Paraphernalia supply and its impact

Report
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
Agency Based Syringe Exchange Schemes (SES)
in Cheshire & Merseyside (n = 16)
SES Monitoring Forms
Cheshire & Merseyside Agency Based Syringe Exchange
Scheme Monitoring System Minimum Dataset
•Agency details
•Date of Visit
• On first visit
• Subsequent visits
• Initials
• Client Number
• Date of Birth
• Time
• Sex
• Syringes
• 1st Part Postcode
• Needles
• How Heard
• Returns
• In Treatment?
• Main Drug
• Client Number
• Additional Items
• Condoms
• Citric
• Sharing data
Transactions, clients & new clients at SES
(Cheshire & Merseyside 1991 –2003)
4500
4000
No. of clients (<0.01)
25000
No. of new clients (NS)
No. of SES transactions (NS)
20000
Number of Clients
3500
3000
15000
2500
2000
10000
1500
1000
5000
500
0
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year of Presentation/Attendance
Number of syringe exchange transactions
5000
Gender of Clients Attending SES
(Cheshire & Merseyside 1991 –2003)
NUMBER OF INDIVIDUALS
4500
4000
Female (NS)
3500
Male (<0.01)
3000
2500
2000
1500
1000
500
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
YEAR OF ATTENDANCE
Age Group
All Individuals Attending SES
Cheshire & Merseyside (1991-2003)
1400
1200
Under 15 (NS)
1000
INDIVIDUALS
15 - 19 (NS)
20 - 24 (<0.05)
800
25 - 29 (NS)
600
30 - 34 (<0.01)
35 - 39 (<0.01)
400
40 - 44 (<0.01)
45 - 49 (<0.01)
200
50+ (<0.01)
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
YEAR OF ATTENDANCE
New Clients Declaring Receipt of Drug Treatment
(Cheshire & Merseyside 1991-2003)
1200
In treatment (<0.01)
Not in treatment (<0.05)
NUMBER OF INDIVIDUALS
1000
800
600
400
200
0
1991
1992
1993
1994
1995
1996
1997
1998
YEAR OF PRESENTATION
1999
2000
2001
2002
2003
Main Drug of All Clients at SES
(Cheshire & Merseyside 1991 – 2003)
NUMBER OF INDIVIDUALS
2500
2000
Heroin (< 0.01)
Methadone (<0.05)
Amphetamine (<0.05)
Steroids (<0.01)
Cocaine/crack (NS)
Other / Various (NS)
1500
1000
500
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
YEAR OF ATTENDANCE
Main Drug of New Clients at SES
(Cheshire & Merseyside 1991 – 2003)
1000
NUMBER OF INDIVIDUALS
900
800
700
Heroin (<NS)
Methadone (<0.01)
Amphetamine (<0.01)
Steroids (<0.01)
Cocaine (<0.01)
Other/Various (<0.01)
600
500
400
300
200
100
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
YEAR OF PRESENTATION
Opiate Injectors
(Cheshire & Merseyside 1992 – 2003)
40
2500
2000
30
25
1500
20
1000
15
10
500
5
0
0
1992 1993 1994 1995
1996 1997 1998 1999
2000 2001 2002 2003
Opiate injecting client & new clients
Mean number of visits & syringes per visit each year
35
Transactions (<0.05)
Syringes per visit (*)
All Clients (<0.01)
New Clients (<0.05)
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.
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.
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.
ACMD Response
YES
NO
•Sterile water ampoules
•Filters
•Swabs
•Tourniquets
•Mixing utensils
spoons, bowls
•Citric acid
Why is Citric Acid Provision Important?
Alternatives
•Lemon juice
Infections
•At the injection site
•Vinegar
•Systemic (compromised
health and immunity)
ACMD Recommendation
Citric acid should be supplied by
pharmacists and others appropriately
trained in quantities and its effects.
Aim: to assess the impact of the introduction
of citric acid on SES provision in Cheshire &
Merseyside
Methods: qualitative and quantitative
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
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
1. Service uptake
2. Harm related behaviours
3. Engagement
4. Other issues
1. 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”
1. Service Uptake
Type of injector
Number of SES
No particular type
5
Younger injectors
2
Women
1
Chaotic injectors
1
Crack injectors
1
Older injectors (40+)
1
Total
11
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.”
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.”
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.
What Else Should be Provided?
Paraphernalia
Sterile water
Number of
SES
8
Improved spoons
2
Tourniquet
2
Filters
1
Tin foil
1
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.
