Introduction

There are a number of important issues not yet dealt with in this book that surround the

day-to-day practice of needle exchange work, and the organisation of syringe exchange services. This section discusses the practicalities and legal constraints of effective needle and syringe exchange provision.

The law
Paraphernalia
Section 9a of the Misuse of Drugs Act 1971 prohibits the supply of articles for administering or preparing controlled drugs. However, subsection 2 allows for the provision of syringes and needles, but nothing else.

The paraphernalia laws were intended to prevent the commercial sale of drug use 'kits'. Unfortunately they have had the unintended effect of restricting the public health gain which could be had from giving out all appropriate injecting equipment alongside messages for their safe use. It is much easier to raise the subject of safer use of an article when actually giving it to someone.

Because of the benefits to clients, many projects do give out a wide range of equipment other than syringes and needles. These include:

Filters

Sterile water

Alcohol swabs

Spoons.

Prosecutions under the Act would be brought by the Crown Prosecution Service (CPS). The CPS is required to bring prosecutions 'in the public interest'. As there would be no public interest served by prosecuting drug services giving out injecting paraphernalia alongside harm reduction messages, prosecutions are unlikely.

Some projects have managed to get assurances from their local CPS that they will not (or are very unlikely to) be prosecuted for giving out paraphernalia (usually sterile water). However, other areas have been unsuccessful in these approaches, probably because the CPS is wary of attracting adverse publicity, rather than because they intend to prosecute breaches of the law.

Even those projects which have received assurances of immunity are still put in the iniquitous position of breaking the law, even though they know they are unlikely to be prosecuted.

Reform of the paraphernalia laws would allow a more consistent message to be developed and propagated. Needle and syringe exchanges could then perhaps fulfil their greater potential and become injecting equipment exchanges.

Prosecution
Although criminal prosecution under the Misuse of Drugs Act is unlikely, there is a small risk of services being prosecuted under civil law for supplying inappropriate or wrong advice or equipment, which resulted in damage. Such a case would probably be brought by, or on behalf of, an injured party.

In the event of a prosecution, it would be the agency or employing authority not the individual worker that defended the action and paid any damages, as employers are responsible for the actions of their employees.

Given that such a case would be expensive and difficult to take to court, it is an unlikely event. More likely, and possibly more damaging, is an injured party using the media to blame the agency for the perceived wrongdoing.

Clearly, working with young people is an area with greater sensitivity and legislation and there are likely to be more court cases than in any other area of the work.

Duty of care
Duty of care is the legal responsibility which falls on all those offering a service, to provide adequate care. If a person suffers harm because of a failure to care for them properly, they may sue on the grounds of negligence.

Duty of care was defined in the case of Donoghue v Stephenson (House of Lords 1932) as:
"You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure... persons who are so closely and directly affected by my act that I ought to have them in contemplation as being so affected..."¹¹⁶

The key word in the above quote is 'reasonably'. It would be unreasonable to hold workers responsible for injury caused by inexpert use of equipment or advice supplied by them, unless that equipment or advice was not correct (e.g. giving steroid injectors advice on injecting intravenously rather than intramuscularly).

Scotland
The law relating to needle exchange in Scotland is slightly complicated by the existence there of a common law crime of 'reckless conduct'. As Roberts et al. report, this
"...makes it impossible to say that the supply of needles and syringes to be used for injecting controlled drugs could never amount to the commission of a criminal offence."¹²⁸

Guidance in 1988 from the Scottish Office, regarding the sale of injecting equipment, included a statement from the Lord Advocate that in his view the prosecution of a pharmacist for 'reckless conduct' would only happen in exceptional circumstances. However, he wished to retain the discretion to be able to do this.

Equipment and its uses

It is important for needle exchange workers to be familiar with the safe use of injecting equipment and with what equipment is appropriate for particular activities. Tables 8.1 and 8.2 give some basic information about injecting equipment, followed by information about other specific equipment.

