Pharmacy Based Needle Exchange

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Pharmacy Based Needle Exchange

• The Can Partnership
• Claire Raines

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Introductions brief overview of training plan

• Who we are
• Length
• Break
• House-keeping
• Can Partnership
• Referrals/Open Access

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Aims Objectives

• Promotion of the value of a PBNX to the local
  community and to the individual.
• Enhance awareness of who may use the PBNX
• To give insight into why NX exists
• To show how you can follow best practice (to run
  an PBNX with excellence!)

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Feelings / expectations / attitudes

• Staff
• Shoplifting
• Fear
• Mistrust
• Lack Of Confidence
• Personal Feelings (disgust/distaste)

• NX Customer
• Social Embarasment /Stigma
• Fear
• Questions/Fear of
• Low expectations of staff knowledge

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Taking a walk in their shoes exercise

• 2 volunteers required!

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In their shoes

• Mirrored expectations.
• IDUs research shows that heroin users have a
  more acute ability to spot signs of
  fear/disgust/anger in a persons facial
  expressions.
• Also that they are very bad at recognising
  happiness/love/affection. This is thought to be
  due to expectation of these expressions in family
  and loved ones.
• As a result its incredibly important for
  pharmacy staff to be more aware of their manner
  when dealing with substance users.
• Being more aware of how the transaction may feel
  for the IDU will also mean they feel less
  stigmatised, this is also when it is important
  that the transaction doesnt happen on the shop
  floor but in a consultation room.

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Desired expectations / attitudes

• Staff
• Respect/polite
• Positive / friendly
• Open
• Confident
• Confidential / Boundaried
• Knowledgable

• PBNX Customer
• Respectful/Polite
• Friendly
• Clear
• Confidence in staff
• Open / understanding
• Knows boundaries
• Willing to accept advice.

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WHY?, WHY? WHY?
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Why your pharmacy might offer PBNX ?

• You are able to advise on a range of issues
  including the prevention of drug-related death,
  overdose prevention, blood-borne infections, oral
  health, sexual health, contraception and safer
  sex, nutrition, minor infections, wound
  dressings, dental health and nicotine replacement
  therapy.
• Opening hours
• Alternative option
• Location

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Why are you providing this service anyway?

• You will become one of the gateways in bringing
  people who inject drugs into contact with a range
  of community services.
• To assist the person to remain healthy until they
  are ready and willing to cease injecting and
  ultimately achieve recovery .
• encouraging people to remain healthy with
  self-care or to address their other health needs.
  
• To protect health and reduce drug related deaths.
  
• To reduce sharing /risky behaviours by providing
  sterile injecting equipment, advice and
  information.

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• To promote safer injecting practices by providing
  and reinforcing harm reduction messages -
  including safe sex advice and advice on overdose
  prevention (e.g. risks of poly-drug use and
  alcohol use).
• To improve the health of local communities by
  preventing the spread of blood-borne infections
  by ensuring the safe disposal of used injecting
  equipment.
• To maximise the access to help of all injectors,
  especially the socially excluded.
• To help people access other health and social
  care eg CAN Partnership / The Terrance Higgins
  Trust/ AA / The Kings Arms Project.
• To join close working relationships with other
  local community services.

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if youre still not convinced

• The cost of providing health services to someone
  who injects drugs is estimated to be about
  35,000 over their lifetime. The related costs of
  crime are estimated to be an additional 445,000
  over a lifetime.
• -
  NICE.ORG.UK

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Why inject?

• Substance misuse (Lifestyle,boredom,socialising,
  experimental,addiction,needle fixation,tolerance
  levels,coping mechanism,other abuse past or
  present)
• PIEDS (confidence/status,lifestyle,other abuse
  past or present, self-image/peer
  pressure/competition/mental health)

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Target PBNX population

• PBNXs aim to help people over the age of 18 who
  inject illicit substances. This includes opioids
  (eg heroin) and stimulants (eg amphetamines or
  cocaine) either separately or in combination (eg
  speed-balling) and also adults who inject
  non-prescribed anabolic steroids and other
  performance and image-enhancing drugs (PIEDs).

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These customers can include

• High volumes
• In a hurry to be served /withdrawing/intoxicated
• Sex Workers
• Homeless
• Dual diagnosis
• Clients of services that prescribe
• All of the above

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1ml RED (A) pack 2.81

• 10 x 1ml combined needle syringe
• 10 x cooking spoons
• 10 x citric acid sachets
• 10 x alcohol swabs
• 1 x 0.25litre bin
• For I.V use / injecting into surface veins.
  Suitable for opiate/amphetamine use.

