Pick and mix or packs: what is best for pharmacy needle and syringe programmes (NSPs)?

We're often asked whether we think pharmacy needle and syringe exchange schemes should be all 'pick and mix' type needle exchanges, or whether they should give out packs.

There is, of course, no single answer to this question, and in this article we set out the background to the debate, the pros and cons of each, and identify some of the things that can be done to maximise effectiveness of both systems.

The article aims to give those charged with making decisions about shaping service provision an understanding of the issues, and guidance on how to best configure needle exchange services for their area.

Pharmacy needle exchange is part of a bigger system
According to the only comprehensive survey of needle exchanges in England published in 'Findings of a survey of needle exchanges in England' (Abdulrahim et al, National Treatment Agency, Research Briefing 17, May 2006) the majority of pharmacy exchange (64%) was providing equipment via packs.

This report describes a varied pattern of services around the country, and an optimal picture of the provision of equipment via a ‘mixed economy’ of specialist and pharmacy needle and syringe provision.

Best practice is a mix of delivery styles encompassing specialist centres, outreach and secondary needle exchange, and pharmacy pick and mix and/or pack distribution.

The optimal combination will reflect:

• the geography and demographics of the area;

• what is viable in terms of service providers; and

• attractive to injecting drug users...

and may change over time.

For example, pharmacy provision is more likely to be attractive to under 25's who are not currently experiencing major problems (traditionally a hard to reach group), whereas specialist provision tends to attract older injectors with more problems, as well as attracting more women.

Little research has been done in this respect in terms of the groups attracted by pharmacy pick and mix versus pack provision, but similar factors are likely to be at play and so effective user consultation is an essential feature of successful service design.

In situations where it is currently unnecessary or impossible to achieve such a mix of provision, it’s important to bear in mind that some provision is always better than no provision, and the closer geographically services can be to injectors, the better.

The aim of needle and syringe programmes
Needle and Syringe Programmes have several important objectives to fulfil in order to reduce blood borne virus transmission, and other drug related harms - they are:

• Objective 1: distribute enough injecting equipment to reduce syringe reuse and prevent sharing;

• Objective 2: give drug users accurate information about the risks of injecting drug use;

• Objective 3: provide a route into drug treatments that can reduce injecting;

• Objective 4: provide safe disposal of used injecting equipment.; and

• provide a route into drug treatment and other health and social care service.

The fundamental rules of good needle and syringe programme delivery include the rules that:

• Objective 1 should never be sacrificed to achieve objective 2,

• Objectives 1 and 2 should never be sacrificed to achieve objective 3

• Objectives 1, 2 and 3 should never be sacrificed to achieve objective 4.

These rules are often broken, and the consequence is often sharing, and sharing = life changing blood-borne virus transmission for injecting drug users, which is why the decision about the best type of pharmacy needle exchange is a very important one.

Pharmacy needle exchange: Pros and Cons of 'pick and mix'
The main argument for pick and mix style needle exchange is that it means each transaction can be tailored to individual need.

Other arguments FOR pick and mix include;

• the fact that injectors enter into a dialogue with pharmacy staff about what they want opens the door to other discussions;

• it can help to reduce drug litter because you're not giving people things they don't want; and

• pharmacy staff inevitably gain deeper knowledge of what people want and need, (including a knowledge of things that may not currently be supplied).

• the contact builds up rapport so injectors feel more comfortable to engage in conversation and ask for help and/or referral to.

However, this has to be weighed against the fact that, for a variety of reasons, it can be hard for injectors to ask for the amount and range of equipment they actually need.

Reasons for this include the facts that they may:

• fear that asking for what they will actually need, could lead to disapproval, refusal or awkward questions;

• simply have not got into the habit of working out how much equipment they will need over a given period to be able to use a sterile syringe each time and consistently under-estimate;

• not take account of the impact of requests from other injectors who may not have their own equipment, and

• be having difficulty successfully accessing veins, If so, they will need extra equipment to avoid causing needless pain and damage.

All these factors can limit the amount of equipment given out, which in turn is likely to lead to increased sharing and re-use.

It can be important to openly explore people’s needs with them, for some, this will include helping them work out how much equipment they will need until their next visit. Key questions in doing this include:

• how many times a day do you usually inject?

• how many days will it be until your next visit?

• are you likely to need to supply others with equipment?

• are you having problems with injecting that mean you sometimes need to use more than one syringe to achieve a successful injection?

If pharmacy staff are not well trained and do not properly understand the reasons behind provision of needle and syringe programmes, then these things are unlikely to be discussed. In such circumstances, pick and mix may limit the distribution of equipment and is likely to be less effective than pack distribution.

