Preventing initiation into injecting
by Neil Hunt, Jon Derricott, Andrew Preston and Garry Stillwell
© Exchange Campaigns / Department of Health. 2001.
Plain English Campaign approved the clarity of this guide, and the campaign materials that go with it.
Intervening in the initiation process
The 'Break the Cycle' campaign
Possible risks to the person being initiated
Possible risks to the initiator
Teaching social learning theory
Introduction
The ‘Break the Cycle’ campaign is a simple intervention which aims to reduce the number of people who begin injecting.
This guide to the intervention:
- explains the ‘Break the Cycle’ campaign;
- gives suggestions on using the campaign as a peer intervention; and
- gives further information and suggestions on using the intervention
- more formal settings.
The campaign is based on evidence that:
- current injectors play an important role other people’s decision to try injecting;
- most people who inject disapprove of initiating others into injecting; and
- injectors do not always realise that they may be unintentionally increasing the chances of someone deciding to try injecting.
The campaign works by reducing:
- injecting in front of non-injectors (modelling);
- discussion about injecting - especially about its benefits - with people who are at risk of trying it ; and by developing
- people’s resistance to giving someone
- their first hit; and
- skills for managing requests to give someone their first hit.
It is important to recognise that initiation to injecting is a complicated social process and that the ‘Break the Cycle’ intervention:
- will not prevent all new initiations to injecting, but it can delay some and prevent others;
- needs to be delivered with sensitivity and tact;
- should not be used as a basis to criticise injectors for what they do or have done (as this is unlikely to be productive), but as an opportunity to support the concerns that most injectors already have about the initiation of others; and
- should be used alongside existing high quality harm reduction work promoting safer injecting for people who begin and continue to inject.
The campaign materials should be used with care - they are intended to be seen by current injectors and should not generally be used in settings where there are non-injectors.
The ‘Break the Cycle’ intervention draws on the principles of motivational interviewing.
Benefits of the intervention
The intervention has potential benefits for injecting drug users, services and public health.
It offers injecting drug users a chance to:
- consider their feelings about initiating others into injecting;
- learn about the problems that can be associated with initiation;
- think about their behaviour around non-injectors;
- work out ways to avoid initiating people into injecting; and
- learn how to manage situations in ways they choose.
It offers services the opportunity to:
- provide an intervention which has been proved to be effective;
- talk to clients positively (most injectors like the intervention and appreciate the opportunity to think about this aspect of their drug use);
- meet clients’ expectations (many clients expect services to try to reduce injecting); and
- add to the value of existing service provision.
In terms of public health, the intervention could reduce the number of:
- blood-borne viral infections associated with injecting - HIV, hepatitis B and hepatitis C;
- other health problems caused by injecting such as local and systemic infections;
- deaths from overdose; and
- people injecting drugs, which is also associated with higher levels of dependence.
Evidence of effectiveness
There is evidence, from a study carried out in Kent, London and Surrey in 1997, that supports the basis of the intervention, its feasibility and effectiveness. The evaluation was published in the journal Drugs: Education, Prevention and Policy.
However, this is a new area of practice and further research is needed into how this work can best be carried out with different groups - such as younger injectors - and in different settings.
The study that evaluated the original intervention found that:
- it was possible to train drug workers to deliver an effective intervention, which was acceptable both to them and to drug users;
- less than 1 in 10 of the injecting drug users interviewed felt that pressure from injectors had been an important influence on their own decision to try injecting. Many more had been active in seeking initiation;
- about 7 out of 10 considered that seeing someone inject had been an important factor in their decision to inject for the first time;
- more than half thought talking about injecting with an injecting drug user was an important part of their decision to start injecting;
- more than 8 out of 10 had injected in front of a non-injecting drug user at some time and well over half had done so in the three months before the first interview; and
- only about 2 out of 10 of those who had used treatment services had ever discussed initiation with a drug worker before.
After receiving the intervention:
- injecting in front of non-injectors was halved;
- people’s disapproval of initiating others was higher;
- people taking part were receiving fewer than half as many requests to initiate others; and
- the number of people initiated by those taking part fell.
