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Chapter 6: Interventions provided by needle exchange services

Headlines from this chapter

• Practices regarding client assessment and review varied in needle exchange services. Less than a quarter of non-pharmacy services (10 out of 45) reported that an initial assessment was always undertaken with new clients before sterile injecting equipment was provided. About a third (16 out of 45) said they encouraged a client review. However, the majority (27 out of 45) said that a review of client needs was not systematically undertaken.
• There were differences between services in the types of interventions that they offered to their clients on-site. More than half of non-pharmacy services provided their clients with face-to-face harm reduction advice, a list of other needle exchange facilities in the area, referral to structured treatment and brief motivational interventions. Fewer provided key working, structured counselling, care for minor infections, complementary therapies, training in overdose prevention, housing, social welfare or legal advice, and nutrition advice.
• Pharmacy schemes across Scotland offered a much smaller range of interventions to IDUs than non-pharmacy services.
• Only about half of Scottish non-pharmacy needle exchanges (25 out of 45) provided any form of on-site intervention related to BBVs. The interventions most commonly provided were HIV and Hepatitis C pre- and post-test counselling. Two-fifths of services provided Hepatitis C testing, but a third or less provided Hepatitis B testing, HIV testing or any form of immunisation. Only one service in Scotland offered their clients tetanus immunisation. There appeared to be an association between NHS Board and provision of on-site BBV interventions.
• In terms of injecting paraphernalia, the vast majority of both pharmacy and non-pharmacy services in Scotland provided their service users with sharps bins and wipes or swabs. However, there was variation in relation to the distribution of citric acid, stericups / cookers, filters, tourniquets, sterile water and other paraphernalia. Variations in paraphernalia distribution appeared to be associated with NHS Board.
• Focus group participants felt that these variations were unfair and sent mixed messages to service users about what constituted safe injecting practice. Participants in this study argued in favour of formal standards for paraphernalia distribution.
• Concerns were voiced by specialist service providers about the wide use of 'packs' to distribute syringes and other paraphernalia in pharmacies. There was a feeling that the use of a 'pick-and-mix' system resulted in less waste, and provided a good basis for a discussion with clients about the nature of their drug use and injecting practices. However, pharmacists felt that the use of a 'pick-and-mix' system was not practical in many busy pharmacies.

Many needle exchange facilities in Scotland provide services and interventions beyond the simple distribution of sterile needles and syringes. This chapter will look in detail at some of these interventions. It covers practices regarding client assessment and review, since an assessment of need is the first step to any further intervention. Paraphernalia distribution and blood-borne virus vaccination and testing will also be discussed.

The focus here is mainly on interventions delivered on-site by non-pharmacy services. It was assumed that pharmacy needle exchange services would offer fewer on-site harm reduction interventions and the Pharmacy Co-ordinator questionnaires reflected this.

Client assessment and review in non-pharmacy services

Assessment practices

Non-pharmacy needle exchange services were asked about their arrangements for the initial assessment of new needle exchange clients. The term "assessment" was defined as the identification of a client's needs based on an agreed and written set of questions. The results showed that:

• Less than a quarter of services (10 out of 45) reported that an initial assessment was always undertaken with new clients before sterile injecting equipment was provided.
• Just over a quarter (12 out of 45) said that no assessment was ever undertaken of new clients; half of these were either police custody suite exchanges, or exchanges based in hospitals.
• The majority (20 out of 45) said that they encouraged an initial client assessment, but this was not a condition of access to the service.

There was no apparent relationship between assessment practices and NHS Board or DAT area.

Those that did carry out an initial assessment (n=33) were asked to indicate which issues they covered. The results are shown in Table 6.1 opposite.

Client review

Services were also asked about their arrangements for the planned review of clients' needs. Again, it was specifically stipulated that "review" in this context meant a review based on an agreed and written set of questions. The findings showed that:

• Only one service in Scotland reported that a planned review was always undertaken as a condition of continued access to sterile injecting equipment.
• Just over a third (16 out of 45) said that they encouraged a client review, but it is not a condition of continued access to injecting equipment.
• The majority of services (27 out of 45) said that the review of client needs was not systematically undertaken.

