Heroin and Crack Injection: Providing integrated responses and interventions for combination drug injectors

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1 Heroin and Crack Injection: Providing integrated responses and interventions for combination drug injectors Claire Robbins, Clinical Nurse Specialist, Soho Rapid Access Clinic Danny Morris, Development Manager, Drug Services, Herefordshire PCT

2 Snowballing quiz 1. Injecting heroin and crack together makes it less likely to overdose? 2. Injecting Crack is a quicker route than smoking 3. Snowballing is a new form of drug use, and therefore needs a new pharmacological intervention to deal with it? 4. If the dose of Methadone is high enough, then it will block the cravings for crack and therefore stop combined drug use? 5. People who use Crack, even if it used with Heroin need to go to separate services that deal only with stimulant users, as they have different needs? 6. People who inject heroin and crack in combination are more likely to experience mental health problems, than people who inject Heroin alone?

3 Literature overview Most non UK papers refers to cocaine and heroin as a Speedball Treatment experiences in UK predominantly crack cocaine Combined injection of heroin and crack referred to as Snowball There is currently no drug treatment for cocaine dependence

4 Literature overview The use of cocaine/crack by heroin dependant individuals or those in treatment is substantial High levels of cocaine use associated with poor outcomes QuickTime an TIFF (Uncompresse are needed to see Increased spending and therefore increased crime Increased co-morbidity, poor mental health More likely to drop out of treatment

5 Prevalence Not a new phenomenon Crack use and injection on the increase among injecting drug users in London G Hunter et al Addiction = 16% use crack 1993 = 59% use crack Crack injection rose from 1%- 27% 41% use heroin and crack in combination 26% combined use with alcohol, BZs and methadone SRAC Drugs on Admission QuickTime and a TIFF (Uncompressed) deco are needed to see this pic Under-reporting a feature?

6 Prevalence Transition towards IV crack 40% of IDU s report crack IV in last 4months Reports of over 70% in some areas 40% in combination with heroin T. Rhodes et al IJDP 2006

7 Pharmacology The pharmacological reasons for cocaine use in opoid dependant users poorly understood Opoids and cocaine have different modes of action Cocaine and heroin share an important characteristic: serve as powerful motivators of appetitive behaviour Considerable evidence that reinforcing and incentive effects associated with increased dopamine levels

8 Heroin

9 Cocaine

10 Heroin QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

11 Pharmacology However different and complex cellular systems at play as result of repeated use and tolerance, duration of drug exposure Clinical evidence indicates that simultaneous administration of cocaine/crack and heroin does not induce a novel set of subjective effects; nor is it more reinforcing than either drug alone Francesco Leri et al 2003

12 Street Pharmacology Anecdotal reporting suggests that opoid dependant users snowball because it feels better it was quite an experience. especially when doin the crack and the smack...what an intense rush of the crack...and then the feeling of the heroin coming in in the background so Snowballer

13 Advances in pharmacology Advances in computational neuro-scientific models Development of specific interventions reflect varying behavioural and psychological stages of dependence every reason to hope that new drugs for speedballing and cocaine dependence perhaps combined with specific behavioural treatments are on the horizon Bankole A Johnson 2000 How far away is that horizon?

14 Developing service delivery Combined use difficult to understand Other papers not so concerned with the why Social science perspective - a fashion? Can identify important issues in the study of snowball pharmacology Emphasis on increased health and social damage Enhancement of core drug worker interventions

15 Drug availability Demand or supply? and the heroin dealers are selling crack now though it s mostly all crack even the crack addicts are being sold little bits of heroin as well so even the crack addicts are turning into doing snowballs Snowballer 95% of people out there won t do one without the other So heroin dealers started dealing crack as well So now you can buy both off people you could only score one off Snowballer

16 Concerns Those who report injecting crack have higher prevalence of HIV and HCV Crack use associated with increasing injecting risk behaviours Shooting Up HPA % report IV use with shared needles/ syringes 55% report sharing other equipment A.Judd et al BMJ 2004 Yeah anyone who says that they don t is a liar everybody shared mine, everybody shares Snowballer

17 Overdose Snowballing increases the risk of overdose Difficult to assess effect of either drug individually Crack use increases when heroin is scarce Increase in alcohol and BZ use and secondary addiction RCGP Guidelines for working with crack users in primary care 2004 Cocaine deaths doubled in first six months 2003 US studies show up to 50% of drug overdose cocaine related

18 Injecting damage and harms Pharmacology associated with increased injecting risk behaviours Local anesthetic and vasoconstriction Vein damage more prevalent Missed hits Frequency of injection, lifestyle, hygiene issues further contribute to evident vein and associated damage

19 Frequency Two, three, maybe more... it just depends...on giro day..five or six...on my DLA day ten, fifteen, twenty QuickTime TIFF (Uncompres are needed to se Snowballer

20 Injecting sites All sites used but correlated with tissue damage and vein collapse 44% groin injecting sample report IV crack Recent reports from across UK suggest that the groin increasingly considered normative, rational, and socially acceptable injecting site Move to femoral injecting associate with crack and speedball injecting particularly amongst homeless users (T Rhodes at al IJP )

21 Femoral injecting Reports from across UK suggest that the groin injecting increasingly associated with snowballing cos I was more impatient to get the hit I have got veins. I could find them if I took the time but I was just desperate to get the Snowball in me So I use my groin cos it s quicker isn t it? Snowballer

22 Treatment considerations Treatment retention compromised, poor outcomes Tend to have unstable accommodation, increased homelessness and limited support C Amalia Marrero et al Addictive Behaviours Studies report that cocaine using opiate dependent users suffer more severe co-morbid psychopathology (dual diagnosis) Increased health and social concerns F Leri et al Addiction 98, 2003

23 What s offered I don't think there's a lot of support when you're snowballing. a lot of people are going around thinking it's alright to snowball when it's highly fuckin' dangerous As I said I was ignorant Snowballer

24 Crack services That's pointless because I take heroin as well.it needs to be something that deals with them both If you sort the heroin, I need something to sort the crack and if you sort the crack, I need something to sort the heroin...y'know what I mean It's got to be something for both. Service user

25 Recommendations: enhanced services No pharmacological substitute treatment for cocaine use has been identified but treatment approaches aimed at modifying behaviour provide some benefits EMCDDA Annual Report 2004 Enhanced NEX with increased provision of syringes, safer injecting support Accessible BBV testing, awareness and vaccination and treatment Sexual health (for sex workers) OD awareness and training Access to specialist wound care

26 Enhanced services Working co-operatively with service users Helping with planning money management Access to secure/safe accommodation Working on the individuals triggers and cravings Provision of mental health support Awareness of benefits and limitations of opiate substitution prescribing

27 Conclusion Numbers of sterile syringes available for injectors limited and insufficient Many examples of good practice but substantial groups of injectors being denied interventions in-line with MoC: Update 2006 NTA NXS Audit 2006 Developing mechanisms to ensure that services that aim to prevent or reduce infections among IDU s can respond to evolving patterns of drug (such as increased cocaine/crack use) and risk Shooting Up HPA 2005

28 With special thanks to Maggie Borham for contributing users quotes from unpublished dissertation Thank you. Claire Robbins Danny Morris