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There are two basic types of sterile needle access strategies: needle exchange and pharmacy sales. The Minnesota Syringe Access Initiative is a law that promotes pharmacy sales to help reduce the spread of human immunodeficiency virus (HIV), the virus that causes AIDS, among PWID.
This law, passed by the Minnesota State Legislature, began July 1, 1998. Since then, persons are able to purchase up to 10 new syringes/needles without a prescription at pharmacies that voluntarily participate with this initiative in Minnesota.
An evaluation was completed to assess the impact the syringe access initiative had on: needle sharing practices; syringe disposal practices; access to syringes; and, syringe sales at participating pharmacies.
The evaluation showed that pharmacy-based syringe purchases increased significantly while the sharing of syringes between PWID decreased during the initiative. There was no change in the frequency of safe disposal of the syringes as a result of the initiative.
Pharmacies are eligible under New York State's Expanded Syringe Access Program (ESAP) may sell or finish syringes to persons 18 years or older, without a prescription. Under this program, health care facilities and health care providers (medical providers who can prescribe syringes) may furnish syringes.
Under a new law in New York State, persons age 18 years and older can legally possess hypodermic needles and syringes obtained through ESAP. These syringes and needles may be purchased or obtained without prescription from participating licensed pharmacies, hospitals, nursing homes, community health centers, doctors, nurse practitioners and physician assistants ( Public Health Law Section: 3381, Chapter 56, Laws of 2000).
Possession of syringes in accordance with the Public Health Law is legal. Persons legally possessing syringes are not subject to arrest or prosecution under the Penal Law. Lawful sale or furnishing of syringes by participating providers/facilities is also legal. This applies to ESAP providers and authorized syringe exchange programs.
Hospitals and nursing homes are required to accept household sharps (used syringes and needles). The use syringes and needles then become regulated medical waste and the hospitals must handle them in accordance with Environmental Conservation Law. This helps to protect the environment.
Community pharmacies are important for health access by rural populations and those who do not have optimum access to the health system, because they provide myriad health services and are found in most communities. This includes the sale of non-prescription syringes, a practice that is legal in the USA in all but two states. However, people who inject drugs (PWID) face significant barriers accessing sterile syringes, particularly in states without laws allowing syringe services programming. To our knowledge, no recent studies of pharmacy-based syringe purchase experience have been conducted in communities that are both rural and urban, and none in the Southwestern US. This study seeks to understand the experience of retail pharmacy syringe purchase in Arizona by PWID.
An interview study was conducted between August and December 2018 with 37 people living in 3 rural and 2 urban Arizona counties who identified as current or former users of injection drugs. Coding was both a priori and emergent, focusing on syringe access through pharmacies, pharmacy experiences generally, experiences of stigma, and recommendations for harm reduction services delivered by pharmacies.
All participants reported being refused syringe purchase at pharmacies. Six themes emerged about syringe purchase: (1) experience of stigma and judgment by pharmacy staff, (2) feelings of internalized stigma, (3) inconsistent sales outcomes at the same pharmacy or pharmacy chain, (4) pharmacies as last resort for syringes, (5) fear of arrest for syringe possession, and (6) health risks resulting from syringe refusal.
Non-prescription syringe sales in community pharmacies are a missed opportunity to improve the health of PWID by reducing syringe sharing and reuse. Yet, current pharmacy syringe sales refusal and stigmatization by staff suggest that pharmacy-level interventions will be necessary to impact pharmacy practice. Lack of access to sterile syringes reinforces health risk behaviors among PWID. Retail syringe sales at pharmacies remain an important, yet barrier-laden, element of a comprehensive public health response to reduce HIV and hepatitis C among PWID. Future studies should test multilevel evidence-based interventions to decrease staff discrimination and stigma and increase syringe sales.
Retail sale of syringes through pharmacies is widely recognized as a public good, as only two states (TN and DE) expressly prevent it . That all but two states allow retail syringe sales is a testament to the importance of sterile syringe access to prevent HIV, hepatitis C (HCV), HBV, and other health conditions caused by syringe reuse and/or sharing. However, state policies are not uniform among or even sometimes within states, and some states allow significant latitude for pharmacist discretion , while others require cumbersome documentation of personal information [17, 18]. Further, paraphernalia possession laws often conflict with retail syringe laws, implying that prescribed substances are the only allowable purpose for syringe purchase .
Despite the significant health need for sterile syringes, the implementation of syringe services programs (SSP) in the USA has been variable. Not every community has an SSP, and even those that operate have limited hours and locations [32, 33]. This is particularly an issue for people in rural areas with limited transportation options . The lack of access may explain why at least 25% of PWID report sharing syringes, and only 52% received their sterile syringes from syringe services programs .
The public health importance of and opportunity for syringe access through pharmacy purchase sharpens in view of significant health need, varied implementation of syringe services programs, and the existing law allowing pharmacy syringe sales. It has been argued that the combination of pharmacy syringe sales and SSPs can help to reduce HIV and HCV among PWID [10, 34, 35].
Interview participants were offered a gift card worth $20.00 for participation. Anonymity in interviews was encouraged for participant protection, and interviews were conducted in a private room. Interviews were audio recorded, transcribed, deidentified as necessary, and checked for accuracy by the principal investigator (Meyerson). Coding was both a priori and emergent, with a focus on syringe access through pharmacies, pharmacy experiences generally, experiences of stigma, and recommendations for harm reduction services delivered by pharmacies. A second researcher (Eldridge) independently coded a sample of interviews for an examination of inter-rater reliability. An initial coding conference was held to identify and manage discrepancies. Two minor coding discrepancies were identified. A final coding scheme emerged and was used for all interviews. Once coding and analysis was completed, a conference was held with the entire study team to confirm observations and to determine priority findings and dissemination of those findings. The study was deemed exempt by the Indiana University Institutional Review Board.
All participants reported experiences purchasing or attempting to purchase syringes at an Arizona pharmacy at some point in the last 2 years. Despite having experience buying syringes or attempting to do so, all reported being refused at least once. Participants indicated that because of syringe sales refusal, pharmacies were not their primary source of sterile syringes. The vast majority of participants (81%) reported being part of a secondary syringe access network where they received and/or provided sterile syringes to others when possible.
Table 1 reports the major themes and exemplar interview statements from participants when asked to describe their experiences buying or trying to buy syringes at Arizona pharmacies. These themes included experiences of stigma and judgment from pharmacy staff, feelings of internalized stigma, inconsistent sales outcomes at the same pharmacy or pharmacy chain, pharmacies as last resort for sterile syringes, fear of arrest for syringe possession, and health risks resulting from syringe refusal.
The most frequent experience reported in the pharmacy while trying to purchase syringes was of stigma in the form of discrimination or judgment expressed by the pharmacy staff. Participants did not differentiate whether stigma was expressed by pharmacy technicians, pharmacists, or both, though it was clear that the person at the counter receiving the request for the syringes enacted the first behavioral response. Participants felt that the expressed stigmatizing behavior was syringe-related because the behavior occurred as soon as they asked for syringes. Pharmacy staff behavior was described as a demeanor change following syringe request.
Participants felt that staff judgment was not necessarily focused on the syringes, per se, because they noted that others purchased syringes for more socially acceptable uses such as diabetes or for medicating their pets. Instead, participants believed that pharmacy staff judged their drug use.
Participants indicated that their pharmacy experience influenced whether they would try again to buy syringes at another time. The choices resulting from syringe sales refusal were not only burdensome, but injurious.
There was also the perception that the paraphernalia law extended to pharmacies, even though in Arizona, retail syringe sale is legal. In this example, the participant thought it was a pharmacy policy not to sell syringes based on state paraphernalia law. This participant identified the outcome of the conflict between current retail syringe sales and paraphernalia laws. 59ce067264