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2ml Green (B) pack 2.75

• 10 x 2ml barrel
• 10 x Blue 1 ¼ needles
• 10 x Green 1 ½needles FOR DRAWING UP
• 10 x Cooking spoons
• 10 x Citric Acid sachets
• 10 x Alcohol Swabs
• 1 x 0.45litre bin
• For injecting into deeper veins (femoral/ groin
  veins).
• For I.M injecting.

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1ml Brown ( C ) pack 2.83

• 10 x 1ml combined needle syringe
• 10 x Cooking spoons
• 10 x Vit C sachets
• 10 x Alcohol swabs
• 1 x 0.25litre bin
• For injecting into surface veins, I.V injecting.
  Alternative to Red Pack (A) Vit C instead of
  Citric Acid

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5ml Yellow (D) pack 1.84

• 10 x 5ml barrels
• 10 x alcohol swabs
• 10 x blue 1¼ needles
• 10 x green 1½needles FOR DRAWING UP
• 1 0.45 litre bin
• For injecting into deeper veins, I.M injecting.
  Suitable for steroid injectors.

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Pharmacy Needle and Syringe Provision operating
policies procedures might include

• Client dignity, privacy, confidentiality and data
  protection
• Sharps safety
• Needle Stick Injury / Body spill proceedure
• Individual Syringe Identification
• Return of used injecting equipment
• Provision for Young People
• Client complaints procedure
• Signposting

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Why do injectors prefer this method?

• Different drugs can be introduced into the body
  in several ways.
• Drugs can be snorted, smoked, swallowed, taken
  rectally, or injected. Each of these processes
  has the same ultimate purpose to get the blood
  into the bloodstream, and to reach the brain!.
• Injection has the optimumBioavailability It is
  the quickest way and bypasses most barriers to
  get to the CNS.

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What is injected?

• Heroin
• Amphetamines
• Crack
• Heroin and crack
• Methadone Amps / Sugar Free mixture
• Crushed Pills
• Steroids
• Malanatan/Malanotan 1 and 2 (1tanning2tanning/s
  exual disfunfunction)stimulates the pigment cells
  in your body to produce more melanin
  ,unregulated,from inside out change in skin tone.

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Intravenous injection(I.V)

• Intravenous injecting is a highly efficient way
  of introducing drugs into the body.
• When drugs are injected - the filtering and
  delaying mechanisms that protect us when things
  are absorbed via the gastro-intestinal tract,
  lungs or skin - are bypassed.
• The potential for infection and overdose are
  increased.

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Intramuscular Injecting(I.M)Discuss as a group!
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Subcutaneous Injecting(S.C)

• Provide handouts
• Discuss as a group

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Briefly, how do drugs enter and exit our body?.

• If drugs are swallowed, the drug is absorbed into
  the bloodstream through the stomach and the
  digestive tract.
• This process can take a considerable time, an
  hour or longer.
• As mentioned, injecting has the fastest
  introduction rate of the ways (UTB/Swallowed/Snort
  ed/Oral/Smoked).
• Once in the blood stream, the blood from the
  stomach and the intestines passes through the
  liver before reaching the heart.
• The liver removes toxins from the blood stream,
  and part of this process includes breaking down
  substances such as drugs.
• Each subsequent pass round the body and through
  the liver removes more of the drug from
  circulation.

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Arteries Veins

• Arteries take oxygenated blood from the lungs to
  the rest of the body They branch out,
  diminishing in size, until they reach the
  capillaries.
• The blood passes through the capillaries in the
  tissues, releases its oxygen, and is collected
  again in small veins , which by joining together
  progressively increase in size.
• The arteries return de-oxygenated blood back to
  the lungs via the heart. All drugs injected into
  veins must follow a route back through veins of
  increasing size to the heart.
• From the heart the drugs are pumped the short
  distance to the lungs where the blood passes
  through the capillaries of the lungs to be
  re-oxygenated, and then they return to the heart
  to be pumped to the brain.
• (The exception to this description is the
  pulmonary artery, it carries de-oxygenated blood
  from the heart to the lungs. All other arteries
  carry oxygenated blood. The pulmonary vein is
  unique because it carries oxygenated blood from
  the lungs to the heart.)
• Valves are only found in veins, they assist the
  flow of blood back to the heart by preventing
  back flow.

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The basic theory behind needle sizes

• Needle Gauge
• Needles are measured in terms of their Length,
  and their Gauge.
• Length may be given in millimetres (mm) or in
  imperial measures.
• The size of a needle is also measured by the
  external diameter of the needle, which is called
  the Gauge (G or GA).
• The hubs of needles are also colour coded, and
  shorthand for different gauges.This colour-coding
  only refers to gauge not length.

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What happens after injecting?

