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Chapter 1: Background and context
Headlines from this chapter
- The National Needle Exchange Survey was a UK-wide study carried out in partnership with the National Treatment Agency ( NTA) in England; the Welsh Substance Misuse Policy Development Team; and the Northern Ireland Department of Health, Social Services & Public Safety. The Scottish study was funded by the Scottish Executive under the Drug Misuse Research Programme, and was carried out between 15 January and 30 September 2005.
- Needle exchanges have a vital role to play in reducing the risks associated with injecting drug use. However, until now, there has been very little information available on needle exchange provision in Scotland. There has been no accurate data on the number and location of services, the ways in which they are organised, or the interventions offered by them. Previous research has suggested that there is a great deal of variation in service provision.
- The National Needle Exchange Survey aimed to:
- Map needle exchange service provision
- Investigate the nature of that service provision
- Identify areas of good and innovative practice
- Identify barriers and difficulties in commissioning and delivering needle exchange services.
This document reports on the findings of a survey of needle exchange provision in Scotland. The study was part of a larger UK-wide study carried out in partnership with the National Treatment Agency ( NTA) in England; the Welsh Substance Misuse Policy Development Team; and the Northern Ireland Department of Health, Social Services & Public Safety. The Scottish study was funded by the Scottish Executive under the Drug Misuse Research Programme and was carried out between 15 January 2005 and 30 September 2005.
Policy and research context
Findings from the most recent Scottish prevalence study indicate there are an estimated 51,582 problem drug users in Scotland (Hay et al, 2005), where problem drug use was defined as the misuse of opiates and / or benzodiazepines. Of these, 18,737 individuals were estimated to be injectors.
There are a number of serious risks associated with injecting drug use. Compared to non-injectors, injectors have higher rates of drug-related mortality. They are also at increased risk of acquiring blood-borne viruses ( BBVs) such as HIV and viral hepatitis, and bacterial infections ( HPAet al, 2005).
Needle exchange services have a vital role to play in reducing the risks associated with injecting - particularly in relation to preventing transmission of BBVs. And while the effectiveness of needle exchange programmes in the prevention of HIV is now well-established ( WHO, 2004), the evidence suggests that needle exchange has been less effective in controlling Hepatitis C infection. However, until recently, it has not been clear why.
In Scotland, it is estimated that 50,000 people are infected with the Hepatitis C virus ( HPAet al, 2005). The vast majority of these individuals acquired their infection through injecting and roughly two-thirds have undiagnosed infections. Incidence among injecting drug users ( IDUs) is also very high. Surveillance studies of injectors in Glasgow have shown that 50% of IDUs who had been injecting for less than two years in 2004 were already infected with Hepatitis C ( HPAet al, 2005). There is also some evidence that Hepatitis C prevalence among injectors may vary considerably across Scotland although it is not clear why this should be so. What is clear is that both incidence and prevalence of Hepatitis C have been on the rise in Scotland.
In Scotland, national policy in relation to needle exchange is different to other parts of the UK. In Scotland, there is a limit on the numbers of needles and syringes that may be given out to an individual in any one transaction in a needle exchange. These limits have been set by Scotland's Lord Advocate, and were revised upwards in December 2002 in response to growing concerns about the Hepatitis C epidemic among IDUs ( NHSHDL No.(2002)90). The current limits on needle and syringe provision are:
- Maximum 20 needles/syringes on the first visit (up from 5)
- Maximum 60 needles/syringes on subsequent visits (up from 15)
- An exceptional upper limit of 120 for holiday periods when facilities are closed or where facilities are difficult to access (up from 30).
An evaluation of the impact of this change in policy found that, over a year after the change had taken place, few injectors were aware of it. This same study also found wide variation in practices among pharmacy needle exchange services in Glasgow in terms of whether IDUs were encouraged to take a greater number of needles / syringes at each transaction. Furthermore, interviews with IDUs found that few injectors wanted as many as 60 needles / syringes when they visited the needle exchange, despite admitting that they frequently re-used needles / syringes (Taylor et al, 2005). These findings suggest that the current limits set by the Lord Advocate on needle / syringe distribution are not directly contributing to the growing prevalence of Hepatitis C in Scotland.
It has been suggested that the sharing of needles, syringes and other injecting paraphernalia such as filters, spoons and water may be a contributing factor, both in Scotland and elsewhere, and in August 2003, upon the recommendation of the Advisory Council on the Misuse of Drugs, an amendment to Section 9A of the UK Misuse of Drugs Act (paraphernalia) came into effect. The change in law allows doctors, drug treatment workers and pharmacists to supply drug users with ampoules of water for injection, swabs, spoons, filters and citric acid to help prevent disease and infection.
