Availability of needle and syringe exchange programs and opioid substitution therapy

Via:  http://goo.gl/T673pu

“We get by with a little help from our friends”: Small-scale informal and large-scale formal peer distribution networks of sterile injecting equipment in Australia

Background

In Australia, sterile needles and syringes are distributed to people who inject drugs (PWID) through formal services for the purposes of preventing blood borne viruses (BBV). Peer distribution involves people acquiring needles from formal services and redistributing them to others. This paper investigates the dynamics of the distribution of sterile injecting equipment among networks of people who inject drugs in four sites in New South Wales (NSW), Australia.

Methods

Qualitative data exploring the practice of peer distribution were collected through in-depth, semi-structured interviews and participatory social network mapping. These interviews explored injecting equipment demand, access to services, relationship pathways through which peer distribution occurred, an estimate of the size of the different peer distribution roles and participants’ understanding of the illegality of peer distribution in NSW.

Results

Data were collected from 32 participants, and 31 (98%) reported participating in peer distribution in the months prior to interview. Of those 31 participants, five reported large-scale formal distribution, with an estimated volume of 34,970 needles and syringes annually. Twenty-two participated in reciprocal exchange, where equipment was distributed and received on an informal basis that appeared dependent on context and circumstance and four participants reported recipient peer distribution as their only access to sterile injecting equipment. Most (n = 27) were unaware that it was illegal to distribute injecting equipment to their peers.

Conclusion

Peer distribution was almost ubiquitous amongst the PWID participating in the study, and although five participants reported taking part in the highly organised, large-scale distribution of injecting equipment for altruistic reasons, peer distribution was more commonly reported to take place in small networks of friends and/or partners for reasons of convenience. The law regarding the illegality of peer distribution needs to change so that NSPs can capitalise on peer distribution to increase the options available to PWID and to acknowledge PWID as essential harm reduction agents in the prevention of BBVs.

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By:  Jamee Newland, Christy Newman, Carla Treloar

Centre of Social Research in Health, UNSW Australia, John Goodsell Building, UNSW 2052 Australia 

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Injecting drugs in tight spaces: HIV, cocaine and collinearity in the Downtown Eastside, Vancouver, Canada

This commentary revisits the political turmoil and scientific controversy over epidemiological study findings linking high HIV seroincidence to syringe exchange attendance in Vancouver in the mid-1990s. The association was mobilized polemically by US politicians and hard-line drug warriors to attack needle exchange policies and funding. In turn, program restrictions limiting access to syringes at the Vancouver exchange may have interfaced with a complex conjunction of historical, geographic, political economic and cultural forces and physiological vulnerabilities to create an extraordinary HIV risk environment: 

1. ghettoization of services for indigent populations in a rapidly gentrifying, post-industrial city; 
2. rural-urban migration of vulnerable populations subject to historical colonization and current patterns of racism; and 
3. the flooding of North America with inexpensive powder cocaine and heroin, and the popularity of crack. 

In fact, we will never know with certainty the precise cause for the extreme seroincidence rates in Vancouver in the early to mid-1990s. 

The tendency for modern social epidemiology to decontextualize research subjects and assign excessive importance to discrete, "magic bullet" variables resulted in a counterproductive scientific and political debate in the late 1990s that has obfuscated potentially useful practical lessons for organizing the logistics of harm reduction services - especially syringe exchange - to better serve the needs of vulnerable populations and to mitigate the effects of political-economically imposed HIV risk environments. 

We would benefit from humbly acknowledging the limits of public health science and learn to recognize the unintended consequences of well-intentioned interventions rather than sweep embarrassing histories under the rug.

Purchase full article at:   http://goo.gl/FubNuW

By:  Ciccarone D¹, Bourgois P².

¹Family and Community Medicine, UCSF 500 Parnassus Avenue, MU-3E, Box 0900, San Francisco, CA 94143-0900, United States. Electronic address: Daniel.Ciccarone@ucsf.edu.

²Psychiatry, Center for Social Medicine, UCLA, 760 Westwood Plaza, B7-435, Los Angeles, CA 90025, United States.

Int J Drug Policy. 2016 Mar 8. pii: S0955-3959(16)30060-3. doi: 10.1016/j.drugpo.2016.02.028.

