I. Outreach to Injection Drug Users

MODule 4: exTernAl iSSueS

OuTreAcH TO inJecTiOn Drug uSerS

Outreach can be a valuable tool for expanding the reach of SAP services and ensuring that IDUs have access to sterile injection equipment when they most need it. It can also be an effective way of reaching IDUs who are less likely to visit an SAP onsite. Determine the purpose of specific outreach and identify which services, if any, will be able to be delivered based on capacity, resources and need.

There are several methods of outreach that can be implemented. In some cases, staff will simply travel around to areas where drug users may be in order to inform people that an SAP exists and provide more information about the services that are available. This can be done by visiting community-based or AIDS-service organizations and doing scheduled presentations or by going to parks, single-room occupancy hotels and shelters and other public places where drug users congregate. Results from any preliminary needs assessment can be useful for identifying targets for outreach.

Street outreach can also be a means of providing syringe access and other supplies to different locations. Backpacks can easily transport syringes, other sterile injection equipment, condoms, educational materials and disposal containers for distribution. Some programs set up a table on the sidewalk to attract people. In cases where staff and volunteers will be traveling with sterile injection equipment and collecting used syringes for disposal, it is important to inform local law enforcement of outreach activities. In addition, an SAP will need to develop policies and procedures specifically for outreach teams in order to protect the safety of outreach teams and participants. The following recommendations ought to be taken into consideration: • Street outreach may be safer if conducted in pairs or small groups, taking gender into consideration to account for safety. Exceptions may be made in cases involving peer or secondary distribution or under other circumstances. If outreach is done alone, extra communication and safety planning may be necessary. • The outreach team should be familiar with the area where outreach will be conducted. • Suitable outreach attire should include comfortable shoes and conservative or subtle and weather-appropriate clothing. • Proper training on outreach regulations, methods, confidentiality and safety is essential. • Outreach workers should carry identification at all time and whenever possible, provided with documentation from the program about their relationship to the SAP. • Follow procedures for safe disposal of syringes and carry sharps containers that are small enough to transport, but large enough that they will accommodate several transactions. • Avoid carrying valuables such as jewelry, money and electronics while on outreach. • Do not carry weapons or drugs on outreach. • Outreach workers should be trained in overdose prevention, recognition and response. • Develop simple tools for documenting outreach activities. • Log books are useful for recording any important incidents and/or other information from outreach shifts. • Develop educational materials and program advertisements specifically for use on outreach; this can be used to begin conversations and to distribute to people who can’t stop.

Both hours and location influence the success of outreach. Choose times when drug users will both be present at a location, and available to stop and engage with workers for a brief conversation. For example, mornings may be a bad time to engage IDUs because they may be primarily concerned with avoiding withdrawal sickness. In addition, while weather and seasonal changes may be cause for shifts in outreach schedules, every attempt should be made

to maintain a regular outreach schedule. Outreach times can also vary depending on the target population and outreach location. For example, outreach to sex workers will likely be more effective in the evenings, at night or very early in the morning, while outreach near homeless shelters may be more effective in the morning or evening when people are arriving and/or leaving.

Making contact with iDus

Making contact with IDUs and building an initial outreach base can take time. When initially approaching potential participants, outreach workers should always identify themselves and the program they represent. Be especially mindful not to interrupt IDUs during “business transactions” as this can put everyone involved at risk, can compromise trust and is generally an ineffective time to engage with someone about their health or injection practices. At all times, it is important to take cues from the participant. If they do not want to stop and talk or seem to be in a rush, don’t push them; let people know what services you can provide and when you will be back. Respect that people may have different boundaries and comfort levels with being identified as an IDU inside and outside of an SAP. Maintain confidentiality and be cautious when discussing any personal information with people in groups.

Trust takes time and participants may not feel comfortable talking about personal issues right away, especially in a public or exposed setting that might make them feel vulnerable. Feel free to joke and engage in casual conversation to establish rapport. People usually have different norms and expectations for interacting with people on the street, as opposed to in a more formal setting. Be open to developing a more laid-back relationship, while also keeping outreach and service-delivery as the priority. The best outreach workers will be able to incorporate safer injection and health messages into conversation in a way that does not feel forced and that takes cues from participants.

Peers can be an incredibly valuable resource for conducting street outreach. They possess special skills and insight and may be able to build trust with participants faster than other workers. Peers are likely to be able to identify the best areas for outreach, point out potential challenges and assess a situation rapidly.

referrals and linkage to Drug Treatment

Research shows that syringe access services increase referrals to drug treatment services, serving as a critical link for IDUs. Drug treatment can be difficult to access for IDUs. There are insufficient treatment resources and those that are available often have intake requirements (ID, individual health and drug use circumstances, hours of intake, etc.), insurance limitations or prohibitive costs, complex regulations (e.g., methadone). Beyond those barriers, there are challenges in understanding the different treatment options that are available. Compounding these difficulties is the fact that drug treatment is often sought in times of crisis, when even easier tasks are challenging and thus very difficult decisions about changes in drug use can seem paralyzing.

SAPs are uniquely positioned to assist IDUs in understanding their treatment options and connecting them with services. SAPs have frequent contact with people struggling with their drug use, creating an opportunity for staff to build relationships and trust that facilitate ongoing dialogue with people about their drug use and its impact on their lives. When a person decides to make changes to their drug use – such as taking a break, cutting back or stopping completely – they have a safe place to discuss the possibilities and find the treatment option and program that will best meet their needs.

Staff should understand how to engage with people about treatment decisions in a way that respects autonomy, offers assistance, and does not feel judgmental. This allows people to make decisions and set goals for themselves. Participants should also feel safe to return to an SAP after treatment, knowing that they will be accepted and welcomed, regardless of treatment outcomes. Many IDUs have a complicated and long history with drug treatment. This can mean that even basic discussions about treatment could bring up painful associations in addition to issues around self-confidence and internalized shame.