1 Recommendations

This guidance replaces 'Needle and syringe programmes: providing people who inject drugs with injecting equipment', NICE public health guidance 18 (2009).

Recommendation 1 Consult with and involve users, practitioners and the local community

Health and wellbeing boards, directors of public health, commissioners and public health practitioners (see Who should take action?) should:

  • Involve the following when assessing the need for, and when planning, expanding or improving, a needle and syringe programme:

    • different groups of people who inject drugs (including both those who use a needle and syringe programme and those who don't)

    • under-represented groups, for example, young people and people from black and minority ethnic groups who inject drugs

    • families and carers of people who inject drugs

    • frontline workers in needle and syringe programmes, pharmacies and related services in the statutory, voluntary and private sectors.

  • Consult local communities about how best to implement new or reconfigured needle and syringe programmes. Promote the benefits of the service. For example, explain how these programmes have helped prevent an HIV epidemic in the UK and that they provide a route into drug treatment. Also explain that they may help reduce drug-related litter, by providing safe disposal facilities such as drop boxes and sharps bins.

For further recommendations on how to work with communities, see Community engagement (NICE public health guidance 9).

Recommendation 2 Collate and analyse data on injecting drug use

Health and wellbeing boards, directors of public health, commissioners and public health practitioners (see Who should take action?) should:

  • Regularly collate and analyse data from a range of sources (including data from Public Health England) to build reliable local estimates of the:

    • Prevalence and incidence of infections related to injecting drug use (for example, hepatitis C and bacterial infections) and other problems caused by injecting drug use (for example, number of people overdosing).

    • Types of drugs used and the numbers, demographics and other characteristics of people who inject, for example:

      • rates of poly-drug use

      • young people aged under 18 who are injecting, or being injected

      • people who inject image- and performance-enhancing drugs (this includes new cohorts of users, for example, of tanning agents and other image-enhancing drugs)

      • new psychoactive substance injectors

      • people who inject occasionally, for example, when they go to night clubs

      • other groups, such as men who have sex with men, ex-prisoners, sex workers or homeless people.

    • Number and percentage of injections covered by sterile needles and syringes in each of the groups identified above. (That is, the number and percentage of occasions when sterile equipment was available to use.)

    • Number and percentage of people who had more sterile needles and syringes than they needed (more than 100% coverage).

    • Number and percentage of people who inject drugs and who are in regular contact with a needle and syringe programme. (The definition of regular will vary depending on the needle and syringe programme user and the types of drugs they use.)

  • Map other services that are commonly used by people who inject drugs, for example, opioid substitution therapy services, homeless services and custody centres.

Recommendation 3 Commission both generic and targeted services to meet local need

Health and wellbeing boards, directors of public health and commissioners (see Who should take action?) should:

  • Ensure the results of consultation and data analysis (in recommendations 1 and 2) inform the local joint strategic needs assessment.

  • Commission a range of generic and targeted needle and syringe programmes to meet local need, based on these results. For example, ensure services are offered at a range of times and in a number of different locations. Take the geography and demographics of the area into account (for example, whether it is an urban or rural area). Targeted services should focus on the specific groups identified.

  • Ensure services aim to be accessible and:

    • Increase the proportion of people who have more than 100% coverage (that is, the number who have more than 1 sterile needle and syringe available for every injection).

    • Increase the proportion of people who have been tested for hepatitis B and C and other blood-borne viruses (including HIV) in the past 12 months.

    • Increase the proportion of each group of people who inject drugs who are in contact with a needle and syringe programme.

    • Ensure syringes and needles are available in a range of sizes and at a range of locations throughout the area.

    • Encourage identification schemes (involving, for example, the use of coloured syringes).

    • Offer, and encourage the use of, low dead-space injecting equipment.

    • Provide advice and information on services that aim to: reduce the harm associated with injecting drug use; encourage people to stop using drugs or to switch to a safer approach if one is available (for example, opioid substitution therapy); and address their other health needs. Where possible, offer referrals to those services.

  • If applicable, commission outreach or detached services for areas where there are high levels of drug use or populations that do not use existing needle and syringe programmes.

  • Promote needle and syringe programmes to groups that may be under-represented among those who use them, for example, club-drug injectors and people who inject image- and performance-enhancing drugs.

  • Develop plans for needle and syringe disposal, in line with Tackling drug-related litter (Department for Environment, Food and Rural Affairs 2005). Include the provision and disposal of sharps boxes for the safe disposal of needles. Consider providing public sharps bins (drop boxes) in areas where drug-related litter is common. Work with members of the local community, people who inject drugs and the local police service to agree the location for drop boxes.

  • Commission integrated care pathways for people who inject drugs so that they can move seamlessly between the full range of services, including treatment services.

Recommendation 4 Monitor services

Commissioners and providers of needle and syringe programmes, with support from public health practitioners, should:

  • Collect data on service usage as follows:

    • All services should monitor the number and types of packs or equipment they distribute.

