Needle_exchange_provision_in_Birmingham_A_systematic_needs_assessment_Sep2008

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Needle exchange provision in Birmingham: A systematic needs assessment

Jessica Loaring

David Best

Birmingham Drug and Alcohol Action Team

September 2008

For further information contact Jessica Loaring at:

[email protected]

Telephone: 0121 3012355

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TABLE OF CONTENTS

EXECUTIVE SUMMARY.........................................................................................................................................................................3

INTRODUCTION AND BACKGROUND..................................................................................................................................................7

AIMS AND OBJECTIVES........................................................................................................................................................................8

SYRINGE AND NEEDLE COVERAGE FOR INJECTING DRUG USERS..............................................................................................9

INJECTING STATUS IN BIRMINGHAM..................................................................................................................................................9

DATA AND FINDINGS ..........................................................................................................................................................................11

SYRINGE AND NEEDLE EXCHANGE PROGRAMME DATA..............................................................................................................11

MODELS OF NEEDLE EXCHANGE.....................................................................................................................................................11

NEEDLE EXCHANGE USER PROFILES .............................................................................................................................................12

NEEDLE EXCHANGE TRANSACTIONS..............................................................................................................................................13

COMPARISONS BETWEEN PHARMACY AND NON-PHARMACY POPULATIONS..........................................................................14

NON-PHARMACY SERVICES DATA UPDATE – SEPTEMBER 2008.................................................................................................15

PHARMACY SURVEY...........................................................................................................................................................................19

NEEDLE EXCHANGE MAPPING..........................................................................................................................................................21

EXPERT GROUP MEETINGS ..............................................................................................................................................................22

KEY INFORMANT INTERVIEWS..........................................................................................................................................................23

NEEDLE EXCHANGE NEEDS ASSESSMENT RECOMMENDATIONS..............................................................................................25

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Needle Exchange Needs Assessment

Executive Summary

This report describes the rationale, methods and findings of the 2008 Birmingham DAAT needle exchange

needs assessment. The method for this needs assessment is consistent with that used with the Treatment

Planning Needs Assessment for drug services in Birmingham – this involves the convening of an advisory

group to oversee a process of accessing as much quantifiable data as possible and reconciling the data

obtained with key informant interviews on the adequacy of needle exchange provision across the city. For

needle exchange provision, this also means assessing the activity levels within community pharmacy and non-

pharmacy based ‘specialist’ needle exchange schemes, and mapping these against estimated national

assessment of needle exchange ‘coverage’. This information is then broken down to profile the individuals

accessing these services, for example by age, gender and ethnicity both within services and across both

pharmacy and specialist providers. The coverage, accessibility, and variety of services are also measured to

assess current levels of functioning.

Key Data Findings

There were 604 (604/4918) current injectors engaged in structured treatment during 2005/6 and 634

during 2006/7 (634/5177), a rise of 5.0%.

When calculating the engagement of Injecting Drug Users (IDU) in treatment and based on the Glasgow

prevalence estimates of IDU, only 21.9% of the estimated IDU in Birmingham were engaged in

treatment during 2006/7.

The majority of needle exchange (Nx) users across both pharmacy and non-pharmacy specialist

services were in the 25-34 year age group (53%), 38% were between the ages of 35 and 64 years and

9% were under the age of 24. There were only six recorded transactions for people under 18.

The gender spilt shows an over representation of males (85%) compared to female needle exchange

users (15%). This contrasts with the gender representation of individuals engaged in structured

treatment services (taken from NDTMS data), of whom 26% were female.

The majority of users were of white ethnicity (93%) and again demonstrates the difference in user

profiles compared to the wider NDTMS population

The number of needle and syringe returns was significantly smaller than the number of syringes/packs

distributed. Across the sample of Nx providers 2,545 ‘sharps containers’ were returned by IDU.

The injecting PDU estimate for Birmingham is 2,895 injectors (CI: 2,343 – 3,664), and the approximate

total number of syringes distributed over the 3 month period and extrapolated over 12 months is

590,180 syringes. This equates to 1,204 syringes per person per year (or between 252 and 161

syringes based on associated confidence intervals) and just over 1 syringe every two days (0.6 per day).

In total 11 interviews with key stakeholders were conducted – with commissioners, community

pharmacists, specialist service providers and team managers and identified the following issues:

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o Opening times and related issues of access arose as an issue

o Increased steroid users accessing services

o Review of what people want in the exchange packs and the inconsistencies in the current

level of provision, particularly around pick and mix provision

o Training or information for new pharmacy workers

o Picking up bins from pharmacies

o Good coverage across the city and the need to map against reported client needs

o The need for fast and responsive services

o Ability to provide what the service user wants in a non-judgemental service

o The need for better supported and resourced crack interventions

These findings resulted in the following recommendations:

Finding Recommendation

1 The treatment status of IDUs accessing

Nx facilities is largely unknown. Treatment

status has now been added as a

monitoring question on all DAT Nx return

forms

To continue to collect treatment status information. To use this information

to assess the number of Nx users currently in or not engaged with

structured treatment services, and to inform the treatment planning process

accordingly. This is particularly important given the high rate of users

estimated to be not in treatment from snapshot analysis (56%)

2 Pharmacy Nx services have

proportionately more IDU under the age of

25 accessing these services. These

groups are traditionally ‘hard to reach’

from a treatment perspective.

Ensure that harm reduction and treatment options information and advice

are available to these users to maximise the opportunity of signposting

them into structured treatment – and options for early onsite brief

motivational interventions. Additional resources in providing enhanced

treatment pathways for these groups (particularly at high activity

exchanges) should be examined and qualitative research work done to

identify barriers to treatment in these populations. Brief information packs

and training and support for general pharmacy staff may be important

particularly in the high volume pharmacies within the scheme.

3 There are growing numbers of steroid

users accessing both specialist and

pharmacy based Nx services.

To assess the workforce training needs in relation to this group of IDU.

Provide information or training where identified around the management

and provision of injecting equipment and harm reduction advice for steroid

users. To investigate funding sources for the provision of needles and

syringes to steroid users, and to assess the public health implications of

working with this group.

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4 There is a clear need to improve coverage

of the city using both existing types of

needle exchange provision and innovative

techniques

Consideration should be given to developing new methods of delivering

equipment, either by piloting automated dispensing facilities or by

generating greater coverage of the city through the recruitment of

additional pharmacy services.

5 Policies for the return of injecting

equipment vary by pharmacy and service

resulting in variable and often low return

rates

Ongoing working group required to develop consistent policies across the

city that can be tested against ongoing data collection – clarity of policies

and resulting training and support for staff required

6 There are varying levels of awareness

amongst pharmacy Tier 1 workers about

the harm reduction approach for providing

Nx services to injecting drug users

To produce an information/induction pack for pharmacy workers

introducing them to the harm reduction rationale and reasons for providing

needle exchange facilities for IDU. This should be included in training for

Tier 1 staff and pathways to and from needle exchanges disseminated

more effectively.

7 Based on the estimates of injecting PDU

in Birmingham and the analysed activity

data, there is a sub-optimum level of

syringe and needle coverage across the

city

Work with user groups and pharmacy working group to develop strategies

for improved overall levels and consistency of penetration into this

population. This should also include work to increase the uptake of needle

exchange services in harder to engage groups such as BME and female

IDU. There are initial indications that less than half of the users of NX

facilities are in treatment – more local data is required to characterise the

populations out of treatment and to develop appropriate interventions and

pathways for this group.

8 Data collection procedures are

inconsistent and analysis of this data is

problematic

Review data collection mechanisms particularly in light of the amended

data collection form (already implemented across all Nx services) and

develop areas of identified data weaknesses. Although initial steps have

been taken to address this, local analysis of injecting groups and their

needs is urgently required alongside evaluations of effectiveness of both

specialist and pharmacy exchange schemes.

9 Interventions to reduce the harm caused

by smoking crack cocaine are not

currently adequately resourced

To consider replicating the work done in Walsall to provide crack smoking

equipment to crack users. To provide harm reduction information to crack

users (and all other drug users) accessing needle exchange services in a

range of different languages. To clarify policies around crack packs and

their link to BTEI interventions for cocaine powder and the COCA training

initiative around cocaine powder and crack.

10 There is a low rate of treatment

engagement for injecting drug users.

Increased focus on engaging injectors in treatment services. Once data are

available on treatment status via needle exchanges, there is a need for

health screening, harm reduction and rapid (and possibly incentivised)

methods of effectively engaging this group in some form of structured

interventions

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11 There is little known about IDU being

released from Prison in Birmingham and

whether appropriate needle exchange

services are available.

To conduct further work on assessing the level of prison leavers who are

current or previous IDU and investigate the views of pharmacies in close

proximity to the prison towards providing targeted harm reduction

interventions to this population.

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Introduction and Background

Injecting drug use carries a number of serious risks for drug users and also a public health and safety risk

associated with blood-borne virus and increased risk of overdose. Compared to non-injectors, injectors have

higher rates of drug-related mortality, are at increased risk of acquiring blood-borne viruses (BBVs) such as

HIV and viral hepatitis, and bacterial infections (HPA, 2005).

In the UK, it was reported that the annual mortality rate of injecting drug users between 1982 and 1994 was

almost 2%, this study also showed that injecting drug users are 22 times more likely to die as a result of

overdose than their non-drug using peers (Frischer et al, 1997). A more recent study assessing the mortality

rate of heroin users in London found that the rate was 17 times higher among heroin users compared to the

non-heroin-using population aged between 15–59 years (Hickman et al, 2003). Non-fatal overdose is also a

major risk with up to 56% of opiate users in contact with treatment services experiencing an overdose on

opiates at some time in their lives, with 20% reporting an overdose in the previous year (Best et al, 2002). In

another study assessing the number of previous non-fatal overdoses in a treatment population in London (Man

et al, 2002) 49% reported a lifetime overdose on a mean of 4.1 occasions, which equated to 201 personal

overdoses, among this cohort of 116 methadone maintenance clients.

In England and Wales there are an estimated 231,000 cases of antibody positive HCV virus in the 15-59 year

age group. Within this model 31% are estimated to be current IDUs, 57% are ex-IDUs and 12% are non-IDUs

(HPA, 2006). Therefore approximately 88% of HCV cases are attributable to IDU.

The prevalence of HCV among injecting drug users can vary from 27% to 74% dependent on geographical

location and associated risk factors (Hickman et al 2006). These estimates are an increase on estimates from

the late 1990’s and current surveillance and research data suggest that the prevalence of HCV has increased

(Judd et al, 2004; Judd et al, 2005). Injecting related bacterial infections have also increased (HPA, 2004)

suggesting a need for further targeted interventions towards injecting drug users. To date research has been

unable to explain these increases in terms of increased injecting risk and alarmingly have found that new

initiates to injecting are particularly susceptible to acquiring antibody-HCV positivity (Judd et al, 2004; Judd et

al 2005; Sutton et al, 2006; and Hickman et al 2007).

Needle exchange services have a critical role to play in reducing the risks associated with injecting, particularly

in preventing transmission of BBVs, by improving risk awareness in IDUs and by providing supplies of injecting

equipment to reduce needle sharing and the use of blunt equipment. The effectiveness of needle exchange

programmes in the prevention of HIV is well- established (WHO, 2004), however the evidence suggests that

needle exchange has been less effective in controlling the spread of Hepatitis C infection.

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Recent statistics show that Birmingham has a low prevalence of injecting drug users, particularly among opiate

users relative to the rest of England (West Midlands Public Health Observatory, 2007). However, little is known

about the profile of these users or about what services they access outside of formal treatment providers.

Aims and Objectives

The key aims of this needs assessment, based on the availability of data nationally and locally are:

To evaluate and map needle and syringe exchange provision including coverage, disposal of needles,

and communication and education on wider issues relating to injecting drug use (IDU).

Measure these in relation to the available data on local rates of injecting, coverage of injecting, and

the relationship to needle exchange provision. In essence, this will be a gap analysis that will try to

clarify questions about the current rate of injecting in the city and the adequacy of needle exchange

coverage and distribution. Traditionally, this has been done by attempting to calculate rate of syringe

distribution per IVDU both in and out of treatment.

A review of needle exchange policies across the city in relation to the national and international

evidence base.

To use this as the basis for a subsequent assessment of the effectiveness of other ‘low threshold’

provision in the city including the availability of outreach and drop-in facilities in the city and the overall

mapping of harm reduction provision.

To contribute to the overall DAAT treatment planning process and the review of harm reduction

provision in the city.

The approach outlined below amends the established data-driven needs process for lower threshold services,

attempting to maximise existing data sources as the basis for expert input and as a means of identifying gaps

and in developing a method for improving the overall treatment system.

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Syringe and needle coverage for injecting drug users

Coverage of syringes and needles for injecting drug users (IDU) can be defined as the number of sterile

syringes provided to IDU divided by the number of injections during a specified time frame (Jones and Vlahov,

1998). From a public health perspective this would ideally mean needle exchange programmes providing a

clean sterile needle for each and every injection. Strathdee and Vlahov (2001) offered a rudimentary

assumption that an average IDU administering two injections per day results in the need for 730 clean syringes

per year to reach the target of “one set, one shot”. Clearly there are variations in drug use patterns and the

factors affecting injecting frequency, for example it is particularly suggested that cocaine injectors have a

higher frequency of daily injection than heroin IDU (Strathdee et al, 1997).

Research in the UK can gives some idea of the levels of coverage in major urban areas. A study assessing

coverage in three cities (London, Liverpool and Brighton) found that available data indicated that in London

nearly five million syringes were distributed per annum, with over 400,000 in Brighton, and 560,000 in Liverpool

(Hickman et al, 2004). These numbers equated to approximately the same proportionate coverage in Brighton

and Liverpool at around 190 syringes per injector per year (or one syringe every two days) and slightly less in

London at around one syringe every 2.5 days. This research used the average number of times that IDU’s

inject (twice a day) to predict the current activity in the cities investigated. The authors therefore suggested

that current levels of activity provided sterile equipment for approximately 27% of all injections by IDU in

Brighton and Liverpool and 20% in London (Hickman et al, 2004). This research suggests that providing 730

clean sterile syringes per IDU per year is clearly not yet being realised, and that this may be an ‘ideal’ target

that is in practice unlikely to be achieved.

Injecting Status in Birmingham

There has been no known published research on the number of syringes and injecting equipment used by

IDUs in Birmingham, and we are reliant on Home Office estimates of the number of injectors as part of the

national assessment of prevalence of drug use. Were this information available we would be able to map the

coverage of syringes for each known or estimated IDU, and this needs assessment should be the start of an

improved data synthesis process in this area. What this would mean is that we would be able to provide

information on the level of syringe and needle exchange activity for problem drug users (PDU) in Birmingham

and map this against the estimated total number of PDU’s and the numbers of reported PDU’s who are

engaged in structured drug treatment.

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Data from the National Drug Treatment Monitoring System (NDTMS) for the 2005/6 and the 2006/07 financial

years provide an illustration of the reported injecting status of problem drug users in treatment in the

Birmingham DAT area (those defined as primarily opiate and/or crack cocaine users).

Injecting Status In 05/06 % In 06/07 %

Current 604 12 634 12

Previous 992 20 1156 22

Never 2777 56 3053 59

Not known 545 11 334 6

Table 1. Injecting status of clients in Birmingham engaged in Tier 3 or 4 structured drug treatment and

entered onto NDTMS in 2005/6 and 2006/7

These data from the NDTMS suggest that in 2005/6 there were 604 current injectors engaged in structured

drug treatment and 634 in the 2006/7 financial year, this represents an increase from the previous year of 5%,

but also that the adequacy of data capture is improving as the proportion of ‘not known’ among clients’

injecting status has reduced markedly.

Figure 1. Reported injecting status among problem drug users in Birmingham engaged in treatment

during the financial years 2005/06 and 2006/07.

According to the Glasgow prevalence estimates of problem drug users in England (Home Office 2006) there

are 137,141 injectors nationally (95% CI: 133,118 – 149,144) and 14, 734 injectors in the West Midlands (95%

CI: 13,589 – 17,007) of which 2,895 injectors (CI: 2,343 – 3,664) were estimated to be based in Birmingham.

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Therefore, when comparing this estimate of IDU in Birmingham against the total number of current IDU

engaged in drug treatment in 2006/7 (634 reported clients), this would suggest that there was in the region of

2,261 (78.1%) IDU not in contact with structured treatment services during 2006/7 (or between 1,709 – 3,030

IDU, based on the published confidence intervals). More worryingly, the data would suggest that only 21.9% of

injectors were in contact with drug treatment services in 2006/07, while more than one-third of those not in

contact with services were injectors. Using this information in the reverse manner, NDTMS data from 2004/5

suggested that 17.3% clients engaged in treatment were heroin injectors. This would suggest that a

substantial proportion of injectors are not in touch with structured services and so harm reduction initiatives are

reliant on the impact and effectiveness of low threshold services to reduce risk and to engage in health

messages with this population.

Data and Findings

Syringe and Needle Exchange Programme Data

A snapshot of Birmingham has been collated onto a database and used for analysis, although it is important to

note that there were major limitations with the data available in this area. Below is a summary of the analysis

of this database that attempts to investigate the number of needles, syringes, and injecting equipment supplied

to drug users over a 3-month period between July and September 2007. This provides a further description of

the profile of injecting and other drug users who use low threshold services and potentially provides a picture

of those only accessing these services and therefore characterised by the NTA as currently not engaged in

structured drug treatment (i.e. a hidden population).

Models of Needle Exchange

Needle exchange services in Birmingham are predominantly split into two models of service delivery,

pharmacy and non-pharmacy based services. The non-pharmacy based services are set within specialist

substance misuse services (such as Tier 2 providers or Tier 3 community drug teams) with pharmacy based

services delivered from community pharmacies recruited onto a DAT commissioned scheme. The pharmacy

based schemes typically provide needle exchange services through a standardised ‘pack’ scheme where

needles, syringes and injecting equipment are distributed in standardised packs consisting of syringes (usually

10 fixed head syringes per pack) and injection preparation equipment (pre-injection swabs, acidifiers,

cups/cookers, and filters). The packs can also contain condoms and harm reduction literature. In the

specialist services this equipment and information is distributed through a ‘pick and mix’ system where

injecting drug users can obtain injecting equipment based on need and not in a standardised pack. At the time

of reporting there were 92 community pharmacies providing needle exchange services and 6 specialist

services providing in house needle exchange services.

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Needle Exchange User Profiles

Across the sample of needle exchange users (both pharmacy and non-pharmacy) the majority of users were in

the 25-34 year age group (53%), 38% were between the ages of 35 and 64 years and 9% were under the age

of 24. There were only six recorded transactions for people under the age of 18. The gender spilt shows an

over representation of males (85%) compared to female needle exchange users (15%). This contrasts with the

gender representation of individuals engaged in structured treatment services (taken from NDTMS data), of

which 26% were female. The majority of users were of white ethnicity (93%) and again demonstrates the

difference in user profiles compared to the wider NDTMS population; this is illustrated in Figure 1 below.

White93%

Mixed3%

Asian/Asian Other3%

Black/Black Other1%

All Needle Exchange Users

White69%

Asian/Asian Other13%

Black/Black Other1%

Mixed8%

Other1%

NDTMS (New Presentations)

Thus, there is a concern that the needle exchange provision in Birmingham is targeted at only white and only

male drug using clients – and it is too early to state with confidence whether this is the group who primarily use

by injecting.

Figure 2. Ethnicity comparisons of needle exchange users and the population of substance misusers

engaged in structured treatment (Tiers 3 and 4).

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Needle Exchange Transactions

During the period used for analysis (July – September 2007) there were 6,940 individual transactions within

pharmacy based needle exchange services, with a high level distribution of smaller 1ml and 2ml syringes

compared to the larger syringes available. The total number of 1ml syringes distributed was 87,530 (68% of

the total number of syringes distributed through community pharmacies) and 38,260 syringes of the 2ml size

(30%). A smaller number of 5ml syringes were distributed (n= 3,730), however there were no recorded 10ml

syringes distributed during the 3-month period. Due to the smaller number of non-pharmacy based needle

exchanges the number of transactions in non-pharmacy services was significantly smaller than in pharmacy-

based services with a total number of 65,146 syringes distributed for all needle types. Table 2 below

demonstrates the number of syringes distributes by needle/syringe type.

1ml Diabetic 1ml 2ml 5ml 10ml Orange1 Blue Green

1,701 23,320 7,697 1,090 342 7,503 15,120 8,373

Table 2. Number of needles and syringes distributed by type across specialist needle exchange

services in Birmingham.

