Needle exchange provision in Birmingham: A systematic needs assessment
Jessica Loaring David Best Birmingham Drug and Alcohol Action Team September 2008
For further information contact Jessica Loaring at: j.loaring@bham.ac.uk Telephone: 0121 3012355
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TABLE OF CONTENTS EXECUTIVE SUMMARY.........................................................................................................................................................................3 INTRODUCTION AND BACKGROUND..................................................................................................................................................7 AIMS AND OBJECTIVES........................................................................................................................................................................8 SYRINGE AND NEEDLE COVERAGE FOR INJECTING DRUG USERS..............................................................................................9 INJECTING STATUS IN BIRMINGHAM..................................................................................................................................................9 DATA AND FINDINGS ..........................................................................................................................................................................11 SYRINGE AND NEEDLE EXCHANGE PROGRAMME DATA..............................................................................................................11 MODELS OF NEEDLE EXCHANGE.....................................................................................................................................................11 NEEDLE EXCHANGE USER PROFILES .............................................................................................................................................12 NEEDLE EXCHANGE TRANSACTIONS ..............................................................................................................................................13 COMPARISONS BETWEEN PHARMACY AND NON-PHARMACY POPULATIONS..........................................................................14 NON-PHARMACY SERVICES DATA UPDATE – SEPTEMBER 2008.................................................................................................15 PHARMACY SURVEY...........................................................................................................................................................................19 NEEDLE EXCHANGE MAPPING..........................................................................................................................................................21 EXPERT GROUP MEETINGS ..............................................................................................................................................................22 KEY INFORMANT INTERVIEWS..........................................................................................................................................................23 NEEDLE EXCHANGE NEEDS ASSESSMENT RECOMMENDATIONS..............................................................................................25
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Needle Exchange Needs Assessment Executive Summary This report describes the rationale, methods and findings of the 2008 Birmingham DAAT needle exchange needs assessment. The method for this needs assessment is consistent with that used with the Treatment Planning Needs Assessment for drug services in Birmingham – this involves the convening of an advisory group to oversee a process of accessing as much quantifiable data as possible and reconciling the data obtained with key informant interviews on the adequacy of needle exchange provision across the city. For needle exchange provision, this also means assessing the activity levels within community pharmacy and nonpharmacy based ‘specialist’ needle exchange schemes, and mapping these against estimated national assessment of needle exchange ‘coverage’. This information is then broken down to profile the individuals accessing these services, for example by age, gender and ethnicity both within services and across both pharmacy and specialist providers. The coverage, accessibility, and variety of services are also measured to assess current levels of functioning. Key Data Findings There were 604 (604/4918) current injectors engaged in structured treatment during 2005/6 and 634 during 2006/7 (634/5177), a rise of 5.0%. When calculating the engagement of Injecting Drug Users (IDU) in treatment and based on the Glasgow prevalence estimates of IDU, only 21.9% of the estimated IDU in Birmingham were engaged in treatment during 2006/7. The majority of needle exchange (Nx) users across both pharmacy and non-pharmacy specialist services were in the 25-34 year age group (53%), 38% were between the ages of 35 and 64 years and 9% were under the age of 24. There were only six recorded transactions for people under 18. The gender spilt shows an over representation of males (85%) compared to female needle exchange users (15%). This contrasts with the gender representation of individuals engaged in structured treatment services (taken from NDTMS data), of whom 26% were female. The majority of users were of white ethnicity (93%) and again demonstrates the difference in user profiles compared to the wider NDTMS population The number of needle and syringe returns was significantly smaller than the number of syringes/packs distributed. Across the sample of Nx providers 2,545 ‘sharps containers’ were returned by IDU. The injecting PDU estimate for Birmingham is 2,895 injectors (CI: 2,343 – 3,664), and the approximate total number of syringes distributed over the 3 month period and extrapolated over 12 months is 590,180 syringes. This equates to 1,204 syringes per person per year (or between 252 and 161 syringes based on associated confidence intervals) and just over 1 syringe every two days (0.6 per day). In total 11 interviews with key stakeholders were conducted – with commissioners, community pharmacists, specialist service providers and team managers and identified the following issues:
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o Opening times and related issues of access arose as an issue o Increased steroid users accessing services o Review of what people want in the exchange packs and the inconsistencies in the current level of provision, particularly around pick and mix provision o Training or information for new pharmacy workers o Picking up bins from pharmacies o Good coverage across the city and the need to map against reported client needs o The need for fast and responsive services o Ability to provide what the service user wants in a non-judgemental service o The need for better supported and resourced crack interventions These findings resulted in the following recommendations:
1
2
Finding
Recommendation
The treatment status of IDUs accessing
To continue to collect treatment status information. To use this information
Nx facilities is largely unknown. Treatment
to assess the number of Nx users currently in or not engaged with
status has now been added as a
structured treatment services, and to inform the treatment planning process
monitoring question on all DAT Nx return
accordingly. This is particularly important given the high rate of users
forms
estimated to be not in treatment from snapshot analysis (56%)
Pharmacy Nx services have
Ensure that harm reduction and treatment options information and advice
proportionately more IDU under the age of
are available to these users to maximise the opportunity of signposting
25 accessing these services. These
them into structured treatment – and options for early onsite brief
groups are traditionally ‘hard to reach’
motivational interventions. Additional resources in providing enhanced
from a treatment perspective.
treatment pathways for these groups (particularly at high activity exchanges) should be examined and qualitative research work done to identify barriers to treatment in these populations. Brief information packs and training and support for general pharmacy staff may be important particularly in the high volume pharmacies within the scheme.
