Moving from needle exchange to safer injecting services

Needle exchange was a term that was coined in the 1980's when the idea of providing injecting equipment to injecting drug users was novel and challenging. In those early days it wasn't initially clear how things would work out and, as early users of services brought back their used injecting equipment, needle exchange was an accurate description of the service on offer.

However, that was over 20 years ago and, on our view, the term is now both inaccurate and unhelpful.

We do not normally name a form of service provision simply after one of the predominant activities that goes on within it, unless that is the only activity. If we did, then we might for example find ourselves with Methadone Prescribing Teams, or Community Methadone Teams. Why then do we persist with the name needle exchange? A terminology that doesn't really describe what usually occurs in a community pharmacy (usually with low return rates, pharmacies [quite rightly] are needle and syringe provision services) and certainly does not encompass the range of activities that should take place within agency based needle exchanges.

'Needle exchange' is widely considered to be a harmless euphemism for 'free provision'. However, in Australia the literal interpretation, and the resulting expectation that the mission of services was to exchange injecting equipment led to severe public relations problems, with funders and communities (understandably) measuring success, at least in part, by the return rate. Following these problems there has been the almost universal adoption in Australia of the term needle and syringe program as a more accurate description of what services do.

In the UK, the idea that the primary goal of needle and syringe exchange programs (to distribute sterile injecting equipment) should not be sacrificed to achieve a secondary goal (safe collection and disposal of used injecting equipment) is one that has not always been apparent to funders, critics and other practitioners.

There may also be a conceptual problem with the term, not least for those commissioning services. A 'needle exchange' may actually engage in many valuable activities, with an often socially excluded client group who may be in contact with few if any other services.

There often been an assumption that the task is a simple one of simply giving out sterile injecting equipment and receive back used needles and syringes. Although this is central to the operation of a needle exchange – it is innacurate, in that it implies in all cases a '1 for 1' approach. Thankfully, most UK exchanges do not work to this sort of model, and remain prepared to supply sterile equipment to those who do not consistently return used equipment.

The expansion in the number of needle exchanges across the UK in the past 13 years has been striking. However, that expansion has been accompanied by little if any guidance, consensus or research on what actually constitutes a needle exchange.

There are many often unrealised opportunities for health promotion and engagement with a group of drug users who are not as yet prepared to stop using drugs.

Activities undertaken by specialist services may include:

• facilitate the supdistribution of sterile equipment;
  

• distribution of sterile equipment;
  

• information and advice on injecting technique;
  

• information and advice on drugs;
  

• information and advice on blood borne viruses;
  

• contraceptive advice and equipment;
  

• testing for blood borne viruses;
  

• referral into drug treatment;
  

• referral to A&E, GP;
  

• primary healthcare including treatment of injecting related injuries;
  

• client advocacy;
  

• facilitation of user groups;
  

• group work;
  

• benefit and housing advice; and
  

• pregnancy and smear testing.
  

However, there has to be an understanding of the full potential of services if it is to be realised. The lack of a suitable descriptive term may be one of the factors involved in holding back that potential - although other obvious factors are finite resources and competing agendas.

However, this is not an argument that all needle exchanges should be attempting to provide such a wide range of services. The provision and disposal of injecting equipment is essentially a simple task. Our belief is that the best option is to have the widest possible involvement of pharmacy needle and syringe provision, supported by Safer Injecting Services, which would:

• help to develop and define good practice;
  

• provide services other than those easily able to be provided in pharmacies; and
  

• recruit pharmacies and train pharmacy staff.
  

Recent unpublished work in the North West of England looking at the range of services provided by specialist needle exchanges, the staff roles and premises has tended to confirm the diversity of services operating under the title 'needle exchange'. The majority have several factors in common, in that they:

• operate from the same premises as drug treatment services;
  

• are staffed by workers whose primary role is drug treatment; and
  

• are usually poorly resourced in terms of space and equipment.
  

The first two factors are connected in leading to role conflict for workers and potential difficulties for clients in receipt of substitute prescribing in accessing clean injecting equipment. The fact that the primary role of needle exchange workers is often in prescribing says something about the value attached to the needle exchange portion of their work. Workers engage with large caseloads, a proportion of whom are always likely to be experiencing some form of crisis.

The workers reputation and standing within the client group is at least partly determined by their efficiency in dealing with prescriptions and prescription changes. It is not hard to empathise with those workers who express their frustrations by describing needle exchange work as distracting them from their 'real' (prescribing and counselling) work.

As the nature and extent of the hepatitis C infection has become apparent needle and syringe services will have to continue to adapt and better engage with their service users to provide more detailed information on safer injecting practice. It would seem reasonable to suggest that the recognition of hepatitis C should provoke a re-evaluation of needle exchange. The original emphasis on HIV prevention was certainly laudable and perhaps more importantly,highly effective. Perhaps this success was because of a single focus on HIV, utilising the fears and concerns of drug users and of wider society. Looking back, the lack of a concurrent focus from the beginning on Hepatitis B, an infection long known to be a problem for injectors and largely preventable through vaccination, can be seen as a missed opportunity.

We propose that a move away from calling services needle exchanges and a change to the use of more accurate and encompassing terminology such as 'needle and syringe provision' or 'Safer Injecting Services' would:

• allow a re-conceptualisation of service provision;
  

• prevent the issue of return rates achieving greater significance than they deserve; and
  

• promote the move towards more uniform, comprehensive and competent service provision.
  

This article was written by Andrew Preston and Jon Derricott, in 2001 (!)