10 The evidence
The evidence statements from 2 reviews conducted for the original guidance and 2 reviews conducted for the updated guidance are provided by external contractors. In addition, they provided consensus statements from the policy review and consensus development exercise.
This section lists how the evidence statements and the consensus statements link to the recommendations and sets out a brief summary of findings from the economic analysis and the fieldwork.
This section also sets out a brief summary of findings from the economic analysis conducted for the original guidance.
The evidence statements are short summaries of evidence, in a review, report or paper (provided by an expert in the topic area). Each statement has a short code indicating which document the evidence has come from.
Evidence statement E6.2b indicates that the linked statement is numbered 6.2b in the review, 'A review of the effectiveness and cost-effectiveness of needle and syringe programmes for injecting drug users' (conducted for the original guidance). Evidence statement Q3.3a indicates that the linked statement is numbered 3.3a in the review, 'Injecting equipment schemes for injecting drug users: qualitative evidence review' (conducted for the original guidance). Evidence statement U2b indicates that the linked statement is numbered 2b in the review, 'Update of NICE guidance PH18 on needle and syringe programmes: qualitative and quantitative review updates'. Evidence statement Y10 indicates that the linked statement is numbered 10 in the review, 'Injecting drug use among young people – risk, harm and factors affecting access to services: a systematic review of the evidence'.
Where a recommendation is not directly taken from the evidence statements, but is inferred from the evidence, this is indicated by IDE (inference derived from the evidence).
Recommendation 1: evidence statements Q3.2a, Q3.3b, Q3.3c, Q3.3d, Q3.4a, Q3.6a, Q3.6b; IDE
Recommendation 2: evidence statements E7.1b, E7.1c, U1a, U1b, Y13, IDE
Recommendation 3: evidence statements E5.1a, E5.1b, E5.1c, E6.3b, E6.3c, E7.1a, E7.1b, E7.1c, Q3.3a, Q3.3b, Q3.3d, Q3.4a, Q3.4c, Q3.6a, U2c, U3c, U8; IDE
Recommendation 4: IDE
Recommendation 5: Y5, Y6; Consensus statements from table 1 of the policy review and consensus development
Recommendation 6: evidence statements E5.1a, E5.1b, E5.1c, E6.3b, E6.3c, E6.4b, E7.1a, E7.1b, Q3.3c, Q3.3d, Q3.4b, Q3.5a, U2b; IDE
Recommendation 7: evidence statements E5.1a, E5.1b, E6.3b, E6.3c, E7.1a, E7.1b, Q3.3a, U2e, U3a, U3b, U6; IDE
Recommendation 8: evidence statements E5.1c, E6.3b, E6.3c, E7.1a, E7.1b, Q3.3b, Q3.4b, Q3.6b, U5, U7, Y14; IDE
Recommendation 9: evidence statements E6.3b, E6.3c, E7.1a, E7.1b, Q3.3b, Q3.3c, Q3.4b, Q3.6b, U7; IDE
Recommendation 10: IDE from 'Update of NICE guidance PH18 on needle and syringe programmes: PIEDs review'
The analyses for the original guidance estimated that needle and syringe programmes used as a channel for treating injecting drug users for chronic hepatitis C were cost effective. They can reduce the costs for society of drugs misuse by:
improving the health of people who inject drugs
ensuring the disease cannot be passed on after treatment.
The modelling showed that if only health costs and benefits are counted, then a needle and syringe programme that increased coverage by 25% in a city with a high incidence of hepatitis C virus was cost effective (estimated ICER £11,400). However, an increase in coverage by 12.5% was not cost effective (estimated ICER £31,600). For a low-incidence city, the estimated ICER for an increase in coverage of 25% was £11,800, whereas for an increase of 12.5% the ICER was estimated as £26,100.
If the costs to the criminal justice system are included, the modelling showed that a 12.5% increase in coverage for a high-incidence city was not cost effective (estimated ICER £38,700). But if coverage increased to 25%, the estimated ICER fell to £19,900. For a low-incidence city, for a 12.5% increase in coverage the ICER was £29,300, and for a 25% increase in coverage the ICER was £12,300.
Needle and syringe programmes can also help reduce the number of people who are injecting drug users by acting as a 'gateway' to opiate substitution therapy. So these programmes may help reduce the costs of drug-related crime. When these indirect ('gateway') effects were modelled, it showed that a 13.5% increase in the rate of referral to opiate substitution therapy resulted in ICERs of between dominant and £17,000, depending on prevalence.
The modelling found that overall, it is cost effective to give users more than one free needle per successful injection, if the cost of reaching them is not excessive and if use of this service increases by more than about 25% as a result.
There were no additional analyses undertaken for the updated guidance.
Fieldwork aimed to test the relevance, usefulness and feasibility of putting the recommendations into practice. The PHAC considered the findings when developing the final recommendations. For details, go to fieldwork.
Fieldwork participants who work with people who inject drugs were very positive about the recommendations and their potential to improve needle and syringe programmes. Many participants stated that the new recommendations about young people and about people who inject image- and performance-enhancing drugs were much needed and would be very useful.