1. NICE Guidance on Needle and Syringe Programmes: Providing Injecting Equipment to People who Inject Drugs. Professor Mike Kelly, PhD, FFPH. Director, The Centre for Public Health Excellence, NICE

2. Public Health at NICE At NICE the Centre for Public Health Excellence develops public health guidance. Established 2005 31 staff based in London and Manchester, plus collaborating centres based in Sheffield, Birmingham, Exeter, London, Oxford, Liverpool and York

3. Methodological Principles

4. Methodological principles governing all NICEs work Base recommendations on the best available evidence. To determine cost effectiveness using the QALY. To be open and transparent and to involve stakeholders. To be clear about scientific and other values To allow contestability. To be seen to be independent of government, the pharmaceutical industry and other vested interests.

5. Origins of this referral NICE does not choose the topics it works on these are determined by Ministers and Officials. Prevention of infection of blood borne viruses. To consider optimal provision.

7. Stages in the production of guidance Scope drafted. Public stakeholder meeting. Stakeholder comments received. Final scope and responses published on the website. Reviews of evidence undertaken. Public Health Interventions Advisory Committee (PHIAC) reviews the evidence and drafts recommendations. Draft recommendations published on the website and stakeholders asked to comment. PHIAC meets to consider stakeholder comments and evidence from fieldwork. Publication.

9. Background 115,000 - 200,000 injecting drug users (IDUs) in England 23% of IDUs report recently sharing needles Over 40% of IDUs are Hepatitis C positive IDUs are ten times more likely to die prematurely than the rest of the population In 2006, over 1400 deaths were linked to controlled drugs

10. Scope The optimal provision of needle exchange and syringe programmes (NSPs) for people who inject illicit substances and non-prescribed anabolic steroids Majority of NSPs are run by pharmacies and drug services Some NSPs offer other services such as help to stop taking drugs This guidance refers to people of 18 years and older

11. Recommendations

12. Aims

13. To reduce the transmission of blood borne viruses and other infections. To get people into treatment. To help them get off drugs. To provide advice on safer injecting practices. To help avoid overdoses. Safe disposal. Access to testing, vaccination and treatment. Access to other welfare services.

14. Audiences NHS and other professionals with direct responsibility for NSPs. Drug and alcohol action teams. Pharmacies Local authorities. Voluntary and community sector.

15. Target population People over the age of eighteen who inject drugs, opioids, stimulants or in conjunction. The guidance also applies to people injecting anabolic steroids and image enhancing drugs.

16. Needs assessment Collect and analyse data locally on: –Prevalence and incidence of drug related infections; –Demographics of users; –Coverage; –Injectors in contact with NSPs. Make sure services meet local need. Consult users and communities.

17. Commission services which: Are targeted and generic and –Increase the proportion of people who have 100% coverage; –Increase proportion of people in touch with services; –Ensure syringes and needs are available in a range of sizes and locations; –Offer advice; –Encourage people to stop or switch to non- injecting methods.

18. Commissioning (cont) Deal with safe disposal. Encourage identification schemes. Commission integrated care pathways. Audit and monitor services.

19. Levels of service and availability Levels –Distribution of equipment. –Bespoke equipment and health promotion. –As above with access to specialist services. Co-ordinate maximum opening availability. Ensure that opioid substitution services also offer needles and syringes.

20. Equipment and advice Provide adequate amounts of equipment to reflect need. Provide sharps bins. Ensure safer injecting advice is available. Ensure that the hazards of using long needles are made clear. Encourage people to switch to other methods of use. Encourage people to mark their syringes. Encourage them to stop.

21. In the community

22. Provide sharps bins. Ensure staff receive appropriate training in health and safety. Ensure staff doing levels 2 and 3 have training in doing health promotion. Ensure that Hepatitis B vaccination is available for staff.

23. Specialist services

24. Provide sharps bins. Have appropriate training. Provide the full range of equipment. Offer comprehensive harm reduction services. Offer help. Opioid substitution therapy. Treatment of site infections. Hep A and B and tetanus vaccinations. Testing for Hep B and C and HIV.

25. Economics Cost effective use of resources. Savings to both the NHS and wider society.

26. Evidence based Reductions in risky behaviour. Reductions in HIV infection. Reduction in A&E admissions. Reduction in risky injecting practices. Reduction in incidence of Hep C. The reductions in HIV cost effective.

27. Find out more Visit www.nice.org.uk/PH18 for the:www.nice.org.uk/PH18 –guidance –quick reference guide –Costing statement and costing template –audit support –local authority planning checklist –factsheet for commissioners

28. Conclusion

30. First come I; my name is Jowett. Theres no knowledge but I know it. I am master of this college: What I dont know isnt knowledge. The Masque of Balliol Revd. H.C. Beeching

32. It is very important not to get stuck in a very narrow interpretation of what evidence based public health means. Must not fall into the trap of assuming the evidence speaks for itself…

33. Because All evidence requires interpretation. Absence of evidence of effect does not necessarily mean there is no effect. Strong evidence of effect may not relate to the important issue. So….

34. Interpreting the evidence of complex interventions requires an assessment of: Plausibility: a scientific assessment – biologically, organizationally, socially, psychologically. Likelihood of success: the nature of local conditions married to tacit knowledge of practitioners

35. And it is therefore important to: Embrace a range of evidence Evidence from trials and from other sources of systematic investigation Evidence from practice