Ethnographic research among IDUs in Glasgow has provided an additional perspective on this issue. This research found little evidence of direct sharing of needles and syringes among IDUs, but frequent sharing and reusing of paraphernalia such as filters, spoons and water. IDUs also commonly engaged in "indirect" sharing of previously-used, potentially contaminated needles and syringes. The researchers concluded that IDUs need more information about the ways in which injecting equipment can become contaminated during the process of preparing drugs (Taylor et al, 2004).
The findings from this research have important implications for needle exchange services. The message is clear: it is not enough to simply give IDUs sterile needles, syringes and other paraphernalia; they need to understand how to use this equipment correctly. Needle exchanges therefore must take on much more of an educational role with IDUs.
In Spring 2005, input from key stakeholders to the drafting of Scotland's Hepatitis C Action Plan identified the expansion and development of needle exchange services as one of Scotland's top priorities for action in relation to Hepatitis C prevention (Scottish Executive, 2005, Annex B). This sentiment was echoed in the annual Shooting Up report published in October 2005 ( HPAet al, 2005). The latter document made specific recommendations regarding needle exchange services, which included:
- Ensuring sufficient distribution of injecting equipment to prevent the sharing of needles and syringes
- Providing injecting-related equipment other than needles and syringes as appropriate
- Ensuring an appropriate range of needle exchange services are provided ( i.e., through drug services, pharmacies and mobile or outreach services)
- Ensuring appropriate training for needle exchange staff
- Expanding the educational role of needle exchange services
- Expanding the services available through needle exchanges - to include on-site vaccination for Hepatitis B, and testing for HIV and Hepatitis C.
At the same time, in 2005, a decision was taken to update the Scottish guidelines on needle exchange published in 2000. 4 National guidelines on needle exchange were produced in 1999 by a working party of the UK National Needle Exchange Forum. This document provided a guide to best practice in organising and delivering needle exchange services. A year later, a Scottish version of this document was published by the Scottish Drugs Forum ( SDF), who host the Scottish Needle Exchange Workers Forum. The National Guidelines for Needle Exchange in Scotland included modifications of the UK guidelines which reflected local issues facing services in Scotland. The Scottish guidelines were intended to provide a standard against which needle exchange services in Scotland could be evaluated.
However, until now, there has been very little information available on needle exchange provision in Scotland. Corporate Action Plans, submitted annually to the Scottish Executive by Drug Action Teams ( DATs), only require details on the total number of specialist, outreach and community pharmacy needle exchange facilities in their area, and the total number of needles / syringes distributed and returned for each category. Apart from this, it has not been clear how services are organised or what interventions are offered by needle exchange facilities, but previous research in local areas has suggested that there was a great deal of variation in service provision.
It is within this context that the Scottish Needle Exchange Survey was commissioned.
Aims of the study
The Needle Exchange Survey in Scotland had the following aims:
- To map needle exchange service provision
- To investigate the nature of that service provision
- To identify areas of good and innovative practice in this area
- To identify barriers and difficulties in commissioning and delivering needle exchange services.
The results of the study are intended to lead to improvements in needle exchange services.
Structure of the report
This report will look in detail at aspects of needle exchange provision in Scotland.
Part 1 will focus on needle exchange service delivery and activity. It will cover:
- The number, location and types of services ( Chapter 3)
- The accessibility of needle exchange services ( Chapter 4)
- Day-to-day needle exchange activity - in terms of numbers of transactions / client contacts, number of clients, numbers of syringes distributed and returned ( Chapter 5)
- Other on-site interventions provided by needle exchange services in Scotland ( Chapter 6)
- Needle exchange policies and procedures ( Chapter 7)
- Selected comparisons between services in Scotland and England ( Chapter 8).
Part 2 of the report will focus on findings in relation to the planning and commissioning of needle exchange services in Scotland. It will cover:
- The co-ordination, planning and commissioning of services ( Chapter 9)
- Staff training and qualifications ( Chapter 10)
- Perspectives on good practice ( Chapter 11)
- Problems and impediments in commissioning and delivering services ( Chapter 12).
Chapter 13 will draw some conclusions from both parts of the report, and make recommendations to policy-makers, service commissioners and service providers.
A summary of the main findings (or "Headlines") will be presented at the start of each chapter.
However, before going on to present the findings, Chapter 2 first describes the methods used to carry out the research.
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