03 August 2015

Carrots and Sticks and NSPs

[part 2 of a series about Needle and Syringe Provision, exploring practice and ethical issues]

The preceding blog article highlighted some of the legal issues regarding secondary distribution. This one considers reasons why secondary distribution happens, and some of the pros and cons of secondary distribution.

A key function of NSPs is to get sterile equipment in to the hands of injectors when it is needed and hopefully remove used equipment from circulation. Secondary distribution assists this process and as such represents an essential facet of distribution. Although essential, it isn't ideal. For a collection of reasons, some people will be unable or unwilling to attend NSP themselves and so rely on others to attend.

It could simply be that geography, travel costs, work or other commitments make it impractical to attend an NSP in person.

Where the NSP is primarily just distributing equipment and offering little more in terms of advice or other input, getting someone else to collect for you makes a lot of sense. In such settings the perception will be that there's little benefit in attending in person. In order to attend there needs to be some sense of added value, or why bother?

For other people, barriers to attending NSP may be more complex:
  • injectors may have been ASBOd out of area or have other restrictions that make it difficult to attend in person
  • there may be fears around child protection issues, deterring people from attending
  • in hub-style provision, scripted injectors may be wary of attending as it could draw attention to use on top
  • perception may be that the service is not "for me" - not orientated to steroid users, BME or LGBT injectors, young people, those not in recovery.
  • pressure to bring back returns 
  • onerous assessment tools.
So secondary distribution represents an essential access point to sterile equipment for an unknown number of people. As such the NICE guidance on NSPs rightly endorses it. However, it is not without disadvantages. Some of these are significant.

Where injectors take advantage of secondary distribution, this can create another barrier to service access. The distributor can become a gate-keeper. The recipient receives injecting equipment from them. They may also receive advice, information, guidance and other input from the distributor.

As the recipient can access sterile equipment from the distributor (along with additional advice) there is reduced reason for the recipient to attend a NSP. What they receive is therefore limited to what the distributor can offer. A range of interventions such as professional wound care, testing for BBVs, vaccines and access to treatment are therefore less accessible.

In truth we can't be confident that the distributor is distributing the "correct" equipment or accurate information. They may have only collected one or two types of equipment and so can't offer a range of paraphernalia.

And we don't know how it's being distributed. Is it being sold? Distributed pre-filled? Single item distributed with each bag of gear sold? There may be a tacit assumption that the secondary distribution is a benign, philanthropic activity but this may not be the case. We can't even be confident that the equipment distributed is sterile, as the move towards bulk-bagged Insulin syringes increases the risk that used equipment can be passed off as sterile.

The role of distributor as gate-keeper could be especially significant where the recipient is vulnerable, where abuse or exploitation could be an issue or where the recipient is a young person. So far from being an atruistic act, the distributor could be maintaining control and power through the act of distribution.From a Maslowe-esque point of view, the role of distributor can confer status, recognition, respect and status.

Returns is another key issue. Agencies may give out large quantities of injecting equipment for secondary distribution but there isn't always consideration of how it is to be returned. Now in some settings, especially amongst some steroid users, secondary distribution is associated with secondary returns. Here, one person collects and returns used equipment for a number of peers, bringing back large amounts of equipment. Whilst this is to be welcomed, it's probably the exception not the rule so secondary distribution risks contributing to the problem of low returns.

As it will be preferable for people who currently get injecting equipment from peers to attend NSP in person,  in coming articles we'll look in more detail at how to address some of these barriers, especially pressure on returns, assessment, scripting and safeguarding concerns.

In the meantime, looking at the issue from a broad perspective, organisations need to:
  • acknowledge and accept that secondary distribution is a component of comprehensive NSP
  • make proactive efforts to encourage recipients of secondary distribution attend in person:
    • stressing to distributors the benefits of attending in person
    • exploring reasons why they can't/won't attend in person
    • weighing up "greater harm" principle - does withholding the secondary distribution increase or reduce risk?
    • working with distributors to ensure they give out the correct equipment and 'right' advice - especially those who are distributing significant amounts of equipment to a number of peers
  • address barriers to attending in person
    • outreach where geography is an issue
    • addressing fears around confidentiality and scripting
    • streamlining assessment processes
  • maximise and stress benefits of attending service in person - informed, compassionate, caring staff offering a confidential, non-judgemental service including but not limited to needle distribution.
  • identify and challenge situations where secondary distribution increases rather than reducing risk, such as the sale of pre-filled syringes, incorrect equipment distribution, lack of disposal options and inadequate amounts supplied.

No comments: