Background and context
This document contains guidelines on best practice for services providing injecting equipment ( IEP) services. The development of these guidelines was an action arising from the Hepatitis C Action Plan for Scotland: Phase II: May 2008 - March 2011.1
Action 14 of this plan states that "national guidelines for services providing injection equipment to injecting drug users will be developed" (p. 18 and p. 44) and Action 15 states that:
Services providing injection equipment (needles / syringes and other injection paraphernalia) will be improved in accordance with the guidelines…. Improvements will be made in terms of the quantity…, quality….and nature of provision (See p. 19 and p. 44).
The guidelines concern the provision of needles, syringes and other injecting paraphernalia to people who inject opioids (including heroin and methadone), stimulants and other illicit substances (for example, prescribed drugs injected illicitly). The guidelines do not cover the provision of injecting equipment to:
- Young people under 16 years of age
- People who use illicit drugs, but who do not inject
- People who inject prescribed drugs for a medical condition, such as diabetes.
NHS Boards and commissioners should consider how the guidelines may be applied to any populations not specifically covered by the guidance.
IEP services in Scotland deliver a wide range of interventions, including sexual health interventions, interventions which aim to prevent injecting, and those which encourage people to cease injecting. These interventions are extremely important and should continue to be provided. However, these interventions are not specifically addressed by these guidelines. Rather, the focus of these guidelines is on more effectively meeting the needs of people who are current injectors.
The Scottish Government has provided funding to all NHS Boards in Scotland to improve Hepatitis C services in their areas. Part of this funding includes additional funds to deliver expanded and improved IEP services.
Although these guidelines have been developed as an action under Scotland's Hepatitis C Action Plan, Phase II, they also fit within the context of the principles outlined in the Scottish Government's Road to Recovery.2 For many injectors, engagement with an IEP service is a first step towards recovery.
Why does Scotland need guidelines for IEP services?
It has been estimated that there are approximately 24,000 injecting drug users in Scotland. 3 There are a number of health risks associated with injecting drug use, including bacterial infections such as septicaemia and tetanus. Abscesses, cellulitis and collapsed veins can result from injecting with a blunt needle. 4 Injectors are also susceptible to a range of blood-borne virus ( BBV) infections, the most prevalent of which is Hepatitis C infection.
It is estimated that well over 90% of new Hepatitis C virus ( HCV) infections in Scotland occur in people who have injected drugs. 5
There is sufficient evidence from around the world to show that IEP services are effective in reducing injection risk behaviours among injecting drug users (in particular, self-reported sharing of needles and syringes, and frequency of injection) and there is some evidence that IEPs reduce HIV infection among injecting drug users. 6,7,8,9IEP services are also cost-effective when compared with the lifetime cost of treating HIV infection. 6, 7
However, the picture with relation to Hepatitis C is less clear. There is currently insufficient review-level evidence to either support or discount the effectiveness of IEP programmes in reducing HCV transmission among injectors. However, this lack of evidence is mainly due to limitations in the studies reviewed. 7 Some ecological studies have demonstrated stable or declining HCV prevalence in association with IEP programmes. 7, 10
There is evidence to suggest that low levels of change in injecting risk behaviour may not be sufficient to reduce HCV transmission because of the large pool of infection in the injecting population, 11 and the high rate of transmission among new injectors. 4 Therefore, there must be much greater reductions in needle sharing and much higher sterile needle / syringe coverage to reduce HCV prevalence in the injecting population.
At the same time, the literature is clear that the distribution of sterile needles and syringes alone is not sufficient to reduce the transmission of blood-borne viruses (especially, HCV) among injecting drug users. 6,12 For example, injectors need to be educated not to reuse or share needles or other injecting paraphernalia.
In Scotland, despite reports of a decreasing trend in sharing needles, HCV prevalence remains high among injecting drug users. A recent study of prevalence among injectors attending IEP services in three Scottish Health Board areas found that overall, over half of the injectors surveyed had been infected with HCV. 13 However, there was substantial regional variation in prevalence, ranging from 36% in NHS Lothian to 71% in NHS Greater Glasgow & Clyde. This same study also found similar variations in incidence among new injectors in this group.