Table 8.1: Syringes

Size	Use	Not to be supplied for
Insulin syringes 0.5 mL syringe/needle 1 mL syringe/needle	Intravenous injecting into superficial veins Subcutaneous injecting	Injecting into deep veins Intramuscular injection
1 mL syringe	Intravenous Intramuscular Subcutaneous
2 mL syringe	Intravenous Intramuscular	Subcutaneous injecting - volume too great
5 mL syringe	Intravenous	Intramuscular injecting - volume too great [Requests for 5 mL syringes should provoke questions about intended use - many will want to use them to inject crushed tablets]
10 mL syringe or larger	Injecting crushed tablets Injecting methadone mixture	[Giving out large barrels will not reduce the likelihood of harm]

Table 8.2: Needles

Colour	Size	Uses	Not to be used for
Brown	26G x 5/8"	Superficial intravenous injecting	Intramuscular injecting
Orange	25G x 1" 25G x 5/8"	Deeper veins Superficial intravenous injecting	Intramuscular injecting
Blue	23G x 1"	Intramuscular injecting Deeper veins	Superficial intravenous injecting
Green	21G x 1.5"	Intramuscular injecting	Intravenous injecting

Sterile water
As well as being paraphernalia, ampoules of water for injection are a prescription only medicine (POM) under The Medicines Act 1968, and as such can only be legally supplied on receipt of a valid prescription for a named person. A number of exchanges give out sterile water (water for injections), although it is technically illegal to do so.

Again, a blanket prescription for a service is not legal, although many services that dispense water for injection use this device. Prosecution is unlikely because it would be not be in the public interest.

If sterile water is to be given out, it should be supplied in ampoules sufficient for once-only use, in order to minimise the risk of ampoules being shared or stored and reused.

Needle exchange packs
Ready-made packs are provided by needle exchanges and community pharmacies to supply the most commonly used equipment to injectors quickly and easily. They usually contain syringes of a type appropriate for accessing superficial veins often the all-in-one insulin syringe.

Sharps containers
It is essential that equipment is given out with adequate means for safe storage and return. Sharps containers are made by many manufacturers in a wide variety of sizes and styles, some discrete and small enough to be carried in a pocket, some large enough for storage of used equipment over a longer period. It is important when considering which size and type of sharps containers to use to ensure that:

The containers supplied are of an appropriate size

Different sizes of container are given where necessary

Clients understand how to use them safely and particularly, do not attempt to overfill them.

Bleach
In situations and countries where there is no provision for clean injecting equipment, bleaching previously used equipment is better than doing nothing.

As a solitary strategy to prevent viral spread, the advocacy of the use of bleach has serious problems, most of which are bound up in the fact that the majority of people practise bleaching inconsistently or idiosyncratically.

Most accepted guidance about bleaching includes advice to:

Do it only when it is unavoidable

If you are going to reuse equipment, reuse your own

Flush out works with cold water immediately after use.

To clean a needle and syringe prior to reuse:

Rinse with cold water

Draw up full-strength household bleach and shake for at least 30 seconds

Flush out with clean, cold water

Again draw up full-strength household bleach and shake for at least 30 seconds

Finally flush out with clean, cold water again.

The efficacy of bleach against the hepatitis C virus has not been proven.

Condoms
Condoms should be freely available from needle exchanges, along with advice on their use and encouragement to use them. As wide a range of condoms as funding allows should be provided. Extra strong condoms intended for anal sex should be easily obtainable.

Strategies to promote safe disposal of equipment

There is evidence to suggest that needle exchanges do not cause more injecting equipment to be discarded than would be the case if they did not exist¹²⁹.

Occasionally, used injecting equipment is found lying in the open. When this happens it attracts adverse publicity to exchange schemes and represents a risk of viral transmission if someone has an accidental needlestick injury.

Nourse et al. in Dublin followed up 52 cases of childhood needlestick injury outside hospital in a 15-month period between 1995 and 1996. Most of the cases occurred in inner city areas with a recognised high prevalence of injecting drug use. All received hepatitis B vaccination. Although the number of cases is worrying, it was encouraging that of the nine cases with completed tests for HIV, hepatitis B and hepatitis C, none had seroconverted¹³⁰.

Injectors should be strongly encouraged to return all used injecting equipment in sharps containers. Ideally this should be to the place it was dispensed from, although this may not always be possible or practical. Measures to promote returns include:

Verbal encouragement from staff

Verbal encouragement from peers

Written encouragement in the form of leaflets

Written/visual encouragement in the form of posters.

