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CHAPTER FIVE: DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
Introduction to this chapter
5.1 The purpose of this chapter is to consider the results of this work and what they mean for practice. It is particularly important to discuss the limits of the methodology and their impact, as several changes had to be made to the original design for pragmatic and financial reasons. The methods used influence what can be deduced from the results and also the scope for future work.
5.2 Each aim and their corresponding objectives will be considered, highlighting results in the context of their meaning, limits and previous findings. The chapter ends with a summary of the recommendations that can be made for practice and future work that could be done.
The laboratory based work
5.3 The aims of this work was to test paraphernalia items and injection preparation methods in the laboratory to quantify the theoretical benefits and/or risks that they present to health, thereby identifying from those tested the items of paraphernalia and preparation methods that present the least theoretical risk to individual health.
Objectives 1 and 2
- 'Develop experimental methods for use in the laboratory that replicate the injection preparation practices of IDUs, based on the ethnographic work of Taylor et al (2004) and previous work'
- 'Identify the key equipment variables and method variables in the preparation process to be investigated in the laboratory experiments'.
5.4 Both these objectives were met using appropriate methodology. A questionnaire was designed to capture the necessary data from the videos made by Taylor et al and researchers in her team completed these. This provided a detailed dataset of injection preparation practices established from 60 episodes. Analysis produced a standardised preparation process (figure 4) which concurred with previous work conducted in different locations (Ponton & Scott, 2004) and anecdotal reports. The process was shown in validation work (not reported here) to be reproducible and reliable. The key variables to be studied in the laboratory were identified as effects of hand cleansing on skin contamination, consequences of using aluminium cookers on aluminium content of injections, effects of different types and amounts of acid on likelihood to damage veins and impact of various filters on particle content of injections and retention of drug. The methods used to in this part of the work were considered sound and reliable. The resulting process does not in itself have any application to harm reduction practice but it could be applied in future laboratory studies of paraphernalia e.g. with different quantities of heroin.
Objectives 3, 4 and 5
- 'Prepare injections using the developed method. Control all the variables in the preparation process (equipment and method) to allow the study of the impact of each variable'.
This was done, producing injections that represented as closely as possible the preparation of a single person injection of a £10 bag heroin equivalent. Most variables were controlled by measurement but length of time heating, height of spoon from the flame and use of stirring were based on visual replication of methods captured on Taylor's videos.
- 'Study the impact of each variable by performing scientific experiments on injections prepared in different ways using different equipment'.
- 'Where possible, benchmark the prepared injection results against standards used within the pharmaceutical industry for small volume injections and other relevant aspects of aseptic ('sterile') manufacturing. This will allow comparison of the preparation method and paraphernalia against theoretical standards that present minimal risk'.
Both these objectives relate to the laboratory investigations which will now be considered in turn.
The hand cleansing study
5.5 This work combined practice based data collection with laboratory based analysis. The practice based data collection was successfully performed. The target of 50 participants were recruited and randomised to hand cleanse with one of the two comparative methods. Contamination levels were studied by identifying the number of 'colony forming units' (growth spots of microbes) produced from finger dabs on agar plates before and after hand cleansing with the allocated method. The results demonstrated the level of contamination prior to cleansing was reduced by either method of cleansing, Prior to hand cleansing the majority of participants had average finger dab levels of between 20-50 CFUs, this was reduced to less than 5 by cleansing. Both cleansing methods significantly reduced microbial contamination, and although the alcohol hand gel reduced contamination to a greater extent, it did not perform statistically better. No previous work examining microbial contamination of IDUs hands or the effects of skin cleansers could be found.
Methodological considerations and future work
5.6 The method used to quantify CFUs was considered appropriate. The hand cleansing study made no attempt to identify individual contaminating organisms. Future work could focus on doing so, in order to describe the range of contamination on IDUs hands, demonstrate any links with commonly seen skin and soft tissue infecting organisms and add further evidence of the effects of hand cleansing agents.
Implications for practice
5.7 The majority of participants did not regularly wash their hands before preparing injections. The main reason given was being 'in too much of a hurry to get a hit' (44%) followed by 27% who said they thought there was no need to wash hands. Similar findings were found in the qualitative field work. This suggests a need for targeted campaigns to promote hand cleansing prior to injection preparation to IDUs.
