- Email: [email protected]
Dead space: A risk factor we did not see
20
Responses / International Journal of Drug Policy 24 (2013) 15–22
reverse the epidemic amongst people who inject drugs are comprehensive structural changes including drug law reform, community empowerment, and enabling, as opposed to repressive, legal environments. Without the latter, the choice between low- and high dead-space syringes will remain a luxury for the few.
Reference Zule, W. A., Cross, H. E., Stover, J., & Pretorius, C. Are major reductions in new HIV infections possible with people who inject drugs? The case for low dead-space syringes in highly affected countries. International Journal of Drug Policy, in press doi:10.1016/j.drugpo.2012.09.008
Dead space: A risk factor we did not see Andrew Preston ∗ Exchange Supplies, 1 Great Western Industrial Centre, Dorchester, Dorset DT1 1RD, UK
a r t i c l e
i n f o
Article history: Received 25 September 2012 Accepted 25 September 2012
For many years we thought the answer to preventing HIV and hepatitis C amongst injecting drug users was simply the scaling up of needle and syringe availability, and the promotion of the ‘new syringe for every injection’ message. However, as our understanding of these epidemics has grown, the importance of opiate substitution therapy, providing antiviral treatments, and of reducing the risks of accidental sharing have all been added to the list of essential components of an effective blood borne virus prevention strategy. Although the implementation of harm reduction measures has kept the UK’s HIV epidemic at low levels, one-fifth of people who inject drugs continue to share needles and syringes (Health Protection Agency, 2012). Our efforts have not been successful in reducing the incidence hepatitis C, which was already at high prevalence levels when needle exchange was introduced. Now, the work of Zule and colleagues (in press) has demonstrated the likelihood that we can take significant further steps to reduce the risks associated with syringe reuse and sharing that are aggravated by the ‘high dead space’ design of some of the equipment we dispense. Their message that these steps will reduce the probability of infection dramatically, but not necessarily prevent it, will challenge those who have a personal rather than public health perspective on epidemics and infection risk. At Exchange Supplies, we have been collectively purchasing equipment for the harm reduction field to distribute to injecting drug users for 10 years. We know from our experience in trying to get services to take steps to reduce accidental sharing, that it is hard for some to implement strategies that they know may not guarantee safety for the injecting drug users they are working with. However, this should not be insurmountable: exactly this sort of pragmatism lies at the heart of a harm reduction approach. Saying ‘it would be better if people did not inject but if they do they should use this syringe’, is the same as saying ‘it would be better people did not reuse syringes, but if they do, it is better to re-use this type’. In a world where even the best services only get a new syringe for every injection to a minority of the injecting drug users they
∗ Tel.: +44 1305 262244. E-mail address: [email protected]
serve, it seems essential that we do everything we can to reduce the risks when those scarce syringes are reused, passed on, or shared. At Exchange Supplies we aim to close the gap between knowledge and practice, and meet the need for specific or specially adapted items to reduce drug related harms. We started with acidifiers, which can increase the frequency of NSP attendance and the amount of syringes collected (Beynon, McVeigh, Chandler, Wareing, & A Bellis, 2007), but in the last five years we have mainly focussed on developing new injecting equipment – starting with insulin type ‘nevershare’ syringes with different coloured plungers designed to reduce the risk of accidental sharing. In response to the work of Bill Zule we are in the process of commissioning a range of cost-equivalent low dead space needles for ‘luer slip’ syringes with detachable needles. As I write, work is underway on the mould for a 25 mm/25 gauge low dead space needle which will be available in December 2012, with all other key needle lengths and gauges becoming available in early 2013. The work of Bill Zule and his colleagues is important: not only have they researched an issue, and identified a possible solution, they have set about lobbying and informing everyone who needs to know about the potential for low dead space syringes to prevent infections. The determined activism that has taken the understanding of this key issue to policy makers, manufacturers, practitioners, and drug user networks is to be commended and encouraged, not least because publishing only in journals, and hoping for action can lead to much lost time, and unnecessary blood borne virus infections. Reference Beynon, C. M., McVeigh, J., Chandler, M., Wareing, M., & A Bellis, M. A. (2007). The impact of citrate introduction at UK syringe exchange programmes: A retrospective cohort study in Cheshire and Merseyside, UK. Harm Reduction Journal, 4, 21. http://www.harmreductionjournal.com/content/4/1/21 Health Protection Agency. (2012). Shooting up: Infections among people who inject drugs in the UK 2010. An update, November 2011. Zule, W. A., Cross, H. E., Stover, J., & Pretorius, C. (in press). Are major reductions in new HIV infections possible with people who inject drugs? The case for low dead-space syringes in highly affected countries. International Journal of Drug Policy. doi:10.1016/j.drugpo.2012.09.010
Responses / International Journal of Drug Policy 24 (2013) 15–22
reverse the epidemic amongst people who inject drugs are comprehensive structural changes including drug law reform, community empowerment, and enabling, as opposed to repressive, legal environments. Without the latter, the choice between low- and high dead-space syringes will remain a luxury for the few.
