SOHO RAPID ACCESSCLINIC.

AIMS:To provide a client focussed, low threshold flexible prescribing service. To offer an easily accessible assessment and treatment service to rough sleepers in Westminster.To provide information and advice to drug and alcohol users aimed at harm minimisation.

BACKGROUND:Pilot project Oct 99-April 00, partnership between Westminster DAT, BKCW, Westminster Social Services, Hungerford Project and Rivendell Clinic.Engaging rough sleeping drug users in the Soho Area, assessment, prescribing services, access to detox and rehab.Over 70 assessments carried out in 6month period.Follow up shows good levels of retention in treatment, but increase in use of Crack. Application for funding to R.S.U, which is successful.Oct 00 Soho Rapid Access Clinic works from the Hungerford Project, while waiting for premises. Hungerford Project continue to be closely associated with SRAC, which is now funded jointly by BKCW and The Rough Sleepers Unit.

BACKGROUND:SRAC opens at Dean St Hostel Jan 2001, in partnership with Bridge Housing and Arlington Care Association.SRAC continues to be funded by R.S.U until July 2002, when it is absorbed into CNWL Mental Health Trust, and funded by Westminster Substance Misuse Commissioners.All referrals to SRAC are made through named referrers, who work for external agencies, there is a close relationship with the local Substance Misuse Units.SRAC is staffed by a consultant psychiatrist, a team co-ordinator, staff grade Dr, 3 clinical nurse specialists and an administrator.

PARTNERSHIP WORKSRAC currently works with a number of partners.Equinox, Hungerford, Central CAT team, Westminster CAT team, Passage Centre, Mobile Needle Exchange, Connections at St. Martins, are the current main referrers.The clinic is based in Dean St Hostel, which is run by Bridge Housing.All referrals are accompanied by their external worker.Extensive liaison and support from SRAC staff to referrers and agencies involved with service users.

SERVICES OFFEREDAssessment, medical, psychological and social. Access to full psychiatric assessmentReferral for in patient detoxReferral to Care Managers for fundingMethadone titration and on going prescribingSubutex prescribingCommunity alcohol detoxOff site assessment if neededTreatment for a twelve week periodAssurance of transfer of prescribingRe titration on release from prisonExtensive harm minimisation information relating to drug using practices

PHILOSOPHY & MODEL OF WORKThe assessment workers are trained nurses, who have worked in drug services in both the voluntary and statutory sector, and have experience within the field of homelessness.Although the assessment tools are cumbersome, the clinic practises flexibility with information gathering, aiming for a sensitive and detailed history to assist with titration. Medical appointments are flexible, most prescribing appointments offered within two working days, with opportunity for on the spot titration if appropriate. The atmosphere of the clinic is informal, and sensitive to the social exclusion of its service users

A BRIEF GLIMPSE INTO THE INJECTING PRACTICES AND CONCERNS OF A GROUP OF ROUGHSLEEPERS

BACKGROUNDThe Soho Rapid Access Clinic noticed increasing reports of combined drug injecting, heroin & crack cocaine prepared and injected together.

The client group all have a recent and often protracted history of rough sleeping, little or negative experience of prescribing services.

Traditional treatment services have had difficulty engaging this population in treatment.

Service users were expressing concern about the lack of information available on snowballing, experiencing more injecting problems, and having difficulty stopping or controlling their combination use.

RESPONSE:Service user questionnaire completed by 14 service users, seeking their views and experiences.No previous experience of a programme for crack use.Interest in additional help with problems they associated with snowballing and crack use.Triggers for increasing or continuing use were: money, craving, boredom and living in a West End hostel where drug use is pervasive

RESPONSE:Focus group to invite user involvement and consultation.

Feedback from this group has informed, and been part of the development of a series of user informed supportive educational groups.

The group is currently in a period of review, having run at three West End hostels, in the substance misuse units.

COMBINATION DRUG USE QUESTIONAIREBasic questionnaire completed by 91 service users. This is in addition to service requirements.

All service users asked at initial contact about sharing injecting equipment., approximately 98% confirm sharing, many within the past 24 hrs.

Also high levels of groin injecting, amongst this group, users site ease of access being a primary reason for groin injecting.

Data

Total Participants91

Male76

Female15

Total91

Age Groups

16 - 2415

25 - 3049

35-4427

Total91

Ethnicity

White British70

White Scot6

White Irish8

White European3

Black Other3

Black African1

Total91

Do you ever combine heroin and crack in the same syringe?