The number of needle and syringe returns was significantly smaller than the number of syringes/packs

distributed. Across the sample 2,545 ‘sharps containers’ were returned to needle exchange services, however

it is not possible to quantify how many individual syringes this represents or what size syringes were returned

as the sharps containers are sealed to prevent contamination. Geographically, pharmacies with the largest

number of transactions are located in the centre of the city (Boots Chemist, High Street; 13% of all

transactions recorded), Moseley (7%), Kings Norton (5%) and Castle Vale (3%). The comparison of

pharmacy and non-pharmacy distribution is shown in Table 3 below:

Pharmacy Non-Pharmacy

Transactions 6,940 1,680

Total syringes distributed 129,520 65,146

Average number of syringes distributed per

transaction

19 39

Returns (across both types of provider) 2,545 containers (potentially 25,450 syringes)

Extrapolated distribution (over 12 months) 518,080 260,584

Extrapolated returns (over 12 months) 10,180 containers (potentially 101,800 syringes)

1 Colour coded needles refer to the following: Orange (25 gauge), Blue (23 gauge) and Green (21 gauge)

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Table 3. Needle exchange activity in specialist and pharmacy needle exchange schemes (1st July – 30th

September 2007)

The injecting PDU estimate for Birmingham is 2,895 injectors (CI: 2,343 – 3,664), and the approximate total

number of syringes distributed over the 3 month period and extrapolated over 12 months is 590,180 syringes.

This equates to in the region of 1,204 syringes per person per year (or between 252 and 161 syringes based

on associated confidence intervals) and just over 1 syringe every two days (0.6 per day). This also means that

based on the average injector having 2 injections per day, current coverage in Birmingham provides new

sterile equipment for approximately 28% of all injections (or between 22% and 35% based on associated

confidence intervals), assuming that a new needle were to be used for every injection. This is compared to

research discussed previously by Hickman et al (2004) who reported that sterile equipment was provided for

approximately 27% of all injections by IDU in Brighton and Liverpool and 20% in London. This would suggest

that Birmingham is at least consistent with other major English cities although this should not imply that the

situation could not be improved.

Comparisons between Pharmacy and Non-Pharmacy populations

Non-pharmacy needle exchange users were more likely to be older (in the 25-64 year age groups) than those

accessing pharmacy based needle exchanges (χ2 =16.33, df = 2, p <0.001), there was a higher proportion of

18-24 year olds accessing pharmacy based needle exchange services than in non-pharmacy services, this is

illustrated in Figure 3.

Figure 3: Age analysis by specialist versus pharmacy exchange

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Female injecting drug users were more likely to access non-pharmacy based services than community

pharmacies for their needle exchange equipment (χ2 =10.68, df = 1, p = 0.001), while there were no significant

differences in the ethnicity of those accessing either pharmacy or non-pharmacy services.

Limitations in this current data need to be noted; firstly the accuracy of the data is questionable although on

review the activity by pharmacy looks to be consistent with current knowledge as expressed by the expert

group members. However, at a service level, the recording of client details around number of syringes

distributed are problematic. There is also no method at present of knowing whether users are accessing both

the pharmacy and non-pharmacy based services, therefore the sample populations cannot be assumed to be

not independent groups. Current data reporting mechanisms are being improved and implemented at this

time, this will enable a more consistent and standardised measure of activity within needle exchange services

and should provide better quality data for the next annual needs assessment. Until some basic identifiers are

linked to exchange monitoring this type of analysis will be largely speculative.

Non-Pharmacy Services Data Update – September 2008

Developments in the collection of data for needle exchange activity have enabled further analysis at the

specialist provider level (non-pharmacy services). The data summary below is based on data collected by

each of the specialist service providers between November 2007 and July 2008. Analysing the dataset with all

service combined we found that:

The majority of service users are between the ages of 25-30 years (n=668, 36%) followed by 31-35

year olds (n=460, 24.9%), this is roughly consistent with the previous analysis detailed above where

56% of users were between 25-34 years.

Specialist exchange users are predominantly male (86%) and White British (79%), followed by Asian

Pakistani ethnicity (6.7%). This represents an increase in the ethnic diversity of needle exchange

users as previous analysis demonstrated a higher percentage of White users (>90%)

Most clients are not new to the needle exchange service (n=1,558 – 84%), however

The majority of clients are not engaged in structured treatment services (n= 1,024; 56%). These

questions were not previously asked therefore no comparisons could be made. However this provides

support for the prevalence analysis above suggesting that most injectors are out of treatment. It does

however, offer a hope of engaging this group as many appear to be in contact with specialist needle

exchange schemes.

The primary substance injected is heroin (48%) followed by crack cocaine (23%) and steroids (19%) –

at present, the schemes are not commissioned to provide services to steroid users.

66,203 needles and syringes were distributed with 1ml syringes (n=18,337 – 28%) and Green needles

(n=10,248 – 15%) being the most popular.

Only 19,020 returns were made – data does not indicate whether this is individual syringes or bins.

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685 bins were given out – no data on the size of these bins.

Younger Nx users are less likely to be ‘in treatment’ than older Nx users (2 = 22.91, df = 4, p <

0.001). This may further suggest that needle exchange attendance is a stepping stone towards

engagement with formal treatment services, and that needle exchange services may be a particularly

important arena for recruiting young drug users into treatment. .

A comparison between the specialist services shows some variation between client profiles, particularly for

age, gender, substance choice and transactions:

Addaction’s client base has a higher proportion of younger needle exchange users (25-30yrs) when

compared to the other services – 53% compared with 20% at Mary Street and 31% at the Terrace

Slade Road and the Terrace have a higher proportion of older Needle exchange users – see Figure 3

below:

Figure 3: Age analysis of clients across Specialist Needle Exchange Providers

Female clients represent 20% of those accessing the Needle Exchange at Azaadi compared to 8% at

Drugline (highest and lowest)

Slade Road, The Terrace and Addaction have the highest proportion of new clients compared to those

who had previously attended their needle exchange facilities. Further breakdown of this is provided in

Table 4 below:

Has the client accessed this service before?Service

No Yes TotalCount 188 51 239Addaction

% 78.7% 21.3% 100.0%Count 848 77 925Drugline

% 91.7% 8.3% 100.0%Count 68 9 77Mary St

% 88.3% 11.7% 100.0%

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Count 258 34 292Azaadi% 88.4% 11.6% 100.0%

Count 76 21 97Terrace% 78.4% 21.6% 100.0%

Count 120 49 169Slade Rd% 71.0% 29.0% 100.0%

Count 1558 241 1799Total% 86.6% 13.4% 100.0%

Table 4: Number of new clients using the Specialist Needle Exchange services November 2007-

July 2008

All services are asked to record whether clients accessing Nx are engaged in structured drug

treatment. The majority of clients reported that they were not in treatment (n= 1024, 57%) with wide

variation across services, for example 93% (n=75/81) of Nx users at Mary Street and 84% (n=

200/238) at Addaction were not in structured treatment compared to 39% (n=361/923) at Drugline

(highest and lowest proportions) the remaining three CDT’s fell between these (Slade Road 67%,

Azaadi 67%, Terrace 83%). This question needs to be clarified with Nx workers and with

commissioners to ensure the question is asked in a standardised format. The high number of clients

reporting that they are not in treatment requires further investigation and clarification to find out how

reliable this figure is and whether this is a true reflection of treatment engagement amongst Nx users.

Table 5 below illustrates the responses to this question for each service.

In Structured Treatment? Service No Yes Total

N= 200 38 238Addaction% 84.0% 16.0% 100%N= 361 562 923 Drugline% 39.1% 60.9% 100%N= 75 6 81 Mary St% 92.6% 7.4% 100%N= 196 95 291 Azaadi% 67.4% 32.6% 100%N= 80 17 97Terrace% 82.5% 17.5% 100%N= 112 56 168Slade Rd % 66.7% 33.3% 100%N= 1024 774 1798Total% 57.0% 43.0% 100%

Table 5. Number (and percent) of clients accessing specialist Nx provider services who report that

they are not currently engaged in structured treatment

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Steroids: 60% (n=48) of Mary Street, 40% (n=104) of Azaadi and 37% (n=62) of Slade Road needle

exchange clients are primary steroid users compared with 15% (n=134) at Drugline, 3.9% (n=9)

Addaction and 1% (n=1) at the Terrace.

Drugline gives out the highest number of syringes, needles and equipment, however the remaining

services vary by level of activity for each piece of equipment or syringe type, as illustrated below in

Table 6 (yellow for highest, pink for second highest):

Nx Provider 1ml 2ml 5ml 10ml OrBL

1"

BL

1.25"Gr Br Cups Water Acid Bins

Addaction 2,070 632 84 58 280 445 30 713 230 852 225 2,148 24

Drugline 12,296 5,146 584 552 4,325 5,782 3,129 5,206 2,538 7,164 8,978 10,010 454

Mary Street 686 1,027 541 50 328 997 110 1,066 0 132 0 278 37

Azaadi 1,385 2,271 318 10 520 1,559 1,797 1,496 164 275 1 476 51

Terrace 836 55 91 116 279 283 0 279 5 233 5 820 16

Slade Road 1,567 1,759 493 15 408 669 1,230 1,973 208 611 20 1,182 74

Total 18,840 10,890 2,111 801 6,140 9,735 6,296 10,733 3,145 9,267 9,229 14,914 656

Table 6: Needle and syringe distribution across the Specialist Needle Exchange Providers November

2007-July 2008

There were 19,029 returns across all the services. Drugline recorded 15,587 returns compared to 19 returns at

the Terrace. It is unclear whether the number of syringes or the numbers of bins are being recorded or a

mixture of both. The number of returns is shown in Table 7 below:

Service ReturnsAddaction 119Drugline 15587Mary Street 1871Azaadi 1412Terrace 19Slade Road 21Total 19029

Table 7: Number of needle/syringe returns by Specialist Needle Exchange Provider, November 2007-

July 2008

Thus the majority of the returns reported by specialist services were at one agency, Drugline, with very small

numbers in some of the CDT needle exchange providers.

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Pharmacy Survey

To gain an understanding of the use and acceptability of needle exchange packs distributed to pharmacy

based services, the DAT distributed questionnaires to service users via the nine community pharmacies with

the highest needle exchange activity, as shown in Table 8 below. This provides a useful comparison against

the specialist needle exchange service data reported above:

Do you use... Yes No

Syringes and Needles 97% 3%

Sharps Containers 91% 9%

Swabs 90% 10%

Vitamin C 87% 13%

Filters 85% 15%

Condoms 35% 65%

Harm reduction information 32% 68%

Table 8: Client activity reported by users of pharmacy needle exchange schemes

Thus, there is considerable use of a wide range of harm reduction options other than only syringes and

needles, although uptake of information in this group is low. In Table 9, basic information is provided on the

drug of choice for this group:

Drug of Choice n= %

Heroin 92 49.7

Crack and Heroin 32 17.3

Crack Cocaine 11 5.9

Cannabis 4 2.2

Methadone Amps 4 2.2

Steroids 3 1.6

Amphetamine 2 1.1

Diamorphine 1 0.5

Not indicated 36 19.5

Table 9: Primary drug used by pharmacy needle exchange clients

Thus, heroin is the most commonly injected drug followed by the combination of heroin and crack, although

there is a considerable amount of missing data around drug use. In Table 10 below, participants were asked

what else they would like to see being distributed at the exchanges.

