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Training Guide

Guide to Developing and Managing Syringe Access Programs

This module covers:

• Outreach to People Who Inject Drugs
• Community Engagement and Support
• Working with Health Departments
• Relationships with Law Enforcement

OUTREACH TO PEOPLE WHO INJECT DRUGS

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.

The following suggestions are intended to help SAPs prepare in making meaningful treatment referrals:

• Compile treatment directories that include location, intake criteria, hours of operation, payment options, treatment modality, special services, and any additional information that may be helpful to participants; be sure to update the information regularly.
• Cultivate personalized contacts with local drug treatment centers, which can help with intake and availability.
• Ask people for feedback about their experiences at different treatment programs to share with other participants making treatment decisions.
• Investigate public health insurance/Medicaid treatment limits and restrictions.
• Ensure that staff understand the full range of treatment options available, including: detox, short- and long- term inpatient/residential, outpatient, methadone, buprenorphine, 12-step, harm reduction support groups, and therapeutic communities.

COMMUNITY ENGAGEMENT AND SUPPORT

In addition to treatment-related referral networks, SAPs can benefit from proactive engagement and involvement with other community groups as well. IDUs often have a complex range of needs that may not be directly related   to their drug use, but are certainly likely to have an influence on their stability and overall quality of life. SAPs can engage with the community in several ways, including:

• Building referral networks
• Advocacy and community activism
• Public Service

Building Referral Networks

IDUs are likely to seek assistance with a range of issues. While some SAPs may obtain additional funding to incorporate ancillary services into their programming, all SAPs can build networks with community providers that will assist in meeting participant needs. SAPs should create a referral directory that includes information about issues such as:

• Housing programs
• Food pantries
• Public showers
• HAV and HBV vaccination sites
• Sexually transmitted infection (STI) testing
• HIV/AIDS and HCV testing and health services
• General health referrals (clinics with free or sliding-scale fee schedules, local hospitals, etc)
• Legal assistance
• Public benefits assistance
• Faith-based services and organizations
• Complementary and alternative medicine (CAM) practitioners

It is important to include referral options that treat participants from a harm reduction perspective, and to inform participants when this may not be the case. It may be possible to negotiate ways of providing harm reduction/ syringe access training and technical assistance to other community groups, especially in areas where there are few harm reduction referrals available.

SAPs can also establish individualized relationships with service providers. It may be possible to obtain a list of registered community and civic groups to help identify possible partners. A representative of the SAP can visit community organizations and give a brief presentation of SAP services and achievements. Maintain a list of contact information for specific individuals involved in the various agencies that are supportive of the SAP. Emphasize the mutual benefits of working together when building relationships with community players. Remain consistent, update community organizations on SAP changes, and always follow-through on commitments to provide additional information or follow-up. Formal linkage agreements with key partners can strengthen mutual investment and document respective roles and commitments.

Advocacy and Community Activism

SAPs can also serve as a valuable player in community affairs through involvement in advocacy and activism around policies relevant to IDUs. This can occur at the local, state or even national level. Too often, policies that affect drug users are developed and promoted without the input of drug users and drug user allies. Consequently, these policies are not only unhelpful, but often have a direct negative impact on IDUs. By amplifying the voices of IDUs and sharing their expertise and insight, SAPs have the potential to advance meaningful structural changes that will support and promote IDU needs.

One approach to community activism is through the creation of a “user union” or other user-driven advocacy group. This organizing model allows drug users to drive the agenda and identify campaigns that reflect their priorities. User groups support the empowerment of users and offer valuable skills building. User unions may require additional resources and commitment from the SAP to support their efforts and vision. In addition, user unions will likely benefit from the expertise of a community organizer if resources allow. Whether an SAP decides to organize a user union or take another approach to advocacy, it will be essential for IDUs to be involved in the planning process and that their voices and concerns remain central.

Advocacy can also be incorporated into the day-to-day job responsibilities of certain SAP staff members. For example, staff may be encouraged to get involved with planning councils, attend community board meetings, reach out to other community groups or engage with politicians. Staff should develop strategies for keeping abreast of changes in policy at any level that could have implications for participants. In some cases, it may be appropriate for certain staff to be focused on specific issues – for example HIV, HCV, housing or criminal justice.

SAPs should also develop strategies for engaging with the media, both in cases where the SAP may want to promote a specific media campaign, as well as for when comment is sought by the media in response to policy changes or specific incidents in the community. Messages and sound bites should be carefully constructed to ensure respect for participant confidentiality, minimize negative attention to the SAP, and communicate ideas and messages clearly and effectively. Identify media point-people who will be able not only to hone messages and media strategies, but also to build contact lists of journalists who may be more supportive or familiar with the benefits of SAPs. Links to resources for working with the media can be found in Appendix A.

Public Service

SAPs can and should be a resource for the entire community. The more an SAP invests in the community around them, the more likely that the community will identify the SAP as a valuable resource and indispensable member of the community as well.

SAPs can reach out to city workers and departments, as well as residents, business owners and law enforcement as a resource for syringe clean up and disposal, distributing and retrieving sharps containers if necessary. SAPs can provide education and training on topics such as overdose prevention in cases where public injection is an issue. SAPs benefit from identifying themselves as resources to the community and making themselves available to respond to emergencies or concerns.

