Q&A WITH KIRSTEN HORSBURGH

Kirsten Horsburgh is the Director of Operations at Scottish Drugs Forum. She spoke to The Bulletin about Scotland’s high incidence of overdose, the recent HIV outbreak, and how stigma in the healthcare sector is stopping people from accessing lifesaving services.

How did you end up where you are now in your position?

I’m a mental health nurse. My first job working with people who use drugs was when I was working in a mental health ward. We had a couple of beds for people who were experiencing drug problems, so it was a bit of an unusual environment for people to come into. To me, it seemed like people who were coming in with drug and alcohol problems were treated like, “oh well, they don’t really matter as much as the rest of the residents.” I took a particular interest in working with people who use substances, and then a job became available at the local addictions team.

I worked there for a few years and was team manager when the national naloxone program was introduced. We worked on that locally and then a job appeared at Scottish Drugs Forum (SDF) to work on the naloxone work nationally. That led me to SDF, where I’ve now been for 10 years.

And can you just explain briefly what SDF is for the Australian audience?

SDF is a non-government organisation. It’s a charity, membership-based organisation. We are a drugs policy organisation. We’re not a treatment service, but we are policy based and a large part of our work is also delivering training. We have programs of work on peer research, drug-death prevention, on sexual health and blood-borne viruses, and a whole variety of other things.

My understanding of SDF is that it’s fundamentally a harm reduction organisation. And you didn’t mention the words harm reduction just then. Have I got the wrong end of the stick?

No, definitely not. Our ethos is very much based in harm reduction. Over the last few years, harm reduction interventions have been criticised quite heavily by some, particularly organisations that are focused on the residential rehab angle.

I think sometimes we are seen as an organisation that doesn’t support an abstinence-based approach, which is not the case. We believe that people should have the choice for anything and everything in terms of their own personal goals. But we are very much harm reduction focused, so that is always at the core of everything that we do.

One of the things that’s fascinated me in the UK has been the sort of recovery paradigm and the recovery language. Are recovery and harm reduction getting closer or are they still seen as mutually exclusive?

In 2008 we had a drug strategy produced that was called the Road to Recovery, and that whole strategy was about moving away from problem drug use. And whilst it didn’t explicitly talk about an abstinence-focused model, that was certainly how it was construed.

A lot of organisations focused then on that push towards abstinence, which was really quite harmful. I mean, it depends on your definition of recovery. And certainly, ours is more about any positive change.

For one person recovery might be the first time they start using sterile injecting equipment every time they use; for somebody else, it might mean complete abstinence. So I think it’s down to the individual. This narrative gets thrown around a lot about, "Oh you’re either harm reduction or you’re recovery." And we don’t see it like that. It’s very much a spectrum.

A lot of the clients, particularly the ones that are injecting,have got significant mental health issues. How do you seemental health and harm reduction coming together?

Unfortunately, we still have a big issue with the two being seen as very separate things. In Scotland, our staffing for drug services will be a proportion of mental health nurses, as well as general nurses. But if somebody comes to your drug service and they are experiencing significant mental health issues and you refer to a specialist mental health team, often you’ll be faced with “we can’t take them because they need to get their drug use under control first.”

So you’re left in this vicious cycle where somebody is experiencing mental health problems, they’re using drugs often to manage those mental health symptoms, but then they can’t access specialist mental health services.

The majority of people that are experiencing drug problems will have often significant trauma in their life. And that’s something that we don’t capture early enough in people’s lives. People have often experienced unimaginable trauma, and then it’s perpetuated by the situation that they’re finding themselves in, in terms of poverty, deprivation, homelessness. [It’s] this sort of ambivalence where [they think] “I don’t really want to die, but I’m not that fussed about living either.”

Sometimes I worry that we over-diagnose people with a mental health condition when actually, a lot of it is situational. So I think there’s a bit of both, but certainly some severe and enduring mental health issues in amongst all of that as well.

And what about trauma-informed care and harm reduction?

