time and there’s growing interest in steroids, particularly among gay men and bodybuilders.

Is it an aging cohort, like we’re seeing in Australia?

Yes, it is. It’s around 45 to 50 – especially those using opiates.

We’re seeing growth in some of the younger people using meth, and Maori in particular, which is a concern because our Maori population already has the worst statistics across a range of health and social measures.

We haven’t had a consistent practice of collecting client information. We still report what we have collected, but we know that it’s suboptimal.

Would it be right to assume you’re the first non-peer?

Yes, that’s right. The board made that decision. They had somebody external in last year: a consultant. He said “Just find a person who has the skillsets you need for this time of the organisation’s development” and I pitched up with my relevant background and hoped for the best.

Across the country we have about 80–85 staff and around 80 per cent of those are peers. Some are current injectors – I don’t know how many; I’d be guessing – but one of the first things I got the NEST board to do was develop a strategy. It’s very high level and conceptual at the moment. One of the principles we signed up to was to continue to be peer-based.

Within the needle exchange I’ve observed an ‘internalised stigma’ where some staff place limits or constraints on others because they are peers. I’ve heard things like “Oh, they’re peers. Don’t put too much pressure on them – they can’t cope”. I think it’s essential to develop and build the skills of our peers and to recognise that it’s that lived experience and all the ups and downs associated with that which make our service what it is. In any workplace you have vulnerable people. Let’s just treat everybody with the same level of care and respect.

I’m optimistic that if we have good leaders in our organisation we’ll have a more engaged workforce and have them doing what we actually need them to be doing: focusing on our clients’ well-being.

I’m optimistic that if we have good leaders in our organisation we’ll have a more engaged workforce and have them doing what we actually need them to be doing: focusing on our clients’ well-being.

So you define peers as both present and former users?

Yes. We had a lot of volunteers originally in the service; we don’t have that now – all of our staff are paid.

We’ve just brought a new independent trustee onto the NEST board, Tuari Potiki. He’s a Maori leader in NZ who’s very well known and who spoke at the United Nations recently about decriminalising drug use. He says 30 years ago he was a “needle user” and acknowledges that we need people with more recent experience in governance roles.

We’re currently searching for a second independent board member and we really would like a recent peer or a peer.

In each region we really should have some kind of forum where we can invite our clients along and get feedback and engage with them about our service.

What’s your overdose profile in NZ?

Deaths as a result of opioid poisoning or overdose range between 35 and 50 a year.

We also received some other data recently on poisoning by opium, heroin, other opioids and methadone. This includes both people who’ve died and people with multiple hospitalisations, accidental and intentional overdose – near misses. That was up at around 653 last year.

What’s your naloxone availability?

We’re struggling a bit. It’s variable across the country because of the OST (opioid substitution therapy) services that have access to it.

The biggest issue is that we can’t get the provider, the pharmaceutical company, to be interested in supplying it to NZ and meeting the requirements – there’s a whole lot of bureaucracy and red tape getting in the way. There’s a limited supply and it’s dependent on the attitudes of the OST services. Some are more liberal and are providing it; they’ve interpreted the rules to say “We’ve prescribed it. We’re now giving 200 doses to the needle exchange program to distribute” and others are saying “No, you’re breaking the law”.

NZ is about to go through some major health reforms. One of the reasons for this is that there’s too much variability in health services for a small country, with this as just one example.

Last year we distributed about 160-odd kits of the injectable naloxone. In Auckland we’ve just managed to secure the nasal spray. We’re working actively – the [NZ] Drug Foundation, the Ministry and ourselves – to try to break through the rules to make it more available. On International Overdose Awareness Day, August 31, we based a key part of our media campaign around that.

The biggest issue with naloxone is that we can’t get the provider, the pharmaceutical company, to be interested in supplying it to New Zealand and meeting the requirements – there’s a whole lot of bureaucracy and red tape getting in the way.

Are you particularly proud of any individual (or organisational) achievements?

The HIV prevalence is very low among people who inject drugs in NZ – I think 0.2 per cent of people who inject drugs – which is attributed to our program.

Is part of the inconsistency in healthcare across NZ fuelled by geographic isolation or distance?

We have 22 district health boards for a population of 4.5 million. We’re currently moving towards being more like the UK National Health Service with one or two agencies doing the commissioning, because at the moment, commissioning or contracting could occur through any of those 22, a number of other organisations or the Ministry itself.

In the future all commissioning and contracts for service will be done through two centralised agencies. In theory I’m quite positive about it because we’ve all experienced variations of service depending on where we live. It’s called the “postcode lottery” in NZ.

