MeNtAl HeAltH ISSUeS AND INjectINg DrUg USe

MENTAL HEALTH ISSUES

People experiencing a combination of a mental and may believe that a person cannot recover from problem substance use until the mental illness and drug dependency – often fall through disorder is treated. Frustrated by the lack of understanding of their multiple needs, and the cracks in the health care system. As many as of relevant services, these people often slip through the gaps. 500,000 (or one in 40) Australians are estimated to face the dual challenge of drug dependence IMPLICATIONS FOR NSPS NSP services are a valuable component in the and mental illness. Needle and Syringe Programs continuum of care required for people with mental health problems, as they are often (NSPs) are often the first point of contact for many the first point of contact for people with dual drug and mental health problems. Increased people with drug use and mental health problems, awareness, opportunities for training and and are thus well-positioned to provide support professional development, and a collaborative team approach can ensure clients presenting and referrals. in the NSP setting are screened and receive appropriate referrals to drug treatment and mental health services. DO DRUG DEPENDENCY AND MENTAL ILLNESS GO On the other hand, drug dependency may cause or exacerbate a mental health problem. Mental illness may be covered up or masked by drug Strong and reliable referral pathways between NSPs and mental health or specialist dual diagnosis service providers are integral to HAND IN HAND? use. Alternatively, drug use or withdrawal from improved mental health outcomes for people Concurrent disorders are much more widespread than many people realise. For example, it is drugs can mimic or give the appearance of some psychiatric illnesses, thus complicating the who inject drugs. Improved linkages can also facilitate client access to medical services generally estimated that up to three-quarters of diagnostic process. people with drug dependence or mental illness People with mental illness who inject drugs can will also have the other. For many people who get caught up in a vicious cycle that involves inject drugs, including drug-dependent injectors, multiple living problems resulting from poverty, mental illness is significant and persistent and lack of support systems, isolation, physical poses a significant barrier to their overall social illness, housing difficulties, disrupted family functioning. Among this group, depression, functioning and interpersonal relationships, and post-traumatic stress disorder and schizophrenia negative experiences with previous treatment. are common, with behavioural manifestations They often face immense challenges accessing including anxiety and panic attacks. Overall, the services needed to improve their health, says for physical health concerns and medication having a mental illness appears to quadruple the Kerry McKee, Area Coordinator Harm Reduction management, as well as access to other services chance of being diagnosed with any substance and NSP Team Leader at North Coast Area such as housing, employment and family use disorder. Health Service in NSW. supports. This in itself necessitates greater and However, while they often occur in conjunction ‘We often find that comorbid mental illness increasingly formal collaboration between NSPs with one another, the relationship of drug prevents drug users from accessing rehab and mental health services, founded upon the dependency and mental health disorders [rehabilitation] programs and other mental shared understanding that the line between (sometimes referred to as dual diagnosis) is health services, as these services often refuse mental illness and drug-related health problems complex. Mental health problems may promote treatment to a person with an active drug is not always clearly defined. or sustain drug dependency by leading someone dependence,’ she says. Although many NSPs already refer people to self-medicate with drugs for temporary relief from symptoms of their illness. Moreover, drug dependence services are very limited in their ability to treat mental illness who inject drugs with comorbid mental health issues to various mental health services, and provide mental health information and targeted education campaigns, there remains an overall lack of workforce capacity and appropriate infrastructure required to respond appropriately (e.g. drop-in centre / ‘safe space’ based). There are exceptions to this. Chris Hardy, manager at INNER SPACE in Melbourne says that her NSP is fortunate to have access to two psychiatric nurses on-site who work with their clients with mental illnesses. ‘A majority of our community development workers have also completed a two-day mental health first aid course, and receive a lot of help and supervision from the psychiatric nurses,’ she adds. ‘Obviously, community-based NSPs have good referral processes to local mental health services; however, getting the clients to actually access those mental health services and go to appointments is the more difficult part.’ However, NSPs are too under-resourced to be facilitating these referrals and following through with clients. ‘It is very important to recognise the severity of a lot of the mental health issues that clients can have, and also acknowledge that a lot of NSP workers cannot be expected to deal with these illnesses,’ Hardy points out. What is required is a strong infrastructure and adequate resources to effectively participate and integrate with all other parts of the system and to build workforce capacity to work with dual disorders. Workforce training and development would be essential for NSP workers to be able to better identify and generally differentiate between dual disorders. Training would provide NSP workers with the basis to work with dual disorders, including scenarios where symptoms of drug use may be mistaken for mental health ANd INjEcTINg drUg USE disorders, drug use induced symptoms that are not quite a mental health disorder, and drug use induced mental health disorders. Hardy believes, however, that it is unrealistic to expect NSP staff to fulfil this new role given the current restraints on time, funding and resources, and their focus on the delivery of injecting equipment. ‘NSPs can end up being responsible for almost everything that affects people who take drugs. Quite often, staff are lumbered with everything from housing issues through to legal matters and physical disabilities. It seems unfair to expect NSP workers to take all of this [additional workload] on,’ she says. In the absence of specialist dual diagnosis staff, NSPs remain reasonably well placed to help people who inject drugs to access mental health services, due to their provision and promotion of positive, open and trust-based relationships between people who inject drugs and staff. The co-location of NSPs with mental health services or primary care services could enable a pooling of resources, cross-fertilisation of knowledge and expertise, and better communication between different groups of professionals. Such integrated models of care would address both issues of NSP workforce capacity and confidence, and the need for improved referral pathways, and should be considered. ‘Ideally, NSPs would have a dual diagnosis worker attached to them who could attend to clients,’ says Hardy. “ We often find that comorbid mental illness prevents drug users from accessing rehab programs and other mental health services, as these services often refuse treatment to a person with an active drug dependence” Clearly, providing services that support people living with drug dependency and mental illness, promote recovery, and reduce episodes of illness is fundamental to the development of a healthcare system that addresses the needs of all people, in all aspects of their lives. Preventing and reducing the harms to physical, mental and social health associated with drug dependence and mental health requires the establishment or expansion of partnerships between NSPs and mental health and dual diagnosis services.

