1. Interaction and interplay between rapid assessment (HKH) and a local monitoring system (BEWS)
Lisbon Addictions 2017
Liv Flesland,
Consultant
(Psychiatric Nurse Specialist/ MSc)
Competence Centre, Bergen Clinics Foundation,
Bergen, Norway.

2. This study is funded by the Norwegian Directorate of Health
No conflict of interest

3. The BEWS/Føre Var model
Combined monitoring & early warning function
’Follow the drug’- 19 substances
Established in 2002
6 monthly reporting
29 separate datasets collected
15 years trends
Mix of quantitative & qualitative data
- systematic triangulation
Since 2002 the local monitoring system, BEWS (Bergen Early Warning System/Føre Var), has identified drug trends in the city of Bergen, Norway. The system identify and reports changes in patterns of drug consumption and availability, including the introduction of new substances, changes in modes of administration, and changes in user groups.
BEWS are a multi-source and multi-method systems designed for rapid, local monitoring, assessment and response.
Data are collected every six months, analyzed for identifiable patterns and trends, and are disseminated widely. By now, the BEWS utilise approximately fifty drug-related indicators and has reported publicly on 29 occasions. Per now we are working with the data collection to the 30th report in a row since 2002.
The aim is:
In a rapid and reliable way identify, monitor and report back tendencies and trends in drugs and alcohol use in the city of Bergen, Norway – as early as possible.
Aim
In a rapid and reliable way identify, monitor and report back tendencies and trends in drugs and alcohol use in the city of Bergen, Norway

4. RAPID ASSESSMENT STUDIES
Sources used in the BEWS/Føre Var system
RAPID ASSESSMENT STUDIES
ROUTINE DATA
KEY INFORMANT PANEL
BEWS triangulates and cross-references a wide range of statistical data including seizures data, treatment figures and alcohol sales, “leading edge” data like local media, helplines and websites, and two key informant panels.
SCHOOL PANEL
FOCUS GROUPS
MEDIA MONITORING
HELPLINE

5. Increase in availability and use of ecstasy/MDMA
DRUG TRENDS in BERGEN - MAIN FINDINGS SPRING 2017
Increase in availability and use of ecstasy/MDMA
Increase in availability of cannabis
Increase in availability of amphetamines
Decrease in availability and use of heroin
Cannabis
Amphetamines
Every 6th moths BEWS highlight approximately four main findings, and this is the latest report, launched in June 2017
Ecstasy/MDMA

6. RAPID ASSESSMENT METHOD RAR/HKH
adapted and used by a Norwegian city outreach team
in 2002
AIM
To provide a tool kit for rapidly assessing and developing appropriate interventions to minimize adverse consequences of psychoactive substance use
KEY PRINCIPLE
To provide practical information necessary for developing intervention responses
Over the years there has been a need to further explore drug trends which cause concerns, and RAR is a method which has proved to be appropriate for follow-up studies, to better understand the situation.
The Norwegian version of the method, called HKH, is a manualized and supervised early identification and intervention approach based on Rapid Assessment & Response (RAR), a tool developed by the World Health Organization. The method can be used to identify and prioritize community level problems and design appropriate evidence based responses with the involvement of local actors. The Competence Centre at the Bergen Clinics Foundation have developed, piloted and evaluated the tool to suit Norwegian conditions, in cooperation with Bergen Outreach and Detached Service.
By the end of 2017 there will have been conducted around 40 HKH assessments in Norway covering different topics around generic drug and alcohol use, drug specific issues like cannabis and GHB use, overdose deaths and other topics relevant both to prevention, early intervention and harm reduction.