Although there is some evidence of a decline in the frequency of sharing needles and syringes in Scotland since 2001, the sharing of other (non-needle) injecting equipment such as filters, spoons and water continues to be common. 14,15, 16,17,18
At the same time, a national study of IEP services carried out in 2005 (referred to throughout this document as the National Needle Exchange Survey), found inconsistent and variable service delivery among services in Scotland. 19 This research found widespread variation not only in the provision of injecting equipment, but also in staff training, and in the nature of interventions offered within IEP services. Particularly worrying was the finding that there were also very wide geographical variations in the average number of needles distributed per injector per year - ranging from 57 needles per injector per year in one area to 479 needles per injector per year in another. If it is estimated that injectors inject, on average, 2-3 times per day, 20,21 the shortfall in the number of needles currently being distributed in Scotland can be estimated to be several million per year.
The HCV epidemic presents new challenges to IEP services. One of the challenges is to increase the uptake of sterile injecting equipment. In addition, to reduce sharing of injecting equipment, services need to seek ways of undertaking intensified interventions, without alienating service users. Some services may need to change what they are doing with injectors; others may need to do more of what they are already doing.
Aims of the guidelines
These guidelines aim to provide a consistent framework which can be used across Scotland to support the delivery of IEP services. The objectives of the guidelines are:
1. To promote good practice in relation to the planning and development of IEP services
2. To improve the accessibility of sterile needles, syringes and other injecting equipment to injecting drug users who are at risk of acquiring HCV and other BBVs
3. To improve the quality and consistency of IEP services
4. To promote integration between IEP services and other services for injecting drug users, including primary, secondary and social care services
5. To ensure that local areas are taking active steps to protect the health and safety of IEP service staff and clients, and the community in relation to the disposal of used injecting equipment.
Who are these guidelines intended for?
These guidelines have been written for people who have responsibility for the planning, commissioning and delivery of IEP services. This includes senior managers in NHS Boards, local authorities, the police and voluntary sector agencies who have a responsibility for developing and funding services in their local area. It also includes front-line service providers and their staff, both in the voluntary and statutory sectors (including NHS and social work staff, community pharmacists and pharmacy staff; and prison and police officers involved in the provision of needle replacement schemes).
It should be noted that the Hepatitis C Action Plan, Phase II, stipulates that HCV Prevention Leads will be responsible for ensuring the implementation of these guidelines in their area. The order in which individual recommendations are implemented and the overall timescales for implementation may be determined by local NHS Boards. However, the guidelines must be implemented in their entirety by March 2011. The Action Plan requires that service activity be audited against the guidelines, and that performance be measured against targets set by all NHS Boards in 2009.
The structure of this document
This document is in two parts. The first part contains three chapters:
- Chapter 1 (the current chapter) sets out the background and context for developing IEP guidelines for Scotland.
- Chapter 2 describes the process of developing these guidelines, discusses the nature of evidence available and how that evidence has been used in drafting the guidelines.
- Chapter 3 describes and discusses the strengths and limitations of different IEP service models. Note that reference will be made to the information in this chapter throughout the guidelines.
The second part of the document contains the guidelines themselves, which have been grouped into five sections:
- Section 1: Developing an IEP programme - makes recommendations related to the process of developing and reviewing local IEP services.
- Section 2: Increasing the distribution of injecting equipment - focuses on increasing the quantity of injecting equipment (both sterile needles and other injecting paraphernalia) that IEP services give out.
- Section 3: Improving the effectiveness and consistency of IEP services - makes recommendations aimed at improving the quality of IEP services, particularly in relation to the way service providers interact with their clients.
- Section 4: Integrating IEP services with other services - aims to promote more integrated care for injecting drug users, particularly for those who are infected with HCV.
- Section 5: Health and safety of staff, clients and the community - makes recommendations which aim to protect the health and safety of staff and to promote safe disposal of used injecting equipment.