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Background

In December 2002, Scotland's Lord Advocate reviewed the Guidelines that govern the number of needles and syringes ( n/s) dispensed at any one visit to a needle exchange. The new Guidelines increased the number that could be distributed to a maximum of 20 sets (previously 5 sets) on the first visit; a maximum 60 sets (previously 15 sets) on subsequent visits; and an exceptional upper limit of 120 sets (previously 30 sets) for holiday periods when facilities are closed or are difficult to access. These exchanges are subject to the return of used equipment for safe disposal. This study set out to evaluate the effects of this change on IDUs' risk behaviours.

Aims and Objectives

The aim of the evaluation was to determine if increasing the supply of sterile needles and syringes to injectors reduces the frequency of needle and syringe sharing. The main objectives of the study were to ascertain if the lifting of the Lord Advocate's restriction on the number of needles and syringes distributed to injectors:

1. reduces the frequency of needle and syringe sharing among injectors;
2. causes any other behavioural changes among injectors, either beneficial or detrimental, e.g. frequency of visits to needle exchange

The evaluation also sought to determine the views of needle exchange and pharmacy workers on the increase in supply of needles and syringes.

Methodology

Evaluating the impact on risk behaviours

The study originally set out to evaluate the effects of the new Guidelines by comparing risk behaviours of Glasgow IDUs in 2004 with the behaviours of IDUs who had been interviewed in 2001-2002. Only recent initiates to injecting ( i.e. those who had injected for six years or less were included. Recruitment of IDUs commenced a year after the introduction of the new Guidelines. However it soon became apparent that most IDUs were unaware that they could now obtain an increased number of sterile n/s per visit. It was clear that the aim of determining if the increase in supply had reduced risk behaviours could not be achieved.

Therefore, an awareness-raising campaign was incorporated into a new study design. This campaign, consisting of cards and posters displayed in, and distributed through, pharmacies, needle exchanges and drug treatment centres, informed IDUs that they could now collect more n/s and also included harm reduction advice.

The new study design changed to include all current injectors, i.e. those who had injected at least once in the four weeks prior to interview. This allowed the recruitment of a more representative sample of injectors than in the original proposed method. Injectors within the sample who had begun injecting within the previous six years would still be compared to the respondents in 2001-2002 study to determine if there had been any change in behaviours over this longer period.

Between February and May 2004, prior to the introduction of the awareness campaign, 296 IDUs were recruited to the study from a variety of venues including street sites, pharmacies, needle exchanges and drug treatment centres. They were interviewed with a structured questionnaire about their drug use habits and risk behaviours. The results of this phase of the study formed a baseline against which any changes in behaviour following the implementation of the awareness campaign could be measured. Six weeks after the introduction of the awareness campaign, recruiting for the post awareness sample began and 299 IDUs were interviewed over a three-month period.

Evaluation of the views of needle exchange and pharmacy workers

Two members of staff from each participating pharmacy and needle exchange were interviewed. Staff members were asked a series of structured, open-ended questions about their views on the increase in supply of needles and syringes. These included their perceptions of any impact the Lord Advocates guidance had had on their service including frequency of attendance by drug users and any impact on return of used n/s.

Results

The impact on risk behaviours

A total of 595 injectors were interviewed, 296 and 299 IDUs in the pre- and post-awareness campaign respectively. The characteristics of the participants in the pre- and post-campaign phases were comparable with respect to proportion of males (86% and 83% respectively); age at interview (mean 32 yrs in both); age at first injection (mean 21 yrs in both); length of injecting career (mean 11 yrs in both); recruitment setting (79% and 86% recruited in street respectively); type of residence in the six months prior to interview (hostel accommodation 37% and 36% respectively); and having ever been in treatment for drug use (93% and 88% respectively). Heroin was injected by 93% in both samples. A significantly higher proportion of IDUs from the post-awareness campaign phase (54%) injected drugs twice daily or more compared to those recruited pre-campaign (44%).

There were no significant differences in injecting risk behaviours in the four weeks prior to interview. Almost 80% in both sweeps reported never having injected with a n/s previously used by someone else.

There was no significant difference in the number of n/s obtained in an average week from a pharmacy or needle exchange between the pre- and post-awareness surveys. Pre-awareness respondents obtained an average of 26 n/s (median=20) and post awareness IDUs received an average of 27 n/s (median=30) per visit.

There was a significant decrease in the number of respondents obtaining sterile n/s from non-exchange sources ( i.e. friends, other drug users, on street, sexual partner, family, theft and drug dealers) in the post-awareness phase.

The maximum number of needles and syringes that IDUs believed could be obtained per visit from a pharmacy or needle exchange increased significantly from a median of 20 n/s to a median of 25 n/s, an increase of 25%, between the pre- and post-awareness surveys. Few injectors, however, knew that the limit had been changed in either the pre- or post-surveys (20% in both).

About three-fifths of IDUs in both pre and post awareness surveys said that they did not want to obtain as many as 60 n/s per visit and they were, moreover, satisfied generally with the number they were currently receiving (a mean of 19 and 21 (median 15 and 15), pre and post awareness campaign, respectively). In both samples, the main reason for not wishing to obtain a greater number was that this was enough for their injecting needs (206/359, 57%). Despite this claim, half of these respondents (181/359, 50%) stated that, on average, they injected with the same needle more than once. Among IDUs who did wish to receive more n/s than they were currently receiving (236/595, 40%) the most common reason was to cut down the number of visits to the needle exchange (74/236, 31%).

In the 2004 survey, 170 IDUs had begun injecting in the previous six years and their behaviours were compared with those of 385 IDUs with the same length of injecting careers who had been interviewed in 2001-2002.

