Specifying needle and syringe programmes
The key components of needle and syringe programmes (NSPs) are:
- providing needles and syringes and other injecting equipment together with information and advice on harm reduction
- providing a gateway to other services and ensuring access to blood-borne virus testing, vaccinations and drug treatment
- developing high-quality NSPs.
Providing needles and syringes and other injecting equipment together with information and advice on harm reduction
NICE public health guidance PH18 on needle and syringe programmes recommends that local strategic partnerships (LSPs), local drug partnerships including drug (and alcohol) action teams (D[A]ATs), drug joint commissioning managers and primary care trust (PCT) commissioners use pharmacies, specialist NSPs and other healthcare settings to provide a balanced mix of services across three levels:
- level 1: distribution of injecting equipment either loose or in packs, with written information on harm reduction (for example, on safer injecting or overdose prevention)
- level 2: distribution of ‘pick and mix' (bespoke) injecting equipment plus health promotion advice (including advice and information on how to reduce harms caused by injecting drugs)
- level 3: level 2 plus provision of, or referral to, specialist services (for example, vaccinations, drug treatment and secondary care).
Commissioners should ensure that NSP providers (community pharmacies and specialist NSPs) supply people who inject drugs with needles, syringes and other injecting equipment such as filters, mixing containers, sterile water and sharps bins. The quantity of injecting equipment dispensed should be adequate to meet the needs of the injecting drug user (including increased numbers of syringes for stimulant users) and not subject to an arbitrary limit.
Staff who dispense needles and syringes in community pharmacies and specialist NSPs should receive the appropriate level of training for the level of service they offer. For community pharmacists, as a minimum this should include awareness training on the need for discretion and the need to respect the privacy of people who inject drugs. It should also include training on how to treat people in a non-stigmatising way. Staff providing level 2 or level 3 services should be trained to provide health promotion advice, in particular advice on how to reduce the harm caused by injecting.
Providing a gateway to other services and ensuring access to blood-borne virus testing, vaccinations and drug treatment
NSPs can provide an important gateway function for people who inject drugs and bring them into contact with a range of drug treatment services. Therefore commissioners should ensure that local agencies offering further support (level 3 services) are available and accessible and that NSP staff are able to advise people who inject drugs on where and how they can access these services.
Level 3 services should provide:
- injecting equipment, sharps bins and advice on how to dispose of needles and syringes and a service for the safe disposal of used equipment
- comprehensive harm-reduction services, including advice on safer injecting practices, assessment of injection-site infections, advice on preventing overdoses and help to stop injecting drugs
- access, where appropriate, to opioid substitution therapy (OST), treatment for injection-site infections, vaccinations and boosters (including those offering protection from hepatitis A, hepatitis B and tetanus), and testing and counselling for hepatitis B, hepatitis C and HIV.
Commissioners should also ensure that people who inject drugs have access to: secondary care services, for example, treatment for hepatitis C and HIV; primary care services including condom provision, general sexual health services, dental care and general health promotion advice; and welfare and advocacy services, for example advice on housing and legal issues.
Developing high-quality needle and syringe programmes
LSPs, local drug partnerships (including D[A]ATs), drug joint commissioning managers and PCT commissioners should, with the help of the Health Protection Agency and public health observatories, collect and analyse local data to estimate the level of service needed. NICE public health guidance PH18 on needle and syringe programmes recommends analysing data and undertaking consultation with local communities and service users about how best to implement new or reconfigured NSPs and recommends:
- Commissioning a mix of generic and targeted NSP services to meet local need within the area covered by the LSP. Targeted services should focus on specific groups (for example, homeless people and women).
- Commissioners should ensure that services aim to:
- increase the proportion of people who have over 100% ‘coverage' (that is, the proportion who have more than one sterile needle and syringe available for every injection)
- increase the proportion of people from each group of injecting drug users who are in contact with NSPs
- ensure that needles and syringes are available in a range of sizes and at a range of locations throughout the area
- offer advice and information on, and referrals to, services that aim to: reduce harm associated with injecting drug use; encourage people to stop using drugs or switch to non-injecting methods (for example, opioid substitution therapy); and address their other health needs.
LSPs, local drug partnerships (including D[A]ATs), drug joint commissioning managers, PCT commissioners, NSP providers, public health practitioners with a remit for substance misuse and service users should be involved in determining what is needed from an NSP when considering the design or redesign of service models.
Commissioners need to be aware that legal and operational considerations regarding the provision of needles and syringes to people under the age of 18 differ from those for adults. Needle and syringe programmes are commissioned for people under the age of 18 in a number of areas as part of a care plan activity and an intervention should only be provided following a comprehensive young person's assessment.
