Thank you for the informative presentation on harm reduction. Please let me know if you need any other assistance.

1. Harm Reduction
Mary Clare Madden & Jennifer Kelly
Addiction Pharmacists / Independent Prescribers
NHS Greater Glasgow and Clyde Addictions

2. Contents
• Definition of Harm Reduction
• Harm Associated with Drug Administration
• Harm Reduction Services
• Role of the Pharmacist

3. Definition of Harm Reduction
• Harm reduction is a term that defines
policies, programmes, services and actions
that work to reduce the:
• Health, Social and Economic harms to:
- Individuals
- Communities
- Society

4. Principles of Harm Reduction
• Is pragmatic
• It prioritises goals
• It has humanist values
• It focuses on risks and harms
• It does not focus on abstinence
• It seeks to maximise a range of
opportunities

5. Routes of Drug Administration
• Harm is highly contingent on the means by which drugs
are administered
• Injecting drugs is the most common but dangerous way
of taking them.
• Injecting is the main cause of both short term & long
term risks to injecting drug users (IDUs) i.e.
transmission of blood borne viruses (BBVs), drug
overdose & bacterial infections
• According to the ACMD people who inject drugs are 14
times more likely to die than their peers!
• Other routes of admin are less risky than injecting e.g.
smoking & snorting but still carry risk of drug
dependence, overdose and health complications

6. Harm Associated with Drug
Administration

7. BBVs - Hepatitis C
• Sharing injecting equipment increases the risk of
contracting a BBV such as HIV or Hep C
• Hep C is a disease caused by a virus that attacks
the liver
• It is spread through blood to blood contact.
• It mainly affects the liver causing
swelling, scarring and sometimes leading to
cancer
• The virus can lie dormant for 20-30yrs before the
liver is damaged & symptoms begin to show
• It is transmitted primarily through percutaneous
exposure though it can be spread through sexual
intercourse and from mother to child
• There is no vaccine against Hepatitis C!!

8. Hep C Action Plan Phase II
May 2008 – March 2011
• ‘Hep C is one of the most serious & significant
public health risks of our generation’ (Scottish
Government, 2004.)
• ~ 50,000 individuals infected with Hep C
antibody in Scotland.
• Of these 38,000 are chronically infected.
• ~ 45,000 acquired Hep C through sharing
needles & other injecting paraphernalia.
• ~ 1,000 – 1,500 IDUs in Scotland are infected
each year with Hep C.

9. Hep C Action Plan Phase II
May 2008 – March 2011
• Plan involves funding for prevention, testing
and treatment
• Prevention arm aims:
– Increase volume and type of equipment
available
– Introduce novel educational interventions
– Ensure workforce receives consistent training to
enable delivery of service
– Collect data nationally via Information Services
Division (ISD)

10. Injecting Injuries
• People who inject illicit
drugs, reuse injecting
equipment are at risk of
injury, inflammation &
infection at the injection site
• In 2007 around 1/3 of IDU’s in
the UK reported having had an
abscess, sore or open wound
at an injection site
• In 2008 the Shooting Up
Report estimated that it costs
the NHS £47M a year to treat
wounds caused by injecting
drugs!

11. Common Types Of Injecting Injuries in
Drug Users
• Abscesses
• Infections & cellulitis
• ‘Lumps’ and
swellings
• Trackmarks /
phlebitis
• Groin sinuses
• Chronic leg ulcers

12. What Causes Injecting Problems?
 Technique : missed veins, muscle or
skin injecting, ‘digging’, flushing
 Poor hygiene; sharing
equipment, reusing equipment
 The (unknown) injected
substance, unsterile, contaminated,
adulterated –
filter, additives, acid, the
drug, particles (anthrax!)
 Background of poor systemic health
– BBV, malnutrition, mental health
issues

13. Overdose
• People who inject drugs are at greater risk of overdose
than those who smoke or snort drugs
• Medical definition of an overdose is the accidental or
intentional use of a drug or medicine in an amount that
is higher than is normally used. In the substance
misusing community an overdose can occur due to
reduced tolerance, relapse, polydrug use etc
• Overdose with opiate drugs causes drowsiness, drop in
blood pressure, slowed heart rate, and slowed
breathing. Person may stop breathing and die.
• Signs - pinpoint pupils, pale skin, blue lips, unrousable
• In 2010 there were 485 drug related deaths
• Out of the 485 deaths: heroin/morphine was implicated
in 52%, methadone was implicated in 36% of the deaths
& benzos were implicated in 25%.

14. Overdose - Naloxone
• Naloxone pilot introduced in 2007 in Glasgow
• It is a drug which is administered to temporarily
reverse the effects of an opiate overdose & hopefully
save a life
• It is a short acting opiate antagonist which can act
within 2 mins & lasts for approximately 20 mins
• In 2010 became a National Programme
• Supplied within addiction services and other outlets
via Patient Group Direction (PGD) by trained staff in
combination with overdose awareness training
• Naloxone Lead for each Health Board Area

15. Harm Reduction Services

16. General Statistics
• Approximately 19,000 IDU’s in Scotland
• Estimated there is roughly 10 Million
injecting episodes in Glasgow each year
• 1 Million plus needles supplied each year
in Glasgow from Community Pharmacies
and Fixed Sites

17. Injecting Equipment Providers (IEP’s)
• New Guidelines published by the Scottish Government
in March 2010 for all IEPs
• IEPs refers to any Service that distributes injecting
equipment e.g. Pharmacies and fixed-site services
• Pharmacy needle exchange was introduced in 1986 at 5
sites throughout Britain.
• To date there are now roughly 169 Pharmacy IEPs in
Scotland
• Most Pharmacy IEPs supply needles in sealed sterile
packs that contain needles & injecting paraphernalia.
• Needles provided differ in thickness and in length.
• Depending on which site on the body you are injecting
into should determine what size of needle is used.
• Where possible the shortest/thinnest needle should be
used to minimise vein and muscle damage.

