Pharmacy needle exchange in the Republic of Ireland

The current National Drugs Strategy aims to reduce harms arising from substance misuse and to reduce the prevalence of blood-borne viruses among people who inject drugs (PWID) through the expansion of needle exchange provision to include community pharmacy-based programmes. In October 2011, the Health Service Executive (HSE) rolled out the national Pharmacy Needle Exchange Programme, which is a partnership initiative between the Elton John AIDS Foundation, the Irish Pharmacy Union, and the HSE. Once pharmacies have signed a service level agreement with the HSE, their contact details are passed on to the relevant HSE services so that they can promote access to sterile injecting equipment at the participating pharmacies and accept referrals for investigation and treatment. There are pharmacies providing needle exchange in each regional drugs task force area, apart from those covering counties Dublin, Kildare and Wicklow, which are served by a mix of static and outreach needle exchange programmes. At the end of 2014, there were 115 pharmacies providing needle exchange.

In line with best practice, the Steering Group of the HSE Pharmacy Needle Exchange Programme commissioned Liverpool John Moores University – in partnership with Waterford Institute of Technology – to carry out an external evaluation.1 This study was undertaken to evaluate the three-year pilot stage of the programme and the progress in delivering needle exchange services to PWID.

It aimed specifically to:

• Understand client and stakeholder satisfaction with needle exchange and attitudes towards, and experiences of, these services.
• Provide information relating to safer injecting, safer sexual behaviour, and the prevalence of blood-borne viruses that can be compared to international literature and to data collected during future evaluations.
• Provide recommendations regarding the development and delivery of services and policy. 

This article presents the methodology and main findings from this study.

Methodology

All pharmacies participating in the programme in April 2014 were eligible to take part in the study, and staff were asked to complete an online survey. Pharmacy staff were also requested to opt in to additional parts of the research, including participating in an interview with a member of the research team.

Pharmacies were provided with questionnaires that staff were requested to ask any client using the needle exchange to complete. Visits were made to five of the 10 pharmacies participating in the programme that had the greatest number of monthly transactions, where needle exchange clients were approached and asked if they would like to participate in the study through an interview. A brief online consultation with stakeholders was also undertaken, examining their perceptions of the programme effectiveness, and identifying strengths, weaknesses, and areas for further development.

Main findings

Pharmacy staff results

Experience of service provision

Pharmacy staff reported a variety of successes. The service was described in interviews as quick and efficient, with minimal impact on the running of other pharmacy activities. However, uptake was viewed as sporadic in some sites, with comments around levels of heroin availability impacting on injecting rates. Increasing uptake was reported in some sites, but with no change in gender profiles. Although a majority of staff reported positively about the needle exchange and clients, negative impacts of the service identified by small numbers of staff included the risk of crime and undesirable behaviour in the pharmacy and surrounding area. In addition, where pharmacies were located within shopping areas, it was apparent that some local businesses and security objected to the needle exchange.

Engagement and trust in needle exchange

The majority of staff surveyed believed they had engaged well with clients, although difficulties identified included a lack of interest in engagement from some clients. The exchange itself was described by the majority of interviewed staff as a quick process, with service users appearing anxious to leave the site. Lack of interaction was generally due to service user reluctance to engage and pharmacist lack of time. While it was noted that clients may like the speedy transaction, it was also recognised that this limits the opportunity to offer further intervention. First contact characterised by friendliness on the part of the pharmacist and frontline staff was viewed by many as being vital when initially developing positive and trusting relationships with service users.

Needle and equipment provision

Pack size options were described by the majority of interviewees as optimising efficiency and discretion for the user. However, some staff observed that service users report that the needles and syringes provided are not the right size or right volume, and identified that needles for groin injecting would be a useful addition. Further potential additions to packs that were suggested by pharmacy staff included tourniquets and condoms. The needle exchange transaction itself was viewed as efficient, but in some instances hampered by poor dialogue between pharmacist and service users, as well as low return rates.

Training and information needs

The most frequent response when staff were asked to identify methods to improve the service was the provision of more information through training about local services and helplines, as well as refresher courses in response to emergent drug issues and service needs. In particular, training regarding performance and image-enhancing drugs, such as steroids and melanotans, was commonly requested. The majority of pharmacies engaged with local community drug services and methadone clinics, but observed the need for greater visibility of services and referral routes.

Client-reported outcomes

Client satisfaction with services

The survey sample (n=74) included 23 females and 46 males, with five clients not reporting their gender, with a mean age of 32 years. The majority (88%) reported using heroin, with less than 15% reporting use of any other drug. Generally, PWID reported high satisfaction with service provision, including the injecting kits provided, pharmacy location, opening hours, staff knowledge and information provision. A minority of clients reported dissatisfaction with the attitudes of staff (24%) and privacy within the needle exchange (30%), with lower satisfaction on both criteria among females. Experiences of accessing the pharmacies were generally positive, with few comments around stigma associated with injecting drug use, or uncomfortable feelings on accessing the pharmacy. Participants were additionally satisfied with the confidential nature of the exchange. Pharmacy staff were viewed as friendly and polite, with the primary reasons stated for using specific pharmacies being related to location of the pharmacy and staff attitude.

Client behavioural outcomes

Self-reported rates of hepatitis B, C and HIV diagnosis were 7%, 22% and 5%, respectively. Approximately one-third of clients reported never having being tested for each of these blood-borne viruses. Almost half (49%) of the survey sample reporting having used a needle with which someone else had already injected, with 28% having done so in the past month. Females were more likely to have shared a needle ever, or in the past month, than males. Approximately half (47%) of clients reported having multiple sexual partners in the past month, including a small proportion with five or more partners (7%). A minority (39%) of clients reported always using a condom during sexual intercourse.

Stakeholder survey

Six stakeholders completed the survey, including representatives from drug services, the Irish Pharmacy Union, and outreach services. Overall, the programme was rated as being “very effective” (n=3) or “somewhat effective” (n=3). Key strengths identified included the increase in availability and accessibility of needle exchange services, and the impact of this on access to equipment and health professionals. Perceived weaknesses included difficulties encouraging returns, the need for a ‘pick and mix’ service as opposed to premade pre-prepared packs (which are not suitable for all clients), a lack of signposting to other services, and the identification of some stigma affecting needle exchange relations with local businesses and customers.

Conclusions

Overall, the evidence from the study suggests that the Pharmacy Needle Exchange Programme is acceptable and accessible to PWID in Ireland, and largely supported by pharmacy staff. Nevertheless, despite these successes, a number of recommendations were suggested that might help improve service provision and further meet client needs. These were to:

• Provide a wider range of equipment or packs suitable for all clients. Additionally, the possibility of providing ‘pick and mix’ services, in addition to pre-prepared packs, may better meet client needs.
• Develop integrated care pathways to link the exchange programme with other services for PWID, such as drug agencies and sexual health services. As more health interventions become embedded within the pharmacy, this is likely to become increasingly important to prevent pharmacies from becoming isolated from other related organisations providing services for injecting drug users.
• Consider offering within-pharmacy testing for blood-borne viruses. Where this is not possible, ensure that pharmacy staff have sufficient information on local services to enable efficient referral processes and signposting.
• Increase frequency of training provision for pharmacy staff and include information about anabolic steroids, melanotans and associated performance and image-enhancing drugs to help staff provide services to clients who inject these drugs. Training should be constantly reviewed to ensure that it is meeting the needs of pharmacy staff. The profile of PWID is likely to change, and therefore the knowledge and skill requirements of staff will change too, leading to the need for top-up training.
• Ensure that staff have sufficient training and knowledge about drug use and health-related issues to confidently provide harm reduction advice and support.
• Encourage (through training and information for staff) a consistent approach to increase returns and improve engagement with clients. Additionally, build on current work being undertaken regarding appropriate community responses to drug-related litter.
• Oversee the transition from a paper-based monitoring system to an electronic data monitoring system to be used by all participating pharmacies. 

As well as these recommendations, the authors suggest that future evaluations should use the same survey procedures to allow comparison on outcomes as an indication of programme development. In addition, the possibility of collecting biological samples from clients was also mentioned.

1   Bates G, van Hout MC, Hearne E, Mackridge A and McVeigh J (2015) Evaluation of the pilot stage of the Pharmacy Needle Exchange Programme in Ireland. Liverpool: Liverpool John Moores University. https://www.drugsandalcohol.ie/26905