Sheridan, J., Lovell, S., Turnbull, P., Parsons, J., Stimson, G. & Strang, J.,

2000,

Reviewed by Charlotte Ritchie and Ann Buchanan,
Centre for Research into Parenting and Children,
Department of Social Policy & Social Work,
University of Oxford

Methodology

In order to examine the nature and extent of pharmacy-based needle exchange services in south-east England, two postal surveys were carried out during 1997/98. The aim was to consider PBNX activities in relation to reducing the risks associated with injecting drug use. In order to cover all the schemes in the south-east, health authorities were contacted and details of all local schemes were provided. The questionnaire, which was sent to all 440 pharmacies in the south-east covering an area with a population estimated at approximately 13 million (Office for National Statistics, 1999), covered the demographics of pharmacies and pharmacists, the level of exchange activity in the preceding month, the type of equipment given out, the information provided for clients, whether other related services were offered, the support available to pharmacists and problems or suggestions that were raised. A postal survey of the 36 PBNX co-ordinators in the south-east was also carried out.

Critical Appraisal

The UK has a network of more than 12,000 community pharmacies, which provide sterile injecting equipment, either free through pharmacy-based needle exchanges, or for sale over the counter. There are PBNX in nearly all of the health authorities in England, organized into schemes paid for by each health authority, but possibly operated by other organizations commissioned by the health authorities. Pharmacists are not obliged to provide needle exchanges as part of their NHS contract, but those who do so are reimbursed at a mean flat annual fee estimated in this report to be £627. Those participating are supplied with the injecting equipment, supplied by the PBNX scheme free of charge, and clients do not have to pay for needle exchanges. It has been estimated that one in five community pharmacies provide this service in England and Wales.

Whilst the research had a low attrition rate and provided interesting results, the findings are limited both by the lack of comparable data in this field, and by the lack of user report. The latter would have complemented the findings, and provided greater insight into the gaps in service provision and the causal mechanisms behind, for example, low return rates of equipment. The user perspective might also have provided us with a clearer perception of how supply meets demand. In this research, only 9% of PBNXs were identified as being in rural areas, yet we know that drug abuse occurs in clusters including those in rural areas, suggesting that there is a need for a greater mapping of PBNX services to ensure availability even where demand is lower.

Key Findings

• 71% of scheme co-ordinators said that they had a policy for dealing with under 16 year olds attending PBNX.
• On the ground, however, 68% of pharmacists were not aware that the Royal Pharmaceutical Society of Great Britain has guidance available on this issue.
• 83% of PBNX outlets provided injecting equipment already made up in ‘packs’. Only 12% provided a ‘pick and mix’ service, although research suggests this is preferred to ready-made packs (Anthony, Shorrock and Christie, 1995).
• 44% of pharmacists ‘strongly encouraged’ or ‘encouraged’ clients to return used equipment with respondent rated return rates considerably higher where returns were pursued.
• Although 82% of respondents displayed leaflets on safer sex, only 43% had information available on safe injecting, 35% on hepatitis B, and 27% on hepatitis C.
• Clients wanted items that were not included in the packs, such as filters, sterile water, citric acid and ascorbic acid.

Implications for Social Work Practice

PBNX may attract a different group of clients from those who attend drug agencies, due to the anonymity that characterizes the use of PBNX and the fact that community pharmacies are used also by a wide spectrum of the local community. They therefore have the potential to pull in hard-to-reach as well as recreational injectors. The importance for practitioners lies in good inter-agency working, encouraging pharmacists to take part in the scheme and ensuring that users are aware of where their nearest PBNX is. There may also be a role for practitioners in encouraging pharmacists to engage in more proactive health care such as advice on hepatitis B and C, and HIV testing. Whilst awareness of the general public and retail environment should be maintained, it may be appropriate for practitioners to work alongside pharmacists in negotiating a widening of services to include, for example, the provision of more ‘pick and mix’ forms of equipment, advice on its safe use, wound management, referral, and social and welfare advice. The maintenance of this key public health service will rely on the provision of good training, support and inter-agency working by practitioners in the field.

Policy Implications

Although the Department of Health recommended the further expansion of PBNX in 1996, growth has been patchy. The results of this research suggest that the provision of services for intravenous drug users can be carried out successfully from non-specialist outlets. PBNX are an important part of the public health approach to illicit drug use, both in reducing risk from shared needles and dirty equipment, and in promoting healthier lifestyles including the use of contraceptives, the provision of information and so on. This research found that clients wanted several items that were not included in their ready-made packs, such as filters, sterile water, citric acid and ascorbic acid, but in the UK it is illegal to supply any injecting paraphernalia for use in illicit drug-taking, with the exception of needles and syringes (HMSO, 1986).  It may be opportune to amend the legislation so that IDUs can continue to be encouraged to use needle exchanges. The two biggest risks attaching to the use of illicit class A drugs are arguably the links to crime, and the deterioration of health. PBNX represent a modest attempt to contain the health-related risks associated with intravenous drug use. It is tempting to hypothesise that with adequate funding and training, their role could be expanded both in outlet type, and in range of services so that those addicted to use can maintain healthy lifestyles within an environment that is relatively value free and user friendly.