 

WORKING WITH HEALTH DEPARTMENTS

Productive collaboration and communication with health departments can be vital to the success of. Health departments may develop SAPs themselves or seek out community-based organizations to provide syringe access services.

Health departments can be a natural ally given their common interest in reducing the spread of infectious disease and promoting greater public health. The support of health departments can build the credibility of the SAP and garner support from neighbors, the community at-large and law enforcement. However, it may be necessary to educate health departments about the benefits of SAPs, provide scientific evidence supporting their implementation, and describe challenges that can be imposed by certain regulation strategies.

A supportive and engaged health department can validate SAPs as important tools in promoting community health and potentially provide the legal basis for operation. Health departments can allocate valuable funding toward syringe access services. In addition, they can provide numerous resources to the SAP such as access to testing services, vaccination, healthcare referrals and other service linkages. Health departments that are on board with the SAP may also be able to coordinate provision of syringes as well as disposal of biohazard and sharps.

There can also be challenges when collaborating with health departments. Perhaps the biggest challenges will be related to the bureaucracy that can be tied to governmental systems. Health departments may have strict reporting and regulation requirements that, while often valuable, can also be very time-consuming and inefficient. Some policies imposed by health departments may be hard to reconcile with SAP participants (i.e. policies around exchange vs. distribution, limits to the number of syringes that can be exchanged and/or limits on secondary exchange). SAPs may feel a certain loss of autonomy under health department regulation. However, the benefits of collaboration, including the impact on project sustainability often outweigh the drawbacks.

The following principles foster successful collaboration between SAPs and health departments:

• Clear understanding of expectations from both parties
• Open lines of communication
• Reporting SAP achievements, challenges, noteworthy incidents and ongoing needs in a timely manner
• Commitment to mutual support and flexibility
• Willingness to listen to and learn from each other

RELATIONSHIPS WITH LAW ENFORCEMENT

SAPs are responsible for negotiating and communicating with law enforcement to protect their program operations and their participants. Without proper education, law enforcement officers may target SAPs and their participants. This diminishes the effectiveness of the program and places participants at increased risk of prosecution. If people are targeted and arrested at or near the SAP, participants may lose trust and therefore be less willing to access services. Poor interactions with law enforcement can have a number of negative consequences for participants. Fear of law enforcement may keep IDUs from:

• Visiting the SAP
• Returning used syringes
• Collecting a sufficient number of syringes
• Calling 911 in cases of overdose
• Properly disposing of used syringes
• Practicing safer injection and overdose prevention strategies

A great number of the cases that law enforcement deals with involve drug use on some level. Law enforcement officials are unlikely to have a complete understanding of harm reduction, HIV and HCV transmission, and may  also lack information on laws around syringe possession and related public health provisions. Many police officers have fears of accidental needle stick and drug users in general, often expressed in the form of hostility.

Nonetheless, as harm reduction teaches, it is important to meet law enforcement where they’re at. It is important to acknowledge the frustration and helplessness that law enforcement officers can experience as a result of the cyclical nature of drug use and their interactions with drug users. Ongoing and persistent education, training and proactive communication are key to building understanding and avoiding problems.

The following recommendations can be adopted to build strong, productive relationships with law enforcement:

• Begin building relationships with law enforcement as soon as possible. Introduce yourself early to police chiefs and captains, meet with community affairs/relations officers, district attorneys and support staff.
• Always prioritize confidentiality and safety of participants when engaging with law enforcement.
• Be respectful and honest when communicating with law enforcement.
• Always provide contact information and make yourself available to address concerns and issues.
• Acknowledge law enforcement’s perspective and role on drug issues and emphasize the ways that SAPs support them (i.e. reducing accidental needle stick).
• Ask to speak at shift change roll calls. In many places, there will be a roll call before each new police shift comes on where announcements can be made. This is a perfect opportunity to briefly educate officers about the SAP and its benefits to law enforcement. It also provides law enforcement with a name and contact person to turn to with concerns.
• Negotiate agreements with police to ensure that participants will be safe to come and go from the SAP without fear of arrest, intimidation or harassment.
• Train law enforcement on legal statutes that protect the SAP and its participants. Educate law enforcement about the relevant policies and procedures of the SAP.
• Inform police and other law enforcement about the full range of services provided by the SAP, including referrals to drug treatment, counseling, education about HIV, HCV and other blood-borne viruses, etc.
• Ensure that SAP participants understand their rights regarding syringe possession.
• Offer to provide police with sharps containers, puncture-proof gloves and needlestick information  as  needed.
• Invite police to serve on SAP advisory boards whenever appropriate.
• Educate IDUs about the importance of proper sharps disposal and teach participants how to inform police that they have syringes prior to being searched.
• Suggest that SAP participants document badge number, location and time if syringes or SAP card are confiscated by a police officer.
• Train staff on how to engage with law enforcement and when it is appropriate and necessary to call law enforcement for assistance or allow law enforcement onsite at the SAP.
• Develop an onsite protocol for encounters with law enforcement that includes information on maintaining participant confidentiality, designated staff to engage with law enforcement, which information the SAP is and is not legally required to share with law enforcement, and any established contacts the SAP has with law enforcement.
• Establish monitoring processes to gather data (wrongful arrests, unlawful confiscation of syringes/SAP cards, increased surveillance of SAP and interactions with participants coming to and from an SAP).