Yes84

No7

Total91

How often do you combine them?

Always42

Most of the time31

Occasionally9

Rarely3

Never3

Not Applicable

Total88

If you use crack alone before you use heroin, do you smoke or inject?

Mainly smoke22

Mainly inject47

Both6

Neither3

Not Applicable8

Total86

How long do you wait after using crack on average, before using heroin?

Straight away

Under 5 minutes27

5 to 10 minutes9

10 to 30 minutes9

30 to 1 hour6

Over 1 hour11

Not Applicable25

Total87

Have you noticed any increase in injecting problems since injecting crack?

Yes56

No26

Not Applicable

Total82

If yes, what have been the main problems you have had?

Abscesses16

Missed Hits11

DVT / Thrombosis8

Numbness1

Vein Access30

Lumps2

Rushing1

Cellulite1

Blood Congesting1

Inreased Usage / Tolerance Build Up4

Ulcers1

Paranoia1

Endo1

No Response

Total78

Will you be interested in attending a group to help you with crack/combination drug use?

Don't Know6

Yes40

No16

Total62

The group will include sessions on the following, please tick the ones you would find most useful?

Information on Crack13

Cutting down and stopping21

Health related issues17

Triggers12

Cravings11

Safer Injecting14

Day programs10

Detox, rehab and follow on support17

Total115

Gender

76

15

Gender

Responses

Client Gender Breakdown

Age

15

49

27

Age Range

Responses

Client Age Breakdown

Ethnicity

70

6

8

3

3

1

Responses

Ethnicity

Combination

84

7

Combine crack and heroin in the same syringe?

Responses

Crack & Heroin Combination

Often

42

31

9

3

3

Not Applicable

Frequency

Responses

How often are they combined?

Smoke - Inject

22

47

6

3

8

Responses

If using crack on its own, do you smoke or inject?

Wait

Straight away

27

9

9

6

11

25

Waiting Times

Responses

Waiting time before using heroin.

Problems

56

26

Not Applicable

Problems since injecting crack?

Problem Types

16

11

8

1

30

2

1

1

1

4

1

1

1

No Response

Problems

Frequency

Main problems from injecting crack.

Group

6

40

16

Frequency

Interested in a crack group?

Topics

13

21

17

12

11

14

10

17

Topics

Responses

Session Topics

Data

Total Participants91

Male76

Female15

Total91

Age Groups

16 - 2415

25 - 3049

35-4427

Total91

Ethnicity

White British70

White Scot6

White Irish8

White European3

Black Other3

Black African1

Total91

Do you ever combine heroin and crack in the same syringe?

Yes84

No7

Total91

How often do you combine them?

Always42

Most of the time31

Occasionally9

Rarely3

Never3

Not Applicable

Total88

If you use crack alone before you use heroin, do you smoke or inject?

Mainly smoke22

Mainly inject47

Both6

Neither3

Not Applicable8

Total86

How long do you wait after using crack on average, before using heroin?

Straight away

Under 5 minutes27

5 to 10 minutes9

10 to 30 minutes9

30 to 1 hour6

Over 1 hour11

Not Applicable25

Total87

Have you noticed any increase in injecting problems since injecting crack?

Yes56

No26

Not Applicable

Total82

If yes, what have been the main problems you have had?

Abscesses16

Missed Hits11

DVT / Thrombosis8

Numbness1

Vein Access30

Lumps2

Rushing1

Cellulite1

Blood Congesting1

Inreased Usage / Tolerance Build Up4

Ulcers1

Paranoia1

Endo1

No Response

Total78

Will you be interested in attending a group to help you with crack/combination drug use?

Don't Know6

Yes40

No16

Total62

The group will include sessions on the following, please tick the ones you would find most useful?

Information on Crack13

Cutting down and stopping21

Health related issues17

Triggers12

Cravings11

Safer Injecting14

Day programs10

Detox, rehab and follow on support17

Total115

Gender

76

15

Gender

Responses

Client Gender Breakdown

Age

15

49

27

Age Range

Responses

Client Age Breakdown

Ethnicity

70

6

8

3

3

1

Responses

Ethnicity

Combination

84

7

Combine crack and heroin in the same syringe?

Responses

Crack & Heroin Combination

Often

42

31

9

3

3

Not Applicable

Frequency

Responses

How often are they combined?

Smoke - Inject

22

47

6

3

8

Responses

If using crack on its own, do you smoke or inject?