Injecting of cocaine (on its own) had increased with just over half of recent initiates reporting use of cocaine in the previous months in 2004 compared with just under two-fifths of IDUs in 2001-2002. With the increase of cocaine use it might have been expected that the frequency of injecting would also increase, however there was a significant decrease in the frequency of injecting in the previous six months in the 2004 sample compared with the 2001-2002 survey.

Moreover, those interviewed in 2004 were significantly less likely to inject with a n/s previously used by someone else; just over half of the 2001-2002 sample had injected in the previous six months with a n/s previously used by someone else compared with a quarter in 2004.

Views of needle exchange staff

Forty staff were interviewed about their views on the new Guidelines. This included 19 pharmacy assistants, 14 pharmacists, 2 nurses and 5 team workers. The majority of staff (37/40) knew about the new guidelines and nearly two-thirds (25/40) could correctly cite the maximum number of n/s that could be given out per visit.

Almost all (36/40) said that they had informed clients of this change. However, it appeared that, apart from displaying information about the new Guidelines, some staff directly told IDUs of the change only if asked. Other staff were more pro-active and explained the change to clients and encouraged them to take more n/s.

Just over a third of staff approved of the new Guidelines, one-third disapproved and the remainder had mixed views. Furthermore, whilst just under two-thirds said that the number of n/s that they dispensed depended on the number of returns they received, some said that they decided what to dispense according to how well they knew the client.

There were mixed views on the impact that the Guidelines had on exchanges. A third felt that the change in guidance had no impact on the pharmacy/exchange while nearly a quarter believed that the frequency of visits by individuals had reduced. The remainder cited a variety of changes including an increase in numbers of clients (7/40), a decrease in clients (6/40) and an increase in frequency of visits (3/40).

Conclusions

More than a year after the introduction of the Lord Advocate's new Guidelines, very few IDUs in Glasgow were aware of the increase in the maximum number of n/s that could be obtained per needle exchange visit; even a specially designed, targeted campaign failed to raise awareness.

After the introduction of the new Guidelines, needle exchanges and pharmacies displayed information and informed IDUs. The results of the staff survey, however, indicated that some staff did not actively promote the increase to services users. Moreover, only one-third of staff approved of the new guidelines and some used their own judgement in deciding how many n/s should be given out. It may be that the reluctance to implement, or disapproval of, the Guidelines among some staff was one reason for the low level of awareness among IDUs. Needle exchange and pharmacy staff need, therefore, to be made more aware of the necessity to actively provide oral advice and information to their clients. The attitude of some staff, however, does not explain why the targeted awareness campaign also failed to inform the majority of IDUs.

One of the study findings indicated that IDUs did not generally wish to have any more n/s than they were currently receiving. The message contained in the awareness campaign (or imparted by pharmacists) that more n/s were available was therefore meaningless to them. The main reason given for not wanting more n/s was that the current level was sufficient for their needs. However it was noted that half of these IDUs were re-using their own n/s; yet the awareness campaign cards alerted IDUs to the risks involved in this.

Due to time constraints, the time period for the awareness campaign was six weeks. After this period, recruitment for the post awareness group began. Cards and posters were distributed to agencies throughout the city and were placed inside the packs of n/s that are distributed through the pharmacy exchanges. The cards placed within the packs, however, would not have reached some injectors until towards the end of the recruitment period. It may be that if the campaign had run for a longer period it would have had more impact.

There is some evidence, however, that leaflets are not successful in communicating messages to IDUs. Some IDUs may, for example, have literacy problems. There is perhaps a need to evaluate the readability of written harm reduction materials and to design and evaluate new ways of delivering harm reduction messages to IDUs.

Nevertheless, there have been some positive changes among IDUs in Glasgow since the introduction of the awareness campaign and since 2001. The maximum number of n/s that IDUs believed could be obtained per visit from a pharmacy or needle exchange increased significantly. Respondents were also less likely to obtain sterile n/s from non-legitimate sources in the post-awareness phase. Whilst frequency of injecting had increased, there was no increase in sharing behaviour. A comparison between recent initiates to injecting in 2001-2002 and 2004 found a decrease in both frequency of injecting and sharing in 2004.

These changes cannot definitely be proved to arise directly from the increased availability of n/s; other factors may have influenced behaviour between 2001-2002 and 2004. Nevertheless, the association between the introduction of the new Guidelines and behaviour changes suggests that the former may be having a positive impact. It would seem prudent to continue with the current policy on n/s distribution. However, the findings from this study suggest that further work needs to be done by needle exchange staff to inform IDUs of their entitlement to a greater number of n/s and to encourage them to make use of it.

References

Hutchinson S, Taylor A, Goldberg D, Gruer L. (2000). Factors associated with injecting risk behaviours among serial community-wide samples of injecting drug users in Glasgow 1900-1994: implications for control and prevention of bloodborne viruses. Addiction; 95(6): 931-940.

Hutchinson SJ, McIntyre PG, Molyneaux P et al. (2002). Prevalence of hepatitis C among injectors in Scotland 1989-2000: declining trends among young injectors halt in the late 1990s. Epidemiology and Infection; 128: 473-7.

Information Services Division, Scotland. Drug Misuse Statistics Scotland 2004. Edinburgh: ISD 2004.

Preventing HCV in Scotland: Options for Action - a report of a Deliberative Seminar. HEBS, 2002.

Taylor A, Fleming A, Rutherford J, Goldberg D (2004). Examining the injecting practices of injecting drug users in Scotland. Effective Interventions Unit, Scottish Executive, Edinburgh.

Wright N, Oldham N, Jones L. Homelessness and heroin related death - a qualitative study exploring associations. Drug and Alcohol Review (in press).

This publication is available athttp://www.drugmisuse.isdscotland.org/eiu/eiu.htm or from 0131 244 5117 oror from 0131 244 5117 oreiu@scotland.gsi.gov.uk