Other measures to promote safe disposal include:

Examining the appropriateness of exchange locations, e.g. are they too distant from injecting populations?

Secure disposal points in identified 'hotspot' areas

Secure disposal points available at exchanges outside opening hours

Identifying means of safe disposal when none of the above is available.

Strict 'one for one' exchange is impractical and defeats many of the aims of needle exchange. It is more important to ensure that sterile injecting equipment is as widely available as possible, than it is to ensure that all injecting equipment is returned.

Needlestick injuries
The risk of needlestick injury to health care workers is well recognised. The incidence of needlestick injury among injecting drug users is not often considered. Two linked studies of syringe exchange attenders^131,132 have included questions about the incidence and subsequent management of needlestick injuries among injectors.

A significant proportion (30.2%) of the 179 questioned had experienced a needlestick injury at some time; 18.3% had experienced one during the past year. Over half of those who had experienced a needlestick injury reported doing nothing about it, some wiped the site with an alcohol swab and a similar number licked it clean. Only one person sought testing.

The risk of a particular viral infection by needlestick injury from an infected needle, varies:

HIV 0.3%¹⁰⁹

HCV 2.710%¹⁰⁹

HBV 30%¹³³

The recommended management procedure for health care workers includes advice to:

Wash off splashes on the skin with soap and running water

Encourage bleeding if the skin has been broken

Report the accident

Contact your occupational health

department to obtain post-exposure

prophylaxis
Obtain hepatitis B vaccination.

Similar measures should be encouraged for injectors, including easy access to hepatitis B vaccination and post-exposure prophylaxis.

This also highlights the importance of encouraging safe storage of used equipment to minimise dangers to others.

Ritual
Drug workers should be aware of the importance of ritual in the injecting process in their work with injectors. The ritualised nature of drug use makes permanent change of behaviour on the basis of reappraisal of the risks a real possibility.

Objects, events or places associated with injecting can become ritualised and serve as triggers for thought processes or feelings associated with the injecting experience. Certainly workers should not be afraid of discussing the detail of a client's injecting ritual and its triggers in order to identify points of risk and potential for change.
Ritual has a strong place within injecting cultures. For an in depth understanding of the subject, the work of Norman Zinberg¹³⁴ and Jean-Paul Grund⁶⁶ is recommended.

Just as with legal drugs like alcohol, powerful rituals and social sanctions and values operate throughout the process of acquiring and using drugs amongst the drug using population.

An example of how social sanctions or values amongst injectors can influence messages about safer use, is the crucial understanding that sharing of drugs can be a defining focus of injecting networks. For example it would not be unusual for an opiate user to be expected to provide drugs for another user in withdrawal, with the expectation that the favour would be returned in the future. It is important when communicating messages about the risks of sharing injecting equipment that the power of such reciprocal arrangements is borne in mind.

Helping people change behaviour
Helping people to stop injecting can be extremely difficult. It is important for both worker and client to understand what it is the client wants to achieve. The setting of realistic goals is important to prevent disillusionment and disappointment.

A goal of stopping injecting may not be a sensible first goal and, indeed, may have been proposed by the client because they think it is what the worker will want to hear.

It is much better to have a good relationship with a confirmed injector and accept that many, if not the majority, will want to continue injecting, than to develop relationships based on deception, which will result in disillusionment for both parties.

Needle fixation
Many people talk of 'needle fixation', sometimes called 'the draw of the needle', or 'the feel of the steel'. There are many factors operating which make injecting and the events and actions that surround it a powerful experience. Some would say that the ritual of preparation and needle use is a powerful conditional stimulus.

Injectors will often rationalise the reason for their continued injecting as 'needle fixation' or that they are 'addicted to the needle'. Although for some people there may be truth in this, for the majority what they are often really saying is that they enjoy using the drug in this way, they like the immediacy of the mental and physical effects.Claims of needle fixation are too often taken at face value. There is nothing wrong in enjoying the effect of injected drugs and it is better to define exactly what is happening for individuals. It is fundamental to establish whether a person has an attraction towards injecting drugs, or the act of injecting itself. Of course for many the attraction is likely to have elements of both and not be limited to a simple 'either/or'.

Motivational interviewing
Motivational interviewing is a directive client-centred counselling style which aims to allow the client to examine their ambivalence (having conflicting feelings about something) and incorporates concepts such as the cycle of change¹³⁵.