SDF does a lot of training around trauma and substance use, and I guess for me, trauma-informed practice is a lot about also addressing stigma. So yes, being aware of people’s histories and taking that into account and how trauma can affect where somebody is at [is important], but [so is] thinking about the way that we provide our services.

We have to ask ourselves – if you take injecting-related wounds, for instance – why is it that people would have such hideously painful wounds and carry that around rather than approaching one of our health services? It’s about stigma, because people know how they’ll be treated when they attend a service.

There’s a lot of work that we need to do about how we make our services approachable. You can’t be trauma informed if you still have punitive practice and you’ve still got that angle of stigma within your organisation. And that also links to a lot of work that we’ve been doing with other organisations, like police. We recently finished a program where we supported them with a trial of naloxone carriage for police officers, and there was still a lot of stigma amongst police towards people who use drugs, which you can imagine because of the criminalisation.

When I think about Scotland, unfortunately, the thing that jumps to my mind is the very high overdose rate. Why is it so bad?

We have very high rates of people experiencing problem drug use, especially in areas of poverty and deprivation. The number of drugs that people are using together is higher than some other places.

We have lots of opiate use, heroin and methadone are the main ones. We have huge rates of benzodiazepine use. We also have a lot of alcohol use, but we also have other drugs in the mix now. Gabapentin and pregabalin are quite commonly used. Over the last couple of years, we see way more people using cocaine as well. And not just cocaine on its own, but cocaine in combination with opiates.

We also have lower rates of people accessing drug treatment. We have around 60,000 people experiencing drug problems, but less than 40 per cent actually access treatment. A lot of people who die will be parents as well, so there’s that generational impact of a parent dying from a drug-related death. The average age last year of people dying was 44. People over 35 in Scotland are deemed to be older drug users, which is by no means old, but what we see is people experiencing health conditions that are way beyond their actual years.

There was talk a few years ago about a consumption room in Scotland. Is that going to happen?

There absolutely is still a need for safer injecting facilities,and not just in Glasgow where the proposal was made.

Glasgow has been described as having the most compelling case in Europe for one because we had an HIV outbreak as well. That proposal is now with the new Lord Advocate and they’re reviewing that through the Crown Office to see if there’s a way that they can operate the facility within the current legislative framework.

And what about the HIV outbreak, how has that progressed?

It was 2015 when the cases started to emerge. Generally, in Glasgow, there would be around 10 new cases of HIV every year. And there were over 40 in that year. That’s escalated and it’s now well over 100. The rate of increase has slowed, but it’s still definitely there, and the reason it’s slowed is because of the interventions that were put into place. Proactive testing and treatment was key. There were real efforts focused on testing and they commissioned a report looking at the needs of people who were injecting drugs in public places, because that was where it was identified as one of the main issues.

Cocaine injecting was seen as a key driver as well – the injecting frequency was a lot higher and in turn resulted in more people sharing equipment.

It was almost like HIV had been seen as a thing of the past. People were more familiar with hepatitis and that was probably more in people’s discussions and [a focus] for services as well. I think HIV had sort of fallen off the radar for services.

That’s interesting. Is there something I should have asked you or is there something that you wanted to get across particularly?

There’s some been some dramatic changes [in drug policy] over the last while. Organisations had been really applying pressure about the government’s lack of response on the drugs crisis. And then something like COVID comes along and you see what is actually applied when a public health emergency is taken seriously.

Finally, there was recognition from the Scottish government that, in the words of the First Minister, they had taken their eye off the ball in terms of drug deaths. So they introduced, for the first time, a specific ministerial position of Drugs Policy Minister. Previously we’d always had a Minister for Public Health and Sport, who also had drugs in amongst all that, which was really unhelpful. To have a minister dedicated to drugs policy is, in our minds, really positive. The frustration that we have is that we are still talking about piloting things that are evidence based.

Like, come on, in an emergency you don’t pilot things, you just get on and deliver them, especially when they’ve proven to be effective in other countries. Things like drug consumption rooms, for instance, or heroin-assisted treatment. All the things that we should just be getting on with delivering are slow.