Wait

Straight away

27

9

9

6

11

25

Waiting Times

Responses

Waiting time before using heroin.

Problems

56

26

Not Applicable

Problems since injecting crack?

Problem Types

16

11

8

1

30

2

1

1

1

4

1

1

1

No Response

Problems

Frequency

Main problems from injecting crack.

Group

6

40

16

Frequency

Interested in a crack group?

Topics

13

21

17

12

11

14

10

17

Topics

Responses

Session Topics

Data

Total Participants91

Male76

Female15

Total91

Age Groups

16 - 2415

25 - 3049

35-4427

Total91

Ethnicity

White British70

White Scot6

White Irish8

White European3

Black Other3

Black African1

Total91

Do you ever combine heroin and crack in the same syringe?

Yes84

No7

Total91

How often do you combine them?

Always42

Most of the time31

Occasionally9

Rarely3

Never3

Not Applicable

Total88

If you use crack alone before you use heroin, do you smoke or inject?

Mainly smoke22

Mainly inject47

Both6

Neither3

Not Applicable8

Total86

How long do you wait after using crack on average, before using heroin?

Straight away

Under 5 minutes27

5 to 10 minutes9

10 to 30 minutes9

30 to 1 hour6

Over 1 hour11

Not Applicable25

Total87

Have you noticed any increase in injecting problems since injecting crack?

Yes56

No26

Not Applicable

Total82

If yes, what have been the main problems you have had?

Abscesses16

Missed Hits11

DVT / Thrombosis8

Numbness1

Vein Access30

Lumps2

Rushing1

Cellulite1

Blood Congesting1

Inreased Usage / Tolerance Build Up4

Ulcers1

Paranoia1

Endo1

No Response

Total78

Will you be interested in attending a group to help you with crack/combination drug use?

Don't Know6

Yes40

No16

Total62

The group will include sessions on the following, please tick the ones you would find most useful?

Information on Crack13

Cutting down and stopping21

Health related issues17

Triggers12

Cravings11

Safer Injecting14

Day programs10

Detox, rehab and follow on support17

Total115

Gender

76

15

Gender

Responses

Client Gender Breakdown

Age

15

49

27

Age Range

Responses

Client Age Breakdown

Ethnicity

70

6

8

3

3

1

Responses

Ethnicity

Combination

84

7

Combine crack and heroin in the same syringe?

Responses

Crack & Heroin Combination

Often

42

31

9

3

3

Not Applicable

Frequency

Responses

How often are they combined?

Smoke - Inject

22

47

6

3

8

Responses

If using crack on its own, do you smoke or inject?

Wait

Straight away

27

9

9

6

11

25

Waiting Times

Responses

Waiting time before using heroin.

Problems

56

26

Not Applicable

Problems since injecting crack?

Problem Types

16

11

8

1

30

2

1

1

1

4

1

1

1

No Response

Problems

Frequency

Main problems from injecting crack.

Group

6

40

16

Frequency

Interested in a crack group?

Topics

13

21

17

12

11

14

10

17

Topics

Responses

Session Topics

Data

Total Participants91

Male76

Female15

Total91

Age Groups

16 - 2415

25 - 3049

35-4427

Total91

Ethnicity

White British70

White Scot6

White Irish8

White European3

Black Other3

Black African1

Total91

Do you ever combine heroin and crack in the same syringe?

Yes84

No7

Total91

How often do you combine them?

Always42

Most of the time31

Occasionally9

Rarely3

Never3

Not Applicable

Total88

If you use crack alone before you use heroin, do you smoke or inject?

Mainly smoke22

Mainly inject47

Both6

Neither3

Not Applicable8

Total86

How long do you wait after using crack on average, before using heroin?

Straight away

Under 5 minutes27

5 to 10 minutes9

10 to 30 minutes9

30 to 1 hour6

Over 1 hour11

Not Applicable25

Total87

Have you noticed any increase in injecting problems since injecting crack?

Yes56

No26

Not Applicable

Total82

If yes, what have been the main problems you have had?

Abscesses16

Missed Hits11

DVT / Thrombosis8

Numbness1

Vein Access30

Lumps2

Rushing1

Cellulite1

Blood Congesting1

Inreased Usage / Tolerance Build Up4

Ulcers1

Paranoia1

Endo1

No Response

Total78

Will you be interested in attending a group to help you with crack/combination drug use?