    • Specialist services should, where possible, collect more detailed data on: the amount and type of equipment distributed, the demographic details of the person who is injecting, along with details of their injecting practices and the drugs they are injecting (see recommendation 2). Practitioners should only ask for these details if they are confident it will not discourage the person from using the service.

  • Ensure a local mechanism is in place to aggregate and analyse the data collected on at least an annual basis. Aim to build up a picture of injecting practices in the local area and how this may be changing over time. This data should be used as part of the collecting and analysing data process (see recommendation 2).

  • Ensure local service use data are available, in anonymised form, for relevant national bodies and research units (for example, Public Health England).

Recommendation 5 Develop a policy for young people who inject drugs

Directors of public health, children's safeguarding boards, commissioners and providers (see Who should take action?) should:

  • Develop and implement a local, area-wide policy on providing needle and syringe programmes and related services to meet the needs of different groups of young people aged under 18 (including young people under 16) who inject drugs.

  • Ensure the policy details how local services will achieve the right balance between the imperative to provide young people with sterile injecting equipment and the duty to protect (safeguard) them and provide advice on harm reduction and other services. It should take account of:

    • the young person's capacity to consent (Gillick competence)

    • the risks they face

    • the benefits of using services

    • the likelihood that they would inject anyway, even if sterile needles and syringes were not provided.

  • Make the governance responsibilities of drug services and safeguarding boards clear. The safeguarding board should approve the local policy.

  • Ensure the policy emphasises the need to provide young people with sterile injecting equipment. This should be provided as part of a broader package of care to meet their other health and social care needs, where possible. This is especially important for under-16s.

  • Ensure the policy is responsive to the needs of young people in the local area. The developers of the policy should take into account:

    • Provision of specialist young people's substance misuse services, including specialist provision of needle and syringe programmes for those under 18 (including young people under 16).

    • How to encourage young people to ask for advice and help from staff providing the services (as well as providing them with needles, syringes and injecting equipment).

    • How to assess service users:

      • their age

      • the degree or seriousness of their drug misuse

      • whether the harm or risk they face is continuing or increasing

      • the general context in which they are using drugs.

    • The skills, knowledge and awareness that staff need to provide services. This includes ensuring staff are trained to assess whether young people are competent to consent (Gillick competence).

    • The potential for using pharmacies to provide young people with needles, syringes and injecting equipment, if they also encourage the young person to make contact with specialist services.

    • That parental or carer involvement should generally be encouraged, with the consent of the young person. Where this is not possible (or appropriate), the policy should include strategies to address their needs.

    • The role of needle and syringe programmes as part of a range of services for young people that includes seamless transition from youth to adult services.

  • Ensure needle and syringe programmes aimed at young people who inject drugs implement all the recommendations in this guidance, not just those for young people.

  • Regularly review the policy.

Recommendation 6 Provide a mix of services

Health and wellbeing boards and commissioners (see Who should take action?) should:

  • Use pharmacies, specialist needle and syringe programmes and other settings and approaches to provide geographical and demographic coverage. Examples of other settings and approaches that could be used include: custody centres, sexual health services, outreach and detached services. Provide a mix of the following levels of service to meet local needs:

    • Level 1: distribution of injecting equipment either loose or in packs, suitable for different types of injecting practice, with written information on harm reduction. (For example, telling people about specialist agencies, or giving them details about safer injecting practices, including how to prevent an overdose.)

    • Level 2: distribution of 'pick and mix' (bespoke) injecting equipment and referral to specialist services plus health promotion advice. (This includes advice and information on how to reduce the harms caused by injecting drugs.) Some level 2 services might also offer additional services, such as blood-borne virus testing or vaccination.

    • Level 3: level 2 plus provision of, or referral to, other specialist services (for example, specialist clinics, vaccinations, drug treatment and secondary care). See recommendation 9.

  • Establish links and referral pathways between the different levels of service to promote integration and to share learning and expertise.

  • Coordinate services to ensure testing for hepatitis B and C and other blood-borne viruses is readily available to everyone who uses a needle and syringe programme.

  • Coordinate services to ensure injecting equipment is available at times, and in places, that meet the needs of people who inject drugs. For example, it may be appropriate to provide out-of-hours vending machines for groups that would not otherwise have access to services – or not at the time that they need them. (The location of these machines would need to be considered carefully and their use would need to be regularly monitored.) Another example would be to encourage pharmacies with longer opening hours to provide needles, syringes and other injecting equipment.

  • Ensure services offering opioid substitution therapy also make needles and syringes available to their service users, in line with the National Treatment Agency Models of care for treatment of adult drug misusers: update (2006).