7. The Rapid Assessment and Response process
Identification of problem
Initial consultation/meeting
Establish steering/reference group
Assessment/project plan
Assess problem & Assess current response
Gap analysis
Final consultation/meeting
Write report & action plan
HKH is also a multi-source and multi-method system, like BEWS. A key characteristic of the method, is that community level problems are explored simultaneously with the existing responses to these problems. Analysis is based on a systematic triangulation, and the assessment process results in a short summary report including an action plan.
STEPS
Clarify the ’problem’
Plan the assessment
Identify & involve key players
Assessing the ’problem’ & current services
Analyse and present findings
Features of HKH
Rapid (takes 6 – 8 months),
Practical relevance to interventions,
Identifies and strengthens local responses,

8. 2013: PDU 30+ housing situation
2011:
Overdoses
2013: PDU 30+ housing situation
2014 & 2015:
Open drug scenes 1 & 2
Over the years, several HKH surveys have been conducted based on findings from BEWS, and the overview in this slide illustrates some of these reports.
In this presentation I will focus on two trend images, the increasing trend for GHB in and the decreasing trend for heroin from 2012.
2010:
GHB/GBL use
2015: PDU– drug use;
Settings, risks & consequences

9. GBL: the drug of choice; cheaper, more potent & «legal»
Increase in availability and use
GBL a new drug/substance
HKH 2010:
GBL: the drug of choice; cheaper, more potent & «legal»
Used in combination with alcohol and/or amphethamines
Mental problems, addiction problems & overdoses
Lack of knowledge in the health & social services
Action plan: Prevention focus, CPR-training, GBL on the drug list
HKH 2010:
GBL: the drug of choice; cheaper, more potent & «legal»
Used in combination with alcohol and/or amphethamines
Mental problems, addiction problems & overdoses
Lack of knowledge in the health & social services
Action plan: Prevention focus, CPR-training, consultative input related to the proposal to put GBL on the drug list

10. Injecting practice; Polydrug use; ”Sleep” dose;
Heroin: Decreasing trend and purity
Injecting most common
Combinations: benzos & amphethamines
High numbers of overdoses
HKH :
Risk factors:
Injecting practice; Polydrug use; ”Sleep” dose;
Protecting factors: Stay together, avoid polydrug use, smoke heroin
Action plans:
CPR-training; Implementation of SWITCH; Outreach and ambulatory services; Drug consumption room
BEWS has over the last five years identified a change from heroin use to more extensive polydrug use among PDU’s (problem drug users) in Bergen
Heroin: Decreasing trend and decreasing purity
Injecting most common route of administration
Polydrug use is common - As a Key Informant said: “Anyone who uses heroin, also uses amphetamines”.
HKH:
After the closure of the largest open drug scene in the city of Bergen in 2015, the HKH-assessments found that amphetamines was likely as much used as heroin, but the PDUs quality of life had not improved in any way.
Risk factors:
Polydrug use/combinations of heroin, medicines, and amphetamines
”Sleep” dose – be “as high as possible” – increased risk of overdoses
Protecting factors: Stay together when using drugs, avoid polydrug use, smoke rather than inject heroin
From the action plans:
Strengthen the user skills with CPR-training
Implementation of the SWITCH- strategy – peer to peer training of PWID (injecting drug users) to change the habit from injecting to smoking heroin
Establish outreach and ambulatory services and a drug consumption room for the PWID

11. Conclusions
Local monitoring of drug trends (BEWS) identifies problem areas that can be explored further.
HKH-assessments has improved local practice, and contributed to changes in the national policy;
GBL on the drug list
National overdose strategy
Proposals for changing the Injecting rooms Act
Monitoring systems as BEWS indicates changes in drug trends, and identify challenges for further explorations:
HKH has given us broader and more in-depth knowledge related to the changes in the trend picture - which has led to changes in policy – that GBL came on drug list already in March 2010 is one example.
Another example is The overdose report from 2011, which contributed to a local action plan against Open drug scenes in the city of Bergen in and on a National level to the implementation of the Overdose Strategy in Norway ( ).
The overdose report, in addition to three other assessments in the year between , also contributed to the revised Action plan against alcohol and drug problems in the municipality of Bergen and to the local Action plan for preventing overdoses from 2017.
And last, but not least; Findings both from BEWS & HKH has led to a political pressure and a proposal to amend the strict Injecting rooms Act (regulations), to open up for polydrug use and smoking heroin.
And then, to the final conclusion:
This study has shown how a city level drug trend monitoring system can be followed up by rapid assessments. Results of follow-up surveys using the HKH-method, have had an impact on service development and new or modified policy, both on a local and on a national level in Norway.

12. Thank you for your attention!
Contact details:
Funded by the Norwegian Directorate of Health