Paraphernalia supply and its impact

1. Paraphernalia supply and its impact Dr. C Beynon, J McVeigh, M Chandler and Dr. M Wareing Centre for Public Health Faculty of Health & Applied Social Sciences Liverpool John Moores University

2. Agency Based Syringe Exchange Schemes (SES) in Cheshire & Merseyside (n = 16)

3. SES Monitoring Forms

4. Cheshire & Merseyside Agency Based Syringe Exchange Scheme Monitoring System Minimum Dataset • Agency details • Date of Visit • On first visit • Initials • Date of Birth • Sex • 1st Part Postcode • How Heard • In Treatment? • Main Drug • Client Number • Subsequent visits • Client Number • Time • Syringes • Needles • Returns • Additional Items • Condoms • Citric • Sharing data

5. Transactions, clients & new clients at SES (Cheshire & Merseyside 1991 –2003)

6. Gender of Clients Attending SES (Cheshire & Merseyside 1991 –2003)

7. Age Group All Individuals Attending SES Cheshire & Merseyside (1991-2003)

8. New Clients Declaring Receipt of Drug Treatment(Cheshire & Merseyside 1991-2003)

9. Main Drug of All Clients at SES (Cheshire & Merseyside 1991 – 2003)

10. Main Drug of New Clients at SES (Cheshire & Merseyside 1991 – 2003)

11. Opiate Injectors(Cheshire & Merseyside 1992 – 2003)

12. Summary – All Clients Attending SES • Number of clients doubled since 1990s. • Number of new clients fluctuated but increased since mid-1990s. • Substantial increase in males, females remained constant. • Aging cohort of injectors. • Number not in treatment has increased, number in treatment has decreased. • Fall in number of new heroin injectors and large rise in number of new anabolic steroid injectors.

13. Summary – Opiate Injectors • Increase in number of opiate injectors. • Decrease in number of new opiate injectors. • Annual transaction rate has fallen. • Syringes per transaction had been increasing but fallen since 2001.

14. Injecting Paraphernalia – Changes in the Law • Section 9A of Misuse of Drugs Act (1971). • 2002 Home Office initiated a public consultation. • ACMD asked to consider harm reduction benefits of drug paraphernalia.

15. ACMD Response • YES • Sterile water ampoules • Swabs • Mixing utensils • spoons, bowls • Citric acid • NO • Filters • Tourniquets

16. Why is Citric Acid Provision Important? • Alternatives • Lemon juice • Vinegar • Infections • At the injection site • Systemic (compromised health and immunity)

17. ACMD Recommendation Citric acid should be supplied by pharmacists and others appropriately trained in quantities and its effects.

18. Aim: to assess the impact of the introduction of citric acid on SES provision in Cheshire & Merseyside Methods: qualitative and quantitative

19. Agencies in Study (n = 11) • Thirteen agency based syringe exchange scheme commenced the provision of citric acid in 2003/2004 • Two excluded from study as they did not operate a continuous service during the study period

20. Telephone Interviews with Practitioners • Practitioners from each of the 11 agencies were interviewed by telephone to identify perceptions of the impact of citric acid provision at their agency • A range of closed and opened ended questions were employed to identify views on: • Changes in the number of clients accessing services • Changes in the types of clients attending • Frequency of visits • Changes in frequency of injecting problems • Benefits of citric acid provision • Issues relating to other paraphernalia

21. 1. Service uptake • 2. Harm related behaviours • 3. Engagement • 4. Other issues

22. Service Uptake • 8 said introduction had increased number of heroin injectors accessing services. • 9 said introduction had encouraged the engagement of new injectors. “ Encourages them [heroin users] into the agency and hopefully into treatment”

23. 1. Service Uptake

24. 2. Harm Related Behaviours • 7 said there had been a decrease in people presenting with injection related problems. “Good harm reduction tool. Cuts down on lemon juice or vinegar use. It’s worthwhile and cuts down on problems” “Helps reduce damage. Stops them [heroin users] using lemon juice etc.”

25. 3. Service User Engagement • All said they were able to engage more with the clients. • All said it gave them more opportunity to discuss injecting practices. • All said it gave them the opportunity to discuss harm reduction measures. “The more topics we talk about the better, we can keep them [clients] here longer and discuss injecting practices and harm reduction methods.”

26. 4. Other Issues • 2 agencies said an excess of citrate was being used. • “Increasingly clients are using up too much citric acid and they ask for extra” • 1 felt a sachet did not contain sufficient citric.

27. What Else Should be Provided?

28. Analysis of Routine Monitoring Data • Exact date of citric acid introduction was obtained for each of the 11 participating agencies. • Extracted 6 month pre citric acid and 6 month post citric acid for each agencies. • Isolated visits relating to heroin and crack injectors. • Individual client profiles for each period were derived. • Ongoing or new clients.

29. Analysis of Routine Monitoring Data 1. Service Uptake

30. Service Uptake by Ongoing Clients

31. Service Uptake by New Clients

32. Service Uptake - Summary

33. Analysis of Routine Monitoring Data 2. Changes in Service Utilisation

34. Changes in Service Utilisation *Wilcoxon Signed Ranks Test

35. Changes in Service Utilisation; Transaction Rate(heroin and crack only) Spearman’s Correlation: P = NS

36. Seasonal Analysis *Wilcoxon Signed Ranks Test

37. Changes in Service Utilisation: Transaction Rate (n = 314 matched pairs)

38. Steroid Users *Wilcoxon Signed Ranks Test

39. Changes in Service Utilisation 1. Increased transaction rate of ongoing service users (limited amount of citric given out). 2. No change in number of syringes collected per visit by ongoing service users.

40. Implications?

41. 1. Citric acid introduction has not attracted new clients • Should we expect anything else? • Hit saturation of clients attending syringe exchange? • More comprehensive strategy needed to encourage service uptake?

42. 2. Perception among ASES staff that there has been a fall in people presenting with injection related problems • Is this the case? • Was this the main aim of introducing citric acid?

43. 3. Citric acid introduction has significantly increased the transaction rate of ongoing clients • Movement down the hierarchy of harm reduction requires engagement with professionals. • Significant benefit to ongoing clients.

44. 4. Increased transaction rate has been achieved without a fall in the median number of syringes given out per visit • Important public health indicator.

45. Same number of syringes per transaction. More transaction. Where are the additional syringes going?

46. How clients became aware of SES (Cheshire & Merseyside 1991-2003)

47. Are the additional syringes going to others not contact with syringe exchanges? Has the introduction of citric acid been successful in 1. increasing the number of syringes in circulation? 2. number of people using them?

48. And finally…. • Only preliminary investigation, ongoing consistent analysis over time needed. • Are findings replicated in rest of UK? • More information needed on informal distribution networks of syringe distribution and impact of citric acid on these networks. • Need more information on what initially attracts injectors into SES.

49. Over to you…. • Views on introduction of citric acid. • What other injecting paraphernalia would be useful? • Is there sufficient evidence regarding best practice for citric acid provision? • Should the introduction of injecting paraphernalia be expected to increase service uptake? • Views on informal distribution networks.

50. Views on introduction of citric acid • Impact on service use. • New clients? • Old faces re-engaging? • Changing behaviours? • Is the amount of citric acid being provided being limited? • What has the feedback from clients been? • Any research conducted to assess its impact?