Pros and cons of providing needle exchange packs
The main argument FOR packs is that they can deliver significant quantities of injecting equipment and associated injecting paraphernalia in a way that is easy for injectors to access (and pass on to others).

Other arguments FOR packs include the facts that:

• giving them out is almost certainly less time-consuming than pick and mix;

• they may be more likely to attract clients who are actively seeking a quicker and more anonymous transaction;

• recording is more straightforward and as a result may be more likely to be accurate;

• reordering/restocking is much simpler and more straightforward than pick and mix;

• they can be tailored to meet most of the needs of the ‘average’ injector.

However, this has to be weighed against the obvious limitation that the types of equipment delivered can't be personalised in any way.

From the point of view of the pharmacy, giving out ready-made packs can require little or no knowledge beyond the procedure for giving out and recording the transaction (although more knowledge, skills and training is very desirable), so can be a less daunting proposition for those embarking on the provision of injecting equipment for the first time, and those with high staff turnover or staff who are ambivalent about providing the service.

In terms of ensuring that people have enough equipment until their next visit, similar factors to a pick and mix system are at play – and for some people can be amplified because they may only be interested in part of the pack contents, and the sheer physical bulk of packs may mean that they are less likely to take the amount of sterile equipment they need until their next visit. Weighed against this is the fact that people can double the amount of equipment they take away simply by asking for two packs - which is clearly easier than asking individually for larger numbers of lots of different items.

Optimising pharmacy pick and mix needle exchange provision

• Easy order system

If people have to ask the pharmacy staff for their injecting equipment, then they have to be able to do that in a place where people can't overhear their request so the request must either be in a private area, or there should be a simple illustrated form for people to complete to tell the pharmacy staff what they want.

• Encouragement to take more

There is clear evidence that having more injecting equipment over the year than you need is strongly protective against hepatitis C infection - pharmacy staff should be encouraged to ask every customer 'is that enough?' or 'are you sure you don't need more'.

• Discreet service

Providing a discreet service covers the whole transaction, but a key feature will always be having opaque bags that are big enough to contain adequate quantities of equipment.


Optimising pharmacy based needle exchange pack distribution

• No limits

The dispensing of a pack should never be conditional upon the person bringing back returns because refusing injecting equipment could lead to the sharing episode that causes an HIV or hepatitis C infections.

Everyone involved in the scheme should know that they can encourage returns through talking to service users, but that they must never jeopardise the accessibility of the service and should certainly never refuse equipment to someone who hasn't brought anything back. Doing this would fall within the NICE guidance on needle and syringe programmes definition of an 'arbitrary limit' on equipment distribution.

• Picking up for friends

The objective of the service is to provide a sterile syringe for every injection - if injecting drug users are prepared to pick up equipment for friends ('secondary exchange') they should be encouraged to do so.

There is a desire to get those people in contact with services, but that won't be achieved by presenting an unhelpful and unfriendly policy of preventing secondary exchange.

A range of packs
The minimum pack range would include:

• 'emergency pack' for people who are coming into the vicinity of the NSP to buy drugs, and want to take them and move out of the area, usually with 2-5 x 1ml nevershare syringes, and the means of disposal plus paraphernalia.

• 1ml Nevershare insulin type syringe pack, usually with 10-20 syringes, the means of disposal, plus paraphernalia and information

• 2ml pack - 10-20 x 2ml syringes plus blue needles, paraphernalia and information

Other typical packs include

• steroid pack 10-20 x 2ml syringes + 20 green needles (for drawing up) and 20 blue needles, means of disposal, plus information.

• Training

A common reason for distributing packs is lack of adequate training of pharmacy staff. However, having a pack distribution oriented programme isn't a reason to leave the situation unchanged: there is still a responsibility to try and improve knowledge and understanding. Pharmacy needle exchange also has an important and often under-utilised role in accessing and signposting clients to structured treatment. It is important for any type of pharmacy provision to include guidance and training (ideally as part of a service level agreement with pharmacists) for pharmacy staff in the reasons behind what they are doing, what is available locally to back it up, and how people using their services can access it.

Conclusion
There is no one single answer to the question 'which is better, pick and mix, or packs?'.

Packs will usually be better in situations where pharmacy staff are untrained and/or not sympathetic to drug users or the needle and syringe programme, and can significantly increase the amount of injecting equipment that is available to injecting drug users.

Pick and mix will usually be better in areas where pharmacies are big enough to offer privacy for the transactions to take place, and the pharmacy staff are trained to deliver the service sympathetically, and in a way that maximises the distribution of appropriate equipment.