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Pharmacy Needle and Syringe Programme Handbook
Improving Health and Reducing Harm to Individuals and Communities
A Resource for those Working in Pharmacy Needle and Syringe Programmes
Addaction Harm Reduction ServiceBarnsley Drug and Alcohol Action Team
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Acknowledgements
James Pierce, Team Leader Addaction Harm Reduction Service
Claire Barber, Pharmacy Advisor to the Drug & Alcohol Action Team
Pharmacy Staff at Asda Pharmacy
Marie Hemingway, DAAT Administrator
Andy Brooke, Barnsley District Commander, South Yorkshire Police
Revised by the NSP Sub group 23rd May 2013
Revised by the BBV sub group June 2013
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Feedback:
This is the 2nd Edition of the Pharmacy Needle and Syringe Programme handbook produced in Barnsley. We would like your feedback, please send any comments to:
James PierceAddactionJohn StreetBarnsley S70 1LL
01226 289058 07900481263
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Table of ContentsOUR VISION...............................................................................................................7WHY DO WE NEED PHARMACY NEEDLE AND SYRINGE PROGRAMMES?...............8HOW DO WE RUN A PHARMACY NEEDLE AND SYRINGE PROGRAMME?................9SETTING UP A NEEDLE AND SYRINGE PROGRAMME IN PHARMACY...................10HOW TO RUN A NEEDLE AND SYRINGE PROGRAMME.........................THE FUNDAMENTALS.............................................................................13INFORMATION GATHERING..................................................................THE ASSESSMENT.................................................................................19CONFIDENTIALITY & INFORMATION SHARING..............................................20EQUIPMENT.........................................................................................21RETURNS AND WASTE MANAGEMENT............................................NEEDLE AND SYRINGE PROGRAMMES AND RETURNS....................................25CLINICAL WASTE AND DISPOSAL OF USED EQUIPMENT.................................25DEALING WITH DISCARDED SHARPS IN COMMUNITIES..................................26HARM REDUCTION INFORMATION AND ADVICE..............................THE ESSENTIALS...................................................................................29WHY PEOPLE CONTINUE USING HEROIN ONCE IN TREATMENT...........................30COMMON INJECTING RELATED PROBLEMS..................................................31BLOOD BORNE INFECTIONS.....................................................................36BLOOD SPILLAGE AND NEEDLE STICK INJURIES...........................................38PREGNANCY AND NEEDLE EXCHANGE........................................................40OVERDOSE - SIGNS AND SYMPTOMS.........................................................41INFORMATION ABOUT INTRAVENOUS (IV) INJECTION AND INJECTION SITES........43INJECTING TECHNIQUES..........................................................................47REDUCING THE RISKS OF OVERDOSE.........................................................48SERVICE QUALITY........................................................................CLINICAL GOVERNANCE AND QUALITY STANDARDS......................................53QUALITY STANDARDS FOR PHARMACY NEEDLE AND SYRINGE PROGRAMMES....53WORKFORCE DEVELOPMENT...................................................................55SERVICE USER INVOLVEMENT..................................................................56ANY BRIGHT IDEAS – ENCOURAGING INNOVATION........................................56USEFUL CONTACTS.............................................................................57USEFUL DOCUMENTS..........................................................................58QUESTIONS AND ANSWERS.................................................................5910 GOLDEN RULES..............................................................................62APPENDICES................................................................................
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Our Vision
Providing Easy Access, High Quality Needle and Syringe Programme Services and Harm Reduction Interventions
across the Barnsley Borough
Barnsley Drug and Alcohol Action Team (DAAT) aims to reduce the harms of substance misuse to individuals, families and communities. Commissioning a comprehensive needle and syringe programme is integral to that aim and to ensure that individuals, families and communities are not adversely affected by substance misuse.
These schemes are designed to:
Provide adult (over 18 and excluding steroid users) injecting drug users with clean equipment;
Take back used equipment (reducing the discarding of needles etc);
Offer advice and information Reduce the spread of viruses, reduce overdose and deaths
and; Encourage people into treatment.
Barnsley DAAT commissions a specialist Harm Reduction Service from Addaction. This provides:
A specialist needle and syringe programme and Co-ordinates work with community pharmacies offering
facilities for syringe and needle exchange in the community.
As part of this service pharmacies offer harm reduction advice and guidance, and can help service users contact treatment agencies should they wish to engage more fully.
Within the Barnsley drug and alcohol treatment system, service users in treatment work with a Phoenix Futures Recovery Navigator to explore and plan a pathway to recovery. Community pharmacists are an essential link between Recovery Navigators and service users, helping with their care. Contact details for both Addaction and Phoenix Futures are provided in this handbook.
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‘The DAAT is keen to support the development of needle and syringe programmes across the borough in pharmacies. These can offer more
equitable access to safer injecting materials and engagement with substance users not in contact with more structured services, and also can reduce the
impact of drug-related litter on communities and the associated risk of harm.’
Andy Brooke DAAT Board Chair Person
Why do we need Pharmacy Needle and Syringe Programmes?Needle and Syringe Programmes were created in the mid 1980s to ensure the safety of injecting drug users (IDUs) by providing clean needles and equipment. Originally serving heroin users the schemes now see a much wider range of IDUs including users of amphetamine, cocaine, crack cocaine and anabolic steroids. The schemes are a pragmatic solution to the problem of injecting drug use.
They also play an important part in creating safer communities by providing a place where used injecting equipment can be disposed of, reducing the potential for injuries from discarded injecting equipment.
The aims of the service are:
To reduce the spread of blood borne viruses including HBV, HCV and HIV;
To encourage safety and the safe return of used needles; To encourage people into treatment; Provide advice on:
o How to inject drugs safely;o Minimising injecting related injuries and infections
Needle and syringe programmes can also play a part in signposting users into other treatment services when a user feels they are ready to reduce or stop their use of drugs.
Pharmacies provide a non-stigmatising environment and have a public health role. Their staff are experts in their own field and with additional training are ideally placed to hold the full range of skills needed to deliver a high quality service.
Pharmacies can play a vital role in reducing the harms associated with injecting drug use. This handbook is a resource for those pharmacies providing needle and syringe programmes and contains information related to their day-to-day running as well as more detailed information around harm reduction advice; signposting and treatment options.
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How do we run a Pharmacy Needle and Syringe Programme?Needle and Syringe Programmes are an integral part of the overall treatment service in Barnsley. Pharmacies wishing to deliver such a scheme will have a contract and service specification outlining the quality standards required and payments made.
