September 2013

2013 harm reduction conference highlights

The 23rd International Harm Reduction Conference was held in Vilnius, Lithuania, in June. Prominent topics included opioid overdose reversal programs involving naloxone, the rise of synthetic drugs and the great inroads being made in Eastern European harm reduction despite tough policy environments.

Following are some of the issues addressed.

Stimulants not high on agenda

One session of the conference was dedicated to stimulants and other drugs.

Parisian Thierry Charlois discussed a harm reduction program aimed at the nightclub scene, to which a coalition approach is the key, he said, bearing in mind the diversity of what the various interested parties want. Clubbers want drugs, club-owners want more money, police want some form of order and local councils want to avoid complaints about noise.

If anyone was wondering if current legal actions against the ever-changing internet-based synthetics drug trade was manageable from a law enforcement perspective, Basak Tas from England made it clear that there’s little immediate likelihood that systems were going to be able to respond.

There was a strong sense within the audience that there needs to be far greater attention paid to non-opioids within harm reduction.

Harm reduction cafes

Self-confessed harm reduction “tech head” Nigel Brunson explained a new concept that he and other cyberspace tragics are behind: harm reduction cafes.

Little groups, or local networks, of people are able to link up, at first using a new internet site (www.harmreductioncafe.com) and then organising informal meetings on a regular basis.

It was interesting to observe that in England, which is far more densely populated than Australia, there seems to be a sense that far more networking needs to be done.

“Aim for no overdose deaths” says New York naloxone expert

The International Harm Reduction Conference featured a special session launching the World Health Organisation and United Nations Office on Drugs and Crime’s new position paper regarding naloxone. As a ‘naloxone guru’, Matt Curtis, from New York, was the final speaker at the session and summarised key points for those new to naloxone programs.

Matt has been involved with overdose education programs involving naloxone in many countries.

Reduce overdose deaths to zero

“The first point is that the goal should be to reduce overdose deaths to zero. While that is a completely unachievable and unrealistic goal (as people will continue to use heroin or other opioids), if we model programs with this in mind, and continually adapt what we are doing with this as the bottom line, we are on track.

Access

“The second area is access and going back to the idea of saturating communities with naloxone. Programs should be integrated with other services. I never like seeing overdose programs that are stand-alone, where you have your syringe exchange, your counselling going on here, and once a week you have your overdose training…

“It needs to be integrated into the complete array of drug user health services that are being provided anywhere. The idea is that you are trying to maximise the likelihood that if someone out there in the community witnesses an overdose they already have the knowledge to provide the appropriate first aid, they have naloxone on them and are able to use it correctly.

“I think syringe distribution programs are a good analogy for this: no one would ever think that organising a syringe exchange where you had to call an outreach worker in order to get a new sterile syringe every time you needed to inject heroin was a good model. But there are overdose prevention programs that do that. There are some good reasons why some are organised that way, due to political or legal constraints for example, but it is far from ideal.”

Who gets the job done?

“In terms of getting as much information to the street, the first priority needs to be harm reduction programs and service providers. They have a unique relationship with people who use drugs and you know when you are starting from zero or with small programs, the best bang for your buck will be through harm reduction services and programs.

“Related to that is that programs need to be developed with people who use drugs being directly involved at every step of the way. If you don’t do that you are doomed to have much less impact. That said, I think once we get programs established it is very important for overdose services to be offered in other settings. In the US, for instance, we have overdose education and naloxone distribution programs that work out of methadone clinics, rehabs, jails, hospitals and emergency departments, and we’ve been able to have police carry naloxone in their first responder role in several jurisdictions.

Coverage and scale

“The last thing is how do we evaluate how you are getting services out? There are all kinds of folks who will have trouble accessing services. If you only have, say, a drop-in space providing overdose training and naloxone prescription, it may not be accessible for people with disabilities, it may not be welcoming to LGBTI or young people who don’t want to go to a place where the scene is 50-year-old users who have using been using for 25 years. There may also be big geographic gaps that might need to be covered.”

Lemon juice fentanyl mix may help explain ‘vena sclerosis’ fears

In 2010, Albury drug and alcohol clinician Alan Fisher and his colleagues from Dubbo began to notice that some clients who had been injecting fentanyl were having vein damage that appeared worse and had an earlier onset than what usually occurred when clients reported injecting crushed pills.

Along with Professor Bob Batey, Mr Fisher and colleagues speculated that severe abscesses may be due to particle matters, such as those from the matrix embedded in the fentanyl patches, being mixed with the fentanyl extract via the preparation process.

Mr Fisher said: “Processes of getting it [fentanyl] can involve cutting it up into bits and soaking it in a liquid such as vinegar or lemon juice and heating [it]. It’s hardly a sterile procedure.

“We also think it may get contaminated with glue and fibres from the patch, which may explain the high incidence of infection and vein damage.”

The level of acidity in drug preparations may also contribute to vein damage associated with regular drug injection, according to Californian Professor Dr Dan Ciccerone MD.

Famous for his ethnographic work, which identified different health risks associated with differing types of heroin in the United States, Professor Ciccerone is currently exploring the role that the acidity of injected heroin plays in causing vein damage and other harms.

Professor Ciccerone sampled heroin preparations in London and found that when citric acid is used in preparation, which it commonly is, the result was – not surprisingly – an acidic mix.

(Citric acid is supplied in single-use sachets throughout much of the UK harm reduction program, and some sachets carry a small-print warning that citric acid can cause vein damage.)

Based on his as-yet unpublished research, which he presented at the 2013 International Harm Reduction Conference, he believes that the use of lemon juice or vinegar in extracting fentanyl from patches may help explain the vein damage that the likes of Alan Fisher has been reporting.

Alan Fisher told the Bulletin that his clients using fentanyl tended to mix with water in more recent times, rather than lemon juice.

“It may be that they’re already working out that injecting lemon juice is problematic, hence more people using water,” Mr Fisher said.

On the PH scale, the lower the number, the higher the acidity. Blood has a PH level of about 7 which means it is neutral. Lemon juice and vinegar have a PH level of around 2, which is not far behind hydrochloric acid (PH 1). Some people reportedly use vinegar to extract fentanyl from patches.

My experience with drug users is that they are all amateur chemists. They know how to work the drugs. If it’s a good, common sense message, they will adopt it.

Professor Dan Ciccerone

Professor Ciccerone says, “I believe the acid is causing vein damage – or ‘vena sclerosis’ in medical terms – and that vein damage makes it very frustrating to continue to inject. People start injecting in more risky ways, like into their large veins such as their groin or in the neck. And it causes soft tissue infections such as abscesses and cellulitis because of all the messy vein shots and stuff like that.

“I think the lime juice or lemon juice that people are using in their fentanyl preparations is going to hurt their veins and that they will wind up getting abscesses and soft tissue infections from those injections. That’s what I would predict, not having seen the situation.”

Professor Ciccerone said harm reduction messaging should alert people to the possibility that acidic injections increased the risk of vein damage.

“My experience with drug users is that they are all amateur chemists. They know how to work the drugs. If it’s a good, common sense message, they will adopt it.”