The Public Health Interventions Advisory Committee (PHIAC) for the original NICE guidance on needle and syringe programmes (NICE public health guidance 18, 2009) took account of a number of factors and issues when developing the recommendations. Many of these are still relevant (see 4.1 to 4.7 below) and informed the discussions of the Public Health Advisory Committee (PHAC) responsible for updating the guidance. In addition, PHAC took account of a number of additional factors and issues (see 4.8 to 4.19 below).
Please note: this section does not contain recommendations. (See recommendations.)
4.1 Needle and syringe programmes (NSPs) need to be considered as part of a comprehensive substance-misuse strategy that covers prevention, treatment and harm reduction.
4.2 The remit of this guidance was to consider the optimal provision of NSPs, not whether or not these programmes should be provided. Evidence from systematic reviews shows that NSPs are an effective way to reduce many of the risks associated with injecting drugs.
4.3 The ethical issues and social values related to NSPs were discussed in some depth. The Public Health Interventions Advisory Committee (PHIAC) noted that it is difficult to meet the health needs of people who inject drugs without appearing to condone or 'normalise' drug use, especially in young people. It also noted that NSPs cannot reduce all of the potential harms associated with injecting drug use. Furthermore, NSPs might have disadvantages. For example, they may deter people who inject drugs from using safer drug taking methods or from stopping taking drugs altogether. On the other hand, NSPs can provide a means of contact with people who inject drugs and, hence, opportunities for harm reduction as well as support to help them stop injecting. NSPs can also help reduce blood-borne infections among people who inject drugs, to the benefit of society at large. After considering these issues at some length PHIAC felt that, on balance, recommendations on the optimal provision of NSPs were justified.
4.4 Most published research was conducted in the USA. However, PHIAC judged that some of the evidence was applicable to England and could be used to inform the recommendations.
4.5 The coverage provided by NSPs has been defined in a number of ways. The World Health Organization (2007) uses 3 definitions of 'coverage':
percentage of injections 'covered' by sterile needles and syringes
number of needles and syringes supplied to each injecting drug user per year
percentage of injecting drug users in regular contact with NSPs.
PHIAC used the first definition above to describe 'coverage': that is, 'coverage' in this guidance means the percentage of injections for which sterile equipment was available to use.
4.6 Local communities need information about the aims of an NSP and evidence of its effectiveness when proposals are put forward for siting one in their neighbourhood.
4.7 PHIAC emphasised the important 'gateway' function that NSPs may perform in bringing people who inject drugs into contact with a range of services. In particular, NSPs may bring them into contact with services that may help by:
emphasising the dangers of overdosing (about 1% of people who inject drugs die of an overdose each year)
encouraging people to switch to less harmful forms of drug taking
encouraging people to opt for opioid substitution therapy
encouraging people to stop using drugs
encouraging people to be tested and treated for hepatitis C and HIV
encouraging people to address their other health needs.
The Public Health Advisory Committee (PHAC) took account of a number of additional factors and issues when developing the updated recommendations, as follows.
4.8 PHAC noted that only a small amount of evidence had been published since the previous guidance, especially in relation to young people's drug use and the use of image- and performance- enhancing drugs. Furthermore, most of this evidence came from outside the UK. In response, Committee members' used their own knowledge and experience to apply the evidence to England and add further detail to the recommendations.
4.9 PHAC noted the need to balance the number of people who have a sterile needle and syringe for each injection (coverage), with the number of people in direct contact with the NSP. Overall, members felt it was more important to achieve high rates of coverage, because this is the biggest predictor of sterile needle and syringe use. On this basis, the Committee felt that it was acceptable to knowingly provide equipment for secondary distribution (whereby drug users pass on sterile needles and syringes to others).
4.10 Some evidence suggests that 100% coverage among 60% of the population is enough to slow the spread of blood-borne viruses and bacterial infections among people who inject drugs. However, higher coverage rates will have more of an impact. On this basis, PHAC retained the target of more than 100% coverage, as set out in the recommendations made in NICE public health guidance 18. The Committee also noted the need to monitor coverage rates for different sub-populations – not just for the overall population.