5.8 When considering the potential supply of alcohol hand rub to IDUs, the lack of a statistically better performance compared to soap and water could be used as an argument against this expense. However, the utility of this intervention needs to be considered. Alcohol hand rub could be used in place of alcohol swabs to cleanse sites prior to injecting. In the field study 52.4% (n=99) of Aberdeen participants and 67.3% (n=115) of Dundee participants said they pre-cleaned their injecting sites 'always' or 'most of the time'. There is scope to improve this. Those who did 'always or mostly' wipe their sites before injecting were significantly less likely to have a skin or soft tissue infection on their day of participation in the baseline data collection. Hence promotion of site cleansing has the potential to reduce skin and soft tissue infections.
5.9 The field study identified inappropriate use of alcohol swabs, previously known anecdotally. Some participants reported pressing swabs on sites after injecting. This is to be discouraged as the alcohol may inhibit blood clotting. Some interviewees and IDUs in the video work of Taylor et al (2004) and Jones et al (2006) used alcohol swabs as a flammable heat source to prepare injections. Replacing swabs with hand rub would provide a means of hand and injecting site cleansing and prevent inappropriate swab use. The health and economic outcomes from hand rub supply need to be considered in future work.
5.10 The results showed that roofless status made no difference to the level of 'before' contamination suggesting hand cleansing campaigns and strategies should be not limited to homeless IDUs. However access to hand cleansing materials was stated as a main reason for not washing hands by this group, suggesting that packs of alcohol hand gel may be particularly appropriate for them.
Recommendation:Needle exchange services should consider running campaigns to promote hand cleansing to IDUs prior to injection preparation. They should also consider providing alcohol hand rub in convenient to carry (e.g. belt clip) containers and promote their use for skin cleansing. The supply and use of hand rub should be evaluated on both a health and economic basis.
The aluminium cooker tests
5.11 In the lab, small amounts of aluminium were detected in solutions made with acids in Stericup cookers. The significance of this, if any, cannot be assessed based on limited literature on long term aluminium accumulation effects and the difference between absorption from the gastrointestinal tract and injecting. Length of time of use would likely be the most significant factor in determining risk. The benefits of single use cookers in potentially reducing the transmission of BBVs and in improve the cleanliness of injection preparation methods need to be remembered. No previous investigations of this type have been reported.
5.12 The Stericups were found in the lab to be 'single use' in nature. Reheating tended to make them bend at the handle and hence run the risk of spilling the contents. This was also noted by interviewees in the field study and reported to deter reuse of them, whereas conventional spoons are reusable.
5.13 The field study showed sharing of Stericup cookers to be common for batch preparation. This may increase BBV risks if any of the sharers uses a contaminated needle and syringe. The interviews identified strong economic arguments made by IDUs for batch preparation e.g. fair division of drugs purchased through pooled finances.
Methodological considerations and future work
5.14 The laboratory analysis detection method for aluminium content was validated and considered appropriate. A lack of information in the literature on risks from injecting aluminium makes it impossible to place the findings in any sort of context of risk. In the long term this should be remembered and studied. In the more immediate future, work could examine risks from other manufactured aluminium cookers. Future developers of paraphernalia should consider the use of other inert metals.
Implications for practice
5.15 The single-use nature of the aluminium cookers supports their use. However batch preparation is of concern. It is difficult to identify ways to deter this, so future work should seek to do this. However, if all involved in batch preparation used sterile needles and syringes and new containers of sterile water and acid are used in the preparation, then the risks are potentially removed. Therefore, the supply of cookers should be accompanied with strategies to reduce batch preparation risks (adequate quantities of sterile water, sterile acid and clean needles) and clear advice about the risks from batch preparation.
Recommendation:Strategies to prevent BBV risks from batch preparation should be considered by needle exchanges. Education campaigns should focus on the message to always use clean, sterile water and sterile acid to prepare the batch and new sterile needles by all who remove drugs from the batch. Manufacturers of paraphernalia should seek to identify other inert metals to produce affordable cookers.
The acid tests
5.16 The pH data shows that less than half a sachet of citric acid (50mg) achieved a pH of approximately 3 and was sufficient to dissolve the heroin in a '£10 bag' equivalent of drug used in this study. Less than half a sachet of ascorbic acid (135mg of vit C) produces a pH 3.3 and also dissolves the heroin. Heroin samples with different purities and compositions would require varying amounts, so this is a guide. The advice to add acid stepwise and use the minimum amount should be emphasised.