Addaction are commissioned to support pharmacies via the Team Leader of the Harm Reduction Service who:
Manages the organisation’s specialist needle and syringe programme service;
And supports needle and syringe programme activity at pharmacy level across the borough.
They are first point of contact for pharmacy staff needing specific help, advice, information or support on needle and syringe programme activity and harm reduction initiatives.
In addition to the Needle and Syringe Programme Coordinator, Barnsley DAAT employs a Pharmacy Advisor. This post can also offer help and support to pharmacies delivering, or considering delivering, this service.
Appropriate training is given to staff which covers:
Why we provide needle and syringe programmes,
Confidentiality, Harm reduction, The actual function of the needle and
syringe programme, Signposting, Monitoring, Health and safety.
Prior to starting a needle and syringe programme a pharmacy must have a standard operating procedure for blood spills and needle stick
injuries.
In addition all staff delivering the service should have vaccinations for Hepatitis A & B.
Setting up a Needle and Syringe Programme in Pharmacy
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'We are happy to do this important service and there are mainly no problems with
behaviour from either the new or existing clients'
Asda Pharmacy
Apply to Barnsley DAAT to run a scheme
Read Contract and Service specification
Implement any actions necessary to adhere to the contract and service specifications, for example, Standard Operating Procedures, activity
reporting, and attendance at training sessions
Sign and return contract
Pharmacist and staff attend local training session
Follow up visit from Needle and Syringe Programme Coordinator / DAAT Pharmacy Advisor
Delivery of equipment
Waste Disposal arranged
Access to PharmOutcomes for activity reporting arranged
Service advertised word of mouth and also by Needle and Syringe Programme logo
Customers arrive for service
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How to run a Needle and Syringe Programme
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The FundamentalsThe flow chart (Page 10) sets out the basic steps needed to run a needle and syringe programme. Here is some more information:
Greeting People
We remind people to smile and greet the client, not because we wish to be patronising but to underscore the importance of treating clients as ‘normal’ customers.
Substance misusers tell us they lack confidence, feel worthless, under suspicion and largely negative in their dealings with many professional agencies. Those who inject often expect to be treated with hostility, suspicion and disrespect.
When treated respectfully it makes service users feel better. You may be the only professional in contact with the person, so how you treat them is important to their overall safety. (See the flowchart over.)
Programme Aim
This programme promotes harm reduction. Restricting access to clean needles and syringes will increase harm to the individual as equipment may be shared or re-used. Needles that have been shared may carry greater virus risk than ones that have not.
Discarded equipment poses a risk to the wider community. The return of needles, syringes and other used equipment must always be encouraged.
Do not reduce the amount of clean equipment given if the client does not return, or if they return few.
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Smile and greet the service user. Ask them for their initials and DOB
Do they have any returns?
Yes No
Establish what has happened to previously issued equipment and remind of importance of returning to NX to ensure safe disposal
Ask how many and then invite them to place them in sharps bin. If needles are loose then ask service user to place them in a small sharps bin prior to disposal. Record number returned
Ask how things are with their injecting, any problems or concerns?
Some NoneExplore any issues and offer appropriate harm reduction and safer injecting advice. Signpost on to Addaction, A & E, GPs or other relevant services if required
Issue injecting equipment appropriate for substances and injection sites used. Record numbers issued
Establish what substance is being injected, injection sites etc
Check for service user details on PharmOutcomes and input information when prompted
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Loose Needles
If a client brings back loose needles and/or other equipment DO NOT handle them. Ask the client to transfer them to a small sharps bin prior to disposal in the larger bin.
Reducing Harm
DO ask questions - Always ask a few questions about:
How the client is feeling, Do they have they any problems with injecting? Are they feeling unwell? Do they need any extra help and support with anything?
Pharmacy needle and syringe programme staff provide an essential health and social care signposting service to their clients.
DO give harm reduction advice which is a key element of a needle and syringe programme. Pages 23 to 45 of this handbook deal with harm reduction information in detail. Warn the client of the risks of overdose if:
The client is new to service or; Is returning after a break;
Advise how this can be lessened.
If clients disclose high risk injecting behaviour, for example injecting into their neck or femoral vein, DO signpost them to Addaction for extra help and support.
DO let clients know that treatment is available and waiting times are always less than 3 weeks, sometimes a matter of days.
Accurate records of needle and syringe programmes must be kept. This is important so that the DAAT can assess how much money is needed for future needle and syringe programme activity.
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Information Gathering
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The AssessmentThe first time a client attends pharmacy needle and syringe programme a brief verbal assessment should take place. Assessments should not act as barriers to service delivery and are not a pre-requisite for getting sterile injecting equipment.
The confidential nature of the service should also be explained and the minimum data (see page 15) taken.
The assessment should focus on client need and the following should be covered during the assessment:
Reasons for providing injecting equipment The type of drugs used, which ones are injected, how others are taken
(including alcohol) Identify injection sites Identification of any risk factors and appropriate advice given Identify and supply appropriate equipment for the client’s needs Provide appropriate advice on treatment services and current waiting
times
In addition, at regular intervals, or when there is a clear need, the following could also be gathered:
Information on access to BBV screening and immunisation Advice on safer sex/sexual health issues, including the supply of condoms Identify any problems with injecting techniques Signpost to any other services that can meet clients needs Explain the risk of overdose, give advice on overdose prevention and what
to do in overdose situations Detail the importance of returns and safe disposal of injecting equipment
Pharmacy staff are not expected to be experts in substance misuse or injecting techniques or practices. Therefore if patients need further help and advice they should be referred to Addaction.
Addaction can provide detailed advice and information on all aspects of injecting drug use, general drug use and treatment. Information on local and systemic infections, including HIV, HBV, HCV, venous and arterial thrombosis, abscesses, damaged blood vessels, TB and endocarditis may also be provided.
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Confidentiality & Information Sharing While the Needle and Syringe Programme is a confidential service, there is a need to collect some information. All new service users should be made aware that this is in order to provide the service, and advised of the boundaries that surround the confidentiality of that information.
No information that is attributable to the service user will be shared with anyone else without their express permission.
Non-attributable information, demonstrating the level of service provision and demographics of the service user group is shared with Barnsley DAAT, as part of the local performance monitoring and needs analysis processes. This information can be withheld from reporting if the service user wishes.
The minimum data required are two initials and a date of birth, as identifiers.
Upon registration the service user must be asked for this information, which they will use regularly when accessing the programme. They don’t have to be the client’s actual initials or DOB, but they must be able to remember them each time they attend. This ensures that we understand if the numbers of IDUs is rising or falling.
We may ask for more information and this is outlined in Appendix 1 (Pg 61) but this is not obligatory to receive clean equipment.
There are a few occasions when confidentiality will be breached. These are based on reducing risks, either risks to the service user or
those around them.
These exceptional circumstances include:
risks to children and young people, or known life threatening situation (including terrorism acts).
It is important when explaining confidentiality and information exchange with service users that strong emphasis is placed on the protection it provides them. Confidentiality is central to the trust between the service user and the needle and syringe programme provider.
In deciding whether to breach confidentiality it may be useful to first discuss the matter with senior staff within the pharmacy and / or the Team Leader at Addaction.
External training on safeguarding children and adults will be helpful for pharmacy staff. For further information please contact James Pierce at Addaction.
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EquipmentThe assessment must identify all the substances the client takes, and which part of the body they are injecting into. The tables below show the common uses for syringes and needles and also lists uses for which they are not intended.
Needle Colour/size Uses Not to be supplied forBrown 26 G x 5/8” Superficial intravenous
injectingIntramuscular injecting
Short orange 25 G x 5/8”
Long orange 25 G x 1”
Superficial intravenous injectingDeeper veins
Intramuscular injecting
Short blue 23 G x 1”
Long Blue 26 G x 1 ¼ “
Intravenous injecting into deep veins
Intramuscular injecting
Superficial intravenous injecting
Green 21 G x 1.5” Not supplied in pharmacy Not supplied in pharmacy
Syringe Uses Not to be supplied forInsulin Syringe
0.5 ml syringe/needle
Intravenous injecting into superficial veins
Subcutaneous injecting
Injecting into deep veins
Intramuscular injecting
1 ml syringe Intravenous
Intramuscular
subcutaneous 2 ml syringe Intravenous
Intramuscular
Subcutaneous – volume too great
Barnsley DAAT, through the Needle and Syringe Programme Group has devised a “shopping list” for assessment and requesting equipment and can be found at Appendix 1. The list of equipment should be filled out by the client.
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Issuing Other Paraphernalia
As well as needles and syringes, other injecting paraphernalia and harm reduction equipment is made available including:
Citric, Filters, Spoons, Swabs, Condoms etc.
There are clear risks associated with sharing these items as well, particularly the spreading infection. The assessment process at each visit should help to identify the need for these and offer an opportunity to engage the service user in using the equipment in an appropriate way (see Appendix 1, Pg 61).
All equipment is intended to be used just once. The service user should receive spoons, filters and needles in similar quantities, for example: 5 needles, 5 filters and 5 spoons.
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Returns and Waste Management
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Needle and Syringe Programmes and ReturnsProviding a service that gives out enough equipment for an individual to inject safely, while encouraging the return of used equipment for the safety of other injectors and the wider public is the main reason for the programme.
First time visitors to the needle and syringe programme should have the ‘exchange’ part of the service clearly explained to them and be issued with enough injecting equipment to last them until they next come to needle and syringe programme services.
There are no limits on the number of times people can use this programme.
All service users are encouraged to take a used sharps container away with them for their used equipment (see Appendix 1, Pg 62). This should be appropriately sized for their requirements.
Returned containers should be placed in the pharmacy’s own yellow bin by the service user after they have said how many used items they are returning and the worker has completed a visual or audible check.
On no account should a staff member handle returned equipment even if contained within a returned sharps bin.
If the pharmacy does not accept loose sharps or equipment then these should first be placed by the service user into a black Visibin.
The yellow bin must not be over-filled as this places the service user and staff member at risk of an accidental needle stick injury. Service users must be discouraged from placing other non-clinical/sharps waste into the yellow bin.
Paper, needle and syringe packaging and other ‘rubbish’ should be placed within a yellow waste bag for incineration. On no account must sharps be disposed of in this bag.
Clinical Waste and Disposal of Used EquipmentClinical waste should be stored in appropriate containers and a competent contractor should collect these on a regular basis appropriate to the pharmacy needs. Sharps bins must conform to British Standard 7320:1990 and be UN type-approved for transport.
Sharps bins are not to be stored within yellow clinical waste bags.
Yellow clinical waste bags should be used for all non-sharps clinical waste such as paper towels used for cleaning up blood spillages and non-sharps
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paraphernalia that service users wish to dispose of, e.g. used swabs, dressings etc.
Used sharps bins must always be stored within a controlled environment which members of the public are unable to access without supervision. Sharps bins must have their lids kept in the closed position.
The DAAT manage the clinical waste disposal contract with a chosen supplier. If any pharmacy encounters problems with waste collection they should contact the DAAT (see Pg 52).
Dealing with Discarded Sharps in CommunitiesPharmacy staff may be informed of sharps that have been found in a public or private setting. Members of the public should be reassured about the minimal risk involved They should be told to:
Never touch any discarded sharps; Keep others away from them (especially children); Contact someone to remove them safely.
Any discarded sharps are removed by the Council’s Community Safety and Enforcement Service and is usually free of charge. The number should be given to the member of the public, or an offer made to contact the council if they would prefer. The ways to contact for removal are:
Mon – Fri, 9.00am – 5.00pm 01226 775656 or 772468
Email: [email protected]
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Harm Reduction Information and Advice
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The Essentials A key activity of this programme is providing harm reduction advice and information to minimise the problems and risks of injecting drug use.
The best way to avoid problems with injecting drug use is not to inject drugs! Workers should always try to explore alternatives to injecting drug use with service users such as smoking or ‘snorting’.
However if a service user does wish to inject then they should always try to observe the following advice:
NEVER SHARE ANY INJECTING EQUIPMENT – cup, water, filter, spoon, tourniquet, needles or syringes. Any of these could be contaminated with blood and lead to the spread of Blood Borne Infections such as Hepatitis or HIV.
DO NOT inject alone. People should try to use with others so that there is help if they overdose.
DO NOT inject into an artery.
DO NOT inject crushed tablets.
DO NOT use heroin alongside alcohol, Methadone or Benzodiazepines – this is a significant overdose risk.
DO NOT use lemon juice or vinegar for preparing heroin, always use citric acid sachets.
The advice detailed above is the minimum harm reduction advice that pharmacy needle and syringe programmes are expected to give.
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Why People Continue Using Heroin Once in TreatmentOne of the issues raised by pharmacy staff is their concern over providing needle and syringe programme to service users on methadone treatment programmes.
The reasons people continue to use once in treatment are complex and varied:
Some people may continue to use heroin because they are not ‘stabilised’ on their medication This can occur because the medication has not yet reached a level to prevent the symptoms of withdrawal. Once stable they typically stop using heroin.
Others continue to use whilst in treatment as an occasional ‘treat’. Sometimes “use on top” of treatment may indicate the individual is re-
lapsing back into regular drug use.
Methadone treats the physical aspects of an individual’s dependency but not the complex psychological reasons why a person has used heroin. Heroin use can meet many needs in a person’s life and moving away from heroin use can mean embarking on a process of changing many aspects of their lifestyle.
Medical treatments work best alongside psychosocial interventions. These can include:
Counselling, which enables people to explore the psychological reasons for their use, and
Structured day-care programmes which gives people with daily activities so they don’t get bored and tempted to use again.
If a client chooses to use heroin on top of a prescription they put themselves at risk of overdose. Staff in needle and syringe programmes can advise and inform on:
The dangers of using on top of methadone; How to use safely; The range of services available if they want to stop the practice
If a person really wants to use heroin on top of a methadone prescription the safest intervention is:
To advise them strongly of the risks they are taking and; Provide clean equipment so the risks of bbv and vein damage are
lessened.
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Common Injecting Related ProblemsMany injectors experience problems with their injecting drug use, and the following information is intended to give workers a brief overview of some of the common problems and their causes. Under this scheme pharmacies are not experts in substance misuse, or injecting practises, and are not expected to give advice direct to clients on these matters. However, they should be able to recognise when problems arise and signpost clients to the specialist needle and syringe programme service at Addaction; their GP or A&E.
Factors Affecting Healing
Injecting drug users are often in poor health and their immune systems will find it hard to fight infections or to recover from injecting related injuries because of a number of contributing factors, including:
Drug and alcohol use Stress Poor accommodation Poor diet and nutrition
Vein Blockage and Collapse
Many clients will have trouble accessing veins to inject into, leading them to try other, potentially more dangerous sites on their body.
Veins may temporarily collapse as a result of irritation to the vein lining. This may be caused by the needle, the substance injected, or both. Once the swelling subsides the circulation will often become re-established.
Permanent vein collapse occurs as a consequence of:
Long term injection; Repeated injections, especially with blunt injecting equipment; Poor technique; Injection of substances which irritate the vein.
Smaller veins may also collapse as a consequence of too much suction being used when pulling back against the plunger of the syringe to check the needle is in the vein. This will pull the sides of the vein together causing it to become blocked. Removing the needle too quickly after injection may have a similar effect.
For the above reasons it is important that workers stress the importance of a slow and gentle injection technique to service users.
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How Veins Collapse
Deep Vein Thrombosis (DVT)
1. Injection damages the inside lining of the vein – repeated injection at the same site increases the likelihood of problems
2. Clots form in the turbulent blood around the site.
3. As the vein becomes narrower the turbulence increases and clots form more quickly.
4. Finally, the sides of the vein heal together and the vein collapses as the scar tissue draws the sides together.
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A DVT is a blood clot which can completely or partially block a deep vein.
The most common site for a DVT is in the lower limbs, but, on rare occasions, it can occur in the arms. DVTs are most common amongst people who are injecting into their femoral vein.
Symptoms that may indicate the presence of a DVT include:
Pain – usually in the back of the calf; Oedema – swelling of the affected limb, this can be very noticeable
and the affected leg will be much larger than the other; Cyanosis of the limb – blueish colour indicating impaired blood supply; Pulmonary embolism – clot breaking off and travelling through the
blood supply – potentially fatal.
Treatment of a DVT
If a worker suspects a service user may have a DVT they should advise them to attend A & E for treatment. This consists of anticoagulant (blood thinning) therapy with Heparin or Warfarin injections for up to three months following discharge from hospital. It is important that people complete this course of treatment.
If pharmacy staff are aware that a particular service user has suffered from a recent DVT they should:
Check – are they still receiving treatment from Barnsley Hospital, if they are not keeping appointments then explore reasons with service user.
Discourage exercise – this could lead to part of the clot breaking away and cause a pulmonary embolism.
Remind service users of the importance of raising the affected limb above the heart when seated or lying down, in order to assist the healing process.
Avoiding a DVT
The risk of developing a DVT may be reduced if service users are encouraged to:
Appreciate practises which may increase the risk of a DVT, such as femoral injecting;
Identify ways of reducing the risk, e.g. changing injection sites; Change the way drugs are taken to one that does not involve injection.
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Ulcers, Abscesses and infections
Injecting drug users are at high risk of suffering from injecting related ulcers, abscesses and infections. Pharmacy staff can play a part in encouraging service users to access medical treatment to prevent health problems worsening.
Ulcers
Many injecting drug users have reduced blood flow through their body tissue, because of vein collapse due to repeated injecting damage. This leaves them vulnerable to infection and with a reduced capacity to heal. As a result painful broken areas of skin (ulcers) can form.
Once damage has occurred impaired blood flow means that damage is less likely to heal. Ulcers can form either as a direct result of an injecting injury, or as a result of accidental injury after the veins have been damaged by injecting.
Abscesses
An abscess is an infected collection of pus that is contained within a raised area of inflamed tissue. They can be caused by a wide range of bacterial and fungal infections.
An abscess will have a defined edge and shape and may be characterised by:
Raised skin surface Localised heat Tenderness and pain Inflammation of the skin Pus formation A foul smell, if it has begun to discharge
Anyone with an abscess should be referred for medical treatment and advice. The abscess will require antibiotic treatment and / or lancing to release the build up of pus.
IT IS IMPORTANT that service users do not try to lance abscesses themselves. This can spread infection and lead to blood poisoning.
Local infections
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Injecting drugs carries the risk of bacterial and fungal infections of the tissues surrounding the injection site. They are often caused by bacteria being picked up on the needle and forced below the skin.
It is important workers discuss with service users the importance of good hygiene practices when engaged in injecting drug use. At the most basic level this will include communicating effective measures such as:
Washing of hands prior to preparation of injections and; Using alcohol swabs to clean the injection site before injecting.
‘Missed hits’, Lumps and Bumps
A ‘missed hit’ describes swelling which may appear around an injection site during, or immediately after injecting.