Interventions provided on-site by non-pharmacy services

Non-pharmacy services were asked whether they provided other interventions which would be of benefit to injecting drug users. A list of possible interventions was provided. This question sought to determine what types of interventions were offered by services, and the extent to which they provided these interventions on-site - that is, without having to refer clients to other agencies. The results are shown in Figure 6.1.

Forty-four (44) of the 45 non-pharmacy services said they provided at least one of the interventions on the list. Police custody suite exchanges provided the smallest number of interventions - usually just a list of other needle exchange services in the area.

• More than half of services provided their clients with face-to-face harm reduction advice, a list of other needle exchange facilities in the area, referral to structured treatment, and brief motivational interventions.
• Less than half (n < 22 out of 45) provided key working or structured counselling, care for minor infections and complementary therapies.

Table 6.1: Number of services covering specified issues in initial client assessment

Figure 6.1: Number of non-pharmacy needle exchange services that provide the specified intervention on-site

Note to figure:
"Other" interventions included: podiatry services, personal development programmes, a clinic for complex abscesses and ulcers, antibiotic treatment, dental services, pregnancy testing, and access to social activities.

• Less than a third provided overdose prevention training for clients; housing, social welfare or legal advice; or nutrition advice.
• Few provided primary care sessions, well-woman clinics or other interventions.

There did not appear to be a relationship between number or type of interventions offered and NHS Board.

Interventions provided by pharmacy needle exchanges

Pharmacy co-ordinators were asked if their pharmacy schemes offered their service users interventions such as: leaflets containing written harm reduction information; face-to-face harm reduction advice; formal referral to drug treatment services by letter or phone; a list of drug treatment services in the area; and a list of pharmacy needle exchanges in the area. The findings are shown in Table 6.2 opposite.

The pharmacy schemes in Glasgow and Highland were the only ones that provided all five of the interventions listed above.

On-site interventions related to blood-borne viruses

Non-pharmacy services were asked whether they provided certain interventions related to BBVs within the needle exchange - that is on-site, without having to refer clients to another agency. The findings indicated that only about half of Scottish services (25 out of 45) provided any form of on-site intervention related to BBVs. Table 6.3 shows that the interventions most commonly provided were HIV and Hepatitis C ( HCV) pre- and post-test counselling.

• Two-fifths of services provided HCV testing.
• A third or less provided Hepatitis B ( HBV) testing, HIV testing, or any form of immunisation.
• Only one service in Scotland, a hospital-based service in Lanarkshire, offered tetanus immunisation.

These findings appeared to be contrary to findings from the focus group discussions, which had suggested that outreach needle exchange services in Scotland provided a wide range of BBV interventions. In fact, only 13 out of 22 outreach services offered any form of BBV testing or immunisation. There appeared to be an association between the availability of on-site BBV interventions and NHS Board (see Table 6.4) - however, the numbers are too small to undertake any meaningful statistical analysis.

Clients' needs in relation to on-site BBV interventions appeared to be best catered for in Argyll & Clyde, Dumfries & Galloway, Grampian, Lanarkshire, Lothian and Shetland.

One respondent from Lanarkshire said that her service had an arrangement whereby the Infectious Diseases Unit provided a clinic within the needle exchange service one morning per week. A similar arrangement existed within one outreach service in Edinburgh regarding HBV testing and immunisation. Interestingly a respondent from Forth Valley reported that one aspect of good practice in their area was the links that had been established with local hepatology services and the participation in a Hepatitis C Managed Clinic Network. However, it would seem that these positive steps did not extend to the provision of BBV interventions on-site within needle exchange services.

Table 6.2: Interventions offered by pharmacy needle exchange schemes

Note to table
"Other" interventions provided by pharmacy schemes included: a list of the nurse-led needle exchange clinics in the area, and leaflets concerning local issues as and when they arose.

Table 6.3: Number of non-pharmacy services that provide on-site interventions related to blood-borne viruses and tetanus

Table 6.4: Distribution of BBV interventions in services across Scotland, by NHS Board

Note to table
In the table above, a tick (v) represents one service. Note that services in Western Isles and Orkney did not participate in the Services survey. It should be noted that police custody suites were in Fife, Forth Valley, Grampian, and Tayside. These services would not be expected to provide on-site BBV interventions.