18. One Hit Kits

19. One Hit Kit (1HK)
• 1HK’s have been designed to improve the “quality
and nature” of the equipment
• Each kit contains a filter syringe, citric acid
sachet, spoon and swab.
• Water is not included due to lack of 2ml plastic vial
supplier
• The 1HKs are sealed in individual sterile packs in
bundles of 20 with an individual safe disposal cin
bin.
• Encourages single use of all injecting equipment

21. Advantages of Pharmacy IEPs
• User friendly
• Easy Access
• Confidential
• Requires a minimum of information from clients
• Non judgemental
• Information about the risks of injecting and safer
injecting practices
• May be the only point of contact with healthcare
professional
• Gateway to treatment services

22. Not just a supply but a means of safe
disposal of used injecting equipment

23. Specialist / Fixed Site IEPs
• Able to provide more in depth one to one
consultations around injecting drug use
• May offer advice and information around route
transition interventions i.e. encouraging people to
move away from injecting to alternative methods
of drug administration or prevent people from
injecting for the first time
• Some provide specialist services and offer
equipment that is tailored to type of injecting
behaviour e.g. intravenous - groin, intramuscular-
steroid, subcutaneous – melanotan!

24. Needle Replacement
• PNR is a planned harm reduction initiative for
Community and Secondary Addiction Services.
• It involves offering a basic needle pack as part of a
planned appointment to service users identified as
IDUs
• Packs must be offered in combination with safer
injecting advice & referral to pharmacy providers for
further supplies and to dispose of used equipment
• PNR exists alongside the pharmacy providers
• Service Users are free to use one or both of the
services.
• Offered in Addiction Teams, Sexual Health Services and
Police Stations

25. Other Substances of Misuse
• Over the last 5 years there has been a rise
in the range of substances people are
misusing:-
• Steroids
• Human Growth Hormone
• Melanotan
• Legal Highs

26. Steroid Clinic
• The 2009 ACMD report investigating the primary
prevention of Hep C among IDUs noted, “ it is important
to recognise the potential risk of HCV transmission among
people that inject performance & image enhancing drugs
such as anabolic steroids.”
• Glasgow clinic started in Feb 09.
• Clinic aim is to engage with steroid users and encourage
them to move from injecting to diet and exercise
• New needle packs specially designed to be more
acceptable for those who wish to continue injecting
• BBV, LFT, GFR, B.P testing carried out in addition to
providing information & educating users on risks of BBVs,
injecting complications, health and other risks associated
with steroids and their misuse
• Clinic worker directs users to their nearest pharmacy
provider so they can access clean needles more readily

28. Role of the Pharmacist

29. What can you do!
• Lord Advocate guidance now allows Injecting
Equipment Providers to provide as many needle
packs as a service user requires. No longer any limits
on the quantities of needle packs that can be given
out so please encourage people to take as many
packs as they need
• Encourage people to return used equipment to
pharmacy provider or fixed site
• Educate injectors on safer injecting practices.
• Provide information leaflets on safer techniques and
Treatment Services
• Highlight other health services the Pharmacy can
provide.

30. Safer Injecting Advice
• There is no completely safe way of injecting drugs
however if someone is going to inject there are ways
to reduce the risks involved and minimise harm
• Advice given should include:
• Wash hands and injection site with soap and water. If
there is no soap or water available then use a swab
• Find a clean preparation area
• Always use new works when preparing and injecting
drugs. This includes, a sterile syringe, a clean spoon or
cooker, sterile or boiled water, a sealed citric acid
sachet and a new clean filter.
• DO NOT SHARE OR REUSE ANY INJECTING
PARAPHERNALIA!!

31. Safer Injecting Advice Cont’d
• Good Injection Sites: arm, back of leg, ankle, back of
hand
• Bad Injection sites: neck, feet, groin, breasts, armpit
• Change injecting sites, gives veins a chance to heal
• Always inject towards the heart
• Never inject with a tourniquet on
• Inject slowly
• Apply pressure to injection site after injecting with a
clean paper towel for 5 minutes and wash hands.
• Dispose of all injecting equipment safely in a Sharpsafe
container and take to Pharmacy IEP

32. So to conclude, remember!
• Roughly 1,000 – 1,500 IDUs in Scotland are infected each
year with Hep C.
• At least 50% of injectors have problems with their skin
• Costs NHS £47M a year to treat injecting wounds!
• Do they need safer injecting advice?
• Do they need sterile injecting equipment?!!!!
• Do they need wound care?
• Do they need referred to a Clinician/ Treatment Service?
• Early identification, intervention and education can
reduce complications and prevent serious illness.

33. Useful References / Contacts
• Injecting Guidelines available on the Scottish Government
website www.scotland.gov.uk
• Hep C Action Plan - www.scotland.gov.uk
• Assessing the Scale & Impact of Illicit Drug Markets in
Scotland – www.scotland.gov.uk
• Shooting Up Report - www.hpa.org.uk
• NES Substance Misuse Package –
pharmacy@nes.scot.nhs.uk
• Scottish Specialist Pharmacists in Substance Misuse –
Contact Health Board for contact details