You mentioned that you estimate the number of people who might be injecting drugs; we have the same problem here. There’s so much uncertainty, so much secrecy. There’s a natural tendency for that in illicit drug use and the service system accommodates and exacerbates it. We end up trying to argue with bureaucrats that there’s huge need but we can’t easily quantify it.

That’s exactly right. In NZ over the past few years there’s been a lot of lobbying to have drug use decriminalised. The focus of the referendum was cannabis and it just missed going through. But this government does have some empathy or sympathy for decriminalisation so we’ve been doing quite a bit of lobbying, because until we address that, a lot of clients will be hesistant to provide their confidential information to us, no matter how well we convey to them that it’s secure.

I’m putting a paper together for consultation with our managers and the Ministry of Health to look at improving the information we collect from clients as we are currently inconsistent in how and what we collect. It would mean a big change for some staff and for clients who are already feeling fearful We still have people being picked up for possession of utensils, even though there’s a defence against that in the Misuse of Drugs Act.

The one thing I should say is that our strategy is a bit more like what we’re seeing happening in QuIHN in Queensland. We have that trusted and safe front door for clients coming to us because they’re served by peers – that’s our strength. But what other services can we add or partner with so that the group of people who inject drugs can actually access other healthcare support?

We have some very successful hepatitis C clinics that are co-located with our exchanges. For 10 years we’ve been running the one here in Christchurch; it’s doing about 30 per cent of the treatments in Canterbury. But also GP clinics – we have had for a number of years a GP service in our Dunedin NEX that could also extend to OST or counselling. It’s about having those other health professionals who share our philosophy.

If we actually ask people who inject drugs about their mental health, they often suffer depression and anxiety, and some have multiple and serious mental health conditions. Maybe it’s partly criminalisation; maybe it’s partly the stress of running out of money to buy drugs; maybe it’s traumatic childhoods and other trauma.

That’s how I characterise it to people who don’t know anything about our service. I’ve certainly learnt that a good proportion – I’d hate to put a number on it – of our clients have mental health issues, have had trauma, have other complex social needs. There are certain conditions that have been present that have contributed to their taking drugs.

Being focused on mental health is very topical here. The government has done a huge review and we’re failing so badly, it’s terrible. But if we look at drug policy, we talk about supply, demand management, harm minimisation and treatment. In NZ we focus only on the ends of that continuum: supply – going after the dealers – and then treatment. And treatment is largely abstinence based.

There’s a gap. Thinking about ways to reduce demand, like not locking someone up, would be a good start, and enabling people to seek the help they need.

There are certain conditions that have been present that have contributed to their taking drugs.

Are NZ’s cannabis reforms dead for now?

It just missed getting through in a referendum in 2020. The country could see the benefit of decriminalisation but I don’t think it could deal with legalisation in one hit.

Our current Minister of Health is saying “no” to decriminalisation, but there are MPs from across all parties who are sympathetic to decriminalisation and recognise it is a barrier to people getting the help they need as well as perpetuating stigma and discrimination.

We’ll keep picking away and meeting with MPs and agitating, because really that would make the most difference. Providing other healthcare offerings to this group of people at the same time would let us capture that window of opportunity when they’re thinking “Oh, maybe this isn’t that good for me” or “Maybe I’d like some help”. How do they get that help? At the moment they can’t. It’s just not available. They can’t have honest conversations about what’s going on, except with the peers at the needle exchange.

There are MPs from across all parties who are sympathetic to decriminalisation and recognise it is a barrier to people getting the help they need as well as perpetuating stigma and discrimination.

Critical shortage

So low are supplies of naloxone in New Zealand that on August 31, the New Zealand Drug Foundation (NZDF) marked International Overdose Awareness Day by appealing for public support to purchase and distribute 500 kits of Nyxoid nasal spray.

“We’ve been calling for naloxone distribution for years now and we cannot, in good conscience, wait any longer,” NZDF Executive Director Sarah Helm says.

“NZ is grossly under-prepared for an opioid epidemic like those being faced overseas. Tens of thousands people are dying in countries like the United States and Canada and parts of Europe because drugs like heroin, methamphetamine and MDMA are being mixed with fentanyl. If the same thing happens here, we’ll be overwhelmed.”

With NZ$45,000 ($43,000) as the end goal, Sarah says every NZ$90 ($86) raised will put one Nyxoid kit “into the hands of someone who needs it”.

Via the fundraising site Give A Little, NZDF raised almost 10 per cent of its target within the first seven days. The appeal is ongoing.