From Fix to Foil. The Dutch experience in promoting transition away from injecting drug use,

Transcription

1 From Fix to Foil The Dutch experience in promoting transition away from injecting drug use, International Harm Reduction Conference Liverpool, April 2010 John-Peter Kools

2 Contents 1. Dutch context 2. health interventions 3. current situation 4. lessons learned

3 1. Dutch Context Dutch heroin epidemic starts in 1975 bohemians, hippies unemployed youth people with mental health issues, youth trauma Surinamese migrants people from other European countries

4 Situation 1985 Netherlands 25,000 people using drugs Amsterdam 9,000 1/1 heroin (base): 70 1/1 cocaine (salt): 90

5 Injecting 30-40% of all users were injecting: 70% among users from other EU countries 40% among Dutch 5% among ethnic minorities (mainly Surinamese) HIV prevalence among IDUs: Between 30% (Amsterdam) and 1 % in other areas (e.g. Groningen, Arnhem) Sources: Driessen, Methadonverstrekking in Nederland, MOH, 1990 Van Ameijden, 1994 Op de Coul et al, 2003

6 Injecting (motives) economic reasons also cultural and environmental components distinct watershed between: injectors, real drug users non-injectors, sissies

7 Transition towards injecting? 30% of non-injecters start with injecting within 5 years. 70% of those who once injected will continue to inject A substantial number of the percent of drug users in Amsterdam who do not inject can be expected to start injecting in the future needed: health interventions aimed at prevention and cessation of injection but questions on feasibility of these interventions source: Van Ameijden, Evaluation of AIDS prevention measures, 1994

8 2. Range of health interventions endogenous processes of route transition in Dutch drug using communities, recognised and strengthened by health professionals health promotion interventions initiated by NGO Mainline, : promoting non-injecting is HIV prevention.

9 Health promotion onward: articles in magazine on chasing health advice embedded in a lifestyle approach interviews (incl. pictures) with active users on their preferred methods of consumption tool to engage non-injectors: additional aluminum foil

10 Transition away from injecting Eye opener to a new trend in injecting communities: Bumped into Red Harry. Grinning from ear to ear. He said he stopped injecting. After 27 years! Started smoking in prison... You wouldn t think it possible that I can do that. After so may years. Kools, Hit and Health, Mainline, 2004

11 Start of range of health interventions objective: enforcing and accelerating existing trends of transition away from injecting entire article on The Switch, 1993 special edition on chasing, with foil, 1995 special attention during outreach NSEPs started offering/selling non-injecting paraphernalia like foil, pipes

12 Field research injectors and former injectors 1995, Amsterdam, N= 106 Former injectors 47 % (50) had moved away from injecting injectors 53 % (56) currently injecting 73% (41) of them were occasionally using non-iv Source: Kools, De Switch, Verslag van een interventie onderzoek. Mainline, 1996

13 Background for transition health problems, in particular vein problems decreased satisfaction with IV range of social benefits (like sharing, socializing, increased self-respect)

14 Unexpected advantages I m now able to live with my mother. Compare it with someone who sits sociably at the bar and treats everybody to a round.that s totally different from someone sitting in the toilet and tossing back the contents of a hip-flask. I don t think of myself as a junkie any more, but as a user.

15 Peer support campaigns mobile counseling program (bus with outreach workers) 20 min video with testimonials from 10 users who switched to non-injecting 29 times conducted in 20 cities funded by the Ministry of Health

16 Campaigns for health workers 1999 skill building workshops for drug workers 2-day programs in 9 regions support injectors in switching continued by drug agencies funded by the Ministry of Health

17 3. Current situation stable decrease IV Amsterdam Cohort Study, : IV prevalence halved (66%to 36%) IV initiation nearly disappeared (4.1% to 0.7%) IV cessation doubled (10%to 17%) IV relapse halved (21.3% to 11.8%) Source: Van Ameijden et all, Large decline in injecting drug use in Amsterdam, JECH, 2001

18 Current situation II Problematic users, Amsterdam 2009: 20% ever injected 4% current injection (Source: E. Witteveen 2009)

19 Current situation III HIV/ HCV prevalence: rates stable or declined since early 90s HIV/HCV incidence among injectors, Amsterdam HIV: 8.5/100 PY in after 2000 HCV: 27.5/100 PY in after 2000 Source Van de Berg, Eur J epidemiol 2007 number fatal ODs decreased: 65 ODs in Amsterdam, ODs in Amsterdam, 2007

20 Current situation IV numbers of exchanged syringes have dropped Amsterdam: from 1,000,000 to 200,000 Rotterdam: from 400,000 to 170,000 new health harm: individual cases with respiratory problems

21 Lessons learned Environmental success factors: stable heroin market increased popularity of crack cocaine base-form of heroin and cocaine that can easily be vaporised non-injecting peers as a role model

22 Lessons II Heath programmes: stabilization on methadone (OST) FULL RANGE of health interventions (OST, NSEPs, community outreach, consumption rooms, peer support, availability of materials,...) Social programmes: Housing programmes,

23 Lessons III Health promotion success factors : health interventions to promote route transition can be developed especially by stimulating and reinforcing existing harm reducing trends in drug using communities New interventions should be targeted at methods of cessation of injecting as these are amendable to intervention. Source : E. Witteveen, Motives and methods of cessation of injecting among drug users in Amsterdam. TADP, 2000

24 Conclusions A generation of Dutch drug users changed their behavior. Switching became a way of maturing out major success in prevention of BBVs, ODs, endocarditis, DVT, abscesses, blood poisoning etc

25 Challenges for the future Route transition on the HR agenda in developed countries, but also in transitional and developing countries

26 Article From Fix to Foil; The Dutch experience in promoting transition away from injecting drug use, available on John-Peter Kools Consultant on Drug use, HIV and Harm Reduction Tel: Mob: