Section 2: Increasing distribution of injecting equipment
The recommendations in the previous section focused on improving the accessibility of IEP services to injecting drug users. The recommendations in this section are about increasing the quantity of injecting equipment (both sterile needles and other injecting paraphernalia) that services give out. The aim of these recommendations is to make it possible for every injector to use a sterile set of injecting equipment for every injection. This principle should guide the distribution of injecting equipment in allIEP services in Scotland at all times.
Until recently, in Scotland there was a legal limit on the number of sterile needles that IEP services may give out to injecting drug users at any one time. These limits were set by Scotland's Lord Advocate in December 2002. 59 In recognition of the important public health imperative to encourage one needle per injection, the Lord Advocate has agreed to remove any requirement to limit needle and syringe provision, or the requirement to return used needles, and has issued new Guidelines to reflect this agreement in line with the publication of these Scottish Government guidelines for IEP services.
It is important to bear in mind that, although there was previously a legal limit on the number of needles and syringes that IEP services could give out to a client at any one time, there was also evidence from research to indicate that injecting drug users were not receiving anywhere near these numbers of needles when they attended IEP services. The reasons for this are discussed below under Recommendation 5.
Recommendation 5: Provide one needle / syringe per injection
IEP services should provide, free of charge, as many needles as an individual client requires.
Services should continue to encourage clients to return used needles, and individual safe disposal bins should be provided for this purpose. However, the provision of sterile needles should not be dependent on the return of used needles. Services should aim at all times to ensure that all clients have a sterile needle for every injection.
NHS Boards should ensure that all IEP services in their area are actively encouraging their clients to take sufficient numbers of needles.
A review of evidence carried out for NICE found that higher needle coverage is associated with lower levels of injection risk behaviours among injectors, including sharing needles, sharing cookers and syringe re-use. 6 However, findings from the National Needle Exchange Survey showed that the number of needles currently given out to injecting drug users in Scotland falls far short of the number required to ensure one needle per injection. The short-fall is estimated to be in the millions. 19
Statistical modelling studies have shown that there is a need to reduce needle sharing substantially to make a real difference to the incidence of HCV. 11 While there has been a slow decline over the past few years in the intentional sharing of used needles among injecting drug users, 14,15 nevertheless, the re-use of previously used needles and unintentional sharing of needles continues to be common. 16,17
Until recently, there were legal limits set on the numbers of needles and syringes that could be distributed to injecting drug users in any one transaction. However, the findings of the National Needle Exchange Survey in 2005 showed that, within those limits, very few injectors were receiving their entitlement. 19 This was due to a combination of factors. An evaluation of the impact of the Lord Advocate's Guidelines (as published in December 2002) found that injectors often did not ask for their entitlement - either because they did not know what it was, or because they felt they were already receiving sufficient needles for their injecting needs - despite re-using needles. 31
At the same time, some IEP services in Scotland had distribution policies that were contrary to - and which placed greater restrictions on numbers - than the Lord Advocate's Guidelines. 19, 31 In some cases, these policies were intended to "encourage" the client to return used injecting equipment to the IEP service. However, the unintended consequence was that some clients had to re-use or share needles.
The National Needle Exchange Survey also found massive variations between local areas in the numbers of needles distributed per injector in a one-year period - suggesting that the short-fall in distribution may be related to service configuration or local service policies. 19
As of March 2010, there are no legal limits on the numbers of sterile needles and syringes that IEP services can give out to their clients. Therefore, any local policies that limit the distribution of sterile injecting equipment should be removed, and services should make every effort to ensure that all their clients are able to use a new needle and syringe for every injection.
As of March 2010, there is also no legal requirement for clients of IEP services to return used injecting equipment before new equipment can be distributed. Experts agree that it is poor practice to limit the distribution of injecting equipment when clients do not bring back used equipment. 60 Nevertheless, it is good practice to encourage clients to return their used equipment. Furthermore, individuals can be prosecuted if they are found disposing of used injecting equipment in a way that could put members of the public at risk. It is suggested that service commissioners should explore new ways of maximising needle return, for example, through the provision of specially-designed public disposal bins and through home collections. At the same time, service providers should discuss with their clients how best to promote personal and civic responsibility among injectors in relation to this issue.
Above all, IEP services should develop strategies to actively increase needle distribution among injectors, and where there are barriers to increasing uptake (either from the service, or from the client), these should be removed. Clients visiting the IEP service should be encouraged to take more needles, and the message needs to be continually reinforced that individuals should use a sterile needle for every injection.
Recommendation 6: Provide other drug injecting paraphernalia
IEP services should provide, free of charge:
- Water for injections
- Pre-injection swabs
These items should be supplied in sufficient quantities to enable the use of one item each per injection.
The sharing of injecting paraphernalia used in the drug preparation process - for example, cookers, filters and water - may present further opportunities for the transmission of BBVs. Evidence from a laboratory study which tested used paraphernalia from injecting drug users, found HCV on 67% of swabs, 40% of filters, 25% of spoons and 33% of water samples. 61 There is insufficient evidence to indicate that the provision of sterile paraphernalia reduces injecting risk behaviour or the transmission of HCV because few studies have been undertaken. 6,7 A review of epidemiological studies found evidence of a positive association between HCV incidence and sharing paraphernalia, although the studies were limited by methodological issues. 62HCV seroconversion has been particularly associated with sharing spoons and cotton filters. 63,64 Given that the sharing of paraphernalia among injectors is highly prevalent, 14,16,17,18 even among those who report never having shared needles, the potential for transmission via this route is great.
Therefore, these guidelines strongly recommend that IEP services distribute cookers, filters, water for injections and pre-injection swabs to service users, and that this provision should be free of charge. If the provision is not free of charge, it is likely that injectors will use their own "home made" supplies - which are not sterile, and which may be reused again and again - thus increasing the risk of HCV transmission. It is worth noting that recent studies have found that the provision of injecting paraphernalia by IEP services was seen as a high priority among service users themselves. 18, 58
Although the use of an acidifier does not contribute to the prevention of HCV or other BBVs, this recommendation includes the distribution of acidifiers - either citric acid or ascorbic acid (both available in sachets). An acidifier is necessary to make diamorphine soluable for injecting. 65 In addition, there has been some evidence at a local level which shows that the distribution of citric acid can attract people to services. 66 Moreover, if a sterile acidifier is not supplied free of charge, injectors are likely to make use of alternatives such as processed lemon juice or vinegar, which have both been associated with a greater incidence of eye problems in injectors. 30
All of the items recommended for distribution here are permitted under The Misuse of Drugs (Amendment) (No.2) Regulation 2003 which came into force on 1 August 2003. 67 In addition, under the Medicines for Human Use (Prescribing) (Miscellaneous Amendments) Order 2005, which came into force on 30th June 2005, the distribution of water for injections is permitted without a prescription so long as the water is supplied in 2ml quantities or less. 68
The distribution of injecting paraphernalia also needs to be accompanied by a discussion about the correct single-person use of each item of paraphernalia. Service user education is discussed further in Recommendation 11.
In providing a sterile set of injecting paraphernalia for every injection, it must be accepted that there may be some waste of equipment that service users either may not want or not need. For example, one ampoule of water for injections or one full citric acid sachet may be more than is required for one injection. Injectors should be advised to dispose of the remaining water / citric acid safely, rather than attempt to store it for later use. Homeless injectors may not be able to carry large packs of injecting equipment with them, and so where the only supply of sterile injecting equipment is through pre-packed bundles, these injectors are likely to dispose of the equipment they do not immediately need. This latter situation can be avoided through the use of a 'pick-and-mix' arrangement, whereby clients choose the equipment and paraphernalia they need. Furthermore, where injecting supplies are distributed in pre-packed bundles, it may be possible to reduce waste by offering service users a range of packs containing different sizes and numbers of needles / syringes, and involving clients in the design of the packs.
Recommendation 7: Secondary distribution
Secondary distribution should not be discouraged. If a client states that he / she is supplying injecting equipment to others, it is acceptable to provide supplies for the purpose of secondary distribution.
However, those clients who supply equipment to others should be encouraged to bring the other injectors into the IEP service so that they can benefit from advice and information.
Secondary distribution of injecting equipment is very common. 18,32 Chapter 3 set out some of the advantages and disadvantages of secondary distribution in terms of preventing risk behaviour. The main advantage is that it can extend the reach of IEP services to injectors who may not be in contact with services and thus can get sterile injecting equipment to people who might not otherwise have it. The main disadvantage is that services have very little control over the information given to those who are the recipients of secondary distribution.
Where services are aware that secondary distribution is happening, IEP staff should ask the secondary supplier how many people he is supplying to, and whether there is any sharing of needles or other injecting paraphernalia. IEP staff should encourage the secondary supplier to bring those he supplies to into the service, and information should be provided about other IEP services offered in different localities and at different times.
Importantly, the secondary supplier should be asked to spend some time in the IEP service to discuss information about safer injecting practices, and the safe disposal of used injecting equipment, which he can pass on to those he supplies to. IEP services may find it helpful to have a supply of leaflets or other materials which they can talk through with the secondary supplier, and which he can pass on to others.
Where services have a good relationship with a secondary supplier, they should consider whether it might be appropriate to establish a more formal arrangement with this individual, for example, by developing a peer-led outreach service. As mentioned in Chapter 3, peer-led services have the same advantages as secondary distribution, but they also can be used to deliver better, more consistent harm reduction messages to members of the peer distributor's network.
There are examples from the literature of highly effective incentive-based peer-driven educational interventions, where injectors are given rewards for passing on a body of harm reduction information to their peers, and then recruiting those individuals to attend a harm reduction session in an IEP service. These were found to be significantly less expensive than traditional peer outreach interventions. 48
Recommendation 8: Provide methods for syringe identification
Injectors should always be encouraged to use a sterile needle and related paraphernalia for every injection. However, the reality is that some injectors may continue to reuse needles. Therefore, a method of equipment identification should be made available to clients who inject in the company of other injectors in order that they can identify their own equipment and avoid accidental sharing.
Despite the messages that service users are given about not re-using needles, many continue to do so, and where people inject in the company of others, it is possible that they may mix up their needles. An observational study among injectors in Glasgow highlighted the extent to which this situation can result in the accidental sharing of needles. 17
Therefore, injectors need to have some method of distinguishing their own equipment from other people's. This may include, but is not limited to syringes with colour-coded plungers, coloured labels or tags. Different methods may be preferred by different people.
However, at the same time, it is crucial that the central message - to always use a new needle / syringe for every injection - should never be watered down or forgotten. The use of syringe identifiers simply recognises that it may not always be possible for injectors to use a sterile needle / syringe each time. Syringe identification methods can help reduce the risks of cross-infection by helping to prevent accidental sharing of used needles.
The inability to tell the difference between used syringes has been recognised as a significant cause of syringe sharing and BBV transmission. 17 At the present time, there is no robust evidence on the most effective method of identifying / distinguishing syringes. However, it is likely that syringes that have difference built into the design will be more effective than methods that require injectors to mark or label their syringe.