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Factors in the development of a community pharmacy-based needle exchange scheme

Dr David J. Temple
Welsh School of Pharmacy,
Cardiff University

Aim and Objectives

Aim

• to overview needle and syringe exchange schemes within the concept of harm minimisation

Objectives:

1. to understand the rationale for needle/syringe exchange schemes
2. to consider the role for community pharmacies in N & S exchange schemes
3. to list key factors to ensure the success of pharmacy-based schemes

AIDS and Drug Misuse part 1

Main Conclusion

“ HIV is a greater threat to public and individual health than drug misuse. The first goal of work with drug misusers must therefore be to prevent them from acquiring or transmitting the virus. In some cases this will be achieved through abstinence. In others, abstinence will not be achievable for the time being and efforts will have to focus on risk-reduction. Abstinence remains the ultimate goal, but efforts to bring it about in individual cases must not jeopardize any reduction in HIV risk behaviour which has already been achieved.”

ACMD, 1988.

Reducing Drug Related Deaths

Chapter nine: Reducing Deaths from Chronic Illness

“Prevention of virus infections must be a key component in the prevention of drug-related deaths, and a response to hepatitis C and B is now needed of a scope equal to the responses to HIV.”

ACMD, 2000.

Transmission of Hepatitis C

• Percutaneous exposure including:
  • Transfusion or transplantation from an infectious donor
  • Injecting drug use (sharing equipment)
  • Haemodialysis
  • Needlestick injuries
• Sexual or household exposure?
• Multiple sex partners?
• Birth to an HCV infected mother (6% risk?)

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Perinatal Transmission of HCV

• Transmission only from women HCV-RNA positive at delivery Average rate of infection 6% Higher (17%) if woman co-infected with HIV
• No association with Breastfeeding
• Infected infants do well. Severe hepatitis is rare (ongoing research Birmingham)

Features of Hepatitis C Virus Infection

Incubation period: Average 6-7 weeks
Range: 2-26 weeks
Acute illness: (jaundice) Mild (<20%)
Case fatality rate: Low
Chronic infection: 75%-85%
Chronic hepatitis: 70% (most asx)
Cirrhosis: 10%-20%
Mortality from CLD: 1%-5%
Immunity: no protective antibody

Chronic Hepatitis C Factors Promoting Progression or Severity

• Increased alcohol intake
• Age > 40 years at time of infection
• HIV co-infection
• Other
  • Male gender
  • Other co-infections (e.g., HBV)

HCV and Injecting Drug Users

• Injecting Drug Users are the largest group of hepatitis C patients in the UK
  • Hepatitis C is more infectious than HIV
  • Fewer viral particles require for transmission
  • HCV is probably more stable outside the body than HIV
• Greater need for safer injection practices, including no sharing of any injection equipment (swabs, citric acid, water, spoons)

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The Welsh Strategy

Tackling Substance Misuse in Wales - A partnership approach
National Assembly for Wales, April 2000

Aims of the Strategy

• Children, Young People and Adults
• Families and Communities
• Treatment
• Availability

Families and Communities

“ Needle exchange schemes delivered via treatment services and community pharmacists have an important role to play in providing facilities for the safe disposal of used injecting equipment, affording an increased level of protection for local communities.” …...

“ Such {n & e} schemes can have a significant impact on public health through the provision of sterile injecting equipment, which can help to limit the spread of HIV/AIDS,Hepatitis B and C.”

Objectives of Needle & Syringe Exchange Schemes

• To offer sterile syringe and needle distribution
• To offer safe syringe and needle disposal, usually by return
• To offer advice and counselling on HIV, hepatitis and drug problems
• To offer advice and counselling on other health, social and welfare problems
• To provide referral to other treatment services
• To provide easy access and user friendly service for all injecting drug users
• To collect routine information

Needle & Syringe Exchange Schemes – do they work?

• In terms of preventing spread of HIV, there is overwhelming evidence in the UK following over a decade and a half of widespread availability of S & N schemes, that they do work.
• European statistics clearly showed a widening gap in the early 1990’s between the U.K. and other European Countries, especially Switzerland, Italy, Spain and Portugal
• In terms of preventing spread of hepatitis C, the situation is less clear.
• Hepatitis C is more infectious than HIV and probably more infectious outside the body.
  Hence the need to extend syringe and needle exchange schemes, to include other items of paraphernalia.

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Needle & Syringe Exchange Schemes – do they work?

• There is still evidence that users continue to ‘share’ in certain circumstances.
• Therefore a need to continue to inform users of the dangers of ‘sharing’
• Perhaps ‘re-use of dirty works’ would be a better understood term than ‘sharing’

Pharmacy Based Needle & Syringe Exchange

Advantages

• Anonymous transaction
• Convenient location
• No appointment necessary
• Open all week (including Sundays?)
• Health Professional available for advice
• Confidential (but see!)