3
There are growing numbers of steroid
To assess the workforce training needs in relation to this group of IDU.
users accessing both specialist and
Provide information or training where identified around the management
pharmacy based Nx services.
and provision of injecting equipment and harm reduction advice for steroid users. To investigate funding sources for the provision of needles and syringes to steroid users, and to assess the public health implications of working with this group.
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4
5
There is a clear need to improve coverage
Consideration should be given to developing new methods of delivering
of the city using both existing types of
equipment, either by piloting automated dispensing facilities or by
needle exchange provision and innovative
generating greater coverage of the city through the recruitment of
techniques
additional pharmacy services.
Policies for the return of injecting
Ongoing working group required to develop consistent policies across the
equipment vary by pharmacy and service
city that can be tested against ongoing data collection – clarity of policies
resulting in variable and often low return
and resulting training and support for staff required
rates
6
There are varying levels of awareness
To produce an information/induction pack for pharmacy workers
amongst pharmacy Tier 1 workers about
introducing them to the harm reduction rationale and reasons for providing
the harm reduction approach for providing
needle exchange facilities for IDU. This should be included in training for
Nx services to injecting drug users
Tier 1 staff and pathways to and from needle exchanges disseminated more effectively.
7
Based on the estimates of injecting PDU
Work with user groups and pharmacy working group to develop strategies
in Birmingham and the analysed activity
for improved overall levels and consistency of penetration into this
data, there is a sub-optimum level of
population. This should also include work to increase the uptake of needle
syringe and needle coverage across the
exchange services in harder to engage groups such as BME and female
city
IDU. There are initial indications that less than half of the users of NX facilities are in treatment – more local data is required to characterise the populations out of treatment and to develop appropriate interventions and pathways for this group.
8
Data collection procedures are
Review data collection mechanisms particularly in light of the amended
inconsistent and analysis of this data is
data collection form (already implemented across all Nx services) and
problematic
develop areas of identified data weaknesses. Although initial steps have been taken to address this, local analysis of injecting groups and their needs is urgently required alongside evaluations of effectiveness of both specialist and pharmacy exchange schemes.
9
Interventions to reduce the harm caused
To consider replicating the work done in Walsall to provide crack smoking
by smoking crack cocaine are not
equipment to crack users. To provide harm reduction information to crack
currently adequately resourced
users (and all other drug users) accessing needle exchange services in a range of different languages. To clarify policies around crack packs and their link to BTEI interventions for cocaine powder and the COCA training initiative around cocaine powder and crack.
10 There is a low rate of treatment engagement for injecting drug users.
Increased focus on engaging injectors in treatment services. Once data are available on treatment status via needle exchanges, there is a need for health screening, harm reduction and rapid (and possibly incentivised) methods of effectively engaging this group in some form of structured interventions
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11 There is little known about IDU being
To conduct further work on assessing the level of prison leavers who are
released from Prison in Birmingham and
current or previous IDU and investigate the views of pharmacies in close
whether appropriate needle exchange
proximity to the prison towards providing targeted harm reduction
services are available.
interventions to this population.
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Introduction and Background Injecting drug use carries a number of serious risks for drug users and also a public health and safety risk associated with blood-borne virus and increased risk of overdose. Compared to non-injectors, injectors have higher rates of drug-related mortality, are at increased risk of acquiring blood-borne viruses (BBVs) such as HIV and viral hepatitis, and bacterial infections (HPA, 2005). In the UK, it was reported that the annual mortality rate of injecting drug users between 1982 and 1994 was almost 2%, this study also showed that injecting drug users are 22 times more likely to die as a result of overdose than their non-drug using peers (Frischer et al, 1997). A more recent study assessing the mortality rate of heroin users in London found that the rate was 17 times higher among heroin users compared to the non-heroin-using population aged between 15–59 years (Hickman et al, 2003). Non-fatal overdose is also a major risk with up to 56% of opiate users in contact with treatment services experiencing an overdose on opiates at some time in their lives, with 20% reporting an overdose in the previous year (Best et al, 2002). In another study assessing the number of previous non-fatal overdoses in a treatment population in London (Man et al, 2002) 49% reported a lifetime overdose on a mean of 4.1 occasions, which equated to 201 personal overdoses, among this cohort of 116 methadone maintenance clients. In England and Wales there are an estimated 231,000 cases of antibody positive HCV virus in the 15-59 year age group. Within this model 31% are estimated to be current IDUs, 57% are ex-IDUs and 12% are non-IDUs (HPA, 2006). Therefore approximately 88% of HCV cases are attributable to IDU. The prevalence of HCV among injecting drug users can vary from 27% to 74% dependent on geographical location and associated risk factors (Hickman et al 2006). These estimates are an increase on estimates from the late 1990’s and current surveillance and research data suggest that the prevalence of HCV has increased (Judd et al, 2004; Judd et al, 2005). Injecting related bacterial infections have also increased (HPA, 2004) suggesting a need for further targeted interventions towards injecting drug users. To date research has been unable to explain these increases in terms of increased injecting risk and alarmingly have found that new initiates to injecting are particularly susceptible to acquiring antibody-HCV positivity (Judd et al, 2004; Judd et al 2005; Sutton et al, 2006; and Hickman et al 2007). Needle exchange services have a critical role to play in reducing the risks associated with injecting, particularly in preventing transmission of BBVs, by improving risk awareness in IDUs and by providing supplies of injecting equipment to reduce needle sharing and the use of blunt equipment. The effectiveness of needle exchange programmes in the prevention of HIV is well- established (WHO, 2004), however the evidence suggests that needle exchange has been less effective in controlling the spread of Hepatitis C infection.
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Recent statistics show that Birmingham has a low prevalence of injecting drug users, particularly among opiate users relative to the rest of England (West Midlands Public Health Observatory, 2007). However, little is known about the profile of these users or about what services they access outside of formal treatment providers.
Aims and Objectives The key aims of this needs assessment, based on the availability of data nationally and locally are:
To evaluate and map needle and syringe exchange provision including coverage, disposal of needles, and communication and education on wider issues relating to injecting drug use (IDU).
Measure these in relation to the available data on local rates of injecting, coverage of injecting, and the relationship to needle exchange provision. In essence, this will be a gap analysis that will try to clarify questions about the current rate of injecting in the city and the adequacy of needle exchange coverage and distribution. Traditionally, this has been done by attempting to calculate rate of syringe distribution per IVDU both in and out of treatment.
A review of needle exchange policies across the city in relation to the national and international evidence base.
To use this as the basis for a subsequent assessment of the effectiveness of other ‘low threshold’ provision in the city including the availability of outreach and drop-in facilities in the city and the overall mapping of harm reduction provision.
To contribute to the overall DAAT treatment planning process and the review of harm reduction provision in the city.
The approach outlined below amends the established data-driven needs process for lower threshold services, attempting to maximise existing data sources as the basis for expert input and as a means of identifying gaps and in developing a method for improving the overall treatment system.
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Syringe and needle coverage for injecting drug users Coverage of syringes and needles for injecting drug users (IDU) can be defined as the number of sterile syringes provided to IDU divided by the number of injections during a specified time frame (Jones and Vlahov, 1998). From a public health perspective this would ideally mean needle exchange programmes providing a clean sterile needle for each and every injection. Strathdee and Vlahov (2001) offered a rudimentary assumption that an average IDU administering two injections per day results in the need for 730 clean syringes per year to reach the target of “one set, one shot”. Clearly there are variations in drug use patterns and the factors affecting injecting frequency, for example it is particularly suggested that cocaine injectors have a higher frequency of daily injection than heroin IDU (Strathdee et al, 1997). Research in the UK can gives some idea of the levels of coverage in major urban areas. A study assessing coverage in three cities (London, Liverpool and Brighton) found that available data indicated that in London nearly five million syringes were distributed per annum, with over 400,000 in Brighton, and 560,000 in Liverpool (Hickman et al, 2004). These numbers equated to approximately the same proportionate coverage in Brighton and Liverpool at around 190 syringes per injector per year (or one syringe every two days) and slightly less in London at around one syringe every 2.5 days. This research used the average number of times that IDU’s inject (twice a day) to predict the current activity in the cities investigated. The authors therefore suggested that current levels of activity provided sterile equipment for approximately 27% of all injections by IDU in Brighton and Liverpool and 20% in London (Hickman et al, 2004). This research suggests that providing 730 clean sterile syringes per IDU per year is clearly not yet being realised, and that this may be an ‘ideal’ target that is in practice unlikely to be achieved.
Injecting Status in Birmingham There has been no known published research on the number of syringes and injecting equipment used by IDUs in Birmingham, and we are reliant on Home Office estimates of the number of injectors as part of the national assessment of prevalence of drug use. Were this information available we would be able to map the coverage of syringes for each known or estimated IDU, and this needs assessment should be the start of an improved data synthesis process in this area. What this would mean is that we would be able to provide information on the level of syringe and needle exchange activity for problem drug users (PDU) in Birmingham and map this against the estimated total number of PDU’s and the numbers of reported PDU’s who are engaged in structured drug treatment.
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Data from the National Drug Treatment Monitoring System (NDTMS) for the 2005/6 and the 2006/07 financial years provide an illustration of the reported injecting status of problem drug users in treatment in the Birmingham DAT area (those defined as primarily opiate and/or crack cocaine users). Injecting Status
In 05/06
%
In 06/07
%
Current
604
12
634
12
Previous
992
20
1156
22
Never
2777
56
3053
59
Not known
545
11
334
6
Table 1. Injecting status of clients in Birmingham engaged in Tier 3 or 4 structured drug treatment and entered onto NDTMS in 2005/6 and 2006/7 These data from the NDTMS suggest that in 2005/6 there were 604 current injectors engaged in structured drug treatment and 634 in the 2006/7 financial year, this represents an increase from the previous year of 5%, but also that the adequacy of data capture is improving as the proportion of ‘not known’ among clients’ injecting status has reduced markedly.
Figure 1. Reported injecting status among problem drug users in Birmingham engaged in treatment during the financial years 2005/06 and 2006/07. According to the Glasgow prevalence estimates of problem drug users in England (Home Office 2006) there are 137,141 injectors nationally (95% CI: 133,118 – 149,144) and 14, 734 injectors in the West Midlands (95% CI: 13,589 – 17,007) of which 2,895 injectors (CI: 2,343 – 3,664) were estimated to be based in Birmingham.
