Wednesday 19th June. Cardiff Bay. I’m sat outside the Pierhead with a coffee, waiting for my colleagues so we can set up the annual Barod Conference. This year’s focus: setting the blueprint for a more equal and prosperous Wales for people who use substances. I look up and a man rides his bike towards me, he stops in front of me, pulls a paper from his pocket and says, ‘good morning, lovely.’ He politely, but very quickly, tells me that he wishes he didn’t have to ask, and goes on to try to show me his ID and prove that he is just looking for a place to stay tonight, and he needs to raise £20 to do so. As I notice a wound on his head, he coincidentally tells me that he asked someone the same question at 3am, and he was subsequently hit over the head with a glass bottle. I look at him, pause, and think how lucky it is that I needed to get cash out this morning as a card machine in a coffee shop was down. I think of the things we forget about when considering a cashless society, things like this. Before he can leave, I ask him if he has heard of Barod. His expression changes as he sees my lanyard. He speaks slower, calmer now. He tells me he is working with Dyfodol and is on a methadone script, he shares his successes with me. He smiles. He says, ‘I guess I bumped into the right person then.’ We chatted for a few minutes; he tells me he will think about going to A&E. He thanks me for my kindness. It shouldn’t be this way. No one should feel the need to have a speech prepared before they can talk to you. No one should fear being assaulted when they are just looking for a safe place to sleep. No one should only feel they can be at ease once they realise they are speaking to someone who works with homelessness or substance use every day. No one should be surprised that someone’s first concern was a head injury and if they have received medical attention. Imagine being such a stranger to human compassion. There could not have been a more pertinent start to the day.
In Barod, our blueprint for Wales calls out how ‘people who are affected by substance use’ are stigmatised daily and are shamed by society. It highlights firstly how a change in language is vital to reduce this stigma, which according to our CEO, Caroline Phipps, ‘isolates, traumatises and harms.’ The conference highlighted that as an organisation, we believe it is important not to separate people who use substances from concerned others and wider society—after all, the people most affected by substance use are the people who are using substances. By changing our language, we acknowledge that we are ALL affected, and that we are all responsible for safeguarding and supporting those who are using substances. Barod calls for concerned others to be recognised as a group of people within their own right. The reality is that services are vastly underprepared for supporting these individuals who are ‘unseen and unheard,’ as Caroline said in her opening address. As professionals we have access to parent and carer training, however this is not appropriate for young people. Substance use ‘touches so many people’s lives but so often flies under the radar,’ Jane Bryant MS rightly told us. Substance use caseworkers are largely relying on their own wits to create resources to work with concerned others—our blueprint emphasises that this needs to change.
Speaking of things flying under the radar, our blueprint explains that between 2020 and 2021, 53% of treatment referrals were primarily for alcohol – that’s 9,000 people. Between 2022 and 2023, 8,464 people were hospitalised in Wales due to an alcohol-specific condition, i.e. 100% attributable to the use of alcohol. Myself and colleagues have discussed on the Drugs Unwrapped podcast how the normalisation of alcohol in our society is dangerous; we are often ignorant to the long term harms of alcohol use compared to illicit substances, perhaps because it is apparently so dear to our identity as Brits. Despite having an opportunity to be one of the world’s leading countries in substance use treatment, the UK stands out from the crowd by deliberately excluding alcohol dependence from the Equality Act 2010. Despite being able to apply for Personal Independence Payments due to complications from substance use, the UK government contradicts itself in this omission, stating that alcohol dependence is ‘self-induced’. Acknowledging what we, in the field, know, alcohol dependence is usually a response to one or more triggers, often deep-rooted trauma which a person had no choice in experiencing, and an inability to employ healthy coping strategies. To what extent then can we say that those who fall into alcohol dependence have a choice? If you are not taught these strategies and resilience, if you are denied support by friends and family, if you are faced with years-long waiting lists for mental health support only to be told that you cannot be supported while you are actively drinking or using—can we truly say that is self-induced? Or is that a deflection to avoid accountability by those making the laws? Professor Magdalena Harris of the London School of Hygiene and Tropical Medicine expressed, ‘how can people be expected to stop using drugs when they are often using to cope with mental health issues, before they get mental health support, is beyond me.’ As Caroline put it at the Pierhead, ‘we should not be distracted by politics and legislation – we should follow the evidence base.’ The evidence is clear that we need to protect those dealing with these issues from the reinforced public views excused by ‘draconian drug laws,’ put fittingly by Peredur Owen Griffiths, MS. We therefore call for the alcohol-related exclusion clause to be removed from the Equality Act 2010.
