Conflicting Priorities

Written by Nigel Brunsdon on 06 June 2008.

priorities Working in needle exchange can be psychologically a difficult job for some people, but attending an exchange is also a difficult situation for our clients.

In this article I’ll be looking at the roles of conflicting priorities for injectors and how they may impact on the effectiveness of any harm reduction advice given. I’ll also look at the conflicting priorities for the staff.

In a perfect world the advice that workers give would be instantly taken to heart by injectors and passed onto their peers. In fact this is normally expected by some of the staff I’ve trained in the past. After all, if you are telling someone that their actions are likely to cause a DVT why wouldn’t they change?

I’ve often heard staff complaining that some of their (if not all) needle exchange visitors are being ‘resistant’ to change, or that they are ‘not bothered’ about the risks. This is of course rarely the case.

Competing priorities

We have to remember that health is only one of a number of priorities on the minds of the clients. In much the same way that it is for the rest of us (if you doubt this then stop eating any high fat or non organic food ….. it’s bad for you). There are of course hundreds of these priorities but here are a few:

Cost of drugs: It’s all well and good for us to say “never share any equipment”, but if the only way that client can get a deal is to split it with a mate then they will.
Speed: Imagine you are a homeless street injector and you have managed to find somewhere sheltered enough to cook up; you can’t afford the time to struggle to get a vein. But going in the groin can be a fast solution - yeah it’s risky, and the chances are your hands aren’t as clean as they should be, but if you can get it in before someone sees you then you’ll be OK...
Peer pressure: This to me is one of the hardest to work with. Whilst running one workshop on ‘Safer Crack Piping’ (workshop available from this site as a free download) I had one young guy turn and say:

“it’s easy for you to say that we should put clean stems on our pipe. But if a Yardie hands me a crack pipe I’m not going to turn it down, I’d get battered"

It can be difficult, especially for someone who may be young or lacking in self confidence to go against this kind of pressure (especially from Yardies).
Relationships: Most of us have at some time relented to a partner and done something we normally wouldn’t do, maybe even something dangerous. If a partner was withdrawing and the only way you could help was with a used set of equipment then the chances are that you are going to give them a shot, even though it may be against your best judgement.

Staff priorities

Of course clients are not the only people with competing priorities. Staff in needle exchange have them as well, and their priorities can have serious impact on both the kind of advice they give and its quality:

Large workloads: Not every service has the capacity to have full time needle exchange workers and a lot of exchanges are staffed by whoever is available at the time. This can of course result in longer waits to be seen and rushed exchange sessions where the worker is eager to get back to filling in their casenotes/tops forms/database/cristo scores etc.
Service targets: This one is more obvious towards the end of the year (January to April). This is the point that a service realises that it’s going to come up short on something - maybe referrals into treatment or it could be vaccinations. Staff are then put under pressure to focus on these issues at the expense of others.
Finances: Needle exchange in most cases is the poor relative of drug services. Some of this is because in the past all a Drug Action Team had to do was evidence it had enough exchanges, not make sure they are fully equipped. Because of this there is a postcode lottery when it comes to equipment available.
Attitudes: It’s got to be said that some staff have a problem with the concept of NX. This can mean that they may resent being in the exchange or that they may do things like limit equipment. This can also mean some staff have unrealistic goals for clients that they try to impose, e.g. thinking that every client in needle exchange should be working to stop their drug use. While a great concept, trying to impose this view on unwilling clients will only antagonise them and make them avoid the service. This of course also happens with some services trying to impose the goals onto staff.

There are of course far more priorities for both clients and staff teams than this but I think you may be getting the idea.

Conclusion

I wish there were easy solutions. The main thing to realise is that these priorities exist both for injectors and staff and that they will affect the way we work and the way advice is used. Be realistic when you give advice and ask questions. Personally I would normally ask: “When was the last time you shared?” rather than, “Do you ever share” and follow questions like this up with “Really? What about with partners” if it's obvious from the way you ask a question that you are not judging you are more likely to get a straight answer.

Remember that injectors have as full a life as anyone else, and also remember that your competing priorities might be affecting the way you work.