Don't Know6

Yes40

No16

Total62

The group will include sessions on the following, please tick the ones you would find most useful?

Information on Crack13

Cutting down and stopping21

Health related issues17

Triggers12

Cravings11

Safer Injecting14

Day programs10

Detox, rehab and follow on support17

Total115

Gender

76

15

Gender

Responses

Client Gender Breakdown

Age

15

49

27

Age Range

Responses

Client Age Breakdown

Ethnicity

70

6

8

3

3

1

Responses

Ethnicity

Combination

84

7

Combine crack and heroin in the same syringe?

Responses

Crack & Heroin Combination

Often

42

31

9

3

3

Not Applicable

Frequency

Responses

How often are they combined?

Smoke - Inject

22

47

6

3

8

Responses

If using crack on its own, do you smoke or inject?

Wait

Straight away

27

9

9

6

11

25

Waiting Times

Responses

Waiting time before using heroin.

Problems

56

26

Not Applicable

Problems since injecting crack?

Problem Types

16

11

8

1

30

2

1

1

1

4

1

1

1

No Response

Problems

Frequency

Main problems from injecting crack.

Group

6

40

16

Frequency

Interested in a crack group?

Topics

13

21

17

12

11

14

10

17

Topics

Responses

Session Topics

Data

Total Participants91

Male76

Female15

Total91

Age Groups

16 - 2415

25 - 3049

35-4427

Total91

Ethnicity

White British70

White Scot6

White Irish8

White European3

Black Other3

Black African1

Total91

Do you ever combine heroin and crack in the same syringe?

Yes84

No7

Total91

How often do you combine them?

Always42

Most of the time31

Occasionally9

Rarely3

Never3

Not Applicable

Total88

If you use crack alone before you use heroin, do you smoke or inject?

Mainly smoke22

Mainly inject47

Both6

Neither3

Not Applicable8

Total86

How long do you wait after using crack on average, before using heroin?

Straight away

Under 5 minutes27

5 to 10 minutes9

10 to 30 minutes9

30 to 1 hour6

Over 1 hour11

Not Applicable25

Total87

Have you noticed any increase in injecting problems since injecting crack?

Yes56

No26

Not Applicable

Total82

If yes, what have been the main problems you have had?

Abscesses16

Missed Hits11

DVT / Thrombosis8

Numbness1

Vein Access30

Lumps2

Rushing1

Cellulite1

Blood Congesting1

Inreased Usage / Tolerance Build Up4

Ulcers1

Paranoia1

Endo1

No Response

Total78

Will you be interested in attending a group to help you with crack/combination drug use?

Don't Know6

Yes40

No16

Total62

The group will include sessions on the following, please tick the ones you would find most useful?

Information on Crack13

Cutting down and stopping21

Health related issues17

Triggers12

Cravings11

Safer Injecting14

Day programs10

Detox, rehab and follow on support17

Total115

Gender

76

15

Gender

Responses

Client Gender Breakdown

Age

15

49

27

Age Range

Responses

Client Age Breakdown

Ethnicity

70

6

8

3

3

1

Responses

Ethnicity

Combination

84

7

Combine crack and heroin in the same syringe?

Responses

Crack & Heroin Combination

Often

42

31

9

3

3

Not Applicable

Frequency

Responses

How often are they combined?

Smoke - Inject

22

47

6

3

8

Responses

If using crack on its own, do you smoke or inject?

Wait

Straight away

27

9

9

6

11

25

Waiting Times

Responses

Waiting time before using heroin.

Problems

56

26

Not Applicable

Problems since injecting crack?

Problem Types

16

11

8

1

30

2

1

1

1

4

1

1

1

No Response

Problems

Frequency

Main problems from injecting crack.

Group

6

40

16

Frequency

Interested in a crack group?

Topics

13

21

17

12

11

14

10

17

Topics

Responses

Session Topics

Data

Total Participants91

Male76

Female15

Total91

Age Groups

16 - 2415

25 - 3049

35-4427

Total91

Ethnicity

White British70

White Scot6

White Irish8

White European3

Black Other3

Black African1

Total91

Do you ever combine heroin and crack in the same syringe?

Yes84

No7

Total91

How often do you combine them?

Always42

Most of the time31

Occasionally9

Rarely3

Never3

Not Applicable

Total88

If you use crack alone before you use heroin, do you smoke or inject?

Mainly smoke22

Mainly inject47

Both6

Neither3

Not Applicable8

Total86

How long do you wait after using crack on average, before using heroin?

