29 July 2015

Needle and Syringe Programmes: challenges old and new

The last few Safer Injecting and NSP courses have highlighted a resurgence of concerns about key areas of policy and practice. At the heart of this is the ongoing tension between the provision of a low-threshold harm reduction service whilst simultaneously trying to negotiate the needs of injectors, commissioners and the wider public.

As we've navigated these discussions in training, there seemed to be some merit in writing up the key issues not least to open up broader discussions and explore possible solutions.

Secondary Distribution: a starting point

Secondary distribution represents a useful starting point for this discussion. Primary distribution is the 'formal' distribution of syringes and needles via NSPs. It is widely aknowledged that some of this equipment will then be redistributed amongst peers - secondary distribution. In some settings this may be partially formalised where peer advocates undertake such distribution with the explicit knowledge and 'blessing' of the service. More frequently it is undertaken informally where additional equipment is requested for the distribution to family, partners, friends and peers. There is also wholly informal and unplanned distribution where those with equipment will give equipment to those without in emergency or social situations.

We don't really know how much secondary distribution goes on. The explicit, intentional secondary distribution is easier to map as customers directly request additional equipment for distribution. The level and extent of wholly informal secondary distribution is probably widespread but hard to estimate.

Secondary distribution is an essential component of getting sterile equipment in to the hands of an injector at the point where it is needed.

The NICE Guidance on NSP is explicit on the subject stating NSPs should "not discourage people from taking equipment for others (secondary distribution), but rather ask them to encourage those people to use the service themselves."

Despite this, some agencies remain wary of engaging with secondary distribution, with a range of responses on offer ranging from an outright refusal to allow it, allowing it on a one-off basis, through to unrestricted, large quantities being given out.

The Law:
In practice some aspects of secondary distribution are slightly more nuanced than the NICE guidance would suggest.

The distribution of paraphernalia is covered by Section 9a of the Misuse of Drugs Act 1971 (as ammended in 2005).  Section 9a made it an offence to distribute items for the administering or preparing a controlled drug but explicitly exempted syringes from the legislation, meaning they remain legal for distribution. Importantly the exemption did not specify who could undertake this distribution making the secondary distribution of needles and syringes wholly lawful.

After much lobbying and campaigning, the law on other paraphernalia was gradually relaxed and in 2003 the law was amended to allow distribution of other specified items:

"the following articles are exempt if they are dispensed by a doctor, a pharmacist or someone working lawfully within drug treatment services:

  • Swabs
  • Utensils for the preparation of a controlled drug
  • Citric acid
  • Filters
  • Ascorbic acid
  • Water ampoules of up to 2ml"
However, as the text above makes clear, while the revision added some specific paraphernalia to the list of exempt equipment it also specified who could distribute it - certain professionals and "someone working lawfully within drug treatment services." This is a curious wording. Can someone be working lawfully or unlawfully in a drug treatment service? But either way it does mean that secondary distribution of the items listed is generally not lawful. It remains legal for the secondary distribution of needles and syringes to take place but not these other items.If an agency were giving out pre-packaged equipment for secondary distribution, some of the contents of the pack would be unlawful for secondary distribution.

Now in truth, we shouldn't get too hung up about this legal issue. There have been no prosecutions against any services for secondary distribution, nor are there likely to be any. This does not mean that an organisation should be cavalier in terms of secondary distribution.

There is a clear need for thought as to what is distributed, how and why, so an organisation can be clear that (a) secondary distribution is essential in the context and (b) there is a public interest and (c) the organisation has endeavoured to minimise the risks associated with secondary distribution.

The next part of this blog (hopefully next week) will look at barriers to service access and ways to improve access.


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