  

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Legal space for syringe exchange programs in hot spots of injection drug use-related crime

BACKGROUND:

Copious evidence indicates that syringe exchange programs (SEPs) are effective structural interventions for HIV prevention among persons who inject drugs (PWID). The efficacy of SEPs in supporting the public health needs of PWID populations is partially dependent on their accessibility and consistent utilization among injectors. Research has shown that SEP access is an important predictor of PWID retention at SEPs, yet policies exist that may limit the geographic areas where SEP operations may legally occur. Since 2000 in the District of Columbia (DC), SEP operations have been subject to the 1000 Foot Rule (§48-1121), a policy that prohibits the distribution of "any needle or syringe for the hypodermicinjection of any illegal drug in any area of the District of Columbia which is within 1000 feet of a public or private elementary or secondary school (including a public charter school)." The 1000 Foot Rule may impede SEP services in areas that are in urgent need for harm reduction services, such as locations where injections are happening in "real time" or where drugs are purchased or exchanged. We examined the effects of the 1000 Foot Rule on SEP operational space in injection drug use (IDU)-related crime (i.e., heroin possession or distribution) hot spots from 2000 to 2010.

METHODS:

Data from the DC Metropolitan Police Department were used to identify IDU-related crime hot spots. School operation data were matched to a dataset that described the approximate physical property boundaries of land parcels. A 1000-ft buffer was applied to all school property boundaries. The overlap between the IDU-related crime hot spots and the school buffer zones was calculated by academic year.

RESULTS:

When overlaying the land space associated with IDU-related crime hot spots on the maps of school boundaries per the 1000-ft buffer zone stipulation, we found that the majority of land space in these locations was ineligible for legal SEP operations. More specifically, the ineligiblespace in the identified hot spots in each academic year ranged from 51.93 to 88.29 % of the total hot spot area.

CONCLUSIONS:

The removal of the 1000 Foot Rule could significantly improve the public health of PWID via increased access to harm reduction services. Buffer zone policies that restrict SEP operational space negatively affect the provision of harm reduction services to PWID.

Below:  IDU-related crime hot spots and school buffer zones in the 2008 academic year

Full article at:   http://goo.gl/Vesqga

By:  Allen ST1, Ruiz MS2, Jones J3, Turner MM2.

• 1Department of Epidemiology, Johns Hopkins University, 615 N. Wolfe St., Baltimore, MD, 21205, USA. sallen63@jhu.edu.
• 2Department of Prevention & Community Health, Milken Institute School of Public Health at The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA.
• 3Department of Health Policy & Management, Jiann-Ping Hsu College of Public Health at Georgia Southern University, PO Box 8015, Statesboro, GA, 30460, USA 
• Harm Reduct J. 2016 Apr 26;13(1):16. doi: 10.1186/s12954-016-0104-3.

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The impact of an automatic syringe dispensing machine in inner-city Sydney, Australia: No evidence of a 'honey-pot' effect

INTRODUCTION AND AIMS:

Needle and syringe automatic dispensing machines (ADM) aim to increase needle/syringe distribution to people who inject drugs. ADM implementation has been met with community concern about potential perceived increases in crime and drug use and that they will attract non-resident drug users-the 'honey-pot effect'. In April 2013, an ADM commenced operation in inner-city Sydney. We assessed the impact of the ADM on crime and examined its use by non-resident drug users (the honey-pot effect).

DESIGN AND METHODS:

Fixed-site needle and syringe program (n = 207) and ADM clients (n = 55) were surveyed to determine whether they lived within 1 km of the ADM. Police-recorded offences between January 2012 and March 2014 across six crime categories for the local and surrounding areas were assessed for trend to measure impact on crime.

RESULTS:

The majority (78%) of needle and syringe program clients reported residing within 1 km of the service. Most (95%) ADM users were fixed-site service clients. The 2 year trend for crime categories remained stable or decreased, except for fraud, which increased significantly (P < 0.05).

DISCUSSION AND CONCLUSION:

Automatic dispensing machine users were largely clients of the existing fixed-site service and lived locally. There was no apparent concurrent increase in crime or a honey-pot effect. It is important that services continue to be aware of community concerns and respond to them appropriate

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By:  Grau LE1, Zhan W1,2, Heimer R1.

• 1Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA.
• 2Department of Children and Families, Hartford, USA. 
• Drug Alcohol Rev. 2016 Apr 13. doi: 10.1111/dar.12396

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Syringe Stockpiling by Persons Who Inject Drugs: An Evaluation of Current Measures for Needle and Syringe Program Coverage

Needle and syringe program (NSP) coverage is commonly used to assess NSP effectiveness. However, existing measures don't capture whether persons who inject drugs (PWIDs) stockpile syringes, an important and novel aspect of NSP coverage. 

In this study, we determine the extent of stockpiling in a sample of Australian PWIDs and assess whether including stockpiling enhances NSP coverage measures. As part of the Illicit Drug Reporting System study, PWIDs reported syringes procured and given away, total injections in the last month, and syringes currently stockpiled in 2014. We calculated NSP coverage with and without stockpiling to determine proportional change in adequate NSP coverage. We conducted receiver operating characteristic curve analysis to determine whether inclusion of stockpiled syringes in the measure improved sensitivity in discriminating cases and noncases of risky behaviors. 

Three-quarters of the sample reported syringe stockpiling, and stockpiling was positively associated with nonindigenous background, stable accommodation, no prison history, longer injecting careers, and more frequent injecting. Compared with previous measures, our measure was significantly better at discriminating cases of risky behaviors. 

Our results could inform NSP policy to loosen restricted-exchange practice, allowing PWIDs greater flexibility in syringe procurement practices, promoting greater NSP coverage, and reducing PWIDs' engagement in risky behaviors.

Purchase full article at:   http://goo.gl/svAIxK

By:  McCormack AR, Aitken CK, Burns LA, Cogger S, Dietze PM.

Correspondence to Professor Paul M. Dietze, Centre for Population Health, Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia (e-mail:pauld@burnet.edu.au).

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Public Funding of Syringe Exchange in the US: The Challenges of Failures and Successes and the New Heroin Injectors

Via:  https://goo.gl/L1PT5E  More Information:  http://goo.gl/XP29Ha

Predictors of Needle Exchange Program Utilization During Its Implementation & Expansion in Tijuana, Mexico

OBJECTIVE:

Until the early 2000s, there was only one needle exchange program (NEP) offered in Mexico. In 2004, the second Mexican NEP opened in Tijuana, but its utilization has not been studied. We studied predictors of initiating NEP during its early expansion in Tijuana, Mexico.

METHODS:

From April 2006 to April 2007, people who inject drugs (PWID) residing in Tijuana who had injected within the last month were recruited using respondent-driven sampling. Weighted Poisson regression incorporating generalized estimating equations was used to identify predictors of initiating NEP, while accounting for correlation between recruiter and recruits.

RESULTS:

NEP uptake increased from 20% at baseline to 59% after 6 months. Among a subsample of PWID not accessing NEP at baseline (n = 480), 83% were male and median age was 37 years (Interquartile Range: 32-43). At baseline, 4.4% were HIV-infected and 5.9% had syphilis titers >1:8. In multivariate models, factors associated with NEP initiation (p < .05) were attending shooting galleries (Adjusted Relative Risk [ARR]: 1.54); arrest for track-marks (ARR: 1.38); having a family member that ever used drugs (ARR: 1.37); and having a larger PWID network (ARR: 1.01 per 10 persons). NEP initiation was inversely associated with obtaining syringes at pharmacies (ARR: .56); earning >2500 pesos/month (ARR: .66); and reporting needle sharing (ARR: .71).

CONCLUSIONS:

Uptake of NEP expansion in Tijuana was vigorous among PWID. We identified a range of factors that influenced the likelihood of NEP initiation, including police interaction. These findings have important implications for the scale-up of NEP in Mexico

Purchase full article at:   http://goo.gl/aMHjv0

By:  Smith DM1,2, Werb D1, Abramovitz D1, Magis-Rodriguez C3, Vera A1, Patterson TL1, Strathdee SA1; for Proyecto El Cuete.

• 1Division of Global Public Health, Department of Medicine, University of California, San Diego.
• 2Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
• 3Centro Nacional parala Prevencion y Control del VIH/SIDA e ITS (CENSIDA), Mexico City, Mexico. 

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Link to El Bordo -- HIV/SIDA: The Epidemic in Tijuana video:  http://goo.gl/aMSH9Y

A Syringe Exchange Love Story with Atlanta Harm Reduction Coalition

Via:  http://goo.gl/0JHc6G

Changing How We Think About Syringe Exchanges

Via:  http://goo.gl/0JHc6G

A Syringe Exchange Love Story with Atlanta Harm Reduction Coalition

A Syringe Exchange Love Story with Atlanta Harm Reduction Coalition from North Carolina Harm Reduction on Vimeo.

Help End the Ban on the Use of Federal Funds for Syringe Services Programs

The Exchange: Race and Drugs

Veni, vidi, vici: The appearance and dominance of new psychoactive substances among new participants at the largest needle exchange program in Hungary between 2006 and 2014

Highlights

• Since 2010 a number of NPS appeared and disappeared depending on their legal status.
• Heroin and amphetamine combined diminished from 99% until 2010 to 17% in 2014.
• The number of older and female clients have increased due to a number of factors.
• Over 80% of PWIDs use NPS and injecting NPS is linked to increased injecting risks.
• Harm reduction services should be more available to avoid HIV and HCV epidemics.

