Break the cycle as a possible intervention for preventing initiation of injecting among vulnerable youth

1. �Break the cycle� as a possible intervention for preventing initiation of injecting among vulnerable youth Neil Hunt

2. Overview Natural transitions that occur in the route of drug administration Transitions interventions that aim to enhance public health Break The Cycle (BTC) Evidence Implementation options Key questions for discussion

3. Natural transitions 1 People who inject often use the drug(s) by another route first (swallowing/sniffing/smoking) Can we reduce the proportion NIDUs who make an injecting transition? Some people never progress to inject potentially injectable drugs Can we increase resilience and resistance to injecting?

4. Natural transitions 2 Some people (a small proportion) switch from injecting to other routes (temporarily or permanently) Can we increase the size of this proportion? A fifth of the UISR sample inject as their first illicit drug experience How do we respond to this group?

5. Transitions interventions Two main targets for intervention Prevent people from beginning to inject drugs they are using Encourage people to switch from injecting to a safer route

6. Route Transition Interventions overview Preventing transition Group-based work with �at risk� drug users Break the cycle Switching Buprenorphine, methadone Prescribing smokable heroin Targeted information campaigns (social marketing) e.g. �How to chase�

8. The Initiation Process 1 People don�t generally plan to start injecting when they start using drugs They usually learn about injecting by watching injectors and talking about it

9. They often ask existing injectors to give them their first hit Injectors are often reluctant to do this but may have difficulty in dealing with such requests The Initiation Process 2

10. The Intervention Aims Enable people to think about their attitude to initiating others Develop resistance to initiating others Increase awareness of actions that make it more likely that others will start Enhance ability to manage initiation requests

11. The main messages You inject but that doesn�t always mean that you encourage others to do the same. But - without meaning to that�s exactly what you could be doing by: Talking about injecting to non-injectors Injecting in front of non-injectors So - giving people their first hit. Consider whether this is something you are always ok about doing?

12. BTC implementation options Face-to-face structured intervention Peer-delivered intervention But also� Face-to-face brief intervention Group-based activity

13. Face-to-face intervention Assessment Willingness to initiate others Modelling injecting Their initiation history Experience of initiating others Initiation risks To them To the new injector Social learning Discuss difficult situations

14. Face-to-face evaluation Results Injecting in front of non-injectors was halved (97 to 49) Disapproval of initiating others was increased (12 item attitude scale) Participants received fewer than half as many requests to initiate someone (36 to 15) The number of people initiated by participants fell (6 to 2)

15. Can BTC be delivered as a higher coverage, peer-delivered model?

16. Peer delivered intervention 1 All needle exchange users were seen as potential �disseminators� of the Break the Cycle (BTC) message to �recipients� in their social network Those who consented were given an explanation of the aims a pack of BTC materials For each �recipient� in their social network who later presented back to the service and could successfully repeat the main campaign messages they were paid �5 (up to a maximum of 5 people - �25)

17. Peer delivered intervention 2 All recipients who could recite the main messages of the campaign to a member of the needle exchange staff were paid �5 People who had not used the needle exchange before also completed a risk behaviour audit Anonymity was maintained throughout by the use of credit card system that enabled disseminators and recipients to be linked

18. Evaluation results - Disseminators n=49 Number of injectors known locally (median 30, range 8-300) Number known well enough to discuss BTC with? (median 10, range 2-80) Number you spoke to about the BTC campaign? (median 10, range 3-70) Number you gave the BTC leaflet? (median 9.5, range 0-70)

19. Evaluation results - Recipients 181 recipients successfully repeated the main campaign messages 18 people who were new to the NSP

20. Key questions Do conditions in Ukraine suggest that some adaptation of BTC may be successful? If so� How might it need to be changed to meet needs in Ukraine? How can it be implemented sustainably? Are there other useful transitions interventions for Ukraine that: Have been developed elsewhere; or, That people here can �invent��and (of course) evaluate?