Disadvantages

• No counselling service available
• Perhaps too public, therefore loss of confidentiality
• Damage to pharmacist’s business
• Pharmacist works in isolation, therefore potential danger to himself and staff (need to encourage networking, plus full support from a central body - e.g. a drugs agency

Components of UK pharmacy based Syringe & Needle exchange schemes

Coordination at local level

• Local person identified who will visit pharmacies to recruit to scheme and during Participation in scheme (maybe a pharmacist themselves or a drugs worker from the local drug team)
• Good examples in Glasgow, Leicester and Berkshire, N.Wales. N.B. This is crucial for a successful scheme
• Equipment to be provided
  • Syringes - volumes, e.g. 1ml, 2ml, or 5ml?
  • Needles – fixed or separate, length & bore? N.B. Steroid users inject oily preparations i.m., not i.v.

Kits or ‘Pick & Mix’ ?

• Kits are simpler for pharmacists
• Records are easier to maintain
• Usually one or two kits for i.v. plus a separate kit for i.m. users
• 10 S & N’s per kit is normal

Quantity allowed per visit?

• How many kits per person?
• Severe restrictions in Scotland, but not elsewhere in U.K.
• Can client collect for ‘friends’?
• Or are they ‘selling on’?

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What else to include in each kit?

• Educational material, with details of local services, plus ‘safe sex ’ message
• Additional paraphernalia such as swabs, steri-cups, filters, citric acid sachets, plastic ampoules of sterile water

N.B. new legislation in the U.K. in 2003 which allows for paraphernalia to be supplied
(contrary to schedule 9 of the Misuse of Drugs Act 1971)

Other items of paraphernalia

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Adequate supplies must be maintained

• If equipment is refused to a regular client, this may lead to an ugly incident
• If kits are to be used, who will assemble them?
• Can a supply be made to a pharmacy as an emergency?

N.B. This may be role for the coordinator.

One for one exchange?

• No – but must encourage exchange
• Maybe instigate a mini-kit with just two S & N’s for non-returners

N.B. Harm minimisation principles do not allow a refusal.

Return process

• Clients should be provided with a small personal disposable sharps container – colour – black or yellow/red?
• Client should place this into large pharmacy sharps bin (N.B. ensure compatibility of shapes!)
• Pharmacy staff should never touch returned items (safety first!)

Regular collection and disposal of pharmacy sharps containers

• Flexible system according to need
• Do not allow to accumulate in pharmacies
• Proper disposal according to regulations

Drop in service or registered users?

• Do potential clients require registration with another agency before Teagmhálacha ing a pharmacy? Presentation of card?
• Drop in schemes may well uncover pockets of injectors otherwise unknown
• Supply to a person on an oral methadone scheme – ethical dilemma?

Record Keeping

• Anonymous or minimal identifiers?
• Probably required for payment purposes
• Allows trends to be followed

Training for pharmacists and key staff

• Not essential for pharmacists to perform exchange personally, provided other staff are trained.
• Annual meetings of pharmacists and staff in the scheme to discuss issues and potential changes in policy
• Must include locum pharmacists
• Must include attitudes towards clients

National Occupation Standard for Substance Misuse

AH3 Supply and exchange injecting equipment for individuals

Payment arrangements

• Materials and disposal provided free, i.e. paid for centrally
• But a modest fee is required to compensate the pharmacist for time and the hassle factor

N.B. ensure funding is mainstreamed and ringfenced!

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Supplies to young people

• Some evidence in S. Wales of youngsters as young as 9 injecting.
• In the U.K. there is the concept of ‘Gillick competent’ for young people to take responsibility for themselves
• However, usual for pharmacists to refer young people (under 16 in U.K.) to specialist services – what about rural areas?

Local Police cooperation

• Essential for successful operation of scheme.
• However, police stop and search activities may impede schemes, i.e. what to do if a return sharps container is found
• No direct observation of pharmacies

Safety of Pharmacy Staff

• Offer all staff involved hepatitis B vaccination (who pays?)
• Need policy for dealing with spillages
• Record any needle-stick injuries and treat seriously, however minimal. (Main risk here is probably hepatitis C)
• Insurance cover for pharmacy?

Code of Conduct for Clients?

• Abusive behaviour.
• Insistence on immediate attention
• Potential for shop lifting or wilful damage (how does this fit with a drop in service?)

Advertising of Schemes

• Essentially word of mouth.
• Discrete logo in window (national logo recognisable by i.d.u’s.)

Sale of Syringes

• This has been prohibited by RPSGB since November 1997
• “only in exceptional circumstances should pharmacists supply clean injecting equipment for drug misusers if the pharmacy has no arrangements for taking back contaminated equipment’”

Standards for pharmacists providing N & S exchange

• Pharmacists must be aware of local facilities for drug misusers and have established Teagmhálacha s with other health care professionals involved in the care of drug misusers
• All staff who may be involved in the service must be instructed on procedures to be followed to minimise risks
• Supplies of syringes and needles must be made by pharmacists or trained staff
• Individuals must be encouraged to return used contaminated equipment in approved disposal containers, but a supply of clean equipment must not be refused if they omit to do so.
• Used equipment must be disposed of preferably by the individual, into a properly designed sharps container available in the pharmacy
• Suitable arrangements must be made for the disposal of full sharps containers

M.E.P., July 2003

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