Straight away

Under 5 minutes27

5 to 10 minutes9

10 to 30 minutes9

30 to 1 hour6

Over 1 hour11

Not Applicable25

Total87

Have you noticed any increase in injecting problems since injecting crack?

Yes56

No26

Not Applicable

Total82

If yes, what have been the main problems you have had?

Abscesses16

Missed Hits11

DVT / Thrombosis8

Numbness1

Vein Access30

Lumps2

Rushing1

Cellulite1

Blood Congesting1

Inreased Usage / Tolerance Build Up4

Ulcers1

Paranoia1

Endo1

No Response

Total78

Will you be interested in attending a group to help you with crack/combination drug use?

Don't Know6

Yes40

No16

Total62

The group will include sessions on the following, please tick the ones you would find most useful?

Information on Crack13

Cutting down and stopping21

Health related issues17

Triggers12

Cravings11

Safer Injecting14

Day programs10

Detox, rehab and follow on support17

Total115

Gender

76

15

Gender

Responses

Client Gender Breakdown

Age

15

49

27

Age Range

Responses

Client Age Breakdown

Ethnicity

70

6

8

3

3

1

Responses

Ethnicity

Combination

84

7

Combine crack and heroin in the same syringe?

Responses

Crack & Heroin Combination

Often

42

31

9

3

3

Not Applicable

Frequency

Responses

How often are they combined?

Smoke - Inject

22

47

6

3

8

Responses

If using crack on its own, do you smoke or inject?

Wait

Straight away

27

9

9

6

11

25

Waiting Times

Responses

Waiting time before using heroin.

Problems

56

26

Not Applicable

Problems since injecting crack?

Problem Types

16

11

8

1

30

2

1

1

1

4

1

1

1

No Response

Problems

Frequency

Main problems from injecting crack.

Group

6

40

16

Frequency

Interested in a crack group?

Topics

13

21

17

12

11

14

10

17

Topics

Responses

Session Topics

Data

Total Participants91

Male76

Female15

Total91

Age Groups

16 - 2415

25 - 3049

35-4427

Total91

Ethnicity

White British70

White Scot6

White Irish8

White European3

Black Other3

Black African1

Total91

Do you ever combine heroin and crack in the same syringe?

Yes84

No7

Total91

How often do you combine them?

Always42

Most of the time31

Occasionally9

Rarely3

Never3

Not Applicable

Total88

If you use crack alone before you use heroin, do you smoke or inject?

Mainly smoke22

Mainly inject47

Both6

Neither3

Not Applicable8

Total86

How long do you wait after using crack on average, before using heroin?

Straight away

Under 5 minutes27

5 to 10 minutes9

10 to 30 minutes9

30 to 1 hour6

Over 1 hour11

Not Applicable25

Total87

Have you noticed any increase in injecting problems since injecting crack?

Yes56

No26

Not Applicable

Total82

If yes, what have been the main problems you have had?

Abscesses16

Missed Hits11

DVT / Thrombosis8

Numbness1

Vein Access30

Lumps2

Rushing1

Cellulite1

Blood Congesting1

Inreased Usage / Tolerance Build Up4

Ulcers1

Paranoia1

Endo1

No Response

Total78

Will you be interested in attending a group to help you with crack/combination drug use?

Don't Know6

Yes40

No16

Total62

The group will include sessions on the following, please tick the ones you would find most useful?

Information on Crack13

Cutting down and stopping21

Health related issues17

Triggers12

Cravings11

Safer Injecting14

Day programs10

Detox, rehab and follow on support17

Total115

Gender

76

15

Gender

Responses

Client Gender Breakdown

Age

15

49

27

Age Range

Responses

Client Age Breakdown

Ethnicity

70

6

8

3

3

1

Responses

Ethnicity

Combination

84

7

Combine crack and heroin in the same syringe?

Responses

Crack & Heroin Combination

Often

42

31

9

3

3

Not Applicable

Frequency

Responses

How often are they combined?

Smoke - Inject

22

47

6

3

8

Responses

If using crack on its own, do you smoke or inject?

Wait

Straight away

27

9

9

6

11

25

Waiting Times

Responses

Waiting time before using heroin.

Problems

56

26

Not Applicable

Problems since injecting crack?

Problem Types

16

11

8

1

30

2

1

1

1

4

1

1

1

No Response

Problems

Frequency

Main problems from injecting crack.