A Holistic Approach to Drug User Health

Needle and Syringe Programs (NSPs) are the first point of contact for many people who use drugs. With their focus on both preventing and reducing the harms related to drug use, the implementation of a continuum of complementary intervention approaches – including primary, secondary and tertiary interventions – is highly relevant to NSPs. Across the nation, people use a broad array of different drugs There is a trilogy of critical factors which are both via different methods of administration and in different social interdependent and independent of one another: the contexts. Data from the National Drug and Alcohol Research drug itself and its effects, the individual’s mindset or Centre shows that: expectations about the drug using experience, and the environment in which drugs are consumed. These critical factors need to be considered in any approach to the prevention of drug-related harms. • 33.6 per cent of Australians have used The risk of injecting-related injury and disease has increased cannabis at some time in their life and our motivation to reconsider how our health system deals 11.3 per cent had used in the previous with drug-related problems. A more concrete focus on harm 12 months; reduction has led to the establishment of services such • 30.2 per cent used some other form of as NSPs. illicit drug at some time in their life, while NSPs reside within a continuum of specific intervention 8.3 per cent had used during the past 12 months; and approaches aimed at preventing and reducing drug use and related harms. This includes primary, secondary and tertiary interventions. Primary interventions are those that • 7.6 per cent have used prescription drugs aim to prevent drug problems before they start, secondary for non-medical purposes at some time intervention approaches are those that aim to prevent in their life. emerging problems from becoming more serious ones, and tertiary interventions are those that treat serious problems that have developed. With their focus on both preventing and reducing the harms related to drug use, this continuum of complementary intervention approaches is highly Drug use in Australia is a complex and multifaceted phenomenon. relevant to NSPs. It encompasses different drugs, methods of administration and social contexts of use. Contexts of drug use range from experimental use, social or recreational use, and use in response to particular circumstances and situations, through to intensive and compulsive use.

These could include rashes, discharges, sores, blisters, warts and ulcers. Young people, men who have sex with men, Indigenous people, sex workers, and people living with HIV are at high risk of contracting STIs, and are even more vulnerable if they inject drugs. The oral health of people who inject drugs is also of concern, with many (particularly opioid users) often unaware of the need to access treatment. When they do access treatment, issues have escalated and additional problems such as needing to pay for urgent services arise. Mental illness can also impact adversely on the health and well-being of people who inject drugs. Depression, posttraumatic stress disorder and schizophrenia are common among people who inject drugs. Other common manifestations DIRECTIONS ACT NSP Team include anxiety, panic attacks, paranoia and psychosis (the latter two most noticeable with users of amphetamine-type stimulants). Hepatitis C is believed to affect approximately one per cent of the community, and has emerged as the most common reason for liver transplants in Australia. Across Australia, there are an estimated 16,000 new hepatitis C infections each year. With injecting drug use accounting for around 80 per cent of hepatitis C infections nationally, hepatitis C remains a significant health issue for most people who inject drugs. ‘Injecting drug users have a significant risk of contracting hepatitis C within 12 months of injecting,’ says Carol Mead, Executive Director of DIRECTIONS ACT. Associate Professor Lisa Maher and colleagues reported on a prospective cohort study in Addiction in 2006. They found that of the sixtyeight seroconversions that occurred in their study, incidence of hepatitis C was 30.8 per 100 person-years, while among those injecting for less than one year, incidence was 133 per 100 person-years. ‘Management of hepatitis C is an important issue to address,’ she continues, ‘and liver clinics and hepatitis councils in each state and territory should be more accessible for NSP clients and maintain a non-judgmental attitude and environment, as there are substantial shame factors around the transmission of blood-borne viruses and many users fear having their drug habit exposed.’ Being an extremely marginalised group, injecting drug users have a wide range of issues that impact on their quality of life. Issues such as lack of education and housing, unemployment and low income are commonly experienced. Centrelink issues, relationship issues, single parenthood and criminal backgrounds all add to the complex vulnerabilities of injecting drug users. ‘At the primary NSPs run by DIRECTIONS ACT, a lot of time is spent by the crisis support workers on welfare issues. The worker may see up to eight people a day and make many referrals,’ says Mead. ‘While the worker is unable to change some areas such as financial or educational qualifications, they do work hard to offer assistance to crisis issues such as relationships, court letters, seeking crisis accommodation, contacting Centrelink and Housing ACT.’ Welfare issues commonly faced by injecting drug users include: • HOUSING AND HOMELESSNESS • CARE AND PROTECTION (DOCS) AND FAMILY SERVICES • CENTRELINK, LOW FINANCIAL INCOME • RELATIONSHIPS • LEGAL ISSUES AND COURT/ INCARCERATION • 5WORK/ UNEMPLOYMENT • POOR EDUCATION • ISOLATION • SINGLE PARENTHOOD • SHAME AND DISCRIMINATION