If an injector has expressed a wish to change their route of administration, motivational interviewing is a useful technique for allowing clients to determine what changes, if any, they want to make. Part of the process would be to assist in conducting a cost benefit analysis of injecting for that person. A similar comparison can be made for the gains and losses of staying the same or of changing.
An example of an individual's cost benefit analysis might look like that shown in Table 8.3.

Table 8.3: Example of a cost-benefit analysis

Good things about injecting	Bad things about injecting
The rush	Running out of veins
Feeling smashed	Risk of catching diseases
Enjoy preparing the injection	Groin abscess last year
Friends	People always knocking
Better value for money	Risk of OD
I get time to myself	Partner wants me to stop

Motivational interviewing has many aspects which when applied skilfully can help individuals move towards the goals for change that they have set for themselves. For example, many injectors will know only too well the costs and benefits of injecting, they may want to stop, but not believe that they have the capability to do so. Helping such individuals towards a belief in their own ability to make changes will make those changes all the more likely to occur.

Development of basic skills in motivational interviewing would be useful for exchange staff. Recognising that someone is motivated to change their drug taking behaviour to reduce risk, and providing appropriate support for them to do so, would represent excellent harm reduction practice.

For those that do want to stop injecting there are various practical regimes that may be considered, including:

Replacing injected illicit drugs with smoked illicit drugs

Replacing injected illicit drugs with oral prescribed drugs

Replacing injected prescribed drugs with oral prescribed drugs

Becoming abstinent.

For those who achieve their desired goal of change, powerful factors often operate for them to return to their previous use. This can take the form of craving triggered by events, objects or places associated with injecting. Preparing people for these eventualities by talking through them and rehearsing coping strategies can be of benefit.

In an Australian randomised controlled trial amongst injectors not in treatment, Baker et al.¹³⁶ compared the effect of a one-session motivational interviewing brief intervention, against no intervention. At follow-up no significant differences could be found between the groups, but there were significant reductions across both groups in HIV risk-taking injecting behaviour. Baker et al. suggested that it was possible that the subjects who did not receive a formal intervention might be regarded as having received a brief intervention by having their attention directed to their HIV risk-taking behaviour.

Hepatitis and HIV pre- and post-test counselling
Hepatitis C
The availability of hepatitis C testing in the UK has to date been very patchy. There is still a debate in some quarters as to whether testing should even be offered for a condition which has limited effective treatment. The issue is clearly one of informed choice for the client (as with HIV, about which similar issues were raised and largely dealt with a decade ago).

The impact of a positive hepatitis C test should not be underestimated. As Neeleman et al. said in a letter to the British Medical Journal in 1994:
"...disclosure of the fact that a patient is positive for hepatitis C virus can have serious psychological implications, which may mimic those associated with HIV."¹³⁷

Pre- and post-test counselling should be available separately for both HIV and hepatitis C. It has been practice in some areas of the UK to offer both tests at the same time. Although this may be attractive from a resource perspective, it may cause confusion for the client.

Checklist for pre- and post-test counselling
The checklist for pre- and post-test counselling for HIV and hepatitis C is similar.

Some of the issues which need to be examined by a worker with up-to-date knowledge, before testing are:

What the blood tests involve

An assesment of the relevant risk behaviours

An assesment of whether the client has been at risk

Discussion of the implications of a positive test

Discussion of the implications of a negative test

The issue of the 'window period'

Implications for insurance, etc.

After the test, in a session in which enough time is allowed to digest information and to ask questions, some of the issues will be:

Prevention advice for those who appear negative

For those who test positive, what do they want to do about it?

Explain further tests (i.e. for hepatitis C PCR, liver biopsy)

Discuss treatment options

Suggest local support groups

Give accurate literature to take away.

Promoting changes in sexual practice

Sexual transmission of blood-borne viruses such as HIV and hepatitis B remains an underaddressed issue by most UK drug services.

One of the original requirements of needle and syringe exchanges from the DHSS was the provision of advice on safer sex.

Whilst it can be widely demonstrated that syringe exchange had a great impact on the risk behaviours associated with injecting equipment, most evidence suggests that the sexual behaviour of injecting drug users has altered little if at all, except perhaps in the cases of sex workers and those diagnosed HIV positive.

