The Pharmaceutical Journal
Vol 277 No 7413 p185-186
12 August 2006

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Exchanging views on needle exchange

Pharmacists have been offering needle exchange services for 20 years. Matthew Wright (on the staff of The Journal) looks back at the service's beginnings and takes stock of what pharmacists are doing to help minimise harm to drug misusers

Pharmacists have played an important part in the provision of needle exchange services for drug misusers over the past 20 years. “The evidence of the importance of needle exchange services to those who inject drugs is incontrovertible,” says pharmacist Kay Roberts, independent adviser on substance misuse issues to the Royal Pharmaceutical Society and chairman of PharMAG (a group with special interest in pharmacy and substance misuse).

However, experts in the field say that, although pharmacy has filled an invaluable role, much still needs to be done to engage more pharmacists in needle exchange and to offer far more than supply and disposal of syringes and paraphernalia.

Recent survey reports from the Scottish Executive Substance Misuse Research Programme (see Panel) and the National Treatment Agency for Substance Misuse (NTA) have looked at the extent to which needle exchange services are offered in the community, both through pharmacies and via specialist services (which usually incorporate a wider variety of drug treatment services).

Both reports have questioned why there is such variation in practice in all areas of needle exchange, such as accessibility of services, what equipment is provided and the level of advice given.

How it all began

Needle exchange services began in 1986 amid fears of the spread of HIV within the injecting drug user population.

“There is no doubt that the incidence of HIV/AIDS in the UK would be far higher than it is if needle exchange had not been introduced so rapidly in the mid 1980s,” says Mrs Roberts.

A study published in the British Medical Journal (1986;292:527) in February 1986 revealed that an alarming number of injecting drug users in Scotland were infected with “AIDS-related virus”; it had yet to be named HIV at that time. The authors found that 51 per cent of the 164 heroin users tested were seropositive for the virus.

From 1982 to 1986 the Society had taken a firm stance that needles were not to be given to drug misusers, on the grounds that this would help to curb the increase in numbers of people injecting. A statement by the Council required pharmacists to “restrict the sale of syringes and needles to bona fide patients for therapeutic purposes”.

In late 1985, however, the Society’s Scottish Executive agreed to recommend that the Society reconsider its advice on the matter in response to preliminary findings from Edinburgh City Hospital’s new AIDS clinic that “two out of five drug users in Edinburgh were likely to be carriers of the virus compared with one in 100 in London” (PJ, 7 December 1985, p763).

In 1986, the Society reviewed the then-recent findings relating to the risk of cross infection with the sharing and reusing of contaminated injecting equipment. “The Council agreed that it is unreasonable to retain the general restriction preventing the sale of syringes and needles to drug misusers. Where such sales are made it may be possible, in suitable cases, for the pharmacist to give appropriate warnings and information which will encourage a misuser to seek treatment,” The Journal reported (PJ, 15 February 1986, p205).

Britain’s first pharmacy needle exchange began in the same year at Boots West Street Pharmacy in Sheffield.

And the following year, the Society approved a set of guidelines for pharmacists wishing to become involved in needle exchange schemes (PJ, 11 April 1987, p481).

Needle exchange today

Now, nearly 20 years later, the new community pharmacy contract for England and Wales incorporates needle exchange as one of the new enhanced services, and in Scotland needle exchange is commissioned as an additional service.

In February this year, the NTA, the Society, the Pharmaceutical Services Negotiating Committee and PharMAG published best practice guidance for the commissioning of pharmaceutical services for drug misusers (PJ, 25 March, p337). The guidance aims to provide assistance to commissioners and pharmacy contractors in establishing needle exchange schemes, supervised opiate-substitute consumption and other shared care services for drug misusers.

Marion Walker, pharmacist in the NTA’s clinical team, was involved in putting together the guidance. She says that most needle exchanges are commissioned as part of a scheme. However, pharmacists should not be there just to give out equipment; what is wanted is for pharmacists to offer advice about minimising harm and to direct misusers to treatment services to improve their health, Mrs Walker says.

“A huge public health role exists in reducing the spread of blood-borne viruses — getting this hidden population in touch with health professionals,” she adds.

Mrs Walker explains that often drug misusers feel cut off from the rest of society. She says: “Pharmacists can engage with these clients. When you are seeing them every day, you can build a user-friendly, non-judgemental service. Many patients are grateful to have that. But it does depend on how well co-ordinated the scheme is.”