5.17 In the evaluation of the supply of citric acid sachets in Glasgow (Garden et al, 2003) most injectors used '£10 bags'. Sixty percent (n=203) of IDUs reported using a whole sachet during injection preparation, 16% (n=55) used three quarters of a sachet, 22% (n=74) used half a sachet and only 1% (n=3) used less than half a sachet. On weighing ten sachets, the average weight of the contents of a citric acid sachet from Exchange Supplies was found to be 148.6mg (range 131mg-162mg). This suggests that most of the participants in the evaluation reported by Garden et al were using too much citric acid. This may be the reason why there are anecdotal reports that injections made with citric acid are painful on injection. Ascorbic acid allows more margin for error as greater quantities are needed to change pH.
5.18 The qualitative field work showed that lack of access to acid, as found in Aberdeen, is reported to cause considerable distress and promote the use of riskier substances. Some reported lack of acid promotes riskier behaviours, as the urgency to inject increases while the person attempts to source acid. This is discussed later.
Methodological considerations and future work
5.19 The acid experiments used validated methods to measure pH and osmolality. However, the lack of a reliable method to measure drug content meant that the impact of various acid quantities on opiate content could not be established. This should be done in future work as the data would be helpful to support the advice on acids to IDUs.
Implications for practice
5.20 The results do not strongly favour one acid over the other. The key message is that small quantities need to be added stepwise and injections administered slowly. Citric acid is cheaper than ascorbic acid, and for this reason services may be more able to fund citric acid supply. Garden et al also found the concept of single use (i.e. do not keep remainder for later and do not share) was not fully understood or followed, so sharing of sachets should also be discouraged.
Recommendation:IDUs should be encouraged to add small quantities of acid when preparing injections. Depending on purity, less than half of a citric acid or ascorbic acid sachet may be enough to prepare a £10 bag of heroin. Larger quantities of drug will require more acid. IDUs should be advised to inject slowly to reduce irritation by either acid, which may happen because of the low pH of citric acid and high tonicity of ascorbic acid injections.
The filter tests
5.21 In the lab, the Sterifilt and wheel filter (Sartorius 0.2 um syringe filter) reduced the amount and size distribution of particles in the heroin injections better than the makeshift filters. The Sterifilt was considered to perform better overall as it passed a stricter limit that was derived from current British Pharmacopoeial standards. The Sterifilt retained statistically less drug than the others, giving evidence that it is unlikely to be retained for 'bashing down' (drug removal). Although the wheel filter performed well in the particle tests, it retained a lot of drug and is also expensive. These factors do not support its widespread use. There is little other previous work examining the performance of filters used by IDUs. Caflisch et al (1999) compared filters to investigate their ability to remove microbiological contamination, deducing that 0.2 micron syringe filters performed better than cigarette ones. However, no other work has studied particular contamination except Scott (2005), where the superior performance of 5 micron wheel filters compared to makeshift filters was demonstrated.
5.22 However this previous study used a larger pore size wheel filter and did not investigate purpose designed filters such as the Sterifilt.
5.23 Preliminary microbiological investigation of used filters collected from IDUs in the hand washing study showed them to be contaminated and a range of organisms were speculated, suggesting more detailed work in this area would be beneficial.
Methodological considerations and future work
5.24 The British Pharmacopoeial method for particle analysis was used and the standard used to derive the benchmark used. This method was considered appropriate. The microbiology work was only performed to undertake a preliminary investigation of used filters. However, on reflection this work should have attempted to have studied the donated filters in more depth, for example by isolating specific organisms. Discussion with needle exchange staff, raised concern that it would not be possible to collect each donated filter separately or establish a use-history on each one. Therefore, this was not attempted. On reflection this assumption should not have been made and pilot work could have investigated this. However, the number of filter donors was small (12/50) so asking for separately labelled donations may have reduced this further. It should also be remembered that due to limited heroin quantities, only £10 bag equivalents could be tested, therefore the applicability of the findings to other quantities has not been proven.
5.25 Future work could study filter contamination and relate this to history of filter use and storage. It could also collect other items of paraphernalia from IDUs to examine microbiological contamination. Work has been done with needles and syringes to test for HCVRNA, (Crofts et al, 2000) but no previous microbiological examination of used filters was found in the literature.