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Therefore, when comparing this estimate of IDU in Birmingham against the total number of current IDU engaged in drug treatment in 2006/7 (634 reported clients), this would suggest that there was in the region of 2,261 (78.1%) IDU not in contact with structured treatment services during 2006/7 (or between 1,709 – 3,030 IDU, based on the published confidence intervals). More worryingly, the data would suggest that only 21.9% of injectors were in contact with drug treatment services in 2006/07, while more than one-third of those not in contact with services were injectors. Using this information in the reverse manner, NDTMS data from 2004/5 suggested that 17.3% clients engaged in treatment were heroin injectors. This would suggest that a substantial proportion of injectors are not in touch with structured services and so harm reduction initiatives are reliant on the impact and effectiveness of low threshold services to reduce risk and to engage in health messages with this population.
Data and Findings Syringe and Needle Exchange Programme Data A snapshot of Birmingham has been collated onto a database and used for analysis, although it is important to note that there were major limitations with the data available in this area. Below is a summary of the analysis of this database that attempts to investigate the number of needles, syringes, and injecting equipment supplied to drug users over a 3-month period between July and September 2007. This provides a further description of the profile of injecting and other drug users who use low threshold services and potentially provides a picture of those only accessing these services and therefore characterised by the NTA as currently not engaged in structured drug treatment (i.e. a hidden population). Models of Needle Exchange Needle exchange services in Birmingham are predominantly split into two models of service delivery, pharmacy and non-pharmacy based services. The non-pharmacy based services are set within specialist substance misuse services (such as Tier 2 providers or Tier 3 community drug teams) with pharmacy based services delivered from community pharmacies recruited onto a DAT commissioned scheme. The pharmacy based schemes typically provide needle exchange services through a standardised ‘pack’ scheme where needles, syringes and injecting equipment are distributed in standardised packs consisting of syringes (usually 10 fixed head syringes per pack) and injection preparation equipment (pre-injection swabs, acidifiers, cups/cookers, and filters). The packs can also contain condoms and harm reduction literature. In the specialist services this equipment and information is distributed through a ‘pick and mix’ system where injecting drug users can obtain injecting equipment based on need and not in a standardised pack. At the time of reporting there were 92 community pharmacies providing needle exchange services and 6 specialist services providing in house needle exchange services.
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Needle Exchange User Profiles Across the sample of needle exchange users (both pharmacy and non-pharmacy) the majority of users were in the 25-34 year age group (53%), 38% were between the ages of 35 and 64 years and 9% were under the age of 24. There were only six recorded transactions for people under the age of 18. The gender spilt shows an over representation of males (85%) compared to female needle exchange users (15%). This contrasts with the gender representation of individuals engaged in structured treatment services (taken from NDTMS data), of which 26% were female. The majority of users were of white ethnicity (93%) and again demonstrates the difference in user profiles compared to the wider NDTMS population; this is illustrated in Figure 1 below.
All Needle Exchange Users Asian/Asian Other 3% Mixed 3%
NDTMS (New Presentations)
Black/Black Other 1%
Black/Black Other 1%
Other 1% Mixed 8%
White 93%
Asian/Asian Other 13%
White 69%
Figure 2. Ethnicity comparisons of needle exchange users and the population of substance misusers engaged in structured treatment (Tiers 3 and 4).
Thus, there is a concern that the needle exchange provision in Birmingham is targeted at only white and only male drug using clients – and it is too early to state with confidence whether this is the group who primarily use by injecting.
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Needle Exchange Transactions During the period used for analysis (July – September 2007) there were 6,940 individual transactions within pharmacy based needle exchange services, with a high level distribution of smaller 1ml and 2ml syringes compared to the larger syringes available. The total number of 1ml syringes distributed was 87,530 (68% of the total number of syringes distributed through community pharmacies) and 38,260 syringes of the 2ml size (30%). A smaller number of 5ml syringes were distributed (n= 3,730), however there were no recorded 10ml syringes distributed during the 3-month period. Due to the smaller number of non-pharmacy based needle exchanges the number of transactions in non-pharmacy services was significantly smaller than in pharmacybased services with a total number of 65,146 syringes distributed for all needle types. Table 2 below demonstrates the number of syringes distributes by needle/syringe type. 1ml Diabetic 1ml
2ml
5ml
10ml
Orange1
Blue
Green
1,701
7,697
1,090
342
7,503
15,120
8,373
23,320
Table 2. Number of needles and syringes distributed by type across specialist needle exchange services in Birmingham. The number of needle and syringe returns was significantly smaller than the number of syringes/packs distributed. Across the sample 2,545 ‘sharps containers’ were returned to needle exchange services, however it is not possible to quantify how many individual syringes this represents or what size syringes were returned as the sharps containers are sealed to prevent contamination. Geographically, pharmacies with the largest number of transactions are located in the centre of the city (Boots Chemist, High Street; 13% of all transactions recorded), Moseley (7%), Kings Norton (5%) and Castle Vale (3%). The comparison of pharmacy and non-pharmacy distribution is shown in Table 3 below: Pharmacy Transactions Total syringes distributed Average number of syringes distributed per
Non-Pharmacy
6,940
1,680
129,520
65,146
19
39
transaction Returns (across both types of provider)
2,545 containers (potentially 25,450 syringes)
Extrapolated distribution (over 12 months)
518,080
Extrapolated returns (over 12 months)
1
260,584
10,180 containers (potentially 101,800 syringes)
Colour coded needles refer to the following: Orange (25 gauge), Blue (23 gauge) and Green (21 gauge)
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Table 3. Needle exchange activity in specialist and pharmacy needle exchange schemes (1st July – 30th September 2007) The injecting PDU estimate for Birmingham is 2,895 injectors (CI: 2,343 – 3,664), and the approximate total number of syringes distributed over the 3 month period and extrapolated over 12 months is 590,180 syringes. This equates to in the region of 1,204 syringes per person per year (or between 252 and 161 syringes based on associated confidence intervals) and just over 1 syringe every two days (0.6 per day). This also means that based on the average injector having 2 injections per day, current coverage in Birmingham provides new sterile equipment for approximately 28% of all injections (or between 22% and 35% based on associated confidence intervals), assuming that a new needle were to be used for every injection. This is compared to research discussed previously by Hickman et al (2004) who reported that sterile equipment was provided for approximately 27% of all injections by IDU in Brighton and Liverpool and 20% in London. This would suggest that Birmingham is at least consistent with other major English cities although this should not imply that the situation could not be improved. Comparisons between Pharmacy and Non-Pharmacy populations Non-pharmacy needle exchange users were more likely to be older (in the 25-64 year age groups) than those accessing pharmacy based needle exchanges (χ2 =16.33, df = 2, p <0.001), there was a higher proportion of 18-24 year olds accessing pharmacy based needle exchange services than in non-pharmacy services, this is illustrated in Figure 3.
Figure 3: Age analysis by specialist versus pharmacy exchange
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Female injecting drug users were more likely to access non-pharmacy based services than community pharmacies for their needle exchange equipment (χ2 =10.68, df = 1, p = 0.001), while there were no significant differences in the ethnicity of those accessing either pharmacy or non-pharmacy services. Limitations in this current data need to be noted; firstly the accuracy of the data is questionable although on review the activity by pharmacy looks to be consistent with current knowledge as expressed by the expert group members. However, at a service level, the recording of client details around number of syringes distributed are problematic. There is also no method at present of knowing whether users are accessing both the pharmacy and non-pharmacy based services, therefore the sample populations cannot be assumed to be not independent groups. Current data reporting mechanisms are being improved and implemented at this time, this will enable a more consistent and standardised measure of activity within needle exchange services and should provide better quality data for the next annual needs assessment. Until some basic identifiers are linked to exchange monitoring this type of analysis will be largely speculative.
Non-Pharmacy Services Data Update – September 2008 Developments in the collection of data for needle exchange activity have enabled further analysis at the specialist provider level (non-pharmacy services). The data summary below is based on data collected by each of the specialist service providers between November 2007 and July 2008. Analysing the dataset with all service combined we found that: The majority of service users are between the ages of 25-30 years (n=668, 36%) followed by 31-35 year olds (n=460, 24.9%), this is roughly consistent with the previous analysis detailed above where 56% of users were between 25-34 years. Specialist exchange users are predominantly male (86%) and White British (79%), followed by Asian Pakistani ethnicity (6.7%). This represents an increase in the ethnic diversity of needle exchange users as previous analysis demonstrated a higher percentage of White users (>90%) Most clients are not new to the needle exchange service (n=1,558 – 84%), however The majority of clients are not engaged in structured treatment services (n= 1,024; 56%). These questions were not previously asked therefore no comparisons could be made. However this provides support for the prevalence analysis above suggesting that most injectors are out of treatment. It does however, offer a hope of engaging this group as many appear to be in contact with specialist needle exchange schemes. The primary substance injected is heroin (48%) followed by crack cocaine (23%) and steroids (19%) – at present, the schemes are not commissioned to provide services to steroid users. 66,203 needles and syringes were distributed with 1ml syringes (n=18,337 – 28%) and Green needles (n=10,248 – 15%) being the most popular. Only 19,020 returns were made – data does not indicate whether this is individual syringes or bins.