Initiation into injecting
When considering the process of initiation into injecting it is important to understand that:
- most drug users who inject were at one time drug users who believed they never would or could inject;
- as drug users see people inject, they can begin to think about doing it themselves. They often become curious about the ‘rush’, anticipate the benefits, and learn how to inject;
- people generally choose to try injecting rather than being forced into it;
- those who begin injecting usually get help from an existing injector;
- when first asked to initiate someone else, many injectors have not considered how they will deal with the request;
- just as smokers rarely want to encourage non-smokers to begin smoking, few injectors want to give someone else their first hit;
- non-injectors who want to be initiated can be very persistent and a nuisance to people who already inject; and
- new injectors are likely to be at increased risk of overdose and catchingblood-borne viruses as they may not learn how to effectively manage the risks until they have been injecting for a while.
Social learning theory
How people move to inject after using drugs in other ways can be seen in terms of social learning theory. Sources of further information on social learning theory are given on page 12.
An essential part of social learning theory is the idea that people can learn how to do something by seeing people modelling (doing) the behaviour, or hearing them talk about it - even if this is not intended by the person doing the modelling.
Social learning theory separates learning about a behaviour from doing it.
The decision to adopt a particular behaviour, depends in part, on whether the person:
- thinks the benefits of the behaviour outweigh the risks; and
- whether or not they think they will be able to it.
Intervening in the initiation process
It can be difficult to intervene with ‘potential’ injectors before they begin to inject because of:
- the difficulties of identifying and contacting ‘potential’ injectors;
- the ethics of raising the issue with people who may not progress to injecting; and
- people’s resistance to seeing themselves as ‘at risk’.
However, intervening with current injectors raises none of the above problems and can help to:
- supply new information and skills that are seen as relevant and useful to current injectors;
- correct misinformation; and
- reinforce the view of most people who inject that it is undesirable to encourage or initiate people into injecting.
The ‘Break the Cycle’ campaign
The campaign is for use by people working with drug users who are:
currently injecting (mainly in needle exchange services);
or at significant risk of returning to injecting, such as those in:
- community or hospital opiate detoxification programmes;
- relapse prevention counselling; and
- methadone treatment programmes.
The campaign materials are designed to assist workers to enable injectors to:
- consider aspects of their own injecting and ways they might choose to change it; and
- further disseminate the campaign messages amongst other injectors, including those not in direct contact with services.
The ‘Break the Cycle’ campaign materials which accompany this guide include a poster, an ‘intervention pad’ with 30 tear-off leaflets for use by workers and drug injectors and a pocket-sized leaflet.
Using the intervention
In the original evaluation, the intervention was a one-to-one session led by a drug worker and could take up to an hour. This was mainly because it had to be delivered in a standardised way for research purposes.
In everyday practice the intervention can often be tailored to the particular setting and delivered more quickly.
In a needle exchange, the main messages may need to be covered in a few minutes, though people will sometimes want to spend longer discussing them in more depth.
In a methadone treatment service, it may take place during a pre-arranged session, and be covered in a more structured way.
It may be possible to adapt the intervention for use in a group discussion.
For many people who inject there is an existing, informal ‘code of conduct’ which will mean that they do not approve of initiating people into injecting.
Applying the principles of the intervention in ways that support these beliefs among a group may be even more effective than one-to-one work.
Opportunities for this to happen will be greatest where services generally support, and work closely with, local drug user groups across a range of health-related issues.
Introducing the intervention
The aim of the intervention is to allow the injector to consider their behaviour and their attitudes towards initiating others, and to consider how they would want to act in various situations.
It should be explained that there is no intention to be judgmental or tell people what to do. The difficulty of always doing ‘the right thing’ when someone is asking to be injected should be acknowledged.
As a worker it can be useful to do this by making it clear that what you don’t want to pass judgement on their decision to start injecting, but you do want to:
- reduce the numbers of people starting to inject because injecting increases risks of infection, overdose and other drug problems;
- change the way injectors act around non-injectors, to reduce the number of people who start to inject;
- work out the best ways of dealing with people asking for their first hit; and
- talk about how they started injecting to see if there are any lessons to be learnt so those circumstances are not repeated.