Implications for practice
5.26 The laboratory experiments support the supply of Sterifilt over other tested alternatives, suggesting it should be supplied. The field study showed some IDUs disliked Sterifilt as it did not retain drug, so gave nothing to save 'for a rainy day'. Others favoured it as they saw it as 'clean'. Many who favoured it identified that training on its use is essential to promote use to IDUs. This was also noted in the laboratory that it took several attempts to use them successfully. The field study also identified that used Sterifilt are still sometimes passed to others to use, this should be discouraged. Therefore supply should be accompanied by training on how to use them and advice that they do not retain drug. Advice should also emphasise that they should not be used by multiple persons.
Recommendation:Of the filters tested in the lab, the Sterifilt showed the most theoretical benefits to health. However the field study showed they are not universally liked. Supply is advocated and IDUs supplied them for the first time should receive education on the technique to use them correctly.
Objective 6
'Establish the contents of a safer injection 'kit' and preparation method which presents the lowest theoretical risks to health based on the laboratory results'
5.27 This objective brings together the findings described above. The laboratory work advocated hand cleansing and evidence from this and the field work suggested a need for targeted campaigns to promote hand cleansing to IDUs. Alcohol hand gel may be suitable for supply as it can also be used to clean sites and may be potentially more convenient. Work to evaluate such supply would be advocated. The use of aluminium cookers, sterile acid sachets (either citric or ascorbic) and Sterifilt is also suggested from the laboratory work. At all stages education on use and advice to discourage sharing is recognised as important. The supply of a 'kit' is however questionable as supplying one of every item may be wasteful of materials. The field work interviews showed that the single quantities do not equate to single injections. A 'pick and mix' supply method may be more cost favourable. This will be investigated in the current National Institute of Health and Clinical Excellence ( NICE) evaluation of needle exchange (see: http://www.nice.org.uk/guidance/index.jsp?action=folder&o=37994).
The field based study
5.28 The aim of this aspect of the study was to conduct an investigation into the impact that paraphernalia supply is making on sharing and health in the practice setting and compare this with non-supply.
5.29 Findings, methodological considerations and future work are presented separately for the quantitative and qualitative objectives. Implications for practice and recommendations are considered together.
Objective 1
'Perform a study comparing health and sharing practices of IDUs in a location where needle and syringe exchange plus paraphernalia is supplied, with the same measures taken in a location providing needle and syringe exchange only. Establish whether there are any differences and if so, whether these can be attributed to paraphernalia supply'.
5.30 The first objective related to the quantitative aspects of the field based study. Data was collected on the health and sharing practices of two groups of IDUs, one in Aberdeen (n=189) and one in Dundee (n=170). Both were recruited via needle exchange services, Drugs Action ( DA) in Aberdeen and the Harm Reduction Centre ( HRC) in Dundee. In Aberdeen DA did not supply paraphernalia, in Dundee the HRC had been supplying paraphernalia in various forms for considerable time. Since around 2003 paraphernalia had been available across Tayside needle exchange outlets. The two cohorts were comparable except for age and length of time injecting, with the Aberdeen cohort being older and having begun injecting significantly longer ago. Age per se was not considered a factor likely to confound the findings, but length of time injecting may have, so it was controlled for.
Injecting related health complications and infections
5.31 75.1% of the Aberdeen cohort presented with one or more non infected complications of injecting, in Dundee this figure was 71.9%. In Aberdeen, 21.2% of the cohort presented with a skin or soft tissue infection and in Dundee this figure was 17.5%. There were no significant differences between these figures. In Aberdeen, 40.7% of participants had swelling at their injecting sites, in Dundee this figure was lower at 31.0%, but not statistically so. In Aberdeen 26.5% had puffy limbs or digits, compared to 17.5% in Dundee, which was significantly less. However, when length of time injecting was adjusted for the significance disappeared.
5.32 There were no statistical differences between the general health check measures taken for the two groups.
Needle and syringe sharing and risk taking behaviours
5.33 Although not directly the focus of this study, it was considered important to also examine needle and syringe risk taking behaviours. A significantly greater proportion of participants in Aberdeen (51.1%) had ever shared needles and syringes compared to Dundee (37.7%). In the past month, more Aberdeen participants had kept needles and syringes for reuse by others, and used needles and syringes that someone else may have previously used (12.2% in both cases), compared to 7.6% and 10.6% respectively in Dundee, but this was not significantly different. Approximately 90% in both locations were not taking these risks.
5.34 Less encouraging is the high levels of reuse of own needles and syringes in the past month identified in both locations (65.1% in Aberdeen and 70.0% in Dundee). This suggests that levels of equipment supply reaching IDUs in both locations are not adequate. This was further demonstrated in the qualitative interviews.