Director of Operations Huw Thomas and Resilient Families Manager Rachel Wilson, Barod
Director of Operations Huw Thomas and Resilient Families Manager Rachel Wilson walked us through the journey taken by the TRACE working group (Trauma and Adverse Childhood Experiences). The group came together to see how our approaches and spaces could be more trauma informed and designed a tool for assessment. Huw and Rachel told us that this tool was not fit for purpose as it turned out to be a duplication—we were already doing a good job of being trauma informed in our jobs. In Barod we pride ourselves on being honest, adaptable, having integrity and a positive attitude; perhaps it is no surprise then that we were already being considerate of people’s needs from the point of referral. What we did learn was that we can do better with our spaces and an environmental audit was completed. We are aiming to create spaces that are welcoming and comfortable for people who access our services, as well as safe for staff. We have been asking service users and particularly young people to support us in developing a new space in Aberdare from the ground up. Service user involvement should be firmly at the heart of what we do in treatment services, and we seek to implement this from the very start with our recruitment process, with service users present on our interview panels. We want to have a trauma informed approach throughout our service, for our service users and our own staff. Reviewing our policies has been an integral part of this, looking at how we can afford our staff the same compassion that we do our service users. Most recently discussions around vicarious trauma for staff have taken place with senior leadership in response to a question asked at the conference.
Sarah Walsh, Gwent N-Gage Service Manager
We go further than simply asking young people to audit our spaces, though. In Swansea and Gwent, we have established youth panels which help to directly shape our young person’s services. Sarah Walsh, Manager of Gwent N-Gage young person’s service, told us that she has been working with ‘the most awesome young people who never fail to inspire me.’ As a young person’s worker, I can say that this sentiment is not unique to Sarah, we all feel this so strongly. As is the case with anyone who works directly with young people, we know that the UN Convention on the Rights of the Child is right in their ask for children to ‘have their views considered and taken seriously.’ Our young people are not naïve; we learn from them every day; they tell us about trends and what they need. Sarah told us how the Youth Ambassador Service (YAS) in Gwent has come to be, and that they have been directly consulted in Gwent’s bid. The YAS were empowered to provide their own ‘unedited and authentic’ responses to questions, providing ‘raw content’ to commissioners about the reality of what our young people need from services in Wales. These young people are the experts on their own lives and needs, that we should be consulting. Amongst giggles in the audience at her apologies for risking going over time, Sarah raced through her presentation to show us more and more examples of the amazing things achieved by the young people in the YAS, and I think we could have been there all day if time allowed. To hear how a young person who has completely disengaged from school has not missed a single YAS session was inspiring; we have a real opportunity to ensure our young people are accessing a space where they can form positive relationships, build skills and feel valued when they might otherwise feel left behind in society. We can help young people build self-worth and allow them to find out what they’re good at, with some of the YAS developing logos and speaking on the podcast. Sarah shared with us that many are even thinking of becoming substance use workers in the future. The importance of the YAS and youth panels cannot be understated—we will only get better at working with young people if we listen to young people.