NSPs in England are based across a range of services including specialist services, pharmacies, outreach/mobile services, police custody suites, walk-in centres and accident and emergency departments. Over 70% of NSPs are provided by pharmacies. Commissioners should ensure that NSPs are coordinated to provide injecting equipment throughout the area for a significant proportion of any 24-hour period. Therefore commissioners may wish to consider commissioning NSPs in a number of different ways. Mixed models of provision may be appropriate across the LSP area. Commissioners should consult with relevant stakeholders such as the local pharmaceutical committee and local communities about how best to implement new or reconfigured NSPs.
Community pharmacy-based NSPs may be commissioned as part of the ‘necessary enhanced services' offered by ‘100 hour' pharmacies. Commissioners could also consider providing NSPs through community pharmacies that operate extended opening hours. Services offering OST should also make needles and syringes available to their clients, in line with the National Treatment Agency for Substance Misuse's Models of care for treatment of adult drug misusers.
There is a lack of evidence on how particular groups such as women, users of performance and image-enhancing drugs (PIEDs), young people, crack cocaine and speedball injectors (people who inject an opioid such as heroin in combination with a stimulant such as cocaine), homeless people and prison populations can be encouraged to use NSPs. Therefore commissioners may wish to commission and evaluate novel methods of service delivery such as vending machines, mobile vans and non-pharmacy outlets, including sports venues for PIED users.
A NSP in Walsall provides a ‘one-stop shop' for a range of services as part of the Hepatitis Action Project. All clients entering the NSP are assessed, given advice on harm reduction and offered screening for hepatitis, HIV and chlamydia. Vaccinations for hepatitis A and B and regular health checks by the project nurse are also offered, and when necessary referrals are made to the local hospital hepatology clinic. The Hepatitis Action Project also provides an outreach service for anabolic steroid users.
This example is offered to share practice and NICE makes no judgment on the compliance of this service with its guidance.
The service should be client-centred and integrated with other elements of care for people with drug and alcohol problems.
The service specification needs to address:
- the required competencies of, and training for, staff responsible for providing the service at all three service levels and across different settings
- the prevalence and incidence of infections related to injecting drug use (for example, hepatitis C) and other problems caused by injecting drug use, such as number of people overdosing, with help from the Health Protection Agency and the public health observatories
- the expected number of clients, demographics, types of drugs used and other characteristics of injecting drug users (for example, the number of sex workers, number of homeless people, number of crack cocaine and speedball injectors)
- accessibility and service location - see NICE needle and syringe programmes: local authority planning committee checklist; commissioners should place services in response to community consultation and engage service users, other relevant individuals and organisations locally when taking the location of the service into account
- plans for needle and syringe disposal
- integrated care and referral pathways
- information, monitoring and audit requirements, including IT support and infrastructure, and details of data to be submitted to the needle exchange monitoring system
- planned service improvement, including redesign, quality, equitable access and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks
- service monitoring criteria. link to ‘Ensuring corporate and quality assurance' section within this guide
Useful sources of information may include:
- Drug misuse and dependence: UK guidelines on clinical management.
- Good practice in harm reduction.
- Reducing drug-related harm: an action plan.
- Tackling drug related litter.
- Best practice guidance for commissioners and providers of pharmaceutical services for drug users.
- Commissioning young people's specialist substance misuse treatment services.
- NICE public health guidance PH9. Community engagement.
- The NICE shared learning database offers examples of how organisations have implemented NICE guidance locally.
- NICE public health guidance PH18. Needle and syringe programmes: Implementation advice slide set, costing template and commissioner's factsheet.
- NICE public health guidance PH4. Interventions to reduce substance misuse among vulnerable young people.
- NICE clinical guideline CG52. Drug misuse: opioid detoxification.
- NICE clinical guideline CG51. Drug misuse: psychosocial interventions.
- NICE technology appraisal TA114. Methadone and buprenorphine for the management of opioid dependence.
- NICE technology appraisal TA115. Naltrexone for the management of opioid dependence.
- NICE technology appraisal TA96. Adefovir dipivoxil and peginterferon alfa-2a for the treatment of chronic hepatitis B.
- NICE technology appraisal TA106. Peginterferon alfa and ribavirin for the treatment of mild chronic hepatitis C.
- NICE technology appraisal TA75. Interferon alfa (pegylated and non-pegylated) and ribavirin for the treatment of chronic hepatitis C.
This page was last updated: 02 March 2012