5.35 Significantly more Dundee participants who had begun injecting since 2003 had injected someone else (45.8%) or been injected by someone else (56.3%), in the past month compared to those in Aberdeen who had begun injecting since 2003 (25.5% and 38.3%). This suggests a need to focus on discussing these risk taking behaviours with newer injectors, especially in Dundee.
Paraphernalia sharing and risk taking behaviours
5.36 Sharing of all paraphernalia items ever, was higher in Aberdeen. Participants in Aberdeen reported statistically higher levels of ever sharing acids (81.9% vs 63.5%), water (80.2% vs 67.3%) and filters (81.3% vs 65.4%) than those in Dundee. Although not significantly different, the Aberdeen participants reported greater levels of cooker sharing than those in Dundee (76.4% vs 69.2%). Batch preparation, which involves cooker sharing, was shown in the qualitative interviews to be common practice in both areas as a means of pooling resources. This has been identified as a key factor promoting high levels of cooker sharing elsewhere (Koester et al, 2005).
5.37 In the past month, a greater percentage of Aberdeen participants had used the same acid container compared to those in Dundee (61.9% vs 55.3%), given someone a used filter (42.3% vs 33.5%) or kept their own filters for reuse (65.6% vs 55.9%). None of these tested significantly different, but the latter was close to significance. A similar percentage in Aberdeen (56.1%) and Dundee (54.7%) had shared water containers in the past month. Overall, levels of sharing in the past month were less than sharing 'ever', suggesting participants were taking on board harm reduction messages. This was also reported in the qualitative interviews, with many reflecting that current injecting practices were safer than previous ones.
5.38 There were no significant differences in paraphernalia sharing in the past month amongst those who had begun injecting since 2003. In fact levels were slightly higher in Dundee despite participants potentially having access to a range of supplied paraphernalia from all Tayside needle exchanges (passing on filters: 31.4% Aberdeen vs. 31.6% Dundee; using same acid: 51.4% Aberdeen vs. 55.8% Dundee and filter reuse 51.4% Aberdeen vs. 57.9% Dundee). Similarly the extent of past month filter reuse and passing on or past month acid sharing were not significantly different between those in Dundee who used the supplied acids and filters compared to those in Aberdeen who did not use supplied paraphernalia, although levels were higher in Aberdeen (passing on filters: 43.3% Aberdeen vs. 37.0% Dundee; using same acid: 67.5% Aberdeen vs. 60.3% Dundee; filter reuse 64.5% Aberdeen vs. 58.9% Dundee). The NESQ was carefully worded to emphasise sharing of used items rather than passing on sterile packaged unused items, so it is thought unlikely that this was misunderstood. However when the qualitative interviews explored participants understanding of the term 'sharing', a focus on used needles and syringes was identified. In terms of paraphernalia, sharing was not immediately identified with its use and when it was, some appeared not to distinguish passing on new, sterile paraphernalia to others from passing on used paraphernalia. In terms of risk the differences should be highlighted when paraphernalia is supplied.
Methodological considerations
5.39 The first part of the objective was fulfilled in that the study collected data on the extent of injecting related health problems and injecting equipment risk taking behaviours of two cohorts on IDUs. The study found no significant differences in infected and non infected injecting complications or swollen puffy limbs when length of time injecting controlled for. It showed significantly higher numbers of participants in Aberdeen had ever shared needles and syringes and paraphernalia compared to participants in Dundee. It also showed lower, but not significantly different levels of sharing in the past month amongst the two groups. Newer injectors in Dundee showed slightly higher but not significantly different levels of past month sharing. Those who reported using supplied filters and acids in Dundee did not test for significantly lower levels of sharing or reuse of these items compared to those in Aberdeen without access. However, limits of the final revised pragmatic study design following the pilot suggest these results cannot be directly attributed to paraphernalia supply or lack of, i.e. the second part of the objective was not met by the quantitative data. The qualitative data however made a strong argument for paraphernalia supply, as discussed later. The following criticisms can be made of the quantitative data collection method, which influence interpretation.