Rhodes and Quirk¹³⁸ identify several factors which may help to explain this lack of behavioural change:

Condom use amongst drug users is similar to condom use amongst non-drug users,

i.e. unprotected sex is the norm amongst heterosexuals

Because unprotected sex is the norm for many, no concept of risk calculation may be applied to it

Unprotected sex is popularly perceived to carry less risks than injecting or sharing
In heterosexual sex gender issues may operate, i.e. women are more likely to attempt negotiation of safer sex but be coerced into having unprotected sex

That drugs and drug use tend to be the defining focus of drug using networks and they are not communities in the same sense as gay men who, for example, have made demonstrable sexual behaviour changes

Condoms may be seen by sex workers as something to be used with 'punters' rather than non-paying sexual partners

Perceptions of the need for sexual behaviour change come almost universally from outside rather than within drug using networks.

The relationships between drug use and sexual behaviour
The relationships between drug use and sex are complex, but they are often linked, with particular drugs sometimes being valued for their effect on the sexual experience.

Most studies neglect the social and cultural aspects of drug use and sexual behaviour, and concentrate on the perceived pharmacological effects of drug use on sexual desire and risk behaviour.

Rhodes¹³⁹ argues that this is too narrow an approach as it tends to ignore:

The ideas and beliefs of the drug user about the drug and its properties

The ideas and beliefs within a culture about the drug and its properties

That certain drugs such as cocaine may not so much cause sexual disinhibition, as allow it

That drug use may be consciously or unconsciously used as a reason or 'excuse' for unsafe sex.

It is likely that, notwithstanding any pharmacological effects of a given drug, a cultural understanding that it causes sexual disinhibition will, in all probability, increase the likelihood of unsafe sex.

Safer sex education
There are several elements which may be included in safer sex education:¹⁴⁰

Information giving

Information seeking

Counselling

Advice giving

Skills training

Condom use.

The initiation and successful outcome of safer sex education is likely to be more difficult than that of safer drug use education because:

Sexual behaviour change demands broader changes than changes in drug using behaviour

Workers feel uneasy about raising safer sex issues

Workers lack competence in raising safer sex issues

Gender issues i.e. the appropriateness or otherwise of male workers raising sexual issues with female clients and vice versa

Clients perceive a lack of appropriateness of enquiries about their sexual preferences when attending a drugs agency.

Collecting equipment for others

Many services allow one person to collect for others. Often this is in the context of one partner collecting for a couple's use. Given that sex partners are more likely than any other group to share equipment, this should definitely be allowed.

More controversial is the provision of large quantities of injecting equipment to individuals who may act as a community resource to other injectors, providing equipment locally and at hours unlikely to be fulfilled by exchange schemes. In principle this way of disseminating equipment is to be welcomed, as it is likely to increase the numbers of injectors reached and decrease reasons to share. There are some things which help to make this form of distribution both safer and more effective in achieving behaviour change.

Desirable things to have in place for those collecting large amounts of equipment for others are:

Up-to-date basic knowledge of injecting

Knowledge of local support services

Appropriate training and support

Knowledge of boundaries, e.g. young people

Adequate storage and disposal facilities for used equipment.

Some schemes have developed this type of initiative into what are effectively small peer exchange schemes. If this is to happen, then the factors listed above represent a minimum standard for this form of intervention.

Problems that may be encountered with this approach include:

Hostility from the local community, particularly vigilante groups

Arousing the interest of the police

The distributing person becoming ill, or no longer wanting to provide the service

Criticism from opponents of needle exchange schemes.

Confidentiality

Of all services available to drug users, needle exchange is the one that requires the least information. Those attending needle exchanges are usually expected to provide no more personal information than date of birth and initials. Other information will be requested for statistical purposes, especially at the first visit.

Fear of a lack of confidentiality may be one reason for some injectors not attending needle exchanges, especially if they are also attendees at related drug treatment services offering substitute prescribing.

Although confidentiality should be stressed, it can never be absolute and there are certain situations in which it is not the paramount concern, including where:

Children are at risk

There are grave concerns for the safety of the drug user (e.g. suicide)

There are grave concerns for the safety of others.