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685 bins were given out – no data on the size of these bins. Younger Nx users are less likely to be ‘in treatment’ than older Nx users (2 = 22.91, df = 4, p < 0.001). This may further suggest that needle exchange attendance is a stepping stone towards engagement with formal treatment services, and that needle exchange services may be a particularly important arena for recruiting young drug users into treatment. . A comparison between the specialist services shows some variation between client profiles, particularly for age, gender, substance choice and transactions: Addaction’s client base has a higher proportion of younger needle exchange users (25-30yrs) when compared to the other services – 53% compared with 20% at Mary Street and 31% at the Terrace Slade Road and the Terrace have a higher proportion of older Needle exchange users – see Figure 3 below:
Figure 3: Age analysis of clients across Specialist Needle Exchange Providers
Female clients represent 20% of those accessing the Needle Exchange at Azaadi compared to 8% at Drugline (highest and lowest)
Slade Road, The Terrace and Addaction have the highest proportion of new clients compared to those who had previously attended their needle exchange facilities. Further breakdown of this is provided in Table 4 below:
Service Addaction Drugline Mary St
Count % Count % Count %
Has the client accessed this service before? No Yes Total 188 51 239 78.7% 21.3% 100.0% 848 77 925 91.7% 8.3% 100.0% 68 9 77 88.3% 11.7% 100.0%
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Azaadi Terrace Slade Rd Total
Count % Count % Count % Count %
258 88.4% 76 78.4% 120 71.0% 1558 86.6%
34 11.6% 21 21.6% 49 29.0% 241 13.4%
292 100.0% 97 100.0% 169 100.0% 1799 100.0%
Table 4: Number of new clients using the Specialist Needle Exchange services November 2007July 2008 ď&#x201A;ˇ
All services are asked to record whether clients accessing Nx are engaged in structured drug treatment. The majority of clients reported that they were not in treatment (n= 1024, 57%) with wide variation across services, for example 93% (n=75/81) of Nx users at Mary Street and 84% (n= 200/238) at Addaction were not in structured treatment compared to 39% (n=361/923) at Drugline (highest and lowest proportions) the remaining three CDTâ&#x20AC;&#x2122;s fell between these (Slade Road 67%, Azaadi 67%, Terrace 83%). This question needs to be clarified with Nx workers and with commissioners to ensure the question is asked in a standardised format. The high number of clients reporting that they are not in treatment requires further investigation and clarification to find out how reliable this figure is and whether this is a true reflection of treatment engagement amongst Nx users. Table 5 below illustrates the responses to this question for each service.
Service Addaction Drugline Mary St Azaadi Terrace Slade Rd Total
N= % N= % N= % N= % N= % N= % N= %
In Structured Treatment? No Yes 200 38 84.0% 16.0% 361 562 39.1% 60.9% 75 6 92.6% 7.4% 196 95 67.4% 32.6% 80 17 82.5% 17.5% 112 56 66.7% 33.3% 1024 774 57.0% 43.0%
Total 238 100% 923 100% 81 100% 291 100% 97 100% 168 100% 1798 100%
Table 5. Number (and percent) of clients accessing specialist Nx provider services who report that they are not currently engaged in structured treatment
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ď&#x201A;ˇ
Steroids: 60% (n=48) of Mary Street, 40% (n=104) of Azaadi and 37% (n=62) of Slade Road needle exchange clients are primary steroid users compared with 15% (n=134) at Drugline, 3.9% (n=9) Addaction and 1% (n=1) at the Terrace.
ď&#x201A;ˇ
Drugline gives out the highest number of syringes, needles and equipment, however the remaining services vary by level of activity for each piece of equipment or syringe type, as illustrated below in Table 6 (yellow for highest, pink for second highest):
1"
1.25"
445
Cups Water Acid
Bins
30
713
230
852
24
4,325 5,782
3,129
5,206
2,538 7,164 8,978
10,010 454
50
328
997
110
1,066
0
132
0
278
37
318
10
520
1,559
1,797
1,496
164
275
1
476
51
55
91
116
279
283
0
279
5
233
5
820
16
1,759
493
15
408
669
1,230
1,973
208
611
20
1,182
74
6,296
10,733 3,145 9,267 9,229
5ml
10ml Or
Addaction
2,070
632
84
58
280
Drugline
12,296 5,146
584
552
Mary Street
686
1,027
541
Azaadi
1,385
2,271
Terrace
836
Total
BL
Br
2ml
Slade Road 1,567
BL
Gr
Nx Provider 1ml
18,840 10,890 2,111 801
6,140 9,735
225
2,148
14,914 656
Table 6: Needle and syringe distribution across the Specialist Needle Exchange Providers November 2007-July 2008 There were 19,029 returns across all the services. Drugline recorded 15,587 returns compared to 19 returns at the Terrace. It is unclear whether the number of syringes or the numbers of bins are being recorded or a mixture of both. The number of returns is shown in Table 7 below: Service Addaction Drugline Mary Street Azaadi Terrace Slade Road Total
Returns 119 15587 1871 1412 19 21 19029
Table 7: Number of needle/syringe returns by Specialist Needle Exchange Provider, November 2007July 2008 Thus the majority of the returns reported by specialist services were at one agency, Drugline, with very small numbers in some of the CDT needle exchange providers.
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Pharmacy Survey To gain an understanding of the use and acceptability of needle exchange packs distributed to pharmacy based services, the DAT distributed questionnaires to service users via the nine community pharmacies with the highest needle exchange activity, as shown in Table 8 below. This provides a useful comparison against the specialist needle exchange service data reported above: Do you use...
Yes
No
Syringes and Needles
97%
3%
Sharps Containers
91%
9%
Swabs
90%
10%
Vitamin C
87%
13%
Filters
85%
15%
Condoms
35%
65%
Harm reduction information
32%
68%
Table 8: Client activity reported by users of pharmacy needle exchange schemes Thus, there is considerable use of a wide range of harm reduction options other than only syringes and needles, although uptake of information in this group is low. In Table 9, basic information is provided on the drug of choice for this group: Drug of Choice
n=
%
Heroin
92
49.7
Crack and Heroin
32
17.3
Crack Cocaine
11
5.9
Cannabis
4
2.2
Methadone Amps
4
2.2
Steroids
3
1.6
Amphetamine
2
1.1
Diamorphine
1
0.5
Not indicated
36
19.5
Table 9: Primary drug used by pharmacy needle exchange clients Thus, heroin is the most commonly injected drug followed by the combination of heroin and crack, although there is a considerable amount of missing data around drug use. In Table 10 below, participants were asked what else they would like to see being distributed at the exchanges.