BACKGROUND:

There has been an almost exponential growth in the number of new psychoactive substances (NPS) on the drug markets in Europe during the past decade. While most users of NPS use them by routes other than injecting, percutaneous use of NPS is associated with very frequent injecting episodes and paraphernalia sharing.

METHODS:

We assessed to what extent new clients between 2006 and 2014 (N=3680) at Blue Point, Hungary's largest needle exchange program, exhibited a shift during these years in the drugs they primarily injected.

RESULTS:

Until 2010, 99% of clients injected either heroin or amphetamines. After 2010, however, there was a "replacement chain" of new substances, with one appearing and disappearing after the other: between 2010 and 2014, NPS under five names appeared and gained dominant prevalence (from 0% to 80%), and gradually replaced first the two "traditional" drugs amphetamine and heroin (which diminished to 17% together in 2014) and later each other. We also saw an increase in the proportion of female and older clients.

CONCLUSIONS:

While our findings are restricted to injected NPS, they suggest that NPS affect the vast majority of the population of people who inject drugs not only in terms of drug use patterns, but maybe also in terms of demographics. Given that over 80% of people who inject drugs use NPS and injecting NPS is associated with increased injecting risks, harm reduction services should be made more available to avoid an epidemic of blood-borne infections.

Purchase full article at:   http://goo.gl/DWqCUY

By:   Rácz J1, Csák R2, Tóth KT3, Tóth E3, Rozmán K3, Gyarmathy VA4.

• 1Eötvös Loránd University, Institute of Psychology, Budapest, Hungary; Semmelweis University, Faculty of Health Sciences, Budapest, Hungary; Blue Point Drug Counselling and Outpatient Centre, Budapest, Hungary.
• 2Semmelweis University, Faculty of Health Sciences, Budapest, Hungary; Blue Point Drug Counselling and Outpatient Centre, Budapest, Hungary.
• 3Eötvös Loránd University, Institute of Psychology, Budapest, Hungary.
• 4Semmelweis University, Faculty of Health Sciences, Budapest, Hungary; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Electronic address: vgyarmat@jhsph.edu. 

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Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas — United States, 2013

Reducing human immunodeficiency virus (HIV) infection rates in persons who inject drugs (PWID) has been one of the major successes in HIV prevention in the United States. Estimated HIV incidence among PWID declined by approximately 80% during 1990–2006 (1). More recent data indicate that further reductions in HIV incidence are occurring in multiple areas (2). Research results for the effectiveness of risk reduction programs in preventing hepatitis C virus (HCV) infection among PWID (3) have not been as consistent as they have been for HIV; however, a marked decline in the incidence of HCV infection occurred during 1992–2005 in selected U.S. locations when targeted risk reduction efforts for the prevention of HIV were implemented (4). Because syringe service programs (SSPs)* have been one effective component of these risk reduction efforts for PWID (5), and because at least half of PWID are estimated to live outside major urban areas (6), a study was undertaken to characterize the current status of SSPs in the United States and determine whether urban, suburban, and rural SSPs differed. Data from a recent survey of SSPs^† were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services^§ were less available to PWID outside urban settings. Because increases in substance abuse treatment admissions for drug injection have been observed concurrently with increases in reported cases of acute HCV infection in rural and suburban areas (7), state and local jurisdictions could consider extending effective prevention programs, including SSPs, to populations of PWID in rural and suburban areas.

The basic service offered by SSPs allows PWID to exchange used needles and syringes for new, sterile needles and syringes. Providing sterile needles and syringes and establishing appropriate disposal procedures substantially reduces the chances that PWID will share injection equipment and removes potentially HIV- and HCV-contaminated syringes from the community. Many SSPs have become multiservice organizations, providing various health and social services to their participants (8). HIV and HCV testing and linkage to care and treatment for substance use disorders are among the most important of these other services. The availability of new and highly effective curative therapy for HCV infection increases the benefits of integrating testing and linkage to care among the services provided by SSPs.

During the last decade, an increase in drug injection has been reported in the United States, primarily the injection of prescription opioids and heroin among persons who started opioid use with oral analgesics and transitioned to injecting (9). Much of this drug injection has occurred in suburban and rural areas (6). Outbreaks of HCV infection, and more recently HIV infection, in these nonurban areas have been correlated with these injection patterns and trends (7).