5.40 The study was unable to collect sensitive enough data to describe the frequency of visits to all needle exchanges in both locations or use of supplied paraphernalia in Dundee versus use of makeshift. This makes it impossible to separate the effects of needle exchange service use, which is known to reduce HCV risks (Huo and Ouellet, 2007) and be a weak correlate with reduced paraphernalia sharing (Ksobiech K, 2006), from paraphernalia supply. Table 13 shows makeshift paraphernalia was still used in Dundee, but the frequency of this is unknown. The qualitative interviews showed makeshift paraphernalia was still used in Dundee because IDUs did not always have enough supplied paraphernalia at the time of need. Lack of quantifiable information on supplied and makeshift paraphernalia used between each exchange visit and frequency of exchange visits therefore prevents the results being attributable to paraphernalia supply or lack of. The collection of such data was originally planned at each visit using a previous version of the NESQ. However the pilot work showed that the study did not have enough researcher resource to collect this data, due to the need to focus more efforts on recruitment. Although recruitment difficulties in needle exchange studies were identified from previous literature, the human resource needed to address these was underestimated when the design was revised.
5.41 Separating out each stage of consent aided recruitment for the NESQ but this meant researcher time appeared to be limited for health check data collection, and follow up data collection, especially in Dundee. This meant the study was also limited by lack of follow up data which would have provided more robust indicators of the impact of paraphernalia supply coupled with the more detailed data suggested. The advice on maximising follow up reported by Pickering (2003) was followed but was found at times not to be successful or usable for needle exchange clients. For example some were reluctant to nominate other contact points and many mobile phone numbers were no longer in use at follow up.
5.42 Lastly, the power of the study in relation to skin and soft tissue measures can be questioned. The prevalence of skin and soft tissue seen in Aberdeen (21.2%) was less than had been suggested in the literature. The literature data was used to calculate study numbers (see appendix 1). This suggests the study may have been underpowered for this outcome measure. The predicted level detailed in the protocol (33%), was based on previously published community based studies in the USA where the supply of paraphernalia is illegal (Spijkerman et al, 1996, Binswanger et al, 2000 and Bassetti & Battegay, 2004). US data was used due to lack of UK data at the time of design. When estimating the likely impact of paraphernalia, again lack of data meant a 'best guess' had to be made. Data from the Swiss heroin trials (Conrad et al, 2000), where sterile paraphernalia and pharmaceutical grade drugs were supplied, and expert opinion (Carnwarth,T. personal communication with J Scott, 2004), formed the basis of an estimate of 20%. These figures predicted that 180 per group were needed. However, the prevalence of skin and soft tissue infections in Aberdeen closer to that seen in the Swiss studies. Hence to be adequately powered, a greater number of participants per group would be needed. This also raises the question as to why the prevalence of skin and soft tissue infections seen in Aberdeen was less than predicted? It may suggest that despite lack of access to sterile paraphernalia, other factors promote skin hygiene, e.g. following safer injecting advice.
5.43 The qualitative data however did give strong support to the supply of paraphernalia to IDUs and this is considered in the next section.
Future work
5.44 It is unlikely, given the extensive supply of paraphernalia in the UK now (Abdulrahim et al, 2006, Griesbach, 2006) that true baseline data could be collected anywhere (i.e. needle exchanges not supplying any paraphernalia or swabs). Future studies should focus on collecting more sensitive data on frequency of visits to needle exchanges and paraphernalia use for every injection. Future work should also focus on collecting follow up data more successfully. The study showed that this would require considerably more researcher time. It is suggested that each site would require two full time researchers, one to recruit participants and one to collect follow up data. This would also provide holiday cover. Ideally follow up data would be built into needle exchange data collection procedures, but since research ethics would suggest that this extra data should only be collected for consenting participants this may be difficult to implement in practice.
5.45 Future work could focus on why the prevalence of skin and soft tissue infections was lower than expected in Aberdeen to identify protective factors.
Objective 2
In the location where paraphernalia is supplied, establish participant's views on the paraphernalia supplied, including ease of use, self-reported nature of use, compatibility with the injection preparation process and its perceived impact on health and sharing.
5.46 The Dundee participants who took part in the interviews very much preferred to use the paraphernalia supplied by the exchanges compared to makeshift paraphernalia. There were three main factors that underpinned this: (1) Improved cleanliness and safety, which was found to equate to less injecting site complications and visible harms such as abscesses, as opposed to BBVs. (2) Quality -which was found to relate to less risk of losing the 'hit' e.g. through equipment failure. (3) Convenience -which related to comparative easier access and reduced risks from being desperate for a hit.
5.47 Supplied paraphernalia was seen as easy to use by most, although some disliked the Sterifilt as it did not retain drug and some disliked the Stericup filter as it retained too much liquid (i.e. reduced the volume of the hit visibly compared to other filters).