4.11 PHAC noted that needle and syringe vending machines seem to be used by a different type of injector to needle and syringe programmes, notably young people and others at very high risk from injecting drugs. The Committee considered that they were a good way of providing additional, out-of-hours services – but not as a cheaper alternative to staffed NSP services.
4.12 PHAC discussed the distinction between people who regularly inject drugs and those who inject occasionally. The evidence was not clear enough to make a specific recommendation for the latter. However, the Committee agreed that it was important to provide occasional users with a service.
4.13 PHAC discussed at length the potential conflict between safeguarding young people and vulnerable adults who inject drugs and the need to provide them with harm reduction services, including sterile needles and syringes. The Committee was clear that a balance needed to be struck. It noted the need for competent professionals with skills in delivering needle and syringe programmes and with expertise in assessing young people from a safeguarding perspective. Members felt that, with adequate support, this could fall within the remit of both specialist workers and many community pharmacists.
4.14 PHAC discussed how parents and carers could be consulted and involved when their children are using needle and syringe programmes. However, the Committee did not have enough evidence to make a recommendation on how to do this.
4.15 PHAC noted that a focus on recovery (that is, encouraging people to stop taking drugs completely) should not compromise the provision of needle and syringe programmes and any associated harm-reduction initiatives.
4.16 PHAC discussed the lack of information available about the needs of specific populations of people who inject, for example club-drug users or men who have sex with men. It also discussed innovative ways of reaching them to reduce the harms associated with injecting (see research recommendation 5.2).
4.17 PHAC discussed the need for a national monitoring system to systematically gather and aggregate data on people who use needle and syringe programmes. It heard that Public Health England's Needle Exchange Monitoring System (NEXMS) was not well used. PHAC did not consider any evidence to allow a judgment on this matter.
4.18 PHAC was satisfied that the provision of low dead-space injecting equipment was justified if its price was the same as, or only marginally higher than, other equipment.
4.19 PHAC was aware of plans to make Naloxone more available for treating opiate overdose. However, it was not possible to make a recommendation on this due to the current status of the drug and lack of evidence of the effectiveness of providing it through needle and syringe programmes.
4.20 PHAC considered a summary of the findings from the health economic modelling undertaken for the original guidance. This showed that providing people who inject opioid drugs with sterile injecting equipment is estimated to be cost effective from an NHS/personal social services (PSS) perspective (that is, excluding the costs of crime). It is similarly cost effective from a societal perspective. If the indirect 'gateway' effects of needle and syringe programmes – of increasing the proportion of people who inject drugs who take up opioid substitution therapy, or take part in other drug treatment – are included, a fall in the number who inject drugs is likely. This would, in turn, lead to a reduction in crime. If that is the case, modelling shows that these programmes are likely to be cost effective in the longer term. However, the figures in relation to the size of the 'gateway effect' are subject to considerable uncertainty, as are figures relating to any effect that an increase in needle and syringe programmes will have on the number of people injecting drugs.
4.21 PHAC noted that there are insufficient data relating to young people aged under 18 who inject drugs to populate the economic model. However, PHAC thought that the findings are unlikely to differ significantly from people over that age. In fact, the benefits of needle and syringe programmes are probably greater for this group because they are more likely to reuse or share equipment. The marginal costs of extending provision to young people aged under 18 would be lower than the average cost for existing users.
4.22 PHAC noted that there are insufficient data to allow useful modelling for people who inject image- and performance-enhancing drugs. The incidence of hepatitis C virus is probably lower in this group than among groups using other types of drugs because the substances used do not cause such acute withdrawal effects. As the need to inject may be less urgent, users probably have more time to obtain a sterile needle (and can think more clearly about where to get one). Also, many of these drugs are not controlled under the Misuse of Drugs Act/Regulations, or have lesser penalties for use than opiates and stimulants. As a result, users will not be deterred from associating with a supplier of sterile needles. The cost of recommending that all people from this group use existing programmes would be relatively small. However, there is insufficient evidence to determine whether it is cost effective to develop dedicated services for this group.