Assesment
Not everyone will necessarily benefit from all parts of the intervention. A careful assessment will enable the worker to decide whether it should be used, and what should be given priority.
Some careful questioning may be necessary to make an accurate assessment.
Two main areas to assess are:
- the person’s current attitudes towards the initiation of others; and
- the ways in which they may be unintentionally ‘modelling’ injecting to drug users who do not inject.
Some people will already have very strong views about initiating people into injecting, possibly as a result of experiences of being asked to give people their first hit.
If they never inject in front of, or discuss injecting with, non-injectors the focus of the intervention should be to reinforce their existing beliefs, and encourage them to pass this view on to other injectors.
When people have not thought the issues through, or sometimes inject in front of non-injectors it is important to focus on explaining the possible ‘social learning’ consequences of their behaviour.
Their own initiation
Ask for an account of their own initiation. Focus on those things that made them decide to begin injecting - especially the ‘social learning’ processes.
When talking about their first injection ask them:
- to describe how the first injection came about;
- whether they got someone else to give it;
- who showed them how to do it for themselves;
- why they first became attracted to injecting;
- how seeing other people do it, or hearing them talk about it, affected them;
- if there has been anything about injecting that they didn’t expect when they started, for example becoming ‘more addicted’, infection, sickness or difficulty in stopping injecting; and
- what they now think of their decision to start injecting.
Note any expectations that have proved false, for example, thinking they would be able to ‘try it once’ or beliefs that they would not have any injecting related problems.
Ask whether they would still choose to have their first injection.
Summarise what they have told you.
The initiation of others
Encourage injectors to discuss actual or potential situations when they may be asked to give someone their first hit and the difficulties of refusing these requests.
If they have had personal experience of this then talk about:
- if they have ever given someone their first hit; and
- if so, how that came about.
If they have not been asked to give someone their first hit, ask them to imagine:
- being asked to give someone their first injection;
- how they would reply to such a request; and
- the difficulties they might have doing what they think they should do.
Possible risks to the person being initiated
Check their understanding of the risks that may arise for someone who begins injecting.
Any of the main possibilities - such as , overdose, infection and dependency, that are not mentioned, should be raised by you.
The risk of overdose probably increases more than tenfold when opiates are injected.
Even with our widespread needle exchange services, new injectors have about a one in twenty chance of getting hepatitis C for every year they inject.
Research shows that people who inject have a higher ‘severity of dependence’ than those who do not.
Draw attention to the risks of the first injection, and the possibility that someone they give a first injection to might have an undiagnosed medical condition such as asthma or problems with blood pressure, heart, thyroid, liver or kidneys. These health problems could make injecting more dangerous than using drugs in other ways.
If a woman is pregnant (and in the early stages it may not be possible to tell if she is), injecting drugs will increase the risks to the baby.
Ask them to think about the ability of the person they initiate to accurately predict how much they might enjoy injecting and whether they will be able to ‘just try it’ whatever they might say at the time.
Possible risks to the initiator
Check their understanding of the risks that may arise for the person initiating someone into injecting, including:
- criminal prosecution - especially if something goes wrong. In law injecting someone else is an assault and manslaughter charges have been brought against people in cases where the person they injected overdosed;
- guilt - if the person they initiate goes on to have problems associated with injecting;
- criticism from injectors and other people you know for giving someone their first hit; and
- The risk of verbal or physical assault by a relative or friend of the person they initiated.
Raise any of these issues that are not mentioned.
Teaching social learning theory
For non-injectors, seeing someone inject or hearing them talk about injecting can be powerful influences on if, when and how they decide to begin injecting.
These experiences can make them begin to see injecting as something they might do.
Explaining how social learning happens is an important part of the intervention.
Use the participant’s account of their own initiation to see where the theory fits with their own experience.