The NTA report “Findings of a survey of needle exchanges in England” (PDF 3MB) summarises the survey’s results; a full report is due to be published later in the year. It reveals that pharmacies constitute some 80 per cent of needle exchange facilities in England.

Mrs Walker says that the survey highlights the need for needle exchange through both pharmacies and specialist services.

The report says: “The ‘mixed economy’ of facilities maximised the availability and accessibility of sterile injecting equipment and the numbers given out to users. However, the ability of pharmacies to provide the range of interventions and measures necessary to reduce drug-related harm and blood-borne viruses was limited. The survey confirmed that pharmacy needle exchange schemes must be developed as complementary to specialist services rather than as alternative facilities.”

Mrs Walker points out that specialist services are able to spend far more time with individual clients than the pharmacy setting can offer.

Limitations and aspirations

“The Society’s change of advice regarding the sales of needles and syringes was an important turning point,” says Mrs Roberts. “Unfortunately, needle exchange has not had the same impact on the spread of other blood-borne viruses such as hepatitis C. Sharing of paraphernalia other than needles and syringes is still prevalent and the hepatitis C virus is far more infective than HIV,” she adds.

A research group led by Catriona Matheson from the department of general practice and primary care, University of Aberdeen, conducted a survey in Scotland from January to May this year, which is not yet published. According to Dr Matheson, the survey gives the latest figure — 12.5 per cent of pharmacies in Scotland are providing needle exchange services. This compares with some 19 per cent in England in 1996, she says.

Dr Matheson says: “We still cannot get enough pharmacists to offer needle exchange. In Scotland there is just under half the percentage of pharmacies providing the service than in England — for some unknown reason.”

She reveals some of her latest work: “We have recently completed an interview study with pharmacists to further explore barriers to service provision. These were found to be: fear of lack of control of drug misusers perhaps resulting in aggressive behaviour; concern that other customers will be put off; general safety concerns; and pressure from security staff who can intimidate drug misusers. Remuneration was not an issue.”

The pharmacist survey has been done locally in Grampian, funded by the local health board. It updates a Scotland-wide study published by the researchers in 1999 (International Journal of Pharmacy Practice, 1999;7:256) where pharmacists were interviewed about why they would or would not offer drug services, Dr Matheson explains.

But how well are drug misusers accessing these services? And what is their level of satisfaction? Dr Matheson’s team has made some inroads into understanding these uncertainties.

“We are doing an interesting study at present on what injecting drug users want from a needle exchange,” she says.

Drug misuse clients are being asked to choose their preferences from a list — early results indicate that approachable and knowledgeable staff are key, says Dr Matheson.

She adds: “This study has been an eye opener for me and I have been working in this field for some time. I think there is a misperception among pharmacists that drug users know what they are doing when they inject so they do not give much advice on safer injecting. Our preliminary findings indicate that often drug users often don’t know what they are doing and end up with dreadful injecting site injuries, not to mention hepatitis C.”

Mrs Roberts offers her concerns: “Pharmacists appear to be less willing to participate in needle exchange than they were 20 years ago. Yet for the UK, the public health and resource impact of hepatitis C is much greater than it is for HIV. Hepatitis C can remain non-symptomatic for many years but can ultimately result in liver cancer, cirrhosis and the need for a liver transplant.”

She says that drug injecting is now the main vector for the spread of hepatitis C in the UK.

Dr Matheson says that a major difference between pharmacies and specialist services is that “pharmacies are really just supplying and disposing. There are a very small number of dedicated pharmacists who are doing more.”

Mrs Walker holds a similar view: “Certain pharmacists are providing a very high level service. Others are only providing [basic] needle exchange. There are instances where perhaps pharmacists do not have enough support or there is no co-ordinator.

“The aim is to reinvigorate the programme; we want to improve the level of service across the board, with all pharmacists giving harm minimisation advice — the basic messages.”

Mrs Walker highlights pharmacist Martin Bennett’s work in Sheffield as an example of good practice (see Panel below).

Pharmacy needle exchange has the potential to be an important partner in the provision of clean injecting equipment and other paraphernalia and in providing public health information and advice, as well as directing needle exchange clients towards other appropriate services, says Mrs Roberts.