Projects and workers should be explicit from the outset with service users about what confidentiality means to them and what its limits are. It is good practice to have suitable written information for clients to take away explaining agency confidentiality policy.

Leaflets and information

There are many examples of leaflets and printed information available for injecting drug users, intended to help them to inject more safely. It is important to check that the information is:

Accurate

Understandable and not liable to misinterpretation

Credible

Appropriate for the person in terms of information and reading level

Relevant to local injectors.

As in other fields of health promotion, written information enhances and improves information given verbally.

Injecting myths

There are a number of powerful myths or odd beliefs within the injecting drug using community about the causes of things people experience and about the way injecting is done. The examples below are some of the most commonly heard. Needle exchange workers need to be aware of the myths and be able to offer accurate information to counter them especially in the case of the more dangerous ones.

Injecting salt water to counter an overdose
This fairly widespread myth is dangerous as it will offer no help at all to someone who is overdosing and will delay their access to effective treatment.

Other recorded potentially dangerous (or at best entirely useless) responses to overdose include:

Injecting milk

Pouring milk down the unconscious person's throat

Attempting to rouse them by slapping, walking them around, etc.

Putting ice in the groin.

Injecting directly into the heart to counter overdose
It is sometimes believed (and propagated by films such as 'Pulp Fiction') that the treatment for opiate overdose is to inject adrenalin directly into the heart muscle.

See page 85 for the correct advice to give people about dealing with opiate overdose.

Licking the needle tip
It is not uncommon for injectors to lick the tip of the needle before injecting. This practice is difficult to account for in terms of logic.

It may be learnt from other users as an unquestioned part of the injecting process, or it may be a result of expelling air from the syringe, a process which often leaves a small drop of solution on the needle tip. Licking this off may be simply an attempt not to waste it. This practice should be discouraged as the mouth contains organisms (especially fungal infections such as thrush) which can cause infections if injected.

Licking the injection site
Again this behaviour is not that uncommon and may be part of an attempt to 'clean' the injecting site prior to injection. This should be discouraged as it will increase the risks discussed above.

Flushing
'Flushing', 'booting' and 'kicking' are terms which refer to drawing blood back into the syringe after the drug solution has been injected, in an attempt to ensure that no drugs are wasted by being left in the hub of the syringe.

As a small amount of drug solution will be retained in the hub of the syringe (how much depends on the type of syringe and needle being used) it makes sense in terms of maximising the amount of drug getting into the body to do this once.

However, the small benefit of this must be weighed against the extra damage that will be done to the vein and the fact that this practice will ensure that the injecting equipment used is heavily contaminated with blood, which makes the transmission of blood-borne viruses much more likely if the equipment is reused by another person¹⁴¹.

Some users claim that the process of booting or flushing intensifies the rush, so that they get more pleasure from injecting by doing it, and accordingly do it several times. There is no pharmacological basis for this belief, and they are likely to greatly increase the amount of local irritation caused by injecting if they flush repeatedly thus shortening the 'injecting life' of the vein.

To avoid misunderstanding, care should always be employed when using slang terms: in London 'booting' is rhyming slang for smoking heroin (bootlace chase).

Strokes from air bubbles
There is a generalised belief amongst injectors and the general population that injecting air is 'not a good thing'. Whilst this is true, it tends to be somewhat overstressed in terms of importance when priorities for injecting drug users are being considered. It is possible to observe some injectors taking little or no care about hygiene or cross-infection risks whilst injecting, but exhibiting infinite patience when expelling the minutest of air bubbles from a syringe.

Compared to the size of an air bubble it takes a gigantic volume of air to cause circulatory problems (the blood would froth in the chambers of the heart). Although it is desirable not to introduce air into the veins, even a few 1 mL syringes completely full of air would be unlikely to cause any problems.

Carefully removing tiny air bubbles from a syringe can be seen as evidence that injectors are concerned about their health and are prepared to act to preserve it. Some injectors simply need more information about more important priorities such as hygiene.

Having a second hit to sort out a bad one
Some injectors have expressed a belief that the best way to deal with a 'dirty hit' (an acute reaction to injection, characterised by shivering and sweating that is usually self-limiting) is to inject again. Whatever the cause of the reaction, repeating the procedure could at best make the experience worse and at worst cause overdose.