Implementing needle exchange programmes: the evidence base.
, Issue 41, Spring 2012
, pp. 17-18.
The National Drugs Strategy (interim) 2009–2016 1 prioritises the expansion of needle and syringe programmes (NSPs) throughout the local and regional drugs task force areas. While plans to expand the availability of NSPs are welcome, improving access and effectiveness must also be key to the aims of the drugs strategy, which include the reduction of the prevalence of blood-borne viruses among intravenous drug users (IDUs) and the reduction of drug-related deaths. Key to improving access and effectiveness is understanding how best to organise and deliver NSPs.
This article summarises the only review that has examined the evidence base to determine what works best in the organisation and delivery of NSPs.2 The authors reviewed the literature since 1990 to determine:
1. What types of NSP are effective?
2. Which additional harm reduction services offered by NSPs are effective?
3. Are NSPs delivered in parallel with, or alongside, opiate substitution therapy effective?
Of 406 articles screened, 16 studies were judged eligible for inclusion in the review.
Two random controlled trials (RCTs) in the US in 2003 and 2007 were included in the review. The 2003 trial compared pharmacy-only sales with NSP plus pharmacy sales; neither setting produced superior results for reducing injecting risk behaviour. However, IDUs in both groups reduced their injecting drug use over time, but group assignment did not modify this reduction. The 2007 trial examined differences between IDUs attending hospital NSPs and those attending community-based NSPs and found that neither setting had a superior influence on injecting risk behaviours. However, both groups reduced their drug use risk behaviours over time.
Findings from three studies included in the review suggested that mobile van services and vending machines attracted younger IDUs and IDUs with high-risk profiles.
Findings from three studies in the USA suggested that syringe- dispensation dispensing policies had a limited impact on the sharing of needles and syringes but had some impact on the re-use of syringes. Where policies put fewer limits on the number of syringes exchanged, the re-use of syringes for personal use was less likely.
A study involving a cohort of drug users in Amsterdam3 reported that full participation in a harm reduction programme that combined daily methadone maintenance at a dose of 60mg or more with needle and syringe exchange (with all needles exchanged) was associated with a lower risk of HIV and HCV infection in drug users who had ever injected, compared to no participation. The authors of that study claimed: ‘To provide needles and syringes only or methadone only will not be sufficient to curb the rapid spread of these and other blood-borne infections among DU [IDUs]. It is essential to offer a comprehensive programme in which both measures are combined, preferably also with social-medical care and counselling.’ (p. 1461)
One RCT compared the effectiveness of case management (intervention group) with passive referral (control group) among NSP attendees who requested referral to drug treatment. Participants who received case management were more likely to enter treatment compared to the control group. Case management was based on the Strengths Based Case Management model which is designed to build upon the clients’ strengths. Further analysis suggested that the provision of transportation (a lift) to the treatment programme was an important ingredient in the case of management intervention.
Another RCT evaluated the effectiveness of motivational interviewing (MI) in the treatment interest and treatment enrolment of 302 NSP participants. Participants were randomly assigned to MI, job-seeking readiness or (iii) standard care referral. There was no superior effect of MI on treatment enrolment.
The authors of the systematic review concluded ‘it is difficult to draw conclusions on “what works best” within the range of harm reduction services available to IDUs. Further studies are required which have a stated aim of evaluating how different approaches to the organisation and delivery [of] NSPs impact on effectiveness.’
1. Department of Community, Rural and Gaeltacht Affairs (2009) National Drugs Strategy (interim) 2009–2016. Dublin: Department of Community, Rural and Gaeltacht Affairs..
2. Jones L, Pickering L, Sumnall H, McVeigh J and Bellis BA (2010) Optimal provision of needle and syringe programmes for injecting drug users: a systematic review. International Journal of Drug Policy, 21(5): 335–342.
3. Van Den Berg C, Smit C, Van Brussel G, Coutinho R and Prins M (2007) Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: evidence from the Amsterdam Cohort Studies among drug users. Addiction, 102(9): 1454–1462.