Self-reported participation in voluntary nonprescription syringe sales in California's Central Valley

Attitudes, beliefs, knowledge, and practices for over-the-counter syringe sales in community pharmacies: A systematic review

BACKGROUND

Community pharmacies are an important resource for people who inject drugs (PWID) to purchase over-the-counter (OTC) syringes. Access to sterile injection equipment can reduce the transmission of blood-borne illnesses. However, pharmacists and their staff ultimately use discretion over sales.

OBJECTIVE

To identify staff attitudes, beliefs, knowledge, and practices in the sale of OTC syringes in community pharmacies.

METHODS

This systematic review was reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and registered with PROSPERO (CRD42022363040). We systematically searched PubMed, Embase, and Scopus from inception to September 2022. The review included peer-reviewed empirical studies regarding OTC syringe sales among community pharmacy staff (pharmacists, interns, and technicians). We screened records and extracted data using a predefined data extraction form. Findings were narratively synthesized, and critical appraisal was conducted using the Mixed Methods Appraisal Tool.

RESULTS

A total of 1895 potentially relevant articles were identified, and 35 were included. Most studies (23; 63.9%) were cross-sectional descriptive designs. All studies included pharmacists, with seven (19.4%) also including technicians, two (5.6%) including interns, and four (11.1%) including other staff. Studies found relatively high support among respondents for harm reduction-related services within community pharmacies, but less common reports of staff engaging in said services themselves. When studies investigated the perceived positive or negative impacts of OTC syringe sales, prevention of blood-borne illness was widely understood as a benefit, while improper syringe disposal and safety of the pharmacy and its staff commonly reported as concerns. Stigmatizing attitudes/beliefs toward PWID were prevalent across studies.

CONCLUSION

Community pharmacy staff report knowledge regarding the benefits of OTC syringes, but personal attitudes/beliefs heavily influence decisions to engage in sales. Despite support for various syringe-related harm reduction activities, offerings of services were less likely due to concerns around PWID.

Hepatitis C antibody prevalence, correlates and barriers to care among people who inject drugs in Central California

Hepatitis C (HCV) infection among people who inject drugs (PWID) is a major public health concern. We examined correlates of HCV antibody (anti-HCV) seropositivity and characteristics of prior HCV testing and treatment among PWID in Fresno, California, which has among the highest prevalence of injection drug use (IDU) in the United States. We surveyed 494 peer-recruited PWID (≥18 years of age) in 2016 about their experiences with HCV testing and treatment, and conducted HCV and HIV antibody testing for all participants. Bivariate analyses and multivariable logistic regressions were used to identify correlates of anti-HCV seropositivity. A majority (65%) tested positive for anti-HCV, with 32% of those being unaware of their HCV status. Anti-HCV seroprevalence was independently and positively associated with older age (AOR = 1.11 per year, 95% CI = 1.06, 1.17), years injecting (AOR = 1.08 per year, 95% CI = 1.03, 1.13), distributive syringe sharing (AOR = 2.76, 95% CI = 1.29, 5.94), having syringes confiscated by police (AOR = 2.65, 95% CI = 1.22, 5.74), ever trading sex (AOR = 3.51, 95% CI = 1.40, 8.81) and negatively associated with being Black/African American (non-Hispanic) (AOR = 0.06, 95% CI = 0.01, 0.47). Prior HCV testing was associated with older age, ever getting syringes from a syringe services program, and having interactions with police. For those aware of their anti-HCV seropositivity, only 11% had initiated treatment; reasons for not seeing a physician regarding diagnosis included not feeling sick (23%), currently using drugs/alcohol (19%) and not knowing where to go for HCV medical care (19%). Our findings highlight the importance of expanding community-based access to sterile syringes alongside HCV testing and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking testing and treatment.

Community pharmacist engagement in HIV and HCV prevention: Current practices and potential for service uptake

Background

Objective

Methods

Results

Conclusions

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Pharmacists are largely willing to help people who need HIV/HCV prevention services.

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Perception of HIV/HCV prevention fit with pharmacist professional identity varies.

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Cognitive HIV/HCV prevention services are preferred over hands-on clinical services.

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Pharmacists often engage in gatekeeping to limit sales of non-prescription syringes.

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Willingness to sell syringes potentially hinges on minimal contact with requestors.

The Role of Pharmacies in the HIV Prevention and Care Continuums: A Systematic Review

The role of pharmacists in the treatment of HIV has expanded beyond medication dispensing to include a host of cost-effective, evidence-based strategies across the HIV prevention and care continuums. However, wide-scale adoption of pharmacy-based HIV prevention and treatment interventions has been slow. We conducted a systematic review to evaluate the evidence on the role of pharmacists across the HIV prevention and care continuums. Thirty-two studies were identified, most of which provided evidence of feasibility of HIV testing and efficacy of non-prescription syringe sale services in pharmacies. However, only two studies implemented an experimental design to rigorously test pharmacy-based strategies. Notably, no pharmacy-based strategies have specifically targeted the highest HIV risk populations such as black and Latinx men who have sex with men, women, or trans populations. Efficacy trials and effectiveness studies should rigorously test existing pharmacy-based strategies to build greater support for wide-scale adoption and implementation. Moreover, in order to integrate pharmacies into the strategy to end the HIV epidemic, studies are needed to ensure that pharmacy-based HIV prevention and treatment services can reach the highest risk populations.

Effect of strategic purchasing of antiviral drugs and the clinical pathway for the treatment of Chronic Hepatitis C in Colombia (hepC-STRATEGY): study protocol for a quasi-experimental study

Objective

Describe a study protocol to establish the effect of DAA's strategic purchase and the clinical pathway in the clinical outcomes, general costs, and quality of healthcare of patients with CHC in Colombia.

Methods

A quasi-experimental study will be carried out to compare clinical outcomes (treatment effectiveness), healthcare quality (access to treatment, time to treatment, patient's satisfaction and barriers/facilitators perceived) and direct costs before/after the implementation of the mentioned strategies. Patients ≥18 years old initiating DAA treatment between January 2015 and December 2019 in an outpatient pharmacist-led center in Colombia will be included. In order to reduce selection bias, the propensity score method will be used. In the bivariate analysis, χ 2 tests and t student will be used to analyse the study outcomes. A regression analysis will be used to explain the association of multiple variables with access to treatment, time to treatment and effectiveness. Descriptive statistics will be used to analyse the patient's satisfaction and barriers/facilitators perceived.

Key findings

Implementing local government policies is necessary to improve access to medicines and decrease disease burden. The strategies adopted by the Colombian Ministry of Health to manage CHC needs to be evaluated. Therefore, studies are required to establish their effects on clinical outcomes, overall costs, and quality of care.

Conclusions

This study will provide evidence on the effect of Colombian strategies to address the problem of HCC. It will provide information to policymakers in low- and middle-income countries that could reduce disease burden.

'It's just basically a box full of disease'-navigating sterile syringe scarcity in a rural New England state

BACKGROUND AND AIMS

Injection drug use has increased in non-urban communities in the United States where sterile syringe access is limited. This study aimed to characterize how people who inject drugs in a predominantly rural state navigate syringe scarcity.

DESIGN

Qualitative study.

SETTING

New Hampshire (NH), USA. At the time of our study, syringe services programs were illegal in NH but pharmacies could sell ≤ 10 syringes without prescription.

PARTICIPANTS/CASES

Twenty people aged ≥ 18 years who injected at least once in the past 30 days were recruited through provider referral, street-based recruitment and snowball sampling.

MEASUREMENTS

Semi-structured interview guide. Verbatim transcripts were coded based on interview guide constructs and emergent themes. Analysis focused on pharmacy syringe access, unofficial syringe sources and related impacts on syringe sharing and reuse FINDINGS: Participants could identify no local pharmacies that sold syringes without prescription. Pharmacy purchase in neighboring counties, or across state lines, required private transportation and this, along with purchaser identification requirements, presented substantial access barriers. Interstate travel also exposed participants to vigilant policing of interstate highways and potential criminal justice involvement. Many participants thus resorted to informal syringe sources closer to home including purchasing syringes on the street, using discarded syringes, breaking into biohazard containers and constructing improvised syringes out of salvaged syringe parts, metals and plastics. Repeated re-use of syringes until they were no longer operational was common. Overall, syringe scarcity gave participants few options but to engage in syringe sharing and re-use, putting them at risk of serious injection-related infections.

CONCLUSIONS

Limited sterile syringe access contributes to an environment in which people who inject drugs report that they are less able to refrain from risky injection practices.

Consider the Source: Associations between Syringe Sources and Risky Injection Behaviors in California's Central Valley

BACKGROUND

Sterile syringe access is critical to prevent serious viral and bacterial infections among people who inject drugs (PWID) but many areas across the United States lack sufficient access. Although California law allows nonprescription pharmacy syringe sales and syringe services programs (SSPs), access gaps remain in the largely rural Central Valley.

OBJECTIVE

The purpose of this study was to examine syringe access and related injection behaviors among PWID in Fresno, California.

METHODS

We used respondent driven sampling to recruit 494 individuals for a survey about syringe access and injection behaviors between April and September 2016. Participants were ≥18 years old and injected at least twice in the past 30 days. Descriptive statistics examined syringe access and logistic regression determined if discrete syringe source categories were significantly associated with syringe sharing and/or reuse.

RESULTS

A majority (67%) obtained syringes from an authorized source; SSPs were most common (59%), while few reported pharmacy purchase (14%). Unauthorized sources were even more common (79%), primarily friends (64%) or someone on the street (37%). Compared to PWID who used only authorized sources, those using only unauthorized sources had a higher odds of syringe sharing (AOR = 3.40, 95% CI: 1.66, 6.95) and syringe reuse (AOR = 6.22; 95% CI: 2.24, 17.29), as did those who reported mixed sources (AOR = 3.78; 95% CI: 1.90, 7.54 and AOR = 4.64; 95% CI: 2.08, 10.35).

CONCLUSIONS

Our findings demonstrate a need to expand syringe access in nonurban California to prevent the syringe sharing and reuse that contributes to serious viral and bacterial infections among PWID.

Assessing pharmacy-based naloxone access using an innovative purchase trial methodology

OBJECTIVES

Massachusetts was among the first states to allow standing orders to facilitate pharmacy-based naloxone purchases and reduce opioid overdose deaths. We conducted a unique purchase trial to establish a valid measure of standing order naloxone in Massachusetts, using purchasers from 2 high priority populations to determine whether naloxone is less accessible to those who use illicit opioids than other potential purchasers.

DESIGN

Purchase trial.

SETTING AND PARTICIPANTS

The study used a stratified random sample of 200 chain and independent retail pharmacies across Massachusetts. Each pharmacy underwent 2 purchase attempts-1 by a person who used illicit opioids (PWUIO) and 1 by a potential bystander who did not use illicit opioids but had a relationship with someone at risk of opioid overdose.

OUTCOME MEASURE

Successful or unsuccessful naloxone purchase attempt.

RESULTS

Overall, 322 of 397 purchase attempts (81%) were successful, with no statistically significant difference between PWUIO and bystanders (P = 0.221). Most purchases (93%) resulted in the acquisition of single-step nasal naloxone (Narcan; median cost $133.38). Forty percent of the purchases included state-mandated verbal counseling, and PWUIO were significantly less likely to receive counseling than bystanders (30% vs. 51%, P < 0.001). Common reasons for failed purchase were not stocking naloxone (47%), price > $150 (25%), and requiring a prescription (15%). Chain pharmacies were significantly more likely to sell naloxone than independent pharmacies (86% vs. 53%, P < 0.001).

CONCLUSION

We documented high levels of naloxone access for both PWUIO and bystanders, suggesting Massachusetts could serve as a model for states seeking to improve pharmacy-based naloxone access. Additional implementation efforts should focus on expanding availability at independent pharmacies and supporting pharmacies in proactively offering naloxone to PWUIO and other high-risk individuals.

Syringe services programs and real-world research: An overview for pharmacists

OBJECTIVE

To review key arguments supporting and criticizing syringe services programs (SSPs).

DATA SOURCES

Peer-reviewed literature and publicly available documents.

SUMMARY

Pharmacy organizations-including the American Pharmacists Association and the American Society of Health-System Pharmacists-have stated that pharmacists should support programs that supply sterile injection materials to persons who use injection drugs. SSPs may include needle exchanges or other programs that meet these aims. Pharmacists should know that observational public health research demonstrates that SSPs can lower the transmission of blood-borne illnesses, improve linkage to care for substance use disorders, reduce health care expenditures, and reduce drug overdoses. Concerns about SSPs and increases in syringe litter or crime have not been borne out by research. Despite these findings and the positions of professional organizations, contemporary research suggests that pharmacists may be reluctant to support SSPs and other programs that would increase supply of sterile injection supplies to their communities.

CONCLUSION

The review of evidence in this commentary should help pharmacists better understand the evidence in favor of SSPs, the potential criticisms of SSPs, and the reasons that their profession is moving to support these programs.

Pharmacy: Addressing substance use in the 21st century

Across all care environments, pharmacists play an essential role in the care of people who use and misuse psychoactive substances, including those diagnosed with substance use disorders. To optimize, sustain, and expand these independent and collaborative roles, the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) has developed core competencies for pharmacists to address substance use in the 21st century. Key concepts, skills, and attitudes are outlined, with links to entrustable professional activities to assist with integration into a variety of ideally interdisciplinary curricular activities.

Syringe access and health harms: Characterizing "landscapes of antagonism" in California's Central Valley

BACKGROUND

Sterile syringe access reduces injection-related health harms, yet access in the U.S. remains grossly inadequate. In California, syringe services programs (SSPs) are authorized mainly at the local level, and many communities remain underserved. State law also allows, but does not require, non-prescription syringe sales at pharmacies, but participation is low. We draw on the theoretical concept of "landscapes of antagonism" to examine how discordance between state and local decision-making contributes to uneven syringe access and health harms in California's Central Valley, where injection rates are high.

METHODS

Our study took place in Fresno and Kern counties. We draw on participant observation and qualitative interviews with individuals who inject drugs and key informants to examine issues around syringe access.

RESULTS

Overall, 8 key informants represented harm reduction, medical, and faith-based organizations. Among 46 people who inject drugs, mean age was 39 (range: 20-65), 37% were female, and 37% self-identified as Latino. About half of individuals at each site had ever successfully purchased from pharmacies, but limited locations and perceived judgement from pharmacy staff posed common barriers. There was no SSP in Kern County due to political opposition; Fresno's SSP has been run by volunteers for more than 20 years despite opposition, and recently gained authorization. Reflecting this disparity, all but two individuals in Fresno accessed syringes from the SSP, whereas only one person in Kern had ever been to an SSP. To fill gaps in access in both sites, individuals obtained syringes that were often already used from diabetics, friends, and people on the street, sharing and reusing syringes at dangerously high rates.

CONCLUSION

Landscapes of antagonism create syringe access inequities that threaten to exacerbate disease transmission and other health harms. Our study raises questions about accountability for the health of people who use drugs and suggests a need for political action.

Pharmacists are missing an opportunity to save lives and advance the profession by embracing opioid harm reduction

More than 70,000 Americans died as a result of a drug overdose in 2017, and a substantial majority of those deaths involved an opioid. Supply-reduction interventions, such as prescription monitoring programs, tamper-resistant formulations, and prescribing limits have failed to reverse rising rates of opioid-related morbidity and mortality. Instead, they may be contributing to this trend by forcing people with opioid use disorder to an increasingly potent illicit market with scant resources for sterile injection. Pharmacists are recognized by governmental authorities, public health experts, and other health professionals as key partners in opioid harm reduction. This is reflected by the proliferation of state laws supporting pharmacy-based access to naloxone, an opioid antagonist that can rapidly reverse the effects of an opioid overdose. Expanded authority to distribute naloxone without an outside prescription, coupled with the provision of sterile syringes and evidence-based medications for opioid use disorder, represents a powerful opportunity for pharmacists to save lives while advancing the role of the profession. However, numerous studies have documented a lack of readiness among pharmacists to dispense naloxone and little willingness to provide sterile syringes. As a profession, it is imperative that we ensure all pharmacists receive adequate education regarding opioid harm reduction interventions and ongoing support to implement these interventions within their practices.

Injection drug use, HIV/HCV, and related services in nonurban areas of the United States: A systematic review

BACKGROUND

Injection drug use (IDU) in nonurban areas of the United States is a growing public health concern, but there has been no comprehensive assessment of existing research on injection-related HIV and hepatitis C (HCV) in nonurban communities. We conducted a systematic review to assess the current literature and identify knowledge gaps.

METHODS

We systematically searched six databases for relevant articles published between January 1990 and June 2016 and screened, extracted, and analyzed the resulting data. Studies were included if they reported original findings from the nonurban U.S. related to 1) IDU and its role in HIV/HCV transmission, and/or 2) HIV/HCV services for people who inject drugs (PWID).

RESULTS

Of 2330 studies, 34 from 24 unique research projects in 17 states met inclusion criteria. Despite increasing HCV and high vulnerability to injection-related HIV outbreaks in nonurban areas, only three studies since 2010 recruited and tested PWID for HIV/HCV. Twelve reported on sharing injection equipment but used varying definitions of sharing, and only eight examined correlates of injection risk. Nine studies on syringe access suggest limited access through syringe exchange programs and pharmacies. Only two studies addressed HCV testing, none addressed HIV testing, and three examined behavioral or other interventions.

CONCLUSIONS

Despite growing concern regarding nonurban IDU there are few studies of HIV/HCV and related services for PWID, and the existing literature covers a very limited geographical area. Current research provides minimal insights into any unique factors that influence injection risk and HIV/HCV service provision and utilization among nonurban PWID.

Stigma at every turn: Health services experiences among people who inject drugs

BACKGROUND

People who inject drugs (PWID) encounter varying forms of stigma in health services contexts, which can contribute to adverse outcomes. We explored the lived experience of stigma among PWID to elucidate pathways by which stigma influences health care access and utilization.

METHODS

We conducted 46 qualitative interviews with PWID in California's Central Valley between March and December 2015, as part of a multi-phase, multi-method study examining implementation of a new pharmacy syringe access law. A "risk environment" framework guided our data collection and we used a deductive/inductive approach to analyze the qualitative data.

RESULTS

Participants repeatedly cited the impact of stigma on syringe access, particularly in the context of meso-level pharmacist interactions. They described being denied syringe purchase as stigmatizing and embarrassing, and these experiences discouraged them from attempting to purchase syringes under the new pharmacy access law. Participants described feeling similarly stigmatized in their meso-level interactions with first responders and hospital staff, and associated this stigmatization with delayed and substandard medical care for overdoses and injection-related infections. Drug treatment was another area where stigma operated against PWID's health interests; participants described macro-level public stigma towards methadone (e.g., equating methadone treatment with illicit drug use) as discouraging participation in this evidence-based treatment modality and justifying exclusion of methadone patients from recovery support services like sober living and Narcotics Anonymous.

CONCLUSION

Stigma played an undeniably important role in PWID's experiences with health services access and utilization in the Central Valley. Our study illustrates the need to develop and test interventions that target drug use stigma at both structural and individual levels to minimize adverse effects on PWID health.