Group

6

40

16

Frequency

Interested in a crack group?

Topics

13

21

17

12

11

14

10

17

Topics

Responses

Session Topics

Data

Total Participants91

Male76

Female15

Total91

Age Groups

16 - 2415

25 - 3049

35-4427

Total91

Ethnicity

White British70

White Scot6

White Irish8

White European3

Black Other3

Black African1

Total91

Do you ever combine heroin and crack in the same syringe?

Yes84

No7

Total91

How often do you combine them?

Always42

Most of the time31

Occasionally9

Rarely3

Never3

Not Applicable

Total88

If you use crack alone before you use heroin, do you smoke or inject?

Mainly smoke22

Mainly inject47

Both6

Neither3

Not Applicable8

Total86

How long do you wait after using crack on average, before using heroin?

Straight away

Under 5 minutes27

5 to 10 minutes9

10 to 30 minutes9

30 to 1 hour6

Over 1 hour11

Not Applicable25

Total87

Have you noticed any increase in injecting problems since injecting crack?

Yes56

No26

Not Applicable

Total82

If yes, what have been the main problems you have had?

Abscesses16

Missed Hits11

DVT / Thrombosis8

Vein Access30

Inreased Usage / Tolerance Build Up4

Others9

Total78

Will you be interested in attending a group to help you with crack/combination drug use?

Don't Know6

Yes40

No16

Total62

The group will include sessions on the following, please tick the ones you would find most useful?

Information on Crack13

Cutting down and stopping21

Health related issues17

Triggers12

Cravings11

Safer Injecting14

Day programs10

Detox, rehab and follow on support17

Total115

Gender

76

15

Gender

Responses

Client Gender Breakdown

Age

15

49

27

Age Range

Responses

Client Age Breakdown

Ethnicity

70

6

8

3

3

1

Responses

Ethnicity

Combination

84

7

Combine crack and heroin in the same syringe?

Responses

Crack & Heroin Combination

Often

42

31

9

3

3

Not Applicable

Frequency

Responses

How often are they combined?

Smoke - Inject

22

47

6

3

8

Responses

If using crack on its own, do you smoke or inject?

Wait

Straight away

27

9

9

6

11

25

Waiting Times

Responses

Waiting time before using heroin.

Problems

56

26

Not Applicable

Problems since injecting crack?

Problem Types

16

11

8

30

4

9

Problems

Frequency

Main problems from injecting crack.

Group

6

40

16

Frequency

Interested in a crack group?

Topics

13

21

17

12

11

14

10

17

Topics

Responses

Session Topics

Data

Total Participants91

Male76

Female15

Total91

Age Groups

16 - 2415

25 - 3049

35-4427

Total91

Ethnicity

White British70

White Scot6

White Irish8

White European3

Black Other3

Black African1

Total91

Do you ever combine heroin and crack in the same syringe?

Yes84

No7

Total91

How often do you combine them?

Always42

Most of the time31

Occasionally9

Rarely3

Never3

Not Applicable

Total88

If you use crack alone before you use heroin, do you smoke or inject?

Mainly smoke22

Mainly inject47

Both6

Neither3

Not Applicable8

Total86

How long do you wait after using crack on average, before using heroin?

Straight away

Under 5 minutes27

5 to 10 minutes9

10 to 30 minutes9

30 to 1 hour6

Over 1 hour11

Not Applicable25

Total87

Have you noticed any increase in injecting problems since injecting crack?

Yes56

No26

Not Applicable

Total82

If yes, what have been the main problems you have had?

Abscesses16

Missed Hits11

DVT / Thrombosis8

Numbness1

Vein Access30

Lumps2

Rushing1

Cellulite1

Blood Congesting1

Inreased Usage / Tolerance Build Up4

Ulcers1

Paranoia1

Endo1

No Response

Total78

Will you be interested in attending a group to help you with crack/combination drug use?

Don't Know6

Yes40

No16

Total62

The group will include sessions on the following, please tick the ones you would find most useful?

Information on Crack13

Cutting down and stopping21

Health related issues17

Triggers12

Cravings11

Safer Injecting14

Day programs10

Detox, rehab and follow on support17

Total115

Gender

76

15

Gender

Responses

Client Gender Breakdown

Age

15

49

27

Age Range

Responses

Client Age Breakdown

Ethnicity

70

6

8

3

3

1

Responses

Ethnicity

Combination

84

7

Combine crack and heroin in the same syringe?