Reference Zule, W. A., Cross, H. E., Stover, J., & Pretorius, C. Are major reductions in new HIV infections possible with people who inject drugs? The case for low dead-space syringes in highly affected countries. International Journal of Drug Policy, in press doi:10.1016/j.drugpo.2012.09.008
Dead space: A risk factor we did not see Andrew Preston ∗ Exchange Supplies, 1 Great Western Industrial Centre, Dorchester, Dorset DT1 1RD, UK
a r t i c l e
i n f o
Article history: Received 25 September 2012 Accepted 25 September 2012
For many years we thought the answer to preventing HIV and hepatitis C amongst injecting drug users was simply the scaling up of needle and syringe availability, and the promotion of the ‘new syringe for every injection’ message. However, as our understanding of these epidemics has grown, the importance of opiate substitution therapy, providing antiviral treatments, and of reducing the risks of accidental sharing have all been added to the list of essential components of an effective blood borne virus prevention strategy. Although the implementation of harm reduction measures has kept the UK’s HIV epidemic at low levels, one-fifth of people who inject drugs continue to share needles and syringes (Health Protection Agency, 2012). Our efforts have not been successful in reducing the incidence hepatitis C, which was already at high prevalence levels when needle exchange was introduced. Now, the work of Zule and colleagues (in press) has demonstrated the likelihood that we can take significant further steps to reduce the risks associated with syringe reuse and sharing that are aggravated by the ‘high dead space’ design of some of the equipment we dispense. Their message that these steps will reduce the probability of infection dramatically, but not necessarily prevent it, will challenge those who have a personal rather than public health perspective on epidemics and infection risk. At Exchange Supplies, we have been collectively purchasing equipment for the harm reduction field to distribute to injecting drug users for 10 years. We know from our experience in trying to get services to take steps to reduce accidental sharing, that it is hard for some to implement strategies that they know may not guarantee safety for the injecting drug users they are working with. However, this should not be insurmountable: exactly this sort of pragmatism lies at the heart of a harm reduction approach. Saying ‘it would be better if people did not inject but if they do they should use this syringe’, is the same as saying ‘it would be better people did not reuse syringes, but if they do, it is better to re-use this type’. In a world where even the best services only get a new syringe for every injection to a minority of the injecting drug users they
∗ Tel.: +44 1305 262244. E-mail address: [email protected]
serve, it seems essential that we do everything we can to reduce the risks when those scarce syringes are reused, passed on, or shared. At Exchange Supplies we aim to close the gap between knowledge and practice, and meet the need for specific or specially adapted items to reduce drug related harms. We started with acidifiers, which can increase the frequency of NSP attendance and the amount of syringes collected (Beynon, McVeigh, Chandler, Wareing, & A Bellis, 2007), but in the last five years we have mainly focussed on developing new injecting equipment – starting with insulin type ‘nevershare’ syringes with different coloured plungers designed to reduce the risk of accidental sharing. In response to the work of Bill Zule we are in the process of commissioning a range of cost-equivalent low dead space needles for ‘luer slip’ syringes with detachable needles. As I write, work is underway on the mould for a 25 mm/25 gauge low dead space needle which will be available in December 2012, with all other key needle lengths and gauges becoming available in early 2013. The work of Bill Zule and his colleagues is important: not only have they researched an issue, and identified a possible solution, they have set about lobbying and informing everyone who needs to know about the potential for low dead space syringes to prevent infections. The determined activism that has taken the understanding of this key issue to policy makers, manufacturers, practitioners, and drug user networks is to be commended and encouraged, not least because publishing only in journals, and hoping for action can lead to much lost time, and unnecessary blood borne virus infections. Reference Beynon, C. M., McVeigh, J., Chandler, M., Wareing, M., & A Bellis, M. A. (2007). The impact of citrate introduction at UK syringe exchange programmes: A retrospective cohort study in Cheshire and Merseyside, UK. Harm Reduction Journal, 4, 21. http://www.harmreductionjournal.com/content/4/1/21 Health Protection Agency. (2012). Shooting up: Infections among people who inject drugs in the UK 2010. An update, November 2011. Zule, W. A., Cross, H. E., Stover, J., & Pretorius, C. (in press). Are major reductions in new HIV infections possible with people who inject drugs? The case for low dead-space syringes in highly affected countries. International Journal of Drug Policy. doi:10.1016/j.drugpo.2012.09.010