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Suggested Inclusions N= %

Water 52 65

Citric Acid 13 16.2

Other 15 18.8

Table 10: Suggested requests for other items to be distributed at pharmacy needle exchanges

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Needle exchange mapping

In the mapping exercise below (Figure 5) we have mapped levels of needle exchange activity across the city:

The majority of Nx activity on the above map occurs in the Heart of Birmingham PCT area, as signified by the

number of blue, black and green indicator discs. The size and colour of the indicator reflects the level of

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activity in each of the pharmacy based and specialist Nx services, mapped against the identified drug

availability reported by WM police (shaded areas). There are a number of city centre pharmacies where needle

exchange activity is particularly high (as signified by the large blue discs). Drugline is also a key city centre

provider of Nx services in the city. In the south of the city there are two key pharmacies providing high levels of

injecting equipment (black discs), however there are areas of drug availability (pink/yellow shaded areas)

which are not directly covered by needle exchange schemes. This map provides an initial measure of Nx

services mapped against drug availability and requires further investigation to assess the reliability and

interpretation of using these methods.

Expert group meetings

As part of the needs assessment process, an expert group was convened to ensure the widest possible

consultation of local stakeholders. We aimed to provide a balance of stakeholders including individuals who:

Have a professional role in the provision of services to IDU, for example service provider team leaders

and needle exchange workers

Can make changes happen in relation to the needs and harms identified for IDU’s, for example

managers, commissioners and planners.

We aimed to include user representative in this process, however no individuals were available at the

time of conducting this needs assessment although the initial findings were presented to the DAT user

group for comments and feedback.

The expert group was important in appraising from their specialist viewpoint the accuracy and validity of the

data collected and in translating these data into identifiable needs that are compatible with the local treatment

system. The expert group was also a source of additional local data with which to supplement the core data

sets. In other words, they will contributed at three stages:

1. In identifying and accessing relevant data sources – including their own activity data

2. In making sense of the overall data picture, reconciled against their own qualitative knowledge and

their awareness of limitations in particular data sources

3. In the ‘translation’ process for turning the epidemiological map of unmet needs into actions that can be

addressed through the treatment planning process

Discussions held during the expert group process

Pharmacies were seen by the group to provide a relatively anonymous exchange with a brief intervention that

enables the whole process to run as quickly as possible. Drug services are seen as a place for treatment and

so clients may wish to separate their scripted medication from their exchanges. In addition, drug workers are

expected to initiate longer, more detailed interventions which may deter clients. Hence the larger number of

clients who use pharmacies for exchanges - 20% of all needle exchange packs were distributed at the three

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Boots pharmacies within the city centre. This geographic concentration offers both advantages and

disadvantages to the scheme.

It was suggested that a hybrid of these two types of services could be commissioned to create pharmacies

which carried out more extensive interventions, perhaps providing a pick and mix selection of needles- but still

remaining a swift, impersonal service. These extended pharmacy services could perhaps be trialled in one of

the busier pharmacies, for example there are nine pharmacies which register four times the amount of activity

than other pharmacies in Birmingham.

It was suggested that younger, less problematic drug users utilized the pharmacy services and perhaps then,

as their drug habit graduated to a more entrenched level, they began to access actual treatment centres. This

sort of data could be quantified by differentiating Nx figures from pharmacies for users in treatment vs. users

not in treatment. This would then support the view that pharmacy Nx should aim their interventions at Harm

Reduction leaving drug services to promote and encourage clients into treatment.

Gaps in Provision identified in the expert group process

it was suggested that postcode information gathered from needle exchange data it could be used to configure

an average distance for service users to travel to drug service centres and therefore pinpoint where there are

particularly large gaps in provision. Furthermore, working upon information supplied by Environmental Health,

which may give precise needle litter spots, it might be possible to install automated needle exchange services

in the forms of vending machines. This would provide services out-of-hours and also act as waste disposal

points. Other possibilities for data collection were recommended, including: ambulance maps of pick-up areas

and police knowledge of drug transaction points. Both of these sources may indicate areas in need of drug

services and/or needle disposal units. The main area considered to be most deficient in opportunities for

treatment was mapping pathways and services needs for steroid users who are currently overlooked.

Key informant interviews

In order to determine and balance the views of local stakeholders qualitative research methods were used.

Key informant Interviews were conducted to gain an in-depth knowledge of needle and syringe exchange

systems in Birmingham and what gaps and needs may exist within these current systems. Additional

interviewees were identified on the basis of addressing particular issues that arise in the course of the

quantitative data process and the group processes. In total 11 interviews with key stakeholders were

completed including commissioners, community and pharmacy service providers and the key areas for

discussion related to:

Opening times and related issues of access arose as an issue

Increased steroid users accessing services

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Review of what people want in the exchange packs and the inconsistencies in the current

level of provision, particularly around pick and mix provison

Training or information for new pharmacy workers

Picking up bins from pharmacies

Good coverage across the city and the need to map against reported client needs

The need for fast and responsive services

Ability to provide what the service user wants in a non-judgemental service

The need for better supported and resourced crack interventions

A common theme in the key informant interviews was the reported increase in needle exchange transactions

for steroid users, particularly in non-pharmacy services. Respondents felt they had a good knowledge of

responding this profile of drug users however some felt that further training could be needed. These views

were balanced by further concerns about the appropriateness of steroid users accessing needle exchange

provision when there was no current funding for providing needles and paraphernalia to this client group.