Recommendation 7 Provide people with the right type of equipment and advice

Needle and syringe programme providers should:

  • Provide people who inject drugs with needles, syringes and other injecting equipment. The quantity provided should not be subject to a limit but, rather, should meet their needs. Where possible, make needles available in a range of lengths and gauges, provide syringes in a range of sizes and offer low dead-space equipment.

  • Not discourage people from taking equipment for others (secondary distribution), but rather, ask them to encourage those people to use the service themselves.

  • Ensure people who use the programmes are provided with sharps bins and advice on how to dispose of needles and syringes safely. In addition, provide a means for safe disposal of used bins and equipment.

  • Provide advice relevant to the type of drug and injecting practices, especially higher risk practices such as injecting in the groin or neck.

  • Encourage people who inject drugs to mark their syringes and other injecting equipment, or to use easily identifiable equipment, to reduce the risk of accidental sharing.

  • Encourage people who inject drugs to use other services as well. This includes services that aim to: reduce the harm associated with this practice; encourage them to switch to safer methods, if these are available (for example, opioid substitution therapy), or to stop using drugs; and address their other health needs. Tell them where to find these services and refer them as needed.

Recommendation 8 Provide community pharmacy-based needle and syringe programmes

Community pharmacies, coordinators and local pharmaceutical committees (see Who should take action?) should:

  • Ensure staff who distribute needles and syringes are competent to deliver the level of service they offer. As a minimum, this should include awareness of the need for discretion and the need to respect the privacy and confidentiality of people who inject drugs. It should also include an understanding of how to treat people in a non-judgmental way.

  • Ensure staff providing level 2 or 3 services (see recommendation 6) are competent to provide advice about the full range of drugs that people may be using. In particular, they should be able to advise on how to reduce the harm caused by injecting and how to prevent and manage an overdose.

  • Ensure staff have received health and safety training, for example, in relation to blood-borne viruses, needlestick injuries and the safe disposal of needles, syringes and other injecting equipment.

  • Ensure hepatitis B vaccination is available for staff directly involved in the needle and syringe programme.

  • Ensure staff are aware of, encourage and can refer people to, other healthcare services including drug treatment services.

  • Ensure pharmacy staff offer wider health promotion advice, as relevant, to individuals.

See also recommendation 7.

Recommendation 9 Provide specialist (level 3) needle and syringe programmes

Specialist needle and syringe programmes (including community pharmacies offering a level 3 service) should:

  • Ensure a selection of individual needles, syringes and other injecting equipment is available.

  • Provide sharps bins and advice on how to dispose of needles and syringes safely. In addition, provide a service for safe disposal of used equipment.

  • Ensure staff are competent to deliver the service on offer. As a minimum, this should include awareness training on the need for discretion and the need to respect the privacy and confidentiality of people who inject drugs. It should also include training on how to treat people in a non-judgmental way.

  • Ensure staff are competent to provide advice about the full range of drugs that people may be using, how to reduce the harm caused by injecting and how to prevent and manage an overdose.

  • Ensure hepatitis B vaccination is available for staff directly involved in the needle and syringe programme.

  • Offer comprehensive harm-reduction services. This includes: advice on safer injecting practices, assessment of injection-site infections, advice on preventing overdoses and help to stop injecting drugs.

  • Offer (or help people to access):

    • opioid substitution therapy and other drug treatments

    • treatment for injection-site infections

    • vaccinations and boosters (including those offering protection from hepatitis A, hepatitis B and tetanus)

    • testing and treatment for hepatitis B, hepatitis C and HIV

    • services for image- and performance-enhancing drug users

    • specialist substance misuse services and specialist youth services (for young people under 18 who inject)

    • other specialist clinics and services

    • psychosocial interventions

    • primary care services (including condom provision and general sexual health services, dental care and general health promotion advice)

    • secondary care services (for example, mental health services)

    • welfare and advocacy services (for example, advice on housing and legal issues).

Recommendation 10 Provide equipment and advice to people who inject image- and performance-enhancing drugs

Commissioners, providers and public health practitioners (see Who should take action?) should:

  • Ensure needle and syringe programmes:

    • Are provided at times and in places that meet the needs of people who inject image- and performance-enhancing drugs. (For example, offer services outside normal working hours, or provide outreach or detached services in gyms.)

    • Provide the equipment, information and advice needed to support these users.

    • Are provided by trained staff (in line with recommendations 8 and 9).

  • Ensure those level 2 and 3 programmes used by a high proportion of people who take image- and performance-enhancing drugs provide specialist services for this group. This is in addition to routine services set out in recommendations 6–9. It includes:

    • specialist advice about image- and performance-enhancing drugs

    • specialist advice about the side effects of these drugs

    • advice on alternatives (for example, nutrition and physical training can be used as an alternative to anabolic steroids)

    • information about, and referral to, sexual and mental health services

    • information about, and referral to, specialist image- and performance- enhancing drugs clinics, if these exist locally.

  • National Institute for Health and Care Excellence (NICE)