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Suggested Inclusions
N=
%
Water
52
65
Citric Acid
13
16.2
Other
15
18.8
Table 10: Suggested requests for other items to be distributed at pharmacy needle exchanges
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Needle exchange mapping In the mapping exercise below (Figure 5) we have mapped levels of needle exchange activity across the city:
The majority of Nx activity on the above map occurs in the Heart of Birmingham PCT area, as signified by the number of blue, black and green indicator discs. The size and colour of the indicator reflects the level of
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activity in each of the pharmacy based and specialist Nx services, mapped against the identified drug availability reported by WM police (shaded areas). There are a number of city centre pharmacies where needle exchange activity is particularly high (as signified by the large blue discs). Drugline is also a key city centre provider of Nx services in the city. In the south of the city there are two key pharmacies providing high levels of injecting equipment (black discs), however there are areas of drug availability (pink/yellow shaded areas) which are not directly covered by needle exchange schemes. This map provides an initial measure of Nx services mapped against drug availability and requires further investigation to assess the reliability and interpretation of using these methods. Expert group meetings As part of the needs assessment process, an expert group was convened to ensure the widest possible consultation of local stakeholders. We aimed to provide a balance of stakeholders including individuals who: Have a professional role in the provision of services to IDU, for example service provider team leaders
and needle exchange workers Can make changes happen in relation to the needs and harms identified for IDU’s, for example
managers, commissioners and planners. We aimed to include user representative in this process, however no individuals were available at the
time of conducting this needs assessment although the initial findings were presented to the DAT user group for comments and feedback. The expert group was important in appraising from their specialist viewpoint the accuracy and validity of the data collected and in translating these data into identifiable needs that are compatible with the local treatment system. The expert group was also a source of additional local data with which to supplement the core data sets. In other words, they will contributed at three stages: 1. In identifying and accessing relevant data sources – including their own activity data 2. In making sense of the overall data picture, reconciled against their own qualitative knowledge and their awareness of limitations in particular data sources 3. In the ‘translation’ process for turning the epidemiological map of unmet needs into actions that can be addressed through the treatment planning process Discussions held during the expert group process Pharmacies were seen by the group to provide a relatively anonymous exchange with a brief intervention that enables the whole process to run as quickly as possible. Drug services are seen as a place for treatment and so clients may wish to separate their scripted medication from their exchanges. In addition, drug workers are expected to initiate longer, more detailed interventions which may deter clients. Hence the larger number of clients who use pharmacies for exchanges - 20% of all needle exchange packs were distributed at the three
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Boots pharmacies within the city centre. This geographic concentration offers both advantages and disadvantages to the scheme. It was suggested that a hybrid of these two types of services could be commissioned to create pharmacies which carried out more extensive interventions, perhaps providing a pick and mix selection of needles- but still remaining a swift, impersonal service. These extended pharmacy services could perhaps be trialled in one of the busier pharmacies, for example there are nine pharmacies which register four times the amount of activity than other pharmacies in Birmingham. It was suggested that younger, less problematic drug users utilized the pharmacy services and perhaps then, as their drug habit graduated to a more entrenched level, they began to access actual treatment centres. This sort of data could be quantified by differentiating Nx figures from pharmacies for users in treatment vs. users not in treatment. This would then support the view that pharmacy Nx should aim their interventions at Harm Reduction leaving drug services to promote and encourage clients into treatment. Gaps in Provision identified in the expert group process it was suggested that postcode information gathered from needle exchange data it could be used to configure an average distance for service users to travel to drug service centres and therefore pinpoint where there are particularly large gaps in provision. Furthermore, working upon information supplied by Environmental Health, which may give precise needle litter spots, it might be possible to install automated needle exchange services in the forms of vending machines. This would provide services out-of-hours and also act as waste disposal points. Other possibilities for data collection were recommended, including: ambulance maps of pick-up areas and police knowledge of drug transaction points. Both of these sources may indicate areas in need of drug services and/or needle disposal units. The main area considered to be most deficient in opportunities for treatment was mapping pathways and services needs for steroid users who are currently overlooked. Key informant interviews In order to determine and balance the views of local stakeholders qualitative research methods were used. Key informant Interviews were conducted to gain an in-depth knowledge of needle and syringe exchange systems in Birmingham and what gaps and needs may exist within these current systems. Additional interviewees were identified on the basis of addressing particular issues that arise in the course of the quantitative data process and the group processes. In total 11 interviews with key stakeholders were completed including commissioners, community and pharmacy service providers and the key areas for discussion related to: ď&#x201A;ˇ
Opening times and related issues of access arose as an issue
ď&#x201A;ˇ
Increased steroid users accessing services
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Review of what people want in the exchange packs and the inconsistencies in the current level of provision, particularly around pick and mix provison
Training or information for new pharmacy workers
Picking up bins from pharmacies
Good coverage across the city and the need to map against reported client needs
The need for fast and responsive services
Ability to provide what the service user wants in a non-judgemental service
The need for better supported and resourced crack interventions
A common theme in the key informant interviews was the reported increase in needle exchange transactions for steroid users, particularly in non-pharmacy services. Respondents felt they had a good knowledge of responding this profile of drug users however some felt that further training could be needed. These views were balanced by further concerns about the appropriateness of steroid users accessing needle exchange provision when there was no current funding for providing needles and paraphernalia to this client group. Although the general consensus was that the harm reduction philosophy would included providing injecting equipment and advice to this clients group to minimise the harms that could arise from sharing needles and having limited knowledge, particularly as many steroid needle exchange users felt they were not drug users. Crack users were also seen as a client group whose needs could be better met by needle exchange services, particularly in non-pharmacy specialist services. Whilst injecting crack is known to cause considerable harm to veins, some respondents felt that further paraphernalia could be provided for crack users, for example the provision of crack pipes to encourage users to smoke crack rather than inject and to encourage crack users to engage with treatment services. Pharmacy services felt that training for new workers or an information pack for new workers on the validity and importance of providing Nx services to drug users could be a useful addition. It was felt this would help generic workers to understand that Nx services are a key public health intervention. Generally, across both pharmacy and non-pharmacy services it was felt that the provision of Nx to drug users was well resourced, nonjudgemental and efficient in providing harm reduction services for IDU in Birmingham.