Paraphernalia distribution

Lively discussions took place in all three Scottish focus groups on the subject of paraphernalia distribution. Focus group participants reported that paraphernalia distribution varies from one health board to another across Scotland. And moreover, they suggested, the principle factor in deciding what gets distributed is, first, funding, then knowledge of good practice. Participants felt that existing funding constraints led to a number of unsatisfactory trade-offs needing to be made.

For example, in one health board, the decision to distribute paraphernalia meant that there was no funding to allow for an expansion of needle exchange services in the area. In other areas, one set of paraphernalia was being distributed by voluntary sector services, and another by pharmacies and/or NHS harm reduction services.

Service providers were especially concerned about this situation. They argued that it was not only patently unfair, but it sent mixed messages to service users about what constituted safe practice. One service provider expressed frustration with her local health board and suggested that their unwillingness to provide funding for citric acid distribution was undermining her credibility with her clients, and compromising her ability to deliver a high-quality service.

Service providers argued that paraphernalia provision should not be seen by the funders of services as an added luxury - the proper use of sterile paraphernalia was seen to be necessary to reduce harm. It was for this reason that the law regarding distribution of paraphernalia was changed. Service providers and pharmacists strongly felt that the quality of harm reduction services and interventions should be the same for everyone, regardless of where they live or where they access the service.

Findings from the survey

Given this context, it was expected that the findings from the survey would reflect variability across Scotland with respect to paraphernalia distribution. Service providers were asked to indicate which items of paraphernalia their service distributed for free. Table 6.5 presents the results. And indeed, as expected, there were differences between services, and as Table 6.6 suggests, these differences appeared to be associated with NHS Boards.

The vast majority of both pharmacy and non-pharmacy services in Scotland provided their service users with sharps bins and wipes / swabs. Only one pharmacy scheme, NHS Orkney, did not provide these items. However, as already mentioned, the pharmacy scheme in Orkney had not been used in the previous year.

Differences were noticed in relation to other forms of paraphernalia. For example:

• Acidifiers (citric acid / Vit c): Thirty-six (36) services (out of 45) said they supplied some form of acidifier to injectors free of charge. In all cases but one, the acidifier was citric acid (n=35). However, one service in Scotland, the Shetland service, supplied Vit C instead of citric acid, and one service in Edinburgh supplied both citric acid and Vit C. Only nine services in Scotland said they did not supply any form of acidifier free of charge. Eight of these services were located in two NHS Board areas - NHS Grampian and NHS Highland. The ninth service was a police custody suite in central Scotland which operated a needle replacement scheme only.

Similarly, six out of 10 pharmacy schemes supplied citric acid. Those who did not were in Ayrshire & Arran, Grampian, Highland and Orkney. None of the pharmacy schemes distributed Vit C.

Table 6.5: Number of services that distribute injecting paraphernalia free of charge

Table 6.6: Distribution of paraphernalia in non-pharmacy services in Scotland, by NHS Board

Note to table
In the table above, a tick (v) represents one service. Note that non-pharmacy services in Western Isles and Orkney did not participate in the Services survey.

• Stericups / cookers: Thirteen services said they supplied stericups / cookers to their service users. These services were in Argyll & Clyde (3 out of 4 services), Dumfries & Galloway (2/3), Lanarkshire (1/4), Forth Valley (1/2) and Tayside (5/5). In addition, one service in Edinburgh, an outreach service to homeless people, also supplied stericups. The services in Lanarkshire and Forth Valley are the two main needle exchange providers in these areas. Both operated a number of satellite clinics throughout the region. Only one pharmacy scheme, NHS Tayside, supplied stericups.
• Filters: Eleven services said they distributed filters to their service users. Only one pharmacy scheme distributed filters.
• Tourniquets: Tourniquets were distributed by eight services, and sterile water was distributed by only five services.
• Crack-related paraphernalia: Only two services in Scotland reported distributing crack-related paraphernalia. One of these was an A&E exchange and one was a police custody suite.

