News August 2020 Newsletter Last chance to register for joint webinar QNPMHS WEBINAR: VISIONABLE - REMOTE CONSULTATION USE FOR CLINICIANS WORKING IN PRISONS Tuesday 18th August 6:30 - 7:30pm NHSE Health and Justice has invested in a two year pilot of telemedicine across the entire secure estate in England, including prisons, immigration removal centres and the children and young people secure estate (CYPSE), in response to the COVID-19 pandemic. Speakers include: Chantal Edge – Specialty Registrar in Public Health/NIHR Clinical Doctoral Research Fellow, leading on the telemedicine programme rollout Lee Henderson – Visionable Technical Manager, responsible for the NHSE/HMPPS Visionable service Caroline Watson - Lead GP, HMP Bedford, RCGP Clinical Champion Healthcare in Secure Environments. Clinical Update Navigating environmental constraints to injection preparation: The use of saliva and other alternatives to sterile water among unstably housed in PWID in London Harris M, Scott J, Hope V, Wright T, McGowan Catherine, and Ciccarone D. Harm Reduct J. 2020;17:24. Available open access here. The study used a questionnaire with 455 people and in-depth qualitative interviews in 32 people who inject drugs in London as part of the Care and Prevent study. They found that a high proportion of the survey reported a lifetime history of street homelessness (70%) and nearly two-thirds had suffered bacterial infections with 30% of people requiring hospitalisation. The quality of accounts provide the most revealing detail here. They told stories of people using very unsafe, if not outright dangerous injection practices in semipublic spaces. They had difficulties accessing sterile water and ended up using water from toilet cisterns, puddle water and even, horrifically, saliva. We all know that there is a requirement to add water in the preparation of heroin and crack cocaine. The water is needed to dissolve the heroin and get it into solution. This stage needs some heat and that does help kill micro-organisms in contaminated water. However, those in the study who described their process for preparing snowballs used some cold water, the ‘cooler’, before adding the crack cocaine, and putting them at particularly high risk of bacterial and fungal infections. Commentary: I am beginning to suspect I would read a shopping list if it was written by Magdalena Harris who has generated some of the best research in the harm reduction field in recent years. Here’s another study to add to a growing list of essential research that will change your practice. The brilliance of this study, much like the most recent paper on acidifier is, is it takes something that none of us give much thought to and puts in the context of people who inject drugs (PWID). So, here’s the key message if you are not doing this already: start having conversations about access to clean water and harm reduction advice about the cold water phase to help reduce devastating infections. Typically of Harris and the team they are not satisfied with simple academic discourse and practical measures are tied in. The legal regulations were amended in June 2005 and drug treatment services are permitted to supply water for injection to PWID. Harris and colleagues point out that there was a maximum size of 2ml that can be supplied and the Medicines Act was amended in 2012 to allow the supply of 5mg ampoules. However, the distribution of these is limited due to cost and fears of HCV infection through shared ampoules. (Particularly when the ampoules are glass raising anxiety about cuts and increased potential for HCV transmission.) The authors also flag up the 2019 Exchange Supplies water risks poster for display in needle and syringe providers. And check out their excellent description of a prototype street injecting kit addressing cost constraints but maximising harm reduction. Great stuff. Clinical Update edited by Dr Euan Lawson. To access the full Clinical Update, please become an SMMGP Premium Member. What we've been doing to support you We have held a number of free events looking at the effect of the pandemic on services including: A joint webinar with RCGP A joint webinar with RCPsychs on care pathways with prisons A Premium Membership webinar with Adfam A Premium Membership webinar with Collective Voice Over 1,000 people have registered for these events in the past few months, thank you for making these webinars lively and interesting. Dame Carol Black Review We had a great response to a call for evidence for the Dame Carol Black Review, thank you. We were able to submit a full range of evidence to the review. Some of the key points raised were: The need to better fund drug services to achieve the full range of outcomes for people who use drugs including harm reduction and recovery The need for joint working across all agencies including mental health, employment, and housing services The importance of putting the person at the centre of care The need for young people’s services to engage with issues specific to under-18s The damaging effects involvement in the criminal justice system can have on people who use drugs. Please click here to see the review.