Professor Magdalena Harris, London School of Hygiene and Tropical Medicine
Caroline has urged for an ‘innovative and curious’ approach, and this was epitomised when Professor Harris shared a video of her asking a person who uses crack cocaine to show her how to make a crack pipe from an energy drink can. We are trusted with providing harm reduction information to our service users, yet so many of us don’t fully understand their paraphernalia. We sometimes shy away from the more ‘real’ side of the lives of people who use substances due to the criminal aspect of the subject. Professor Harris asked the question we all have in our minds: ‘how do you evidence something that is illegal?’ Many of us working in treatment services will never have lived experience of what our service users have, so the best thing we can do is give them to platform to share their experiences and their reality with us. Our blueprint demands the ability to give out safer inhalation devices (SIDs) to people who use crack cocaine via needle and syringe programmes. Currently, SIDs are not permitted to be given out in needle exchanges under the Misuse of Drugs Act 1971. In order for an item to be lawfully provided an exemption needs to be made, such as with foil which was only made exempt in 2014. We learned through Magdalena’s study that respiratory health is ‘neglected,’ with more women presenting with these issues than men. Professor Harris told us that there is a myth that ‘people who use crack don’t care about their health—it’s just not true.’ Speaking about tin cans, plastic inhalers and metal cannabis pipes, Magdalena reminded us that people who use crack ‘don’t want to use them, but they don’t have an alternative.’ Concerns around the inhalation of plastic shavings and wire wool were alarming and explained why many people are turning to injecting use as a harm reduction measure to avoid further respiratory harm, introducing new risks of blood borne viruses. The study made clear that our services are not adequately oriented towards people who use crack. If we get people into needle exchanges, we can get people into service. Needle exchanges provide us with an opportunity to not only mitigate risk and keep people save, it gives us an opportunity to allow those accessing to take authority over their own narratives and come into treatment that they might not otherwise know how to access. Professor Fiona Measham from the Loop gave us the data: 1/20 of those accessing harm reduction services in the form of drug checking would ask for onward referrals, and 19/20 built trust and opened conversations. Why would this not be replicated in all frontline harm reduction services? By showing these individuals that they are safe with us, they will not be judged, we create a belief in services and most importantly we remind these individuals who are so often isolated and traumatised by stigma that they are valued members of society who can take control of their lives if they seek support. People want help – when asked in the study if they would access clean inhalation devices and substitute therapy, people said yes.
Shayla Schlossenberg, Release.
So, ‘how much is one life worth, or ten, or hundreds?’ Shayla Schlossenberg from Release asked us to remind people that needle and syringe programmes, our front line harm reduction services, are to reduce the risk of overdose, BBVs and drug-related litter. Professor Harris echoed that in our jobs we shouldn’t necessarily be aiming for abstinence, ‘we should be aiming for control, reduction and improving people’s lives.’ Shayla shared that in 2010 there was an average of 10 drug-related deaths per day. UK drug laws, based on American drug laws which are inherently based on racist motives and not on evidence, have ‘devalued the lives of people who use drugs.’ Shayla’s talk highlighted how needle exchanges not only serve as harm reduction centres, but sites where people who use substances can come to feel valued. Sometimes the few minutes we spend speaking to these individuals like the human beings that they are, can be enough to plant the seed in their minds that they are valued members of society who deserve an opportunity to improve their lives. Needle exchanges not only allow people to use in a safer way and reduce risk of BBVs and overdose, but they also mark the very start of many people’s journeys into service. Why would we not want to target as many groups as we can? Why would we not want to introduce SIDs to reduce respiratory harm? Why would we not want to implement more front-line harm reduction services, such as enhanced harm reduction centres (EHRCs), or overdose prevention centres (OPCs). EHRCs allow for the consumption of illegal drugs, within a sterile environment, under the supervision of trained professionals. EHRCs actively reduce the risks of BBV transmission, overdose and drug-related litter, as well as connecting marginalised and isolated populations with treatment services. Our blueprint identifies a need to establish memorandums of understanding to enable the implementation of Enhanced Harm Reduction Centres in Wales. Our needle exchanges already handle the difficulties in the legalities of those in possession of substances accessing these services, so the framework is already in place. Moreover, SIDs and EHRCs will directly reduce strain on our NHS by reducing health issues which will need to be treated later in life. Shayla put it best: ‘criminalisation actively blocks lifesaving harm reduction interventions, interventions that are based on dignity and respect.’ There is already a grassroots approach to EHRCs in place, people who use drugs are usually the first to adapt their approaches, so we should be consulting them in our design. We learned that groups of people who use substances often form their own unsanctioned and non-sterile harm reduction centres, where they share safer injecting or inhalation advice and administer naloxone when necessary. This is the most optimal and only choice for many people who would otherwise choose to use in sterile and safer spaces. Not only do we want EHRCs, but we also recognise a need for a Drug Overdose Good Samaritan Act to be enacted in Wales to help save lives. As in Canada, the act aims to reduce the fear of summoning emergency services to the site of an overdose.
