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A Comprehensive Approach:
Preventing Blood-Borne Infections Among Injection Drug Users

Chapter 3, Section 2: Key Strategies

INTERVENTIONS TO INCREASE IDUS' ACCESS TO STERILE SYRINGES

Clearly, the best solution for injecting drug users is to stop injecting and enter substance abuse treatment. However, many drug users either cannot get into substance abuse treatment programs or will not stop injecting drugs. Even those injectors who are in reatment may relapse to injecting drugs. Given these realities, several governmental bodies and institutions¹ have recommended consistent, one-time-only use of sterile syringes as a central strategy in the effort to reduce the transmission of HIV and other blood-borne pathogens among those individuals who continue to inject drugs.

Most states restrict the sale, distribution, and possession of sterile syringes: 44 states have drug paraphernalia statutes, 5 states have syringe prescription statutes, and 23 states have pharmacy regulations or practice guidelines. These restrictions present significant barriers to the sale of syringes to IDUs by pharmacists, the prescription of sterile syringes to IDUs by physicians, the operation of syringe exchange programs, the safe disposal of blood-contaminated used syringes, and ultimately, to the efforts by IDUs to reduce their risks of acquiring or transmitting blood-borne pathogens (Gostin, 1998).

Three types of interrelated interventions are now being pursued in the U.S. to increase IDUs' access to sterile syringes. Several states and municipalities are working on policy efforts to allow increased pharmacy sales of syringes, remove criminal penalties for syringe possession, and include language in laws stating that preventing HIV and other blood-borne pathogens is a "legitimate medical purpose" for prescribing sterile syringes to IDUs who cannot or will not stop injecting drugs. Many jurisdictions are pursuing efforts to sustain and expand syringe exchange programs, which provide IDUs with free sterile syringes and a way to safely dispose of blood-contaminated used syringes. Many of these syringe exchange programs also provide additional services, such as education and counseling, primary medical services, and referrals to substance abuse treatment and social services.

Initiatives with pharmacists provide education about the role of sterile syringes in reducing the transmission of blood-borne pathogens such as HIV and viral hepatitis, address pharmacist concerns and questions about syringe sales and disposal, and encourage changes in pharmacy policy and practice.

An individual IDU makes approximately 1,000 injections each year, which even in a moderate-size city adds up to millions of syringes and millions of injections a year (Lurie et al., 1998). Given this fact, achieving the recommendation of the one-time-only use of sterile syringes will require the coordination of all of these interventions so that every IDU who cannot or will not stop injecting will be able to obtain and safely dispose of a sufficient number of sterile syringes to prevent the acquisition or transmission of blood-borne pathogens.

In October 1999, the American Medical Association (AMA), the American Pharmaceutical Association (APhA), the Association of State and Territorial Health Officials (ASTHO), the National Association of Boards of Pharmacy (NABP), and the National Alliance of State and Territorial AIDS Directors (NASTAD) issued a joint statement urging state leaders in medicine, pharmacy, and public health to coordinate action to improve IDUs' access to sterile syringes through pharmacy sales. They encouraged public health leaders to work to reduce legal and regulatory barriers that restrict access, expand availability of substance abuse treatment, and improve options for safe disposal of syringes (NASTAD, 1999). This statement builds on previous similar policies adopted by the APhA in 1999, the AMA and NASTAD in 1997, and ASTHO in 1995.

1 This includes the U. S. Public Health Service, the Institute of Medicine of the National Academy of Sciences, and the U. S. Prevention Services Task Force.

INCREASING IDUS' ACCESS TO STERILE SYRINGES

Changing Connecticut's Syringe Laws Results in Increased Pharmacy Sales of Syringes to IDUs

In 1992, in response to a growing AIDS epidemic largely fueled by injection drug use, Connecticut modified its syringe laws to partially remove the legal barriers to pharmacy sales of syringes to IDUs. These changes included repealing the state prescription law to allow the purchase of up to 10 syringes without a prescription and modifying the paraphernalia law to allow possession of up to 10 syringes without drug residue.

An evaluation of the effect of changing Connecticut's syringe laws revealed substantial increases in pharmacy sales of syringes in high injection drug use areas compared with areas of minimal injection drug use. Furthermore, a large number of IDUs reported that they had shifted their primary source of syringes from "the street" to "the pharmacy" and reported substantially reduced rates of syringe sharing after the new laws went into effect.

Connecticut was able to successfully change the state syringe laws because of collaborative efforts between the state health department and the Department of Consumer Affairs, the state's pharmacy regulatory body. Since 1992, there have been several collaborative efforts between the health department and pharmacy schools and organizations to educate pharmacists about the changes in the law and the important role pharmacists can play in helping active IDUs obtain sterile syringes, and to encourage pharmacists to sell syringes to IDUs to help prevent transmission of HIV and other blood-borne pathogens. Other states, including Maine, Minnesota, and Washington, and very recently New York, Rhode Island, and New Hampshire, have used Connecticut's experience as a model in their efforts to change laws and regulations restricting syringe sales.

For more information: Groseclose et al., 1995; Valleroy et al., 1995.


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