This swelling is usually caused by fluid entering the tissue around a vein because the needle has:
Not entered the vein correctly Entered the vein and then slipped out again Entered the vein and gone through to the opposite side Entered the vein correctly but excess pressure has caused the vein to split
Many of these problems can be caused by poor injecting technique, so workers should encourage service users to:
Smoke a small amount of heroin before injecting to ease the withdrawal symptoms and associated shaking
Use the smallest possible needle and syringe Inject at the correct angle Inject slowly Maintain a steady hand whilst injecting Check the needle has entered the vein by pulling back the plunger to see
that a small amount of veinous (dark) blood enters the syringe Always release a tourniquet prior to injection
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Blood Borne InfectionsBlood borne infections are transmitted when blood cells or body fluids from an infected individual are passed into the bloodstream of another. Injecting drug use makes transmission considerably easier. The main risks to IDUs are:
HIV Hepatitis B Hepatitis C
HIV
The HIV epidemic of the mid 1980s led to the establishing of needle and syringe programmes. They have been successful in that prevalence has dropped
HIV is the virus that may lead to development of AIDS and can be transmitted:
Through unprotected sex From mother to child By sharing injecting equipment
Six main types of Hepatitis have been identified. Hepatitis B & C are the most prevalent.
Hepatitis B
Hepatitis B is a more transmissible infection than HIV and can survive in dried blood for at least four months. Therefore ALL EQUIPMENT ONCE USED IS A RISK – e.g. SPOONS, WATER AND FILTERS
A safe vaccination exists for Hep B, making it an almost entirely preventable infection. The current strategy in the UK is vaccinating only ‘high risk’ groups against Hep B infection – staff working in a pharmacy operating a pharmacy needle and syringe programme scheme should have the vaccination.
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Hepatitis C
Current rates of infection are high amongst injecting drug users in the UK. There is no vaccination available to prevent infection.
As with other such illnesses most people who have Hepatitis C have no obvious symptoms and may be unaware that they are infected.
Immunisation (Hep A/B) & Blood Borne Infection Testing
Hepatitis A and B are avoidable infections since they can be vaccinated against. All injecting drug users should be encouraged to access this service through their own GP or via Addaction Harm Reduction Clinic where staff will make the appropriate referrals to see the service.
Addaction Harm Reduction Clinic
The clinic provides vaccination against Hepatitis A & B and testing for all blood borne viruses, including HIV. The clinic will also provide basic sexual health services and specialist wound care for injecting injuries etc. For more information, or to refer an individual for BBV screening and immunisation, please contact Elaine Brealey at Addaction, telephone 01226 289058.
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Blood Spillage and Needle Stick InjuriesAll pharmacies must have a standard operating procedure regarding blood spillage (and the spillage of other bodily fluids). All staff members should be aware how to clean up and protect an area when a blood spillage has occurred.
All pharmacies must have a standard operating procedure regarding needle stick injuries. Needle stick injuries are rare and avoidable if proper care and precautions are taken.
The majority of needle stick injuries occur in hospitals but can also happen:
By not disposing of sharps in appropriate puncture proof bins and; Not doing so in a timely manner; Poor handling techniques, e.g. over-filling a sharps bin.
The risk of a needle stick injury can be greatly reduced by:
Re-capping needles, Disposing of sharps in appropriate sharps bin and Not over-filling sharps bins.
Staff should also take other reasonable precautions, such as not wearing open toed shoes.
Whenever a needle stick injury does occur these must be reported to the pharmacist and / or pharmacy manager as soon as possible and the Needle Stick Injury Policy and Procedures must be followed.
What to do in the Event of a Needle Stick Injury
Encourage the wound to bleed – the normal reaction is to stop it, but this increases any risk of infection
Do not suck the wound – this could increase the risk of infection
Apply pressure at the side of the wound – this will encourage the wound to bleed outwards, reducing the risk of infection
Wash the wound in RUNNING water – this will help the wound to bleed and reduce infection risks
Cover the wound with a plaster – after you have dried it
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Go to a hospital Casualty Department immediately - have your Hepatitis and Tetanus cover checked. If you have not had a recent vaccination you must get one within 48 HOURS of your injury
Report it as soon as possible – inform your manager and complete an incident/accident form
If there is an identified risk of a needle stick injury occurring this must be reported to a line manager immediately and the area made safe as soon as possible.
People often have fears in relation to working with injecting drug use and the possibility of a needle stick injury is one of these. The risks of accidental injury from a needle are very low if staff follow the correct procedures when providing needle and syringe programme.
The risk of infection following a needle stick injury is very low in these circumstances:
With hepatitis C it is estimated to be between 2.7% and 10%
The risk of developing HIV is very low – estimated at approx 3 per 1000.
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Pregnancy and Needle ExchangeThe provision of injecting equipment to women during pregnancy is something people may feel uncomfortable. Pharmacist and their staff often ask for guidance around this issue.
Whatever staff may feel about the woman’s continued drug use during pregnancy, the primary role of NSP services should be kept in mind. They exist to provide sterile injecting equipment to reduce the need re-use or share equipment.
However, injecting drug use during pregnancy is clearly of concern and every effort should be made to ensure that women access appropriate antenatal care.
In Barnsley this is provided by a specialist midwife substance misuse service at Barnsley Hospital, designed to meet the needs of pregnant women who use drugs and/or alcohol. The lead midwife for this service is Jo Poskitt.
If the woman is accessing drug treatment then she will have a Recovery Navigator, based at Burleigh Court. Ideally Pharmacy staff should liaise with them to ensure they are aware of the pregnancy and that appropriate referrals are being made for antenatal care.
In no circumstances should pharmacy staff refuse to provide injecting equipment to a woman based on the fact that she is pregnant.
Equipment should be issued and the pharmacy staff liaise with the Addaction team at John Street for further advice & support. Or, to contact Jo Poskitt please email [email protected].
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Overdose - Signs and SymptomsHeroin
Heroin overdoses may happen instantly after taking the substance. Sometimes they can occur several hours after heroin has been used.
People overdose may exhibit some or all of the symptoms below:
Pale skin/blueish tinge to lips and skin Pinpoint pupils Not waking up Reacting to loud noises Making gurgling, snoring or choking sounds Shallow or disrupted breathing Slow or very faint pulse
It is important for both substance misusers, and those working with them, to recognise the signs of overdose and to know what to do if one occurs. Below are the important steps to take in a heroin overdose situation:
1. Stay calm
2. Put the person in the recovery position, check for obstructions in the mouth,
3. Dial 999 and ask for an ambulance
4. Remain with the person until the ambulance arrives;
5. Provide the ambulance crew with as much information about the person as you have.
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Stimulants
Cocaine and Amphetamine can cause death through overdoses which can involve high body temperatures, convulsions, circulatory problems and respiratory collapse.
A person who has overdosed on stimulant drugs such as amphetamine or cocaine will:
Feel hot to the touch Look flushed Have the above signs but not be sweating
An ambulance should be called and the person kept as cool as possible with damp cloths.
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Information about Intravenous (IV) Injection and Injection SitesIntravenous injection is one way in which to take drugs and is a highly efficient way of using drugs, but also poses risks and dangers.
There are several commonly used sites around the body that injectors will use, these are the:
Arms Hands Legs Feet
Injecting any drug carries risks but there are some injecting sites that carry higher risk than others. These are:
Breasts Armpit Neck Femoral Penis
Information on commonly used sites
Arms
The arms are the most commonly used site for IV injection, with the superficial veins on the inside of the arm being the most accessible. Use of these sites is least likely to result in damage to surrounding tissues and with good hygiene and injecting technique these veins may be useable for a long period of time.
The loss of these veins will present injectors with the choice of stopping injecting or moving to alternative sites on the body.
Hands
The veins on the back of the hands are highly visible, small and fragile. It can be difficult to hide evidence of injecting if these sites are used and any problems such as infections or ulcers are likely to be far more severe if they occur in the hand.
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Veins in the hand are small and can burst easily because of the pressure of injecting. Consequently people should be advised to inject slowly.
Where a worker is aware that a person is injecting into the hands, they must remind the user of the importance of removing any rings they may wear prior to injection. If a finger swells with a ring in place it can obstruct blood flow and lead to loss of the finger.
Legs
Leg veins are unlikely to be of use to IV injectors for a long period as they contain many valves, which increase the likelihood of injecting related problems.
The flow of the blood in the legs is slow and upwards, towards the heart. Staff should remind users of the importance of injecting slowly and with the needle pointing upwards towards the heart.
Because of slow blood flow, healing of injecting injuries and infections will take longer. Abscesses and other infections are likely amongst those who inject into their legs.
It is common for people who inject into their leg to develop varicose veins. These veins have tight, thin walls and should not be injected into as they will bleed profusely.
Feet
Veins in the feet are used by some injectors, but they are problematic for several reasons:
Blood flow is slow If infection occurs it may lead to a loss of mobility Injuries to the feet may be slower to heal Fungal infections are common due to high levels of bacteria in the area
Information on high risk sites
Injecting into breasts, armpits, neck, penis and femoral vein is seen as more risky than the aforementioned ones. If pharmacy staff know a client is injecting into any of these areas they should put the client in touch with the Addaction needle and syringe programme staff for specialist help and advice. Below is some information about each of these sites.
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Breasts
Small veins are visible in the breasts, especially during pregnancy. It is dangerous to inject into them as they are liable to rupture. The fluid may then leak into milk ducts and the risk of developing infections or abscesses is extremely high.
Armpit
This is an unsafe injection site due to the close proximity of arteries and nerves.
Neck
Injecting into the neck is difficult to do and should be strongly discouraged. Arteries, nerves and veins are all very close together. Common injecting problems become even more dangerous in the neck area, for example an abscess in the neck could cause dangerous pressure on the nerves or obstruct the airway.
Self injecting into the veins in the neck is very difficult to do alone and would require the use of a mirror. This may lead people to ask others to inject into their neck for them, increasing chances of viral transmission, injuries and removing personal control over the injecting process.
If the person being injected overdoses, the person injecting them is liable for prosecution.
Other complications of neck injection include:
Accidental injection into an artery – if this occurs then the drug and any other bulking agents contained in the solution will go directly to the brain. This has the potential to cause a range of problems, including strokes.
Aneurysm (weakening of a blood vessel wall) Nerve damage, including paralysis of the vocal chords
Anyone who confirms they are injecting in their neck should be encouraged to meet with the needle and syringe co-ordinator, either at Addaction, or at the pharmacy, to receive specialised harm reduction advice.
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Penis
Injecting into the penis is sometimes attempted when other sites are unusable. Complications such as infections are almost inevitable.
Injecting into the penis can also cause a condition known as priapism – a permanent painful erection.
Femoral Injecting
The femoral vein is in the groin area. There are a numbers of risks associated with femoral injecting:
Hitting the femoral artery instead of the vein Hitting the femoral nerve, causing intense pain and possible paralysis Abscess/ulcer formation at the injecting site Formation of sinuses ‘tunnels’ from the vein to the skin surface Circulatory damage to the leg, including Deep Vein Thrombosis Varicose ulcer in the lower part of the leg – caused by damage to the leg
veins
The dangers of femoral injecting can be complicated by other factors, such as:
The understanding the injector has of their internal anatomy The technique and dexterity of the injector The state of mind of the injector (e.g their state of intoxication) The substance being injected LUCK!!
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Injecting TechniquesBelow is a brief look at best practice for safer IV injection techniques. Pharmacy needle and syringe programme staff should proactively engage with clients to inform them of best practice injecting techniques.
Always use your own clean equipment and try to find a ‘clean space’ to prepare your hit
Try to wash your hands before preparation and use an alcohol swab to clean the injection site
Place the drug onto the spoon, grinding down any lumps in the powder
Add clean sterile water (boiled tap water left to cool) bottled water is not sterile
Add citric—as little as possible as this causes damage to the veins if overused
Stir and heat the solution for 15-30 seconds
Place a whole cigarette filter into the solution and then draw up the solution into the syringe through the filter
Make sure there are no air bubbles in the syringe
Tap the barrel and push the plunger until a drop of liquid appears at the end of the needle
Don't lick the needle - Insert needle at an angle into injecting site
Draw back the plunger until you see blood. The blood should be dark purple. If it is red and frothy or the plunger is forced back then you have probably hit an artery. You should remove the needle and apply pressure
If using a tourniquet it should be released at this point
Push the plunger in at a steady pace
Don't flush as this increases the damage to veins
Slide needle out as gently as possible
If there is any bleeding use clean tissue and apply pressure until it stops
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Reducing the Risks of OverdoseInjecting drugs carries the risk of overdose. There are a number of issues which can increase this risk and these are listed below:
Using again after a period of abstinence or when tolerance is low
After a break from using opiate drugs a person’s tolerance will be much lower, placing them at high risk of overdose. Tolerance can decrease quickly, so if the pharmacy worker thinks a client has not used even for a short while they can raise it with the client by, e.g. asking when they last used. If the client’s response confirms there has been decreasing use or abstinence, or the worker remains concerned that the client tolerance may have lowered they should advise the client to:
Use as small an amount of the drug as possible. Taking the same as before can be very dangerous, even fatal.
To smoke rather than injecting – after a break and with lowered tolerance then the effects from smoking should be enough!
Using stronger than usual drugs
The effect is similar to reduced tolerance and the same advice applies.
Using in unfamiliar situations
Also known as Situation Specific Tolerance, injecting in unfamiliar surroundings can be highly stressful and may lead to an overdose situation.
Workers should try to explore with service users where they use drugs. Service users with chaotic lifestyles are vulnerable to overdosing for this reason –for example, someone who is homeless or sleeping rough is at high risk of overdose.
Poly drug use (using more than one drug)
Some drug users consume more than one substance, which can increase the risks of overdose. Drugs which have a depressant effect on the respiratory
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system such as benzodiazepines, methadone, heroin and alcohol are most associated with overdose – especially if they are combined. If pharmacy staff suspect poly drug use or smell alcohol on a client they should raise the issue of overdose risk.
Using on Top of Prescribed Medication (Including Methadone)
Using on top of prescribed medication such as methadone or benzodiazepines can increase the risk of overdose due to their depressant effect on the respiratory system. The effect is similar to poly-drug use.
Pharmacy staff are in an excellent position to:
identify those service users who are also on drug treatment prescriptions discuss the risk of overdose encourage the client to talk to their key worker about their treatment
However, it is not for pharmacy staff to independently inform the treatment service of client’s access to needle and syringe programme as this is a breach of client confidentiality.
Dealing with Deaths
Sometimes, sadly some clients die as a direct result of taking drugs. What we can say is that many lives have been saved by needle and syringe programmes and the interventions of staff working in them.
Providing more needle and syringe programmes and having competent, friendly staff working in them saves lives. Pharmacies are at the forefront of keeping individuals and communities safer and helping people into treatment and rebuild their lives.
Where deaths occur pharmacy staff will be supported by their employing agency and can also contact Staff at Addaction for support.
If you know that a service user has lost someone close to them as a result of overdose, it may be that they require additional support, either from drug services or from bereavement counsellors to help them come to terms with their loss.
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Dealing with Poor Behaviour
Pharmacies can temporarily, or permanently, ban those clients who abuse the service, e.g. by shoplifting or being rude towards staff. The client should be signposted to the specialist needle and syringe programme service.
If there are concerns regarding violence the information must be shared with all service providers likely to come into contact with the client.
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Service Quality
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Clinical Governance and Quality StandardsThe principles of clinical governance as outlined in ‘Drug Misuse and Dependence – UK Guidelines on Clinical Management’ [2007] apply equally to the pharmacy needle and syringe programme as to any other branch of substance misuse treatment. The National Institute for Clinical Excellence (NICE) give guidance on operating needle and syringe programmes. The principles cover:
Clinical effectiveness Competence and continuous professional development Working in a team Information management Patient, public and carer involvement Risk management Public health
The key aim is to reduce harms caused by the spread of blood borne viruses resulting from sharing injecting equipment. Barnsley DAAT commissions the needle and syringe programme in accordance with the above guidance and requires all contractors to comply with the clinical governance principles outline above.
Claire Barber is the pharmacy representative on the Clinical Governance Group, which is chaired by Dr. Fleur Ashby
If any issues of risk management or practice arise, these will be investigated and reported to these groups.
Additionally, the Service User ‘Praise and Grumble’ scheme ensures that service users’ experiences are reflected at the Clinical Governance Group and the DAAT.
Quality Standards for Pharmacy Needle and Syringe ProgrammesThis service is for adult Injecting drug users within the Borough of Barnsley. There are two exclusions from this service:
1. Individuals under 18 years of age;2. Steroid users
Clients attending from these two categories should be referred immediately to the Specialist Needle and Syringe Programme at John Street in Barnsley for exchange, advice and information.
The same standard of care should apply to all people who visit the pharmacy.
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Barnsley DAAT expects that all pharmacies wishing to take part in this programme will have a standard operating procedure for the safe and efficient delivery of needle and syringe exchange services. In reinforcing this expectation Appendix 2 of this document sets out the minimum desired to contract this services (see Page 58).
The programme will be conducted in an acceptable and safe environment.
A friendly attitude and offers of help for other healthcare needs should be the norm. Information on Blood Borne Viruses and Harm Reduction should be freely available. Where staff feel they do not have sufficient knowledge or experience to help with the query, e.g. wound management or injecting technique, then the needle exchange coordinator should be contacted to meet the client on pharmacy premises, or arrangements made for the client to attend Addaction.
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Workforce DevelopmentPharmacy staff have an important role to play in the integrated drug treatment service. Often pharmacy staff have more regular contact with the most vulnerable drug users: the ones not yet accessing treatment. They also have regular contact via supervised consumption and dispensing services with those accessing and doing well in treatment.
'In Barnsley we are very lucky to have an active programme of training, which is supported by Addaction, Service User Involvement Officers and Service Users themselves. The latter gives a different dimension to the training' Claire Barber Pharmacy Advisor for the DAAT
In recognition of this role Barnsley DAAT provides training updates for all pharmacy staff a minimum of twice a year. In addition to this any reasonable requests for training and development (including conference attendance) for pharmacy staff will be considered and supported by the DAAT if it is found to improve substance misuse treatment in Barnsley and meet the aims of Barnsley DAAT.
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Service User Involvement
Praise and Grumble and Mystery Shopper Scheme
Praise & Grumble is an informal system that allows service users to raise any issues they may have about the service they receive, complement the good work being delivered and make any comments/suggestions for areas of improvement. Praise & Grumble has been officially running for over five years with increasing success. In January 2009 Praise & Grumble hosted the first ever Praise & Grumble Recognition Awards evening with A M Clarke’s Pharmacy of Penistone winning an award. Any grumbles that pharmacists receive from service users should be responded to within 72 hours. The DAAT also undertakes a mystery shopper scheme in pharmacy needle and syringe programmes. The aim of the scheme is to ensure service users are receiving the correct equipment and information, and to offer support and advice to the pharmacies delivering this service.
Any Bright Ideas – Encouraging InnovationBarnsley DAAT is keen to support agencies in the commissioned substance misuse treatment system to develop ideas that meet the needs of the DAAT annual Treatment Plan.
If you have any ideas how your pharmacy can better meet the needs of service users or their carers we would like to hear from you.
Please contact the Drug and Alcohol Action Team to discuss further.
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Useful Contacts
AddactionJohn StreetBarnsleyS70 1LL
01226 289058 07900 481263
Phoenix Futures/SWYFT1 Burleigh CourtBurleigh Street.BarnsleySouth YorkshireS70 1XYTel: 01226 787316
Dr Kakoty’s PracticeWorsbrough CentreMount PleasantWest StreetWorsbrough BridgeBarnsleyS70 5NTTel: 01226 640863
Phoenix Futures/SWYFT9-10 Burleigh CourtBurleigh StreetBarnsleySouth YorkshireS70 1XYTel: 01226 779066
Barnsley Drug and Alcohol Action TeamPO Box 679BarnsleyS70 9JETel: 01226 774956
SwanswellCarer Support ServiceHenry Windsor HousePitt StreetBarnsleyS70 1ALTel: 01226 329686
Barnsley Bereavement Support ServicesTel: 01226 200565 National Helpline: 08457 909090
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Useful DocumentsNeedle and Syringe Programmes Needle and syringe programmes: providing people who inject drugs with injecting equipment, NICE February 2009
http://www.nice.org.uk/PH18
Drug Misuse and DependenceUK Guidelines on Clinical Management Department of Health
http://www.nta.nhs.uk/publications/documents/clinical_guidelines_2007.
Shooting Up
Infections among people who inject drugs in the UK 2011. An update: November 2012
http://www.hpa.org.uk/Publications/InfectiousDiseases/BloodBorneInfections/ShootingUp/1211Shootingup2012/
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Using PharmOutcomes to record Needle and Syringe Programme Activity
Questions and Answers
I need some training on how to use the system?
Training on how to use PharmOutcomes can be provided by Barnsley DAAT and will take around 40 minutes. It can be carried out at your pharmacy or at the DAAT office. To complete the training a computer with internet access will be required.
Alternatively, there are a number of help guides available. You can access these by logging on to PharmOutcomes and selecting the ‘help’ tab at the top of the webpage.
I have a new starter who needs access to PharmOutcomes, how do I set them up?
If you have “admin rights” you will be able to set them up yourself. To see if you have “admin rights” login to PharmOutcomes, if you have the correct privileges you will see an admin tab at the top of the webpage.
Select the “admin tab” and then manage users. Select your account and click “edit”. On the left hand side, you will see an orange button labelled “duplicate user” click this. You can then replace your information with the new starter’s information. If it important that you enter a valid and secure email address as their password will be sent to this email.
Alternatively, you can set-up a new starter by calling the PharmOutcomes support desk or the Barnsley DAAT, Monday to Friday.
How do I reset my password and/or security word?
If another member of staff at your pharmacy has access to PharmOutcomes they may be able to reset your password if they have “admin rights”.
They should login, and click the “admin tab”. If they cannot see the “admin tab”, they do not have the correct rights and you will need to call the PharmOutcomes support desk or the Barnsley DAAT (Monday to Friday).
Once they have logged in and clicked on the “admin tab”, click manage users, they should then see your user name. Click the edit button next to your user name. They will then see an option to reset your password and/or security word. Please note the “known name” and “email box” must be filled in before the system will allow you to reset the password and/or security word. Your password will be sent to this email address so you should make sure it is valid and secure.
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How do I enter the NSP activity information onto PharmOutcomes?
Once you have logged in select the services tab on the top of the webpage. Select “Needle and Syringe Programme”. All of the information you need to complete the fields on the PharmOutcomes system are on the paper form (see Appendix 1, Pg 56 of this handbook).
I have entered the information twice by mistake or have made an error, how do I delete it from the system?
Currently, only the PharmOutcomes support desk can delete data from your system.
How do I view my invoice?
You can view your invoice after the 8th of the month following the quarter end. Login and click the ‘claims’ tab at the top of the webpage. You will then be able to download the claim as a pdf document. To view the pdf you will need to have adobe reader installed on your computer.
Do I need to send my invoice to you for payment?
The invoices are automatically sent to the DAAT on the morning of the 8 th. You do not need to send a copy of your invoice. If there are any problems with your invoice you will be notified with 10 working days.
The client has not divulged all of their personal information e.g. date of birth, last name or postcode, what should I do?
It is important that this information is collected as it helps Barnsley DAAT to improve the service for service users. You should make sure that the client knows that the information is confidential and it will not be used to identify them and it will not be shared with drug treatment agencies or their GP.
If they do not wish to tell you who they are, they can still access the service. However, it is important that you ask them to provide an alias, and that they use the same alias at each exchange. This will allow you to claim for the exchange and allow us to still use the data for performance monitoring.
Can inputting be backdated?
No. All information should be inputted on to PharmOutcomes by the close of business each day. This is to ensure accurate recording and to prevent a back log of inputting at the end of each month thus minimising the number of missed records.
How do I claim?
A quarterly invoice is generated automatically for you by PharmOutcomes, based on the activity you have inputted onto the needle and syringe module. The invoice will be generated on the 7th of the subsequent month following the quarter end (ie 7th July for
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Quarter 1 payments). Therefore, please ensure you input your activity on a regular basis, but particularly before the end of each month as no recorded activity will result in no payment.
The quarterly periods are as follows:
April, May and June = Quarter 1 July, August and September = Quarter 2 October, November and December = Quarter 3 January, February and March = Quarter 4
Will PharmOutcomes automatically generate a stock order?
No. To replenish your stock please contact Addaction on 01226 289058 on the 1st of each month.
For any queries about payments or inputting activity please contact Jo Ekin at [email protected] or 01226 775613.
If you have any further questions please contact either:
Jo Ekin, DAAT Commissioning Officer, 01226 775613
James Pierce, Addaction Harm Reduction Team Leader, 01226 289058
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10 Golden RulesPharmacy staff at the needle and syringe programme can help reduce the harms associated by injecting drug use by using the ten golden rules:
1. Build positive relationships with clients so they feel safe discussing problems and issues they may have
2. Supply clean equipment
3. Encourage the return of used needles, syringes and other equipment
4. Provide sound advice that can lessen the harms caused by injecting drug use
5. Encourage good injecting techniques and safer injecting practices
6. Encourage clients to rotate sites / never inject alone
7. Encourage clients to seek help in overdose situations and understand basic first aid
8. Encourage clients to visit their GP or Addaction needle and syringe programme for sites to be checked regularly
9. Promote recovery and entry to treatment at every opportunity
10. If staff at pharmacies become aware that a service user is experiencing problems with any kind of injecting anywhere on their body they should signpost the client to their GP or Addaction specialist needle and syringe programme
Appendices
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64
66
67
