Harm Reduction

Mary Clare Madden & Jennifer Kelly

Addiction Pharmacists / Independent Prescribers

NHS Greater Glasgow and Clyde Addictions

Contents

• Definition of Harm Reduction

• Harm Associated with Drug Administration

• Harm Reduction Services

• Role of the Pharmacist

Definition of Harm Reduction

• Harm reduction is a term that defines policies, programmes, services and actions that work to reduce the:

• Health, Social and Economic harms to: - Individuals- Communities- Society

Principles of Harm Reduction

• Is pragmatic• It prioritises goals• It has humanist values• It focuses on risks and harms• It does not focus on abstinence• It seeks to maximise a range of

opportunities

Routes of Drug Administration• Harm is highly contingent on the means by which drugs

are administered• Injecting drugs is the most common but dangerous way

of taking them. • Injecting is the main cause of both short term & long

term risks to injecting drug users (IDUs) i.e. transmission of blood borne viruses (BBVs), drug overdose & bacterial infections

• According to the ACMD people who inject drugs are 14 times more likely to die than their peers!

• Other routes of admin are less risky than injecting e.g. smoking & snorting but still carry risk of drug dependence, overdose and health complications

Harm Associated with Drug Administration

BBVs - Hepatitis C• Sharing injecting equipment increases the risk of

contracting a BBV such as HIV or Hep C • Hep C is a disease caused by a virus that attacks

the liver• It is spread through blood to blood contact. • It mainly affects the liver causing swelling,

scarring and sometimes leading to cancer• The virus can lie dormant for 20-30yrs before the

liver is damaged & symptoms begin to show• It is transmitted primarily through percutaneous

exposure though it can be spread through sexual intercourse and from mother to child

• There is no vaccine against Hepatitis C!!

Hep C Action Plan Phase IIMay 2008 – March 2011

• ‘Hep C is one of the most serious & significant public health risks of our generation’ (Scottish Government, 2004.)

• ~ 50,000 individuals infected with Hep C antibody in Scotland.

• Of these 38,000 are chronically infected.• ~ 45,000 acquired Hep C through sharing needles

& other injecting paraphernalia.• ~ 1,000 – 1,500 IDUs in Scotland are infected

each year with Hep C.

Hep C Action Plan Phase IIMay 2008 – March 2011

• Plan involves funding for prevention, testing and treatment

• Prevention arm aims:– Increase volume and type of equipment

available– Introduce novel educational interventions– Ensure workforce receives consistent training to

enable delivery of service– Collect data nationally via Information Services

Division (ISD)

Injecting Injuries• People who inject illicit drugs,

reuse injecting equipment are at risk of injury, inflammation & infection at the injection site

• In 2007 around 1/3 of IDU’s in the UK reported having had an abscess, sore or open wound at an injection site

• In 2008 the Shooting Up Report estimated that it costs the NHS £47M a year to treat wounds caused by injecting drugs!

Common Types Of Injecting Injuries in Drug Users

• Abscesses • Infections & cellulitis• ‘Lumps’ and

swellings• Trackmarks /

phlebitis• Groin sinuses• Chronic leg ulcers

What Causes Injecting Problems?

Technique : missed veins, muscle or skin injecting, ‘digging’, flushing

Poor hygiene; sharing equipment, reusing equipment

The (unknown) injected substance, unsterile, contaminated, adulterated – filter, additives, acid, the drug, particles (anthrax!)

Background of poor systemic health – BBV, malnutrition, mental health issues

Overdose • People who inject drugs are at greater risk of overdose

than those who smoke or snort drugs • Medical definition of an overdose is the accidental or

intentional use of a drug or medicine in an amount that is higher than is normally used. In the substance misusing community an overdose can occur due to reduced tolerance, relapse, polydrug use etc

• Overdose with opiate drugs causes drowsiness, drop in blood pressure, slowed heart rate, and slowed breathing. Person may stop breathing and die.

• Signs - pinpoint pupils, pale skin, blue lips, unrousable• In 2010 there were 485 drug related deaths• Out of the 485 deaths: heroin/morphine was implicated

in 52%, methadone was implicated in 36% of the deaths & benzos were implicated in 25%.

Overdose - Naloxone• Naloxone pilot introduced in 2007 in Glasgow • It is a drug which is administered to temporarily

reverse the effects of an opiate overdose & hopefully save a life

• It is a short acting opiate antagonist which can act within 2 mins & lasts for approximately 20 mins

• In 2010 became a National Programme• Supplied within addiction services and other outlets

via Patient Group Direction (PGD) by trained staff in combination with overdose awareness training

• Naloxone Lead for each Health Board Area

Harm Reduction Services

General Statistics

• Approximately 19,000 IDU’s in Scotland• Estimated there is roughly 10 Million

injecting episodes in Glasgow each year• 1 Million plus needles supplied each year

in Glasgow from Community Pharmacies and Fixed Sites

Injecting Equipment Providers (IEP’s)• New Guidelines published by the Scottish Government

in March 2010 for all IEPs• IEPs refers to any Service that distributes injecting

equipment e.g. Pharmacies and fixed-site services• Pharmacy needle exchange was introduced in 1986 at 5

sites throughout Britain.• To date there are now roughly 169 Pharmacy IEPs in

Scotland• Most Pharmacy IEPs supply needles in sealed sterile

packs that contain needles & injecting paraphernalia. • Needles provided differ in thickness and in length. • Depending on which site on the body you are injecting

into should determine what size of needle is used. • Where possible the shortest/thinnest needle should be

used to minimise vein and muscle damage.

One Hit Kits

One Hit Kit (1HK)• 1HK’s have been designed to improve the

“quality and nature” of the equipment • Each kit contains a filter syringe, citric acid

sachet, spoon and swab.• Water is not included due to lack of 2ml plastic

vial supplier• The 1HKs are sealed in individual sterile packs in

bundles of 20 with an individual safe disposal cin bin.

• Encourages single use of all injecting equipment

Advantages of Pharmacy IEPs• User friendly• Easy Access• Confidential• Requires a minimum of information from clients • Non judgemental• Information about the risks of injecting and safer

injecting practices• May be the only point of contact with healthcare

professional• Gateway to treatment services

Not just a supply but a means of safe disposal of used injecting equipment

Specialist / Fixed Site IEPs

• Able to provide more in depth one to one consultations around injecting drug use

• May offer advice and information around route transition interventions i.e. encouraging people to move away from injecting to alternative methods of drug administration or prevent people from injecting for the first time

• Some provide specialist services and offer equipment that is tailored to type of injecting behaviour e.g. intravenous - groin, intramuscular- steroid, subcutaneous – melanotan!

Needle Replacement

• PNR is a planned harm reduction initiative for Community and Secondary Addiction Services.

• It involves offering a basic needle pack as part of a planned appointment to service users identified as IDUs

• Packs must be offered in combination with safer injecting advice & referral to pharmacy providers for further supplies and to dispose of used equipment

• PNR exists alongside the pharmacy providers• Service Users are free to use one or both of the

services.• Offered in Addiction Teams, Sexual Health Services and

Police Stations

Other Substances of Misuse

• Over the last 5 years there has been a rise in the range of substances people are misusing:-

• Steroids• Human Growth Hormone• Melanotan• Legal Highs

Steroid Clinic• The 2009 ACMD report investigating the primary

prevention of Hep C among IDUs noted, “ it is important to recognise the potential risk of HCV transmission among people that inject performance & image enhancing drugs such as anabolic steroids.”

• Glasgow clinic started in Feb 09. • Clinic aim is to engage with steroid users and encourage

them to move from injecting to diet and exercise • New needle packs specially designed to be more

acceptable for those who wish to continue injecting• BBV, LFT, GFR, B.P testing carried out in addition to

providing information & educating users on risks of BBVs, injecting complications, health and other risks associated with steroids and their misuse

• Clinic worker directs users to their nearest pharmacy provider so they can access clean needles more readily

Role of the Pharmacist

What can you do!• Lord Advocate guidance now allows Injecting

Equipment Providers to provide as many needle packs as a service user requires. No longer any limits on the quantities of needle packs that can be given out so please encourage people to take as many packs as they need

• Encourage people to return used equipment to pharmacy provider or fixed site

• Educate injectors on safer injecting practices. • Provide information leaflets on safer techniques and

Treatment Services• Highlight other health services the Pharmacy can

provide.

Safer Injecting Advice• There is no completely safe way of injecting drugs

however if someone is going to inject there are ways to reduce the risks involved and minimise harm

• Advice given should include:• Wash hands and injection site with soap and water. If

there is no soap or water available then use a swab• Find a clean preparation area• Always use new works when preparing and injecting

drugs. This includes, a sterile syringe, a clean spoon or cooker, sterile or boiled water, a sealed citric acid sachet and a new clean filter.

• DO NOT SHARE OR REUSE ANY INJECTING PARAPHERNALIA!!

Safer Injecting Advice Cont’d• Good Injection Sites: arm, back of leg, ankle, back of

hand• Bad Injection sites: neck, feet, groin, breasts, armpit• Change injecting sites, gives veins a chance to heal• Always inject towards the heart• Never inject with a tourniquet on• Inject slowly• Apply pressure to injection site after injecting with a

clean paper towel for 5 minutes and wash hands.• Dispose of all injecting equipment safely in a Sharpsafe

container and take to Pharmacy IEP

So to conclude, remember!• Roughly 1,000 – 1,500 IDUs in Scotland are infected each

year with Hep C.• At least 50% of injectors have problems with their skin• Costs NHS £47M a year to treat injecting wounds!• Do they need safer injecting advice?• Do they need sterile injecting equipment?!!!!• Do they need wound care?• Do they need referred to a Clinician/ Treatment Service?• Early identification, intervention and education can

reduce complications and prevent serious illness.

Useful References / Contacts• Injecting Guidelines available on the Scottish Government

website www.scotland.gov.uk • Hep C Action Plan - www.scotland.gov.uk • Assessing the Scale & Impact of Illicit Drug Markets in

Scotland – www.scotland.gov.uk • Shooting Up Report - www.hpa.org.uk • NES Substance Misuse Package –

pharmacy@nes.scot.nhs.uk • Scottish Specialist Pharmacists in Substance Misuse –

Contact Health Board for contact details