Time for a syringe standing order to prevent HIV and hepatitis C.

Reflections on pharmacy syringe sales for World AIDS Day 2024. A discussion of trends in syringe access and a call for state standing orders for syringes.
Time for a syringe standing order to prevent HIV and hepatitis C.
Like

Share this post

Choose a social network to share with, or copy the URL to share elsewhere

This is a representation of how your post may appear on social media. The actual post will vary between social networks

Explore the Research

BioMed Central
BioMed Central BioMed Central

Come back when you’re infected: pharmacy access to sterile syringes in an Arizona Secret Shopper Study, 2023 - Harm Reduction Journal

Background Pharmacies are critical healthcare partners in community efforts to eliminate bloodborne illnesses. Pharmacy sale of sterile syringes is central to this effort. Methods A mixed methods “secret shopper” syringe purchase study was conducted in the fall of 2022 with 38 community pharmacies in Maricopa and Pima Counties, Arizona. Pharmacies were geomapped to within 2 miles of areas identified as having a potentially high volume of illicit drug commerce. Daytime venue sampling was used whereby separate investigators with lived/living drug use experience attempted to purchase syringes without a prescription. Investigator response when prompted for purchase rationale was “to protect myself from HIV and hepatitis C.” A 24-item instrument measured sales outcome, pharmacy staff interaction (hostile/neutral/friendly), and the buyer’s subjective experience. Results Only 24.6% (n = 28) of 114 purchase attempts across the 38 pharmacies resulted in syringe sale. Less than one quarter (21.1%) of pharmacies always sold, while 44.7% never sold. Independent and food store pharmacies tended not to sell syringes. There emerged distinct pharmacy staff interactions characterized by body language, customer query, normalization or othering response, response to purchase request and closure. Pharmacy discretion and pharmacy policy not to sell syringes without a prescription limited sterile syringe access. Investigators reported frequent and adverse emotional impact due to pharmacy staff negative and stigmatizing interactions. Conclusions Pharmacies miss opportunities to advance efforts to eliminate bloodborne infections by stringent no-sale policy and discretion about syringe sale. State regulatory policy facilitating pharmacy syringe sales, limiting pharmacist discretion for syringe sales, and targeting pharmacy-staff level education may help advance the achievement of public health goals to eliminate bloodborne infections in Arizona.

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.

Citations

[i] Russell DM, Meyerson BE, Mahoney AN, Garnett I, Ferrell C, Newgass K, Agley JD, Crosby RA, Bentele KG, Vadiei N, Frank D, Linde-Krieger LB. Come Back When You’re Infected: Secret shopper study of pharmacy syringe sales in Arizona, USA 2023. BMC: Harm Reduction Journal 2024; 21(49).https://doi.org/10.1186/s12954-024-00943-w
[ii] Kerr T, Small W, Buchner C, Zhang R, Li K, Montaner J, Wood E. Syringe sharing and HIV incidence among injection drug users and increased access to sterile syringes. Am J Public Health. 2010 Aug;100(8):1449-53. doi: 10.2105/AJPH.2009.178467.
[iii] Compton WM. A multistate trial of pharmacy syringe purchase. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2004;81(4):661-670. doi:10.1093/jurban/jth149 
[iv] Meyerson BE, Davis A, Agley JD, Shannon DJ, Lawrence CA, Ryder PT, Ritchie K, Gassman R. Predicting pharmacy syringe sales to people who inject drugs: Policy practice and perceptions. Int J Drug Policy 2018; 56:46-53. doi: 10.1016/j.drugpo.2018.02.024
[v] Duwve J, Hoover K, Conrad C, Galang R, Hillman D, Hoots B, Patel M, Peters P, Pontones P, Roseberry J, Shields J. Community outbreak of HIV infection linked to injection drug use of oxymorphone–Indiana, 2015. African Journal of Reproduction and Gynaecological Endoscopy. 2015 Jul 1;18.
[vi] Gonsalves, GS, Crawford FW. Dynamics of the HIV outbreak and response in Scott County, IN, USA, 2011-15:A modeling study.  The Lancet HIV. 2018;5(10):569-577. doi:10.1016/s2352-3018(18)30176-0. 
[vii] Meyerson BE, Agley JD, Jayawardene W, Eldridge LA, Arora P, Smith C, Vadiei N, Kennedy A, Moehling T, and the PharmNet Research Team. Feasibility of a pharmacy-based harm reduction intervention to reduce opioid overdose, HIV and hepatitis C – Indiana, 2019. Res Soc Admin Pharm 2020; 16(5):699-709.https://doi.org/10.1016/j.sapharm.2019.08.026
[viii] Agley JD, Meyerson BE, Eldridge LA, Jun M, Vadiei N, Crosby, RA, Bentele, KG, Kennedy A, Anderson K. Exploration of pharmacist comfort with harm reduction behaviors: Cross-sectional latent class analysis.J Am Pharmacists Assoc, 2022; 62(2):432-440 https://doi.org/10.1016/j.japh.2021.10.015
[ix] Reich W, Compton WM, Horton JC, Cottler LB, Cunningham-Williams RM, Booth R, Singer M, Leukefeld C, Fink J, Stopka T, Corsi KF. Pharmacist ambivalence about sale of syringes to injection drug users. Journal of the American Pharmaceutical Association (1996). 2002 Nov 1;42(6):S52-7.
[x] Gionfriddo MR, Owens KM, Leist SE, Schrum LT, Covvey JR. Attitudes, beliefs, knowledge, and practices for over-the-counter syringe sales in community pharmacies: A systematic review. Journal of the American Pharmacists Association. 2023 Jul 8.
[xi] Meyerson BE, Agley J, Crosby RA, Bentele KG, Vadiei N, Linde-Krieger LB, Russell DR, Fine K, Eldridge LA. ASAP: A pharmacy-level intervention to increase nonprescription syringe sales to reduce bloodborne illnesses. Res Soc Adm Pharm 2024; https://authors.elsevier.com/a/1j3ll5WqpYUhyg
[xii] Crawford ND, Amesty S, Rivera AV, Harripersaud K, Turner A, Fuller CM. Community impact of pharmacy-randomