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Correcting misconceptions about syringe service programs

Paraskos, Bridget; Hickinbotham, Lia; Hill, Rachel, RN; Sheridan, Dan, MS, RPh

doi: 10.1097/01.NURSE.0000558091.23346.b2
Department: PATIENT SAFETY
Free

Bridget Paraskos is a PharmD candidate at the University of Toledo College of Pharmacy in Toledo, Ohio; Lia Hickinbotham is a PharmD candidate at Cedarville University College of Pharmacy in Cedarville, Ohio; Rachel Hill is the director of nursing at Marion Public Health in Marion, Ohio; and Dan Sheridan is a medication safety pharmacist at OhioHealth Marion General Hospital in Marion, Ohio, and a member of the Nursing2019 editorial board.

The authors have disclosed no financial relationships related to this article.

SD is a single mother of four who works full time to support her family. She had been 6 months sober from heroin and seeking treatment from an opioid substitution clinic to maintain sobriety. When she had to choose between paying her electric bill and paying for her treatment, she paid the electric bill. Withdrawal overcame SD, causing her to relapse. Every visit to the needle and syringe exchange provides her an opportunity to gather resources and talk about getting sober again.

SYRINGE SERVICE programs (SSPs), formerly called needle exchange programs or needle-syringe programs, are community-based risk reduction services created to decrease infection hazards associated with injection drug use (IDU) and provide people who inject drugs (PWID) with care, services, and resources for recovery.1 There are approximately 330 SSPs across the US.2 Although these programs provide a community service, they are often controversial. As with any contentious topic, it is crucial to assess the facts. This article explores the common misconceptions surrounding syringe and needle exchange programs and the implications for nursing.

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Background

Drug use can alter brain function, and addiction is a disease for which there is no quick cure.3 IDU increases the risk of disease transmission, infection, and overdose.4 Addiction is not limited to IDU, however, and presents in many ways. Opioid use disorder often begins with a prescription for an oral opioid following an injury or surgery (see Fast facts).4 Treatments include medication, lifestyle changes, and therapy and support.5

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Ethical and professional obligations

Many people with addictions use drugs to feel normal and prevent withdrawal rather than to obtain a high. Healthcare professionals are responsible for educating and guiding PWID toward safe practices, appropriate resources, and available treatment options.

Nurses have a professional and ethical obligation to ensure compassionate patient care. All patients are entitled to respect, confidentiality, and privacy in their decisions. The healthcare staff at every organization or facility follows an ethical code to do right by every patient, and they have a responsibility to guide and educate patients using their professional expertise.

However, in the case of patients utilizing SSPs, fulfilling these obligations can be complicated, as the stigma of addiction and drug abuse has given the program a negative connotation. In addition, some healthcare providers have become cynical regarding this patient population due to the relapsing nature of the disease, and neighborhood residents worry about the program's potential negative impacts on local communities.

Introducing an SSP into a community may be seen as a signal that drug use is tolerated, increasing rates of illicit drug use. Similarly, many object to offering supplies at taxpayer expense that may enable illicit drug use.6

The primary fear, however, is that SSPs will increase crime, drug use, and disease in the surrounding community, with a subsequent decrease in safety. These fears may be mitigated by educating the public and dispelling misinformation.

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Myths and facts

SSPs do not provide PWID with drugs or information on where to obtain them, and PWID do not inject drugs at the site.7 The goal of the program is to reduce transmission of bloodborne diseases from contaminated equipment and help people with addictions make the safest possible choices to protect themselves and the general population.8

Many SSPs operate as an exchange, in which PWID are required to bring in used needles and syringes for safe disposal before they are given clean ones. Consequently, no additional injection equipment is introduced into the community and the used materials are disposed of safely, preventing contaminant exposures. A recent news release from the National Institutes of Health detailed the impact of the opioid epidemic in the increased spread of infectious diseases.9 The sterile needles and syringes supplied reduce the likelihood that PWID will share contaminated injection equipment with one another, decreasing the risk of drug-related transmissions of HIV, hepatitis C virus (HCV), and other bloodborne pathogens.8

The one-time use of sterilized needles and syringes is the most effective way to limit HIV transmission from IDU. SSPs have reduced the transmission of HIV in the US by 33% to 40%.10,11 Many provide free supplies, such as alcohol swabs, vials of sterile water, and condoms, to promote safe practices. They may also offer access to other resources, such as referrals to medical, social, and mental health resources for recovery and rehabilitation (see IDU resources).

Many SSPs operate in conjunction with screenings for HCV infection and sexually transmitted infections such as HIV. In cases of a positive result, PWID may access services such as HIV and HCV treatment, pre- and postexposure prophylaxis, vaccinations, sexual partner services, and prevention of mother-to-child HIV transmission.

Most importantly, SSPs offer PWID access to education. Individuals can learn about safe injection practices, wound care, overdose prevention, bloodborne pathogens, and naloxone administration. Each of these may help with illness prevention and can be lifesaving. Utilizing social workers, SSPs also assist with placement in substance abuse treatment programs and counseling once individuals decide they are ready.1

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Cost-effective intervention

According to the CDC, the average cost of treating HCV infection is approximately $90,000 and approximately $450,000 for HIV treatment over a patient's lifetime.11 It costs less than $1 to manufacture a sterile needle and syringe.11 A 2014 study found that $10 million to $50 million in funding for SSPs would prevent 194 to 816 HIV infections in the US, leading to a savings between $65.8 million to $269.1 million in HIV treatment.12

Additionally, many SSPs operate out of previously functioning buildings, such as county health departments or health clinics, and they are run at specific times in conjunction with other public health services. The benefits of state- and government-run SSPs outweigh the cost to the healthcare system.

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Combating a crisis

SSPs are one realistic way to help combat the opioid crisis in the US. Although the concept may seem ethically questionable initially, these concerns are outweighed by the benefits that protect PWID and other communities across the country. By providing sterile needles and syringes, education, and a safe place for support, SSPs decrease the spread of disease, and those who participate in these programs are five times more likely to take steps to get sober.11

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Fast facts4,5,13

  • Approximately 21% to 29% of patients who are prescribed opioid medications will misuse them, and 8% to 12% will become addicted. Of those, between 4% and 6% will eventually switch to heroin.
  • A 2002 study of 61 PWID demonstrated that 51% had graduated high school and 69% were employed. The participants had an average history of drug use spanning 20 years, and 81% were either actively participating in an abstinence-based program or had stated they were willing to do so.
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IDU resources

CDC – Syringe services programs:www.cdc.gov/hiv/risk/ssps.html

CDC – Syringe service programs fact sheet:www.cdc.gov/hiv/pdf/risk/cdchiv-fs-syringe-services.pdf

North American Syringe Exchange Network – SEP locations:https://nasen.org/directory

Substance Abuse and Mental Health Services Administration – Medication-assisted treatment:www.samhsa.gov/medication-assisted-treatment

US Department of Health and Human Services – Syringe services programs: Effective for HIV prevention:www.hhs.gov/hepatitis/blog/2016/12/6/syringe-services-programs-effective-for-hiv-prevention.html.

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REFERENCES

1. Centers for Disease Control and Prevention. Syringe services programs. 2018. http://www.cdc.gov/hiv/risk/ssps.html.
2. North American Syringe Exchange Network. SEP locations. 2019. https://nasen.org/directory.
3. National Institutes of Health: National Institute on Drug Abuse. Drugs, brains, and behavior: the science of addiction. 2018. http://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain.
4. National Institutes of Health: National Institute on Drug Abuse. Opioid overdose crisis. 2019. http://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis.
5. Centers for Disease Control and Prevention. Injection drug use. 2018. http://www.cdc.gov/hiv/risk/drugs/index.html.
6. Salari P, Namazi H, Abdollahi M, et al Code of ethics for the national pharmaceutical system: codifying and compilation. J Res Med Sci. 2013;18(5):442–448.
7. Kulikowski J, Linder E. Making the case for harm reduction programs for injection drug users. Nursing. 2018;48(6):46–51.
8. Des Jarlais DC, Nugent A, Solberg A, Feelemyer J, Mermin J, Holtzman D. Syringe service programs for persons who inject drugs in urban, suburban, and rural areas - United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64(48):1337–1341.
9. National Institutes of Health. Media advisory: opioid epidemic is increasing rates of some infectious diseases. US Department of Health & Human Services. 2019. http://www.nih.gov/news-events/opioid-epidemic-increasing-rates-some-infectious-diseases.
10. Centers for Disease Control and Prevention. Injection drug use and HIV risk. 2018. http://www.cdc.gov/hiv/risk/idu.html.
11. Interventions to prevent HIV risk behaviors. National Institutes of Health Consensus Development Conference Statement February 11-13, 1997. AIDS. 2000;14(suppl 2):S85–S96.
12. Nguyen TQ, Weir BW, Des Jarlais DC, Pinkerton SD, Holtgrave DR. Syringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment. AIDS Behav. 2014;18(11):2144–2155.
13. MacMaster SA, Vail KA. Demystifying the injection drug user: willingness to participate in traditional drug treatment services among participants in a needle exchange program. J Psychoactive Drugs. 2002;34(3):289–294.
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