• When a drug is injected into a vein, it reaches
  the brain via the lungs in a matter of seconds.
• The drug is not significantly diluted hence the
  experience of the 'rush' or 'hit' as the brain
  becomes rapidly intoxicated.
• The fact that all venous blood must pass through
  capillaries in the lungs before going to the
  arteries means that solid matter and air bubbles
  that are injected into veins cannot reach the
  brain (except in exceedingly rare circumstances
  it is only possible if someone has a hole between
  the chambers of the heart) they will instead get
  trapped in the capillaries of the lungs.

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Intravenous injection

• Generally, the arms are the least risky place to
  access veins for injecting. The main aim of
  advice given to injectors, (after prevention of
  spread of blood-borne viruses) should be to
  maximise the length of time they are able to use
  the veins in their arms.
• When the arm veins can no longer be used,
  injectors should consider, and workers should
  promote, switching to a non-injecting route of
  drug use.
• Irreversible damage to the veins can occur where
  there is
• Repeated use of the same injecting site
• Poor technique
• Injection with blunt needles
• Injection with needles that are too large
• Injection of irritant substances.

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Steroid users Injecting
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But what are PIEDS / Steroids?
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Injecting Steroids

• A large proportion of the products on the market
  are low-quality fakes, containing little or no
  active ingredients.
• Standards of production are highly variable, and
  products are liable to be manufactured in
  non-sterile
• environments.
• Products are available in oral preparations,
  single dose ampoules and multi-dose bottles.
• Solutions for injection are intended to be
  injected intramuscularly, and often
  oil-based,resulting in a thicker solution than
  water based preparations.

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Things for injectors to remember
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Basic advice that will help to keep veins and
skin healthy include

• Wash hands before and after ,clean sites before
  with a swab, apply pressure after.
• Keep personal equipment in a defined, clean area.
• Use sterile equipment only, once only, do not
  reuse
• Do not share
• Dispose of items safely
• Introduce, inject and remove needles gently and
  slowly at a shallow angle towards the heart.
• Alternate injection sites, allowing veins to rest
  and recover -Smoke rather than injecting at times
  in order to rest veins
• Become ambidextrous so that they can inject in
  both arms it is best to encourage this before the
  onset of any problems, as it is much easier to
  practise new techniques when relaxed and the
  outcome is not crucial
• Discourage use of tourniquets, release them
  prior to injecting
• Stay away from sites that have become infected ,
  get medical help.
• Do not flush /back-load/front-load
• Do not inject where you feel a pulse or if the
  blood is bright red.
• Just how dangerous injecting will be on any one
  occasion is affected by
• The understanding the injector has of their
  underlying structures
• The dexterity of the injector
• The state of mind of the injector (e.g.
  intoxicated or not)
• The substance being injected
• Luck.
•  

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Discretion

• When handing over the exchange materials,
  consider using a suitable bag, typically an
  opaque dispensing bag
• This opportunity can be taken for
  health-promotion activities/leaflets/flyers
• advice booklets.

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Sharps/ Needle-stick Injuries

• Clean it
• Report it
• Call for help
• Get treated
• ID source / needle /patient if possible.

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Best Practice - Pharmacy-based needle exchange
operation

• Be aware of policies protocols for
• Young people
• The Intoxicated
• Psychological instability
• Body spills
• Staff Hep B vaccinations
• Client confidentiality - including what to do
  when a
• patient requests needle exchange who is also
  being
• prescribed substitute medication.
• Dealing with unacceptable behaviour / guidance
  on
• what constitutes unacceptable behaviour
• ways of minimising unacceptable behaviour.

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Working with Young Service Users

• Adult models of Needle Exchanges are not
  appropriate for young people (a person under the
  age of 18).
• It is therefore recommended that Pharmacy Needle
  Exchanges do not provide this service to those
  under, or who appear to be under 18 years of age.
  
• The course of action to a young person presenting
  to a Pharmacy Needle Exchange will be as follows
  
• Request proof of the young persons age before
  making a decision whether or not to provide
  injecting equipment
• Provide details of specialist local services
  working with young people with addictions, which
  will offer advice, information and specialist
  assessment

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Directing under 18s to Bedfords Young Persons
Services

• Plan B Bedfordshire
• 22 Grove Place, Bedford MK40 3JJ Tel [phone]
  911   
• Plan B offers a range of support, information and
  advice to young people aged between 5 and 18 who
  use drugs and/or alcohol and also supports young
  people affected by someone elses use.

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Further research for the keen.

• Safer Injecting
• http//www.kfx.org.uk/resources/nx08.pdf
• Steroids (PIEDS) http//www.siedsinfo.co.uk/
• Guidance with PBNX
• National Institute for Clinical Excellence
  Guidelines - www.nice.org.uk.
• The Can Partnership
• Can.org.uk