TABLE 1. Program characteristics, by syringe service program location — United States, 2013
Program characteristic	SSP location
	Rural	Suburban	Urban	Missing data*	U.S. total
	No. (%)	No. (%)	No. (%)	No.	No.
Region
Midwest	6 (20)	1 (3)	23 (77)	0	30
Northeast	4 (9)	4 (9)	35 (81)	0	43
Puerto Rico	1 (20)	0 (0)	4 (80)	0	5
South	1 (7)	0 (0)	12 (86)	1	14
West	18 (30)	9 (15)	31 (51)	3	61
Total	30 (20)	14 (9)	105 (69)	4	153
Program size (no. of syringes distributed)
Small (1–9,999)	5 (17)	1 (7)	6 (6)	0	12
Medium (10,000–55,000)	10 (33)	4 (29)	21 (20)	0	35
Large (55,001–499,999)	14 (47)	6 (43)	60 (57)	2	82
Very large (≥500,000)	0 (0)	3 (21)	16 (15)	2	21
None/unknown/missing	1 (3)	0 (0)	2 (2)	0	3
Total	30 (100)	14 (100)	105 (100)	4	153
No. of syringes exchanged
No. of SSPs† reporting no. of syringes	29	14	103	4	150
Median no. of syringes per SSP	55,000	82,681	146,263	1,826,977	121,880
Mean no. of syringes per SSP	91,536	313,555	305,694	1,834,533	305,793
Total no. of syringes	2,654,551	4,389,770	31,486,507	7,338,132	45,868,960
Total SSP funding§
Mean cost per SSP	$26,023	$116,902	$184,738	$501,033	$155,466
Total cost for SSP location	$676,590	$1,636,630	$18,104,328	$1,503,100	$21,920,648
Public funding of SSP (city, county, and state funding)¶
Yes	18 (60)	9 (64)	63 (60)	3	93
No	8 (27)	5 (36)	35 (33)	0	48
Unknown/missing	4 (13)	0 (0)	7 (7)	1	12
Total	30 (100)	14 (100)	105 (100)	4	153
Source: Mount Sinai Beth Israel, New York, NY; North American Syringe Exchange Network. Abbreviation: SSP = syringe service program. * Data on location missing for four SSPs. † Two SSPs did not report the number of syringes distributed, and one SSP reported zero syringes distributed (not operational). § Twelve SSPs did not report total SSP funding. ¶ The use of federal funding for SSP implementation is prohibited.

TABLE 2. Reported client characteristics, by syringe service program location — United States, 2013
Client characteristic	SSP location
	Rural (n = 30)	Suburban (n = 14)	Urban (n = 105)
	Mean % of participants	Mean % of participants	Mean % of participants
Gender
Male	61	67	65
Female	39	32	31
Transgender	0	1	3
Race/Ethnicity
African American	2	7	16
Asian/Pacific Islander	1	1	1
White	80	72	56
Hispanic	11	12	22
Native American	4	5	2
Biracial/Mixed	2	2	2
Other	0	2	1
Types of drugs injected
Heroin by itself	48	69	63
Heroin and cocaine	9	6	21
Heroin mixed with other drug (not cocaine)	12	4	11
Cocaine by itself	10	6	13
Methamphetamine (crystal methamphetamine/ice/crank)	25	18	12
Other opiates (oxycodone)	25	13	15
Steroids	1	1	2
Source: Mount Sinai Beth Israel, New York, NY; North American Syringe Exchange Network. Abbreviation: SSP = syringe service program.

TABLE 3. Selected syringe service program operating characteristics and selected services, by syringe service program location — United States, 2013
Characteristic	SSP location
	Rural (n = 30)	Suburban (n = 14)	Urban (n = 105)
	%	%	%
Operating characteristic
Syringes estimated to be distributed via secondary exchange, peer delivery services, or both	30	28	20
SSPs encouraged secondary exchange	73	79	71
Mobile exchange	23	71	74
Experienced a lack of resources/funding	73	64	63
Experienced problems reaching, recruiting participants, or both	20	36	18
Full-time paid personnel	40	79	77
Former drug users as program personnel	50	86	70
Selected service
HIV counseling and testing	87	71	90
HCV testing	67	79	78
Sexually transmitted diseases screening	40	29	50
HCV referral tracking	33	43	44
Distribution of food	33	29	54
Distribution of naloxone	37	57	61
Referral to methadone, buprenorphine, maintenance or both	70	86	90
Source: Mount Sinai Beth Israel, New York, NY; North American Syringe Exchange Network. Abbreviations: HCV = hepatitis C virus; HIV = human immunodeficiency virus; SSP = syringe service program.

Full article at:  http://goo.gl/7lEkWK

By:  Don C. Des Jarlais, PhD1; Ann Nugent1; Alisa Solberg, MPA2; Jonathan Feelemyer, MS1; Jonathan Mermin, MD3; Deborah Holtzman, PhD4

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