Sometimes the simplest things are hard. Apologies. Those are hard. What makes them hard, I think, is that we must face the person we have wronged. Power and healing are possible in this physical interface. But it is also here, in this space, that disenfranchisement and exclusion occur. This is what field researchers experienced in 2022 during the study Come back when you’re infected:Secret shopper study of pharmacy syringe sales in Arizona, USA 2023.[i]
For World AIDS Day 2024, I am thinking about community pharmacies. I’m a fan of them. I’m a fan of pharmacy staff because they work hard and in working conditions more recently resembling production lines--- a far cry from the careers my pharmacy students envision for themselves. Community pharmacies backstop for our maldistributed U.S. health system. I see it every day with pharmacy-based vaccination.
But here’s the irony: in this health-related space, deleterious outcomes can result from the physical interface of pharmacy staff and pharmacy customer. Not with all customers. Just some customers. What begins as a usual positive pharmacy exchange and greeting turns negative when a customer seeks a product that will protect their health by reducing risk of infection and death. One could split hairs over ‘who is a pharmacy customer?’ but I would suggest that anyone walking into a pharmacy is a customer whether they have a prescription or not.
Buying sterile syringes in pharmacies is hard, even when the rationale is clearly stated as prevention of hepatitis C, HIV or skin and soft tissue damage. This is what field researchers explicitly told pharmacy staff in 2022 when asked why they were seeking to purchase syringes without a prescription. They said, “To protect myself from hepatitis C and HIV.” What was difficult for field researchers, all of whom had lived drug use experience, was the moment of interface between pharmacy staff and them as buyer. The socio-emotional impact of the moment was itself bad, and it had an echo from past refusals for these researchers. Such an echo can forever degrade a person’s future resolve to seek such an important prevention tool.
This is happening now and likely all over the country. In 75% of pharmacies in Arizona (where I live) you will be greeted as a customer at first; but after your request is known, you will no longer be seen. Yes, you will be in the presence of another human (the pharmacy technician or, by hand off, the pharmacist)….but you won’t truly be seen. Your health won’t be seen. Your desire to protect your health by purchasing what will keep you safer will be met with silence. Funny thing, it is not about the money. People are not asking pharmacies to give them syringes for free. They are asking to buy them.
Findings in this published Arizona study is not so different from the situation in other states. In fact, despite years of evidence that sterile syringes prevent HIV and hepatitis C transmission,[ii] it has become increasingly more difficult to purchase syringes without a prescription in pharmacies. We have observed that over the years, fewer pharmacies are dispensing syringes without a prescription. For example, in 2004, 65% of pharmacies in 4 states dispensed syringes without a prescription.[iii] Ten years later, an Indiana study found that 51% of pharmacies dispensed syringes without a prescription.[iv] In that same state, one year later, an HIV outbreak among people who injected drugs occurred – the most significant HIV outbreak in the U.S. in decades.[v] The human impact could have been avoided were syringes widely available at community level.[vi] And yet, after that outbreak, a huge decrease was observed in Indiana: only 29% of pharmacies reported dispensing syringes without a prescription.[vii] Indiana’s experience is unfortunately not unique. In Arizona, 43% of pharmacies dispensed syringes between 2016-2018,[viii] but only 25% dispensed them in 2022.1
We are not really sure why this is the case, but we know that syringe sales refusal is grounded in stigmatization of people who use drugs and of drug use.[ix],[x] Several of us in the research community have focused on changing pharmacy staff beliefs, attitudes, practices and thereby pharmacy culture around dispensing syringes without a prescription. We work on this by developing and testing pharmacy-level interventions to increase nonstigmatized syringe sales.[xi],[xii] While findings from these behavioral and/or socio-educational studies are promising, they are a drop of water in an ocean of need.
Access to syringes at community level is an example of a structural public health intervention.[xiii] Communities across the country have expanded community-based syringe access programs, and this is a huge help, especially when accompanied by state law decriminalizing syringe possession. However these programs are necessary but not sufficient, because they are not well funded and not located everywhere. The ubiquity of pharmacies is a key to their public health importance for the reduction of HIV and hepatitis C. Structural interventions are needed to ensure community-level access.
Our Arizona syringe buy study pointed to the need for better and more systemic solutions. Solutions that would be structural, such as state standing orders for syringes. A standing order is a prescription order issued by the state’s chief medical officer or physician commissioner of health allowing pharmacies to dispense something under the order (prescription). This usually occurs in response to public health emergency or to a major health issue fueled by lack of health access. A tremendously successful example is naloxone, the medication that reverses opioid overdose. We have found that standing order prescriptions for naloxone have increased pharmacy naloxone stocking and dispensing.[xiv] This is the case even with naloxone’s high cost.
We could do the same to ensure access to sterile syringes. One might argue, however, that syringe decriminalization and laws allowing pharmacies to dispense syringes without a prescription may be better solutions. Theoretically yes, but Arizona’s experience would suggest otherwise. Arizona is a state whose law is silent about pharmacy syringe sales to people above the age of 17. We also decriminalized syringe possession in 2021 which allowed syringe service programs to operate with impunity. But these two legal realities did not change pharmacy behavior as found in our 2022 study. In this study, syringe buyers were repeatedly asked this question: Do you have a prescription?
We need to localize discussion of ideas for change because public health is the jurisdiction of states and territories. There is power in that conversation because we are talking with our neighbors and about life in our own communities. While this is hard because we face people we know (just like with apologies), there is power and potentially healing there. We have seen this happen in Arizona around several policy issues of importance to us.
So as we consider our world on this 2024 World AIDS Day, think about how we can – together with others in our own communities --- call for solutions such as a state standing order for syringes. This particular solution is both feasible and grounded in public health science and need. It is about time we ensure one structural intervention (community level syringe access) with another (state law and policy). We can do this. We just must face one another first.
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