Professor Fiona Measham, Chair in Criminology, Sociology, Social Policy and Criminology at Liverpool University
I must admit I was quite excited when Professor Fiona Measham took the stage to tell us about The Loop and the importance of drug checking, having read much of Fiona’s work in university I never knew how important it would come to be in my career. Fiona reminded us that by providing as much information as possible we’re empowering people to make decisions about their own lives. The Loop facilitates this by testing voluntarily submitted substances, and this year they secured their Home Office licence and returned to Parklife festival. According to The Loop, half the people at festivals take drugs and half of those take more at festivals than normal. Fiona reported that The Loop found discussions that took place following drug checking at festivals led to reduced future dosage and reports of intending to be more cautious about poly drug use. Follow ups found that 1 in 5 were still reducing dosage three months after the festival, and 1 in 3 were still being cautious about poly drug use. In instances where a sample contained adulterants, 3 in 5 handed over the substance. We see similar sentiments in our needle exchanges: where nitazene testing strips are offered, many of those collecting choose to take them. The Loop’s impact has a ‘ripple effect beyond the individual service user’ with alerts and information posts highlighting trends, as well as 1 in 10 people telling their dealers about their results which can affect real change. Fiona explained that thanks to alerts on Dutch TV, PMA superman pills were taken off the market because no one wanted to buy them. Drug checking has proven itself as an effective tool for drug market monitoring and early warning systems, with the Loop recently helping to sound the alarm for the rise in nitazenes in the UK. Community drug checking services need to be part and parcel of harm reduction interventions across Wales. The work done by The Loop and other services such as Wedinos is essential, but costly—as free to access services, we need to consider the sustainability of their existence while they are not commissioned and funded services.
So what did we learn from the Barod 2024 Conference? We learned that the evidence shows ‘we shouldn’t be necessarily aiming for abstinence, we should be aiming for control, reduction and improving people’s lives’. That the harm from non-sterile and unsafe inhalation devices is ‘wholly avoidable’. That ‘the numbers are still too high, and every death is a tragedy’. ‘This is ultimately about saving lives, but we don’t want to wait for people to fall before we catch them’. Naloxone is a breakthrough in saving lives, but recently someone was discharged following 12 doses of naloxone and later overdosed due to the half-life of nitazenes. The game is changing, and we need to change our strategy. Perhaps the 4th of July has set some of these strategy changes in motion, with Keir Starmer’s appointment of James Timpson to the House of Lords as Minister of State for Prisons. Timpson has highlighted that ‘we’re addicted to punishment,’ and the Prime Minister himself has said, ‘I’ve often reflected that many of them [people in prisons] could have been taken out of that system earlier if they’d had support.’ This spells hope for our call for even better young person’s services and early intervention. Let’s hope that this new government sees the evidence and realises what was perhaps most eloquently put by the sponsor of this year’s event, Peredur Owen Griffiths MS: ‘The laws around drug use could do with a lot more compassion and common sense.’
Hannah Mealey is a young person’s caseworker in Bridgend. Hannah has worked for Barod since March 2022, working with families and young people. Hannah holds an undergraduate degree in history and studied the history of drugs and body politics, completing her dissertation on gendered presentations of heroin use in British public health campaigns in the 1980s. Hannah is currently aiming to undertake a Masters degree.
You can download our blueprint below.