5.48 The supply of paraphernalia from exchanges was perceived to reduce sharing and improve injecting hygiene amongst the participants, but it was not used exclusively because it was not always in their possession when needed. This was due to a number of factors tied in with lack of ease of predicting required quantities, due to supplying others in need and lack of forward planning of visits to the exchange due to competing priorities such as obtaining drugs. Convenience was also a factor, such as the proximity to an open exchange immediately prior to need.
5.49 Dundee participants appeared to have more belief that they should attempt to always use clean equipment and that access to paraphernalia via exchanges facilitated this. A 'no excuses' sentiment was common, even amongst those who did not always use exchange supplied equipment. However this was in contrast to Aberdeen where a more resigned view of sharing was expressed and the reason for sharing usually being attributed to lack of supply of equipment.
Objective 3
In the location where paraphernalia is not supplied, establish participant's experiences of access to paraphernalia items needed, the items they use and perceptions on their impact on health and sharing.
5.50 The strongest views in Aberdeen from participants were around the difficulties experienced in accessing acids for injection preparation. Availability was the main factor that prevented access, with cost also being a barrier. Quality concerns about shop bought citric acid were common. Distress and subsequent risky behaviours, induced by fear of withdrawal from lack of ability to prepare heroin injections were a common theme. Some were angry about lack of local availability. Other paraphernalia items were considered more readily available such as water from the tap and tea spoons.
5.51 The concept of risk from makeshift items such as cigarette filters was not always recognised and sharing of paraphernalia was not explicitly linked with HCV transmission by most interviewees until prompted. Sharing risks tended to be identified as HIV and applied to needles and syringes. A 'culture of sharing' was more evident from the Aberdeen interviewees with a resigned inevitability expressed by many. Paraphernalia sharing was not viewed in the same 'league' as needle and syringe sharing and for some it was an acceptable norm . As both services provided written and verbal advice on BBV risks, it may be that lack of supply of paraphernalia in Aberdeen is a barrier to emphasising the risks from paraphernalia sharing during the needle exchange transaction, or a barrier to facilitating change. This has been identified as key in the prevention of needle and syringe sharing (Stimson, 1998). Application of this theory to paraphernalia can be suggested but not proven from this work.
Objective 4
Identify participant's suggestions and ideas for promotion of use of appropriate paraphernalia and ways to discourage sharing.
5.52 Several suggestions were made as to how to attract more IDUs into needle exchange services as participants recognised that increased distribution was key in increasing paraphernalia use. Ideas included increasing numbers of outlets, opening times and geographical spread, increasing publicity of services and promoting confidentiality policies. This was particularly highlighted in Dundee where the prescribing service was located in the same building as HRC. Outreach was also considered an important tool in facilitating convenient access to paraphernalia in Dundee. Peer distribution was also reported to contribute to existing supply networks, but also led to a lack of own equipment when needed. Negative attitude of staff was mentioned as a barrier and in all cases related to pharmacy staff. Similar factors were identified from IDU interviews by Neale et al (2007) and are highlighted elsewhere (e.g. Parsons et al, 2002, Griesbach, 2006, Abdulrahim et al, 2006).
5.53 The supply of all necessary items to facilitate safer injecting was considered by interviewees as an important strategy to reduce sharing and reuse. The supply of adequate quantities of equipment was also key -both needles and syringes and paraphernalia. Convenient access was mentioned commonly and the notion of several trips and investment of considerable time to access injecting equipment, and in particular paraphernalia, was not evident.
5.54 Sharing and reuse of equipment was usually attributed to lack of access to clean equipment when needed. It was very clear from the interviews that the ideal of one new set of injecting equipment for every injection is by no means able to be achieved, including paraphernalia supplies. Several needles and syringes were often used per injection and it was clear that supplies obtained do not match the needs of many. The limits of needle and syringe coverage have been previously highlighted e.g. Parsons et al (2002) suggested that on average there is one clean needle for every four injections administered in Scotland, and one in two in England. Note that these suggestions were made before Lord Advocate's Guidance recent update in Scotland. This study showed that injecting equipment including paraphernalia is often donated to peers in need and that there are difficulties in predicting required quantities.
5.55 Sharing of Stericups in Dundee and spoons in Aberdeen for batch preparation was commonly described. The practice of batch preparation was reported to be often used to ensure drugs bought through pooled resource are fairly divided. This has been highlighted as a risk previously by many (e.g. Koester et al, 2005). If all other items used in the preparation are sterile and hands are cleaned, then the risks are effectively removed. Therefore, the economic benefits of batch preparation may be hard to address and efforts should therefore also focus on emphasising ways to make this practice safer. Stericups were shown to discourage reuse due to their fragile nature after heating. However, the interviews suggested that they appear not to reduce batch preparation.