Standards for paraphernalia distribution

In focus group discussions, DATs, service providers and pharmacists unanimously agreed that there should be standards for paraphernalia distribution. However, when asked what those standards should look like, there was less clarity, and there was disagreement about whether the same standards should apply across pharmacy and non-pharmacy services. In general, people felt that standards for paraphernalia should be based on evidence of effectiveness, but there was also a view that there wasn't currently sufficient evidence available, except in the case of citric acid. ⁹

The distribution of citric acid was seen by service providers and pharmacists to be extremely important - not only because of the evidence that it helps to reduce wound problems in injectors, but also because the provision of citric acid has been shown to attract injectors into services. (See Box 6.1.)

Box 6.1: Good practice - provision of citric acid
The Glasgow Drug Crisis Centre ( GDCC) found that visits to their service had dropped significantly after the local pharmacy needle exchanges began to include citric acid in needle and syringe packs. At that time, GDCC wasn't providing citric acid to their clients. GDCC responded to the situation by beginning to distribute citric acid. In less than four months, the number of visits to the service had increased by 31%.

When pressed on the question of standards for paraphernalia distribution, there were some interesting differences in views between DATs, service providers and pharmacists. DATs felt that, as a "basic" standard, all needle exchange services should provide clients with sterile needles and syringes and disposal bins, and then, depending on the availability of funding, additional items of paraphernalia could also be provided above the basic standard.

Pharmacists felt that, ideally, all forms of paraphernalia should be available to clients, but given constraints in funding, the "basic" standard should include at the very least, sterile needles and syringes, disposal bins, citric acid, filters and swabs. Non-pharmacy service providers were very uncomfortable with the idea of differing standards for needle exchange. One individual argued that there should not be any such thing as "two-star needle exchanges" and "four-star exchanges." In general, service providers felt that all forms of paraphernalia that are legally permitted to be distributed should be available to everyone.

However, this is not to say that all forms of paraphernalia should necessarily be distributed to everyone automatically. Service providers made the point that clients need to know how to use paraphernalia safely, and that the distribution of paraphernalia needed to go hand-in-hand with client education.

Different injectors have different needs, and the view of service providers was that it's important to give people what they need, and only what they need. This strategy would save money, result in less waste, and provide a good basis for a discussion with clients about the nature of their drug use and injecting practices. Service providers felt that just handing all clients a box with a full set of paraphernalia was doing them a disservice.

"If we just hand them a box and say, "Here you go, this is what you need," we run the risk of appearing to be condescending. Needle exchange should involve a consultation with the client. It's about providing a service." (Non-pharmacy service provider, focus group attendee)

Pack syringe distribution vs pick-and-mix

In this respect, specialist service providers felt that a 'pick-and-mix' system was preferable to 'pack' distribution of syringes and other paraphernalia. However, pharmacists, while strongly in favour of establishing standards for paraphernalia provision, did not necessarily see this as extending to a 'pick-and-mix' option in all pharmacies, for the simple reason that pharmacy staff don't ordinarily have the time (or the space) to give clients the customised service that a 'pick-and-mix' system requires.

"If a client has to ask for certain things specifically, it requires a conversation, and striking up a relationship with staff. The pick-and-mix system encourages the development of a relationship. The pack system means that you only get the person there for a matter of seconds. But most pharmacies don't have the time for the conversation anyway." (Pharmacy co-ordinator, focus group attendee)

In addition, pharmacists argued that the 'pack' system is more discreet and more economical. Given the public nature of most pharmacies, it was felt that pack distribution was more appropriate in that context. Furthermore, focus group participants pointed out that some injectors prefer to use pharmacy needle exchanges because of the speed of the transaction.

According to the Pharmacy Co-ordinator survey responses:

• Pharmacy schemes in Argyll & Clyde, Fife, Glasgow, Grampian and Lanarkshire distributed syringes and other paraphernalia only through packs.
• The schemes in Orkney and Tayside used only a pick-and-mix system.
• Pharmacy exchange providers in Ayrshire & Arran, Highland and Lothian used both pack and pick-and-mix systems.

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