More than Just Needles: an evidence-informed approach to enhancing harm reduction supply distribution in British Columbia Canadian Public Health Association Meeting June 2008 Jane Buxton Emma Preston, Sunny Mak, Stephanie Harvard and HR committee

Outline Background What is Harm Reduction (HR)? Current HR supplies in BC Methods Mapping product distribution using GIS Qualitative interviews Results What can we do with this information? Future directions and recommendations

Background The BC Harm Reduction Strategies and Services (HRSS) committee Representation for each regional health authority (5), the BC Ministry of Health, FNIH & BCCDC The BC HRSS policy states that: Each health authority and their community partners will provide a full range of HR services to their jurisdiction HR products should be available to all who need them, regardless of where they live and choice of drug Are we there yet?

Background Current Supply list includes varieties of: condoms lubricants needles and syringes alcohol swabs sterile water vials > 150 ordering sites in BC Preliminary analysis revealed wide variations between and within HAs

The objective of this study is to: 1) Analyze distribution of HR products by site using geographic information systems (GIS) 2) Investigate the range, adequacy and methods of HR product distribution using qualitative interviews

Methods Supply Distribution The BCCDC pharmacy database tracks HR supplies distributed to health units and community agencies A 19 month period (May November 2007) was used to ensure inclusion of sites that placed infrequent orders Distribution of HR supplies were calculated All needles (with or without syringe) were collated to produce the total volume of needles distributed Data was analyzed using GIS.

Methods Qualitative Interviews Eleven face-to-face interviews were conducted in eight mainland BC communities: Included outside Vancouver Used an open-ended questionnaire Questionnaire domains included:  How HR supplies are distributed  Perspectives on the adequacy of current HR products  Collection of used needles  Alternative uses of supplies  Perceived community buy-in Themes were identified using standard iterative methods Results were discussed with HRSS committee

Results Supply Distribution

Results Qualitative Interviews How are HR supplies distributed? How supplies were made available: Privacy: separate rooms, brown paper bags One-for-one needle exchange vs. needs based distribution Clients required to ask for all supplies, place order in advance, basket at reception desk Degree of client engagement Referrals to detox, blood borne pathogen/STI testing Secondary distribution First Nations communities Sex trade workers Groups of IDUs

Results Qualitative Interviews Perspectives on the adequacy of Harm Reduction products Male condoms available at each site Lubricated were generally preferred (~5:1) Younger clients preferred flavoured Female condoms not widely used Highest distribution where actively engaged and educated the women Needles and syringes Most clients use 0.5 or 1 cc syringes with needles attached Larger syringes likely used for injecting steroids Water vials Generally, clients are not using sterile water for every injection One site no vials- no one asked for them Additional requests include: Injection: cookers, filters, tourniquets, sharps containers Miscellaneous: brown paper bags, drinking water Crack use: pipes, mouthpieces, screens

Results Qualitative Interviews Collection of used needles All sites reported encouraging clients to return used needles Only one site reported trying to ensure one-for-one exchange Some sites provided clients with individual sharps containers Yellow biohazard container, empty rigid shampoo bottles Requested that they be returned to the provider site when full

Results Qualitative Interviews Alternate uses of HR supplies Condoms Non-lubricated as tourniquets Used by crack smokers to hold exhaled smoke to share or inhale it ‘for a second take’ Water balloons Unusual use of female condoms and Lube Syringes Plungers used as a pusher for crack pipes to recover crack resin dried on the inside of the pipe as it cools ~ 1 in 5 syringes used for this purpose as reported by Vancouver front line staff

Results Qualitative Interviews Community buy in and readiness Participants reported few community development initiatives regarding HR or pick-up of discarded needles Perception that the HR philosophy is new to many healthcare workers and the general public Some interviewees felt their community was ripe to hear the messages because ‘there’s been a few drug related tragedies [recently]’

What have we learned? There is evidence in BC that HR supplies are not equally available throughout the province. GIS illustrates where availability of HR supplies may be lacking With secondary distribution, true reach and availability of supplies cannot be determined Variations within jurisdictions First Nations communities No official HR distribution on First Nations reserves Several barriers to comprehensive HR services

Where do we go from here? ‘Understanding Harm Reduction’ health file developed Health file re: ‘needle distribution vs. exchange’ in development News letter strategies A consultant employed to develop a ‘best practice’ document Development of standard training and protocols within HAs Staff to give HR advice and referrals for services and testing Increase client awareness and engagement Enhance profile and availability of culturally appropriate HR services for Aboriginal populations Improve 2 nd distribution date collection Crack pipe mouthpieces and wooden push sticks are now available and distribution is being explored at local level Different sizes of needles being rationalized Single distributor being explored; acceptability of needles

With thanks to: The interviewees who provided their valuable time, experience, and insights Funding for this study was provided through the BC harm reduction budget

QUESTIONS???