Responses

Crack & Heroin Combination

Often

42

31

9

3

3

Not Applicable

Frequency

Responses

How often are they combined?

Smoke - Inject

22

47

6

3

8

Responses

If using crack on its own, do you smoke or inject?

Wait

Straight away

27

9

9

6

11

25

Waiting Times

Responses

Waiting time before using heroin.

Problems

56

26

Not Applicable

Problems since injecting crack?

Problem Types

16

11

8

1

30

2

1

1

1

4

1

1

1

No Response

Problems

Frequency

Main problems from injecting crack.

Group

6

40

16

Frequency

Interested in a crack group?

Topics

13

21

17

12

11

14

10

17

Topics

Responses

Session Topics

Data

Total Participants91

Male76

Female15

Total91

Age Groups

16 - 2415

25 - 3049

35-4427

Total91

Ethnicity

White British70

White Scot6

White Irish8

White European3

Black Other3

Black African1

Total91

Do you ever combine heroin and crack in the same syringe?

Yes84

No7

Total91

How often do you combine them?

Always42

Most of the time31

Occasionally9

Rarely3

Never3

Not Applicable

Total88

If you use crack alone before you use heroin, do you smoke or inject?

Mainly smoke22

Mainly inject47

Both6

Neither3

Not Applicable8

Total86

How long do you wait after using crack on average, before using heroin?

Straight away

Under 5 minutes27

5 to 10 minutes9

10 to 30 minutes9

30 to 1 hour6

Over 1 hour11

Not Applicable25

Total87

Have you noticed any increase in injecting problems since injecting crack?

Yes56

No26

Not Applicable

Total82

If yes, what have been the main problems you have had?

Abscesses16

Missed Hits11

DVT / Thrombosis8

Numbness1

Vein Access30

Lumps2

Rushing1

Cellulite1

Blood Congesting1

Inreased Usage / Tolerance Build Up4

Ulcers1

Paranoia1

Endo1

No Response

Total78

Will you be interested in attending a group to help you with crack/combination drug use?

Don't Know6

Yes40

No16

Total62

The group will include sessions on the following, please tick the ones you would find most useful?

Information on Crack13

Cutting down and stopping21

Health related issues17

Triggers12

Cravings11

Safer Injecting14

Day programs10

Detox, rehab and follow on support17

Total115

Gender

76

15

Gender

Responses

Client Gender Breakdown

Age

15

49

27

Age Range

Responses

Client Age Breakdown

Ethnicity

70

6

8

3

3

1

Responses

Ethnicity

Combination

84

7

Combine crack and heroin in the same syringe?

Responses

Crack & Heroin Combination

Often

42

31

9

3

3

Not Applicable

Frequency

Responses

How often are they combined?

Smoke - Inject

22

47

6

3

8

Responses

If using crack on its own, do you smoke or inject?

Wait

Straight away

27

9

9

6

11

25

Waiting Times

Responses

Waiting time before using heroin.

Problems

56

26

Not Applicable

Problems since injecting crack?

Problem Types

16

11

8

1

30

2

1

1

1

4

1

1

1

No Response

Problems

Frequency

Main problems from injecting crack.

Group

6

40

16

Frequency

Interested in a crack group?

Topics

13

21

17

12

11

14

10

17

Topics

Responses

Session Topics

SUMMARY What can agencies learn from excluded service users who are homeless?

What prevents services from keeping up with the changing drug use patterns/market ?

How can we respond to drug using practices which challenge traditional treatment provision?

How can we respond to the increase in injecting problems, and service users concerns?