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Needle Exchange Needs Assessment Recommendations
1
Finding
Recommendation
The treatment status of IDUs accessing Nx
To continue to collect treatment status information. To use
facilities is largely unknown. Treatment status
this information to assess the number of Nx users currently in
has now been added as a monitoring
or not engaged with structured treatment services, and to
question on all DAT Nx return forms
inform the treatment planning process accordingly. This is particularly important given the high rate of users estimated to be not in treatment from snapshot analysis (56%)
2
Pharmacy Nx services have proportionately
Ensure that harm reduction and treatment options information
more IDU under the age of 25 accessing
and advice are available to these users to maximise the
these services. These groups are traditionally
opportunity of signposting them into structured treatment â&#x20AC;&#x201C;
â&#x20AC;&#x2DC;hard to reachâ&#x20AC;&#x2122; from a treatment perspective.
and options for early onsite brief motivational interventions. Additional resources in providing enhanced treatment pathways for these groups (particularly at high activity exchanges) should be examined and qualitative research work done to identify barriers to treatment in these populations. Brief information packs and training and support for general pharmacy staff may be important particularly in the high volume pharmacies within the scheme.
3
There are growing numbers of steroid users
To assess the workforce training needs in relation to this
accessing both specialist and pharmacy
group of IDU. Provide information or training where identified
based Nx services.
around the management and provision of injecting equipment and harm reduction advice for steroid users. To investigate funding sources for the provision of needles and syringes to steroid users, and to assess the public health implications of working with this group.
4
There is a clear need to improve coverage of
Consideration should be given to developing new methods of
the city using both existing types of needle
delivering equipment, either by piloting automated dispensing
exchange provision and innovative
facilities or by generating greater coverage of the city through
techniques
the recruitment of additional pharmacy services.
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5
Policies for the return of injecting equipment
Ongoing working group required to develop consistent
vary by pharmacy and service resulting in
policies across the city that can be tested against ongoing
variable and often low return rates
data collection â&#x20AC;&#x201C; clarity of policies and resulting training and support for staff required
6
There are varying levels of awareness
To produce an information/induction pack for pharmacy
amongst pharmacy Tier 1 workers about the
workers introducing them to the harm reduction rationale and
harm reduction approach for providing Nx
reasons for providing needle exchange facilities for IDU. This
services to injecting drug users
should be included in training for Tier 1 staff and pathways to and from needle exchanges disseminated more effectively.
7
Based on the estimates of injecting PDU in
Work with user groups and pharmacy working group to
Birmingham and the analysed activity data,
develop strategies for improved overall levels and consistency
there is a sub-optimum level of syringe and
of penetration into this population. This should also include
needle coverage across the city
work to increase the uptake of needle exchange services in harder to engage groups such as BME and female IDU. There are initial indications that less than half of the users of NX facilities are in treatment â&#x20AC;&#x201C; more local data is required to characterise the populations out of treatment and to develop appropriate interventions and pathways for this group.
8
Data collection procedures are inconsistent
Review data collection mechanisms particularly in light of the
and analysis of this data is problematic
amended data collection form (already implemented across all Nx services) and develop areas of identified data weaknesses. Although initial steps have been taken to address this, local analysis of injecting groups and their needs is urgently required alongside evaluations of effectiveness of both specialist and pharmacy exchange schemes.
9
Interventions to reduce the harm caused by
To consider replicating the work done in Walsall to provide
smoking crack cocaine are not currently
crack smoking equipment to crack users. To provide harm
adequately resourced
reduction information to crack users (and all other drug users) accessing needle exchange services in a range of different languages. To clarify policies around crack packs and their link to BTEI interventions for cocaine powder and the COCA training initiative around cocaine powder and crack.
10 There is a low rate of treatment engagement
Increased focus on accessing injectors into treatment
for injecting drug users.
services. Once data are available on treatment status via needle exchanges, there is a need for health screening, harm reduction and rapid (and possibly incentivised) methods of
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effectively engaging this group in some form of structured interventions
11 There is little known about IDU being
To conduct further work on assessing the level of prison
released from Prison in Birmingham and
leavers who are current or previous IDU and investigate the
whether appropriate needle exchange
views of pharmacies in close proximity to the prison towards
services are available.
providing targeted harm reduction interventions to this population.
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