Analysis of Routine Monitoring Data
1. Service Uptake
Service Uptake by Ongoing Clients
Number of individuals
140
120
Pre citric
Post citric
100
80
60
40
20
0
1
2
3
4
5
6
7
Agencies
8
9
10 11
Number of individuals
Service Uptake by New Clients
100
90
80
70
60
50
40
30
20
10
0
Pre citric
Post citric
1
2
3
4
5
6
7
Agencies
8
9 10 11
Service Uptake - Summary
Pre citric
Post citric
Ongoing clients
584
544
New clients
258
258
Total clients
842
802
Analysis of Routine Monitoring Data
2. Changes in Service Utilisation
Changes in Service Utilisation
Ongoing Matched Clients (n = 398)
Pre citric Post citric P value
Median
transactions
(IQR)
4
(2, 10)
5
(2, 11)
0.029*
Median syringes
(IQR)
15
(10, 30)
15
(10, 25)
NS*
*Wilcoxon Signed Ranks Test
Changes in Service Utilisation; Transaction
Rate (heroin and crack only)
Median transaction rate
4
3
2
1
0
5
4
3
2
1
Years prior to citric introduction
Spearman’s Correlation: P = NS
Seasonal Analysis
Ongoing Matched Clients (n = 314)
Median
transactions
(IQR)
Median syringes
(IQR)
12 months
prior
Post citric
P value
4
(2, 9)
5
(2.75, 12.25)
0.002*
15
(10, 30)
20
(10, 30)
NS*
*Wilcoxon Signed Ranks Test
Changes in Service Utilisation: Transaction
Rate (n = 314 matched pairs)
Median transaction rate
6
5
4
3
2
1
0
12 months
before
pre CA
Time
post CA
Steroid Users
Ongoing Matched Clients (n = 295)
Median
transactions
(IQR)
Median syringes
(IQR)
Pre citric
Post citric
P value
1
(1, 2)
1
(1, 2)
NS*
30
(20, 36)
30
(20, 40)
NS*
*Wilcoxon Signed Ranks Test
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.
Implications?
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?
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?
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.
4. Increased transaction rate has been achieved
without a fall in the median number of syringes
given out per visit
•Important public health indicator.
Same number of syringes per transaction.
More transaction.
Where are the additional syringes going?
How clients became aware of SES
(Cheshire & Merseyside 1991-2003)
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
leaflet/poster
other organisation
friend/other user
media
outreach
other
GP
Chemist
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?
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.
Over to you….
1. Views on introduction of citric acid.
2. What other injecting paraphernalia would be
useful?
3. Is there sufficient evidence regarding best practice
for citric acid provision?
4. Should the introduction of injecting paraphernalia
be expected to increase service uptake?
5. Views on informal distribution networks.
1. 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?
2. What other injecting paraphernalia would be useful?
•
Are injectors aware of what it is legal for services
to provide?
•
Sterile water.
•
Evidence based or injector requested?
3. Is there sufficient evidence and guidance regarding
best practice for citric acid provision?
•
Where is information available?
•
What is the quality of this information?
•
How much citric acid is enough?
•
Are injecting drug users getting a consistent message?
4. Should the introduction of injecting paraphernalia
be expected to increase service uptake?
•
Was this ever a reason for introducing citric acid?
•
If so, why has it not been successful in increasing
service uptake (if this is the case)?
•
What other strategies should be employed to
increase service uptake?
5. Views on informal distribution networks
•
Is it plausible that citric acid has resulted in
increased informal distribution of syringes
resulting in more injectors using clean
syringes?
•
How can these networks be used to benefit
injectors?
Thank you and enjoy the conference
Dr. Caryl Beynon
Centre for Public Health
Faculty of Health & Applied Social Sciences
Liverpool John Moores University
Liverpool, L3 2AY
Tel: 0151 231 4510
www.cph.org.uk
Infection
Out of 102 ‘problematic’ drug users
1. How many die from drug related deaths?
2. How many die from infection?
Infection
Out of 102 ‘problematic’ drug users
1. How many die from drug related deaths?
30 (29%)
2. How many die from infection?
16 (16%)
Infection
Underlying cause*
Acute hepatitis C
Number of deaths
1
Mycoses
Abscess
Cellultis
1
1
1
Septicaemia
Endocarditis
Pneumonia
Acute respiratory
infection
2
2
7
1
*International Classification of Disease (version 10)
Infection may be the most potentially preventable
cause of death among drug users.
What can be done?
Are structures in place to deal with primary care?
Thank you and enjoy the conference
Dr. Caryl Beynon
Centre for Public Health
Faculty of Health & Applied Social Sciences
Liverpool John Moores University
Liverpool, L3 2AY
Tel: 0151 231 4510
www.cph.org.uk

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