These aims are not difficult to achieve, as they are directed at service users, who have been asking in many ways for accessible services for years. The issues of negative stereotyping of drug use is a problem for users and providers, no more so than the tabliod image of the homeless drug user. This is an issue which requires more than accessible services to rectify it. SRAC is often described as an oasis by its population. Here we see how the clinic started, and see the high take up of services, the prescribing partner was from the private sector. This is an unusual combination of providers, and required a high level of commitment from the partners. Prescribing of Physeptone and dexedrine was provided, as an attempt to match the drugs market. Crack was identified as a problem from the beginning, and remains so currently. Later in the presentation I will return to the issue of Crack useThis slide shows the development of the clinic, its partners and funding source.The gateway to SRAC is only open to named referrers, the relationship of the clinic with its referrers is of equal importance as its relationship with service users. We have a weekly meeting which is open to referrers, close working relationships are beneficial to all, but this requires time, and the opportunity to understand and respect the working practices of others.Here are the services we provide, I will just speak briefly to eachHere again I cannot impress enough that this group are perhaps the most marginalized of drug users. Ever present are issues of past treatment failures and negative life experiences, sensitivity and humour are the skills required, as well as a good knowledge of drug using practices.Although my presentation was about rapid access, it is irresponsible to to imply the issues end when the door opens at the right speed. If you open the door you will raise the expectations of service users, and they will engage with new issues, expecting a quality response. This is where we return to Crack, which I believe is also a very current issue in Scotland. I want to present you with information gathered from 91 service users. Without their co-operation and ideas the Snowballing Group would not have happened.Just talk to each point, again stressing the negative view of this group as being outside treatment. The treatmetn services have not responded in an accessible way.I have been aware of snowballing as a way of drug use for many years, but have been focussing on this for the past four years, since seeing this practice grow in the West End, and become the main way of drug using in this populationThe Rapid Access Clinic was set up in response to the increasing street drug use in the West End, as a point of raid assessment for rough sleepers who have difficulty accessing mainstream services. The focus group was made up of SRAC clients, and the feedback has formed the basis for the "Snowballers" group.Here the approach of user consultation and involvement, is vital when responding to drug use, when information is scant. This a respectful and transparent way of working which avoids workers feeling de skilled.The Combination drug use questionnaire is a very basic tool, I knew it was important to gather information, prior to seeking funding for the group.91 service user ( more now) have completed the questionnaire, and the following slides will give you a picture of the results, which are not rocket science. This is the result of workers and service users combining their skills and information.You will also see that sharing injecting equipment is prevalent in the population seeking assessment from SRAC As you may expect, the majority of service users are male, it may be that women are using in a different way, and even with this small number Iam able to tell you that more of the women smoke as well as inject crack/snowballs.This speaks for itself, the majority are under 30, the under 25's still report high levels of combination use. The Rapid Access clinic needs to reach the under 25's more effectivelyNo surprise here, the majority of service users are White British, I don't know off the top of my head whether this is representative of the Rough Sleeping Population in the West End.I guess this is my most important slide, 84 out of 91 service users report combination drug use. This was what I had imagined it to be, and I continued to ask myself why Drug Treatment Centres still focussed mainly on opiate use, when it seemed to be a thing of the past. I checked with both local DTC's fro their response to crack/combination use, and neither had any specific on site response, with people being asked to travel to another agency, after the supervised consumption of thier Methadone, which can take a while, for help with crack use. Why not work with both drugs together?As you can see, 73 out of 91 combine heroin and crack fairly routinely. This is clearly an established way of drug using. So any "on top" use will usually involve a snowball. I began to think that people would leave SRAC with a dependency on three drugs, Heroin, Crack and Methadone. What were we doing, adding another drug, without addressing the issue of Crack. Here we see a fairly high level of solo crack injection, and anecdotally, women are reporting more solo crack injection than men in this small sample. A large majority report increasing injecting problems, and the next slide will give some detailsService users were asked to describe the problems they were experiencing, as you can see a major concern was that injecting sites were failing quickly. Many service users are in very poor health at the point of referral, with hospital admission being quite high for DVT, Pneumonia, abscess, septicaemia and ulceration of iv sites. Service users and myself are aware of amputation as a result of prolonged crack injection. This is a small drug using community, and news travels fast.We ask for an expression of interest in the group, and clearly there is a desire to do something. Many service users have come to the group, and it is now ppart of the programme in three of the SMU's (substance misuse units within hostels)As you can see the majority are interested in cutting down and stopping crack/combination use. Some service users report an increase in crack use when getting onto Methadone initially, and there is a real desire for information on Crack, again we will be able to give more detail of the Snowballing Group this afternoon. Well that was a whirlwind, now some questions for you. If agencies want to plan a rapid response to drug users, the whole picture of exclusion has to be considered, and realise that no one agency can provide all the solutions, partnership work is not just with providers, but with service users. In order to learn, negative views and opinions need to be challenged. Lack of knowledge and fear are a problem for services who rely on medication as there main intervention. There is a lack of information on snowballing. We have been seeing this form of drug use becoming widespread, I am aware that services in South London are seeing a high proportion of snowballers, we are aware that these drugs are sold together, used together, and the snowball is no longer the treat it was in the 70's & 80's. Service users need to be incorporated into service provision, responded to in constructive adult way.