Josh Dumbrell, Peer Navigator.
While still out performing, overdose was an inevitable aspect of my addiction. From day one, my using was characterised in the adage, “one is too many, and a thousand never enough”. Indeed, for many of us, our drug of (no) choice is simply ‘more’. I have come to learn that my transient, chaotic lifestyle and frequent involvement with the criminal justice system meant I was a high risk individual. This coupled with my physical inability to control the amount I took ensured I would eventually (and frequently) meet the conditions for overdose. These conditions are multiple, with risks increasing as time goes on. On top of this bodily compulsion there exist numerous factors contributing to overdose risk, including aging, multi-morbidity, poor mental health, housing instability/homelessness, and exclusion. While abstinence is the only way to completely eradicate the danger of going over, harm reduction interventions focusing on these contributory factors promote overdose prevention and likely reduce drug-related deaths (DRDs).
As a Peer Navigator in Edinburgh, I have been able to make participants an unconditional offer of support around improving their health and general wellbeing.
Of particular concern to this discussion are individuals who have experienced homelessness. As well as housing instability, a significant proportion of this population often also experience tri morbidity and face deep social exclusion, all of which contribute to an increased mortality risk. It is unsurprising, then, that this vulnerable group is over represented in the DRD statistics. While not explicitly focused on preventing overdoses and DRDs, my position on the SHARPS study sees me working alongside some of those most at risk of such outcomes in Scotland. As a Peer Navigator in Edinburgh, I have been able to make participants an unconditional offer of support around improving their health and general wellbeing. This approach meets each individual ‘where they’re at’, and has enabled them to access vital services. For instance, despite many experiencing chronic homelessness, no one on my caseload is currently sleeping rough – with all living in supported accommodation or their own tenancies. Several participants are now receiving Opioid Replacement Therapy, which is, of course, a protective factor against overdose and DRD . Similarly, across study sites, many with co-occurring chronic illnesses have entered into treatment, whilst one person on my caseload has cleared Hepatitis C.
Without a reasonable degree of joint working, however, a number of these life-preserving outcomes would not have materialised. This particular intervention has been designed with experts from academia, the NHS, third sector, and local authorities, to enable as joined-up an approach as possible. Similarly, the recruitment of those delivering the relational intervention was carefully considered, with lived-experience of problem substance use and/or homelessness being a prerequisite for the role. Without such a psychologically-informed approach to the problem, efforts toward collaborative working and, of course, access to funding, any stated desire to intervene in Scotland’s spiralling DRDs is little more than political posturing.
Given the marked improvements in personal circumstances that I have witnessed amongst those I have been working with, it is not unreasonable to argue that those recruited to the study are now significantly less at risk than their peers who are without such support. While it is difficult to formally evidence this, anecdotally I know of at least ten people from the local homeless community who have died as a direct result of drugs in the past year. It strikes me that many of those we lost were no harder to reach than those recruited, sadly, numbers were necessarily limited on the study, and we can only do so much.
As a recovering individual working in front line services, I have become aware of an unnatural and unhelpful dichotomy between harm reduction and recovery.
For me, therefore, the obvious question is could these deaths have been prevented? The answer is yes, some could have been. Consider for example, what we have known about homeless health, multi-morbidity and DRD for some time. Similarly frustrating, is the fact that assertive outreach has long been shown to be highly effective within homeless populations. For example, this ten year old study shows that 41% of ‘hard to reach’ individuals became engaged with drug-treatment services following such an approach. I guess what I am trying to say is that progress has been slow with regards to responding to this crisis. It seems as though successive governments and the media have both played a part in cultivating the culturally-accepted narrative that addiction is a moral issue. This is particularly evident when considering that data outlining the relationship between Adverse Childhood Experiences, problem substance use, and other chronic illnesses, has taken over two decades to begin to filter into public consciousness. More specifically, this information would go a long way towards liberating a demonised and deeply stigmatised population.
I also answered yes to the question above because I worry that harm reduction (as essential as it is) is the only message that some people get exposed to. While not everyone will be able stop using drugs, abstinence remains the only guaranteed way for an individual to avoid overdose and DRD. As a recovering individual working in front line services, I have become aware of an unnatural and unhelpful dichotomy between harm reduction and recovery. We have known through twelve-step mutual aid groups for eighty years about the therapeutic value of one fellow sufferer helping another. Millions have recovered through accessing these groups and the power within. Some of the individuals I work alongside have been on the scene for years and yet I am their first example of a recovering person. Similarly disappointing, I have observed fellow professionals wincing at discussion of a spiritual programme of recovery, perhaps sceptical as to how this applies to (what can be perceived as) such a damaged population. Those most at risk are also those hardest to reach, hardest to engage, hardest to retain in treatment, etc., these are the people for whom mainstream services are unsuitable, and for whom, therefore, allowances must be made. Such allowances might include safer injecting sites and heroin-assisted treatment programmes, which place compassion and understanding at the heart of patient care. A truly person-centred approach dictates, however, that we also offer increasing opportunities for people to access recovery, for example, by funding a greater number of beds in detox and residential rehab, as well as opening significantly more dry-house type supported accommodation. Enhanced housing benefit and grants from local ADPs would fund such accommodation and adherence to best practice would see residents in regular contact with recovering individuals who have found a solution.
Photo credit: Matt Collamer via Unsplash
Matt explains this image as follows:
"I met Michael in a Boston subway station. I told him I liked his sign. “What matters is what it means to you,” he told me. I asked what it meant to him. “Doing a deed or expressing kindness to another person without expecting anything in return,” Michael said. I love approaching strangers wherever I go. Listening and talking to them teaches you about people and how similar we all are to one another.
Just like Michael, we’re all seeking human kindness."