5.56 The reuse of filters to remove trapped drug was common and again can be seen as a difficult practice to change in those who do it, due to the economic benefits. However some interviewees in both locations were against this practice, primarily because of the risk of 'dirty hits' and the perception of skin and soft tissue infection risks. Sharing filters was reported for similar reasons, e.g. to help someone in withdrawal or prevent own withdrawal. Explicit links with filter sharing and HCV risks were not mentioned unprompted by the majority again suggesting a need for more intensive education campaigns.
5.57 On the whole participants in both locations considered that risks tended to be mostly taken early in injecting careers and that attending needle exchanges improved their injecting practice. Many mentioned reluctance of new injectors to access services and highlighted a need for wider publicity of confidentiality policies and services available. In Aberdeen many thought paraphernalia supply would help draw in new injectors. The advice of workers at needle exchanges in both locations was valued and trusted. However the same value and trust was not expressed in relation to pharmacy exchanges.
5.58 Many of the cultural factors identified relating to sharing present challenges for needle exchange workers. For example, concerns about offending people by refusing to use communal water, cultural norms of lending and borrowing equipment, accepted sharing with sex partners and lack of concern for self and others. The desperate fear of drug withdrawal was also reported to increase risk taking leading to later regrets. Higher profile campaigns may empower people to address sharing risks, as suggested by some interviewees. Campaigns should also encourage forward planning. The need for major education campaigns were mentioned by some. In particular several people considered HCV was 'not as important' as HIV because it had not been subject to mass media prevention campaigns. Some mentioned memorable 'tomb stone adverts' and used in HIV prevention campaigns in the 1980's and the impact of shocking magazine adverts that used 'sufferers' to highlight risks. The use of such mass media campaigns raises many questions which warrant debate and discussion by those likely to make decisions on their use.
Methodological considerations and future work
5.59 The design of the qualitative work is considered appropriate. All participants were needle exchange clients therefore their views may not be the same as those not in contact with other services. Future work could establish the views of those not in contact with services and also specifically focus on new injectors.
5.60 Future work could expand on some of the suggestions from participants on how to reduce sharing of paraphernalia. In particular the lack of or low level of awareness of HCV risks is of concern. Suggestions of a need for a high profile media campaign should be explored further. For example, future interviews could explore in more depth IDUs opinions on the advantages of such campaigns and why they think they advocate them. The limits of such campaigns could also be explored.
5.61 Future work should also seek to identify whether paraphernalia introduction in an area not previously supplying it, accompanied with advice, changes cultural 'norms' of sharing.
Implications for practice and recommendations
Several recommendations for practice can be made from the field based study, in particular from the qualitative work. The quantitative work suggests recommendations for future research, as previously discussed. The recommendations are as follows:
Recommendation 1: The term 'paraphernalia' needs to be clarified, as it appears not always to be used by IDUs.
Recommendation 2: Strategies to address the perception and practice of paraphernalia sharing should be implemented and evaluated. These may include the supply of paraphernalia, which is strongly advocated by IDUs.
Recommendation 3: Paraphernalia supply should be accompanied by strategies to encourage forward planning in IDUs, explicitly highlight risks of sharing, and discuss perceptions of HCV compared to HIV. The differences between HCV sexual risks and equipment sharing risks need to be highlighted.
Recommendation 4: The less public profile given to HCV compared to HIV should be discussed with IDUs. It should be explained that lack of mass media campaign does not mean IDUs are themselves at less risk.
Recommendation 5: More research into mass media campaigns on HCV prevention should be undertaken to further explore IDUs views. Subsequently, findings should be used to inform considerations on whether such mass media campaigns should be undertaken.
Recommendation 6: The supply of paraphernalia, if introduced in Aberdeen, should be evaluated to establish if it attracts more IDUs into services and if so, whether this includes newer injectors
Recommendation 7: Strategies are needed to increase needle and syringe distribution. Quantities given to IDUs need to be sufficient and access convenient enough to prevent sharing. This has been recommended by previous research also.
Recommendation 8: When supplying paraphernalia, convenience and accessibility need to be maximised, free distribution is advocated. Peer distribution exists and could be encouraged.
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