You can then use these ideas as a basis for discussing their current behaviour around non-injectors, highlighting actions that may move people towards injecting.
If they have talked about not wanting to encourage others to inject, draw attention to any similarities between things that encouraged them to try injecting and aspects of their own behaviour around non-injectors.
In other words, try to increase ‘dissonance’ - the feelings generated by differences between what people say and what they do.
Scenarios
It can be useful to discuss common difficult situations, and to get injectors to think about how they would react to and manage these situations.
It is important to acknowledge that it is not always easy to deal with people asking for their first hit in a way that feels right. Explain that the aim of the discussion is to help injectors control the outcome of situations that may arise.
Situations or dilemmas worth covering include:
- a close friend who uses drugs but has never injected asking you to inject themwhen they see you are preparing to have a hit;
- the difference between a young person asking to be injected and someone older - it can be useful to get people to think about how old they think someone should be before they try injecting;
- people who use emotional blackmail when asking for their first hit saying things like ‘if you don’t do it I’ll make a mess of it, so it’s better that you do it’ or ‘if you don’t do it I’ll just get someone else to do it for me’;
- people who keep on and on asking for their first injection, even though you keep saying no;
- people who ask for a hit saying ‘its just this once, I only want to try it - I’m not going to keep doing it’;
- someone who you have spent all evening with and who is drunk or stoned and says they want a hit when you cook up;
- having a partner who says they have decided to start injecting because they feel you are getting more out of the drugs, and they are feeling left out of that side of your life;
- having a friend who sometimes sells sex to get cash and asks you to inject them to help cope with the work; and
- being asked to inject someone who you’ve clubbed together to buy drugs with (ask if it makes any difference if you are making something out of the deal).
Further reading
On Social learning theory and motivational interviewing
Bandura A (1977) Social Learning Theory. New Jersey: Prentice Hall.
Bandura A (1986) Social Foundations of Thought and Action: A Social Cognitive Theory. New Jersey: Prentice Hall.
Miller W R and Rollnick S (Eds.) (1991) Motivational Interviewing; Preparing People to Change Addictive Behavior. New York: Guilford Press.
On drug transitions and initiation into injecting
Crofts N, Louie R, Rosenthal D, et al (1996) The first hit: circumstances surrounding initiation into injecting. Addiction, 91, 8: 1187-1196.
Dinwiddie S, Reich T, Cloninger C (1992) Prediction of intravenous drug use. Comprehensive Psychiatry, Vol.33, No.3 (May/June) pp. 173-179
Stenbacka M (1990) Initiation into intravenous drug abuse.
Acta Psychiatrica Scandinavia, 81: 459-462.
Stillwell G, Hunt N, Taylor C, et al (1999) The modelling of injecting behaviour and initiation into injecting.
Addiction Research, Vol.7 No.5 pp.447-459
Strang J, Des-Jarlais DC, Griffiths P, Gossop M. The study of transitions in the route of drug use: the route from one route to another. British Journal of Addiction, 1992;87:473-83.
On the intervention
Hunt N, Griffiths P, Southwell M, Stillwell G and Strang J (1999) Preventing and curtailing injecting drug use: opportunities for developing and delivering ‘route transition interventions’.
Drug and Alcohol Review, 18, 4: 441-451.
Hunt N, Stillwell G, Taylor C, et al (1998) Evaluation of a brief intervention to prevent initiation into injecting.
Drugs: Education, Prevention and Policy, Vol.5 No.2 pp.185-194.
We would like to thank all those who have assisted in producing this guide and the Break the Cycle campaign materials including:
Mike Ashton - Editor, Findings magazine.
Jaye Foster, the service users and the rest of the team - HOT, London.
Mary Glover CADAS - Dorchester.
Steve Redknap - Clinical Nurse Specialist, Leeds.
The research into preventing initiation into injecting on which this guide, and the Break the Cycle campaign, is based was funded by The Mental Health Foundation.
Published by Exchange Campaigns for DrugScope as part of the Department of Health ‘Making Harm Reduction Work’ initiative.
The authors are responsible for any errors or omissions.
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