Although the general consensus was that the harm reduction philosophy would included providing injecting

equipment and advice to this clients group to minimise the harms that could arise from sharing needles and

having limited knowledge, particularly as many steroid needle exchange users felt they were not drug users.

Crack users were also seen as a client group whose needs could be better met by needle exchange services,

particularly in non-pharmacy specialist services. Whilst injecting crack is known to cause considerable harm to

veins, some respondents felt that further paraphernalia could be provided for crack users, for example the

provision of crack pipes to encourage users to smoke crack rather than inject and to encourage crack users to

engage with treatment services.

Pharmacy services felt that training for new workers or an information pack for new workers on the validity and

importance of providing Nx services to drug users could be a useful addition. It was felt this would help generic

workers to understand that Nx services are a key public health intervention. Generally, across both pharmacy

and non-pharmacy services it was felt that the provision of Nx to drug users was well resourced, non-

judgemental and efficient in providing harm reduction services for IDU in Birmingham.

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Needle Exchange Needs Assessment Recommendations

Finding Recommendation

1 The treatment status of IDUs accessing Nx

facilities is largely unknown. Treatment status

has now been added as a monitoring

question on all DAT Nx return forms

To continue to collect treatment status information. To use

this information to assess the number of Nx users currently in

or not engaged with structured treatment services, and to

inform the treatment planning process accordingly. This is

particularly important given the high rate of users estimated to

be not in treatment from snapshot analysis (56%)

2 Pharmacy Nx services have proportionately

more IDU under the age of 25 accessing

these services. These groups are traditionally

‘hard to reach’ from a treatment perspective.

Ensure that harm reduction and treatment options information

and advice are available to these users to maximise the

opportunity of signposting them into structured treatment –

and options for early onsite brief motivational interventions.

Additional resources in providing enhanced treatment

pathways for these groups (particularly at high activity

exchanges) should be examined and qualitative research

work done to identify barriers to treatment in these

populations. Brief information packs and training and support

for general pharmacy staff may be important particularly in the

high volume pharmacies within the scheme.

3 There are growing numbers of steroid users

accessing both specialist and pharmacy

based Nx services.

To assess the workforce training needs in relation to this

group of IDU. Provide information or training where identified

around the management and provision of injecting equipment

and harm reduction advice for steroid users. To investigate

funding sources for the provision of needles and syringes to

steroid users, and to assess the public health implications of

working with this group.

4 There is a clear need to improve coverage of

the city using both existing types of needle

exchange provision and innovative

techniques

Consideration should be given to developing new methods of

delivering equipment, either by piloting automated dispensing

facilities or by generating greater coverage of the city through

the recruitment of additional pharmacy services.

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5 Policies for the return of injecting equipment

vary by pharmacy and service resulting in

variable and often low return rates

Ongoing working group required to develop consistent

policies across the city that can be tested against ongoing

data collection – clarity of policies and resulting training and

support for staff required

6 There are varying levels of awareness

amongst pharmacy Tier 1 workers about the

harm reduction approach for providing Nx

services to injecting drug users

To produce an information/induction pack for pharmacy

workers introducing them to the harm reduction rationale and

reasons for providing needle exchange facilities for IDU. This

should be included in training for Tier 1 staff and pathways to

and from needle exchanges disseminated more effectively.

7 Based on the estimates of injecting PDU in

Birmingham and the analysed activity data,

there is a sub-optimum level of syringe and

needle coverage across the city

Work with user groups and pharmacy working group to

develop strategies for improved overall levels and consistency

of penetration into this population. This should also include

work to increase the uptake of needle exchange services in

harder to engage groups such as BME and female IDU. There

are initial indications that less than half of the users of NX

facilities are in treatment – more local data is required to

characterise the populations out of treatment and to develop

appropriate interventions and pathways for this group.

8 Data collection procedures are inconsistent

and analysis of this data is problematic

Review data collection mechanisms particularly in light of the

amended data collection form (already implemented across all

Nx services) and develop areas of identified data

weaknesses. Although initial steps have been taken to

address this, local analysis of injecting groups and their needs

is urgently required alongside evaluations of effectiveness of

both specialist and pharmacy exchange schemes.

9 Interventions to reduce the harm caused by

smoking crack cocaine are not currently

adequately resourced

To consider replicating the work done in Walsall to provide

crack smoking equipment to crack users. To provide harm

reduction information to crack users (and all other drug users)

accessing needle exchange services in a range of different

languages. To clarify policies around crack packs and their

link to BTEI interventions for cocaine powder and the COCA

training initiative around cocaine powder and crack.

10 There is a low rate of treatment engagement

for injecting drug users.

Increased focus on accessing injectors into treatment

services. Once data are available on treatment status via

needle exchanges, there is a need for health screening, harm

reduction and rapid (and possibly incentivised) methods of

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effectively engaging this group in some form of structured

interventions

11 There is little known about IDU being

released from Prison in Birmingham and

whether appropriate needle exchange

services are available.

To conduct further work on assessing the level of prison

leavers who are current or previous IDU and investigate the

views of pharmacies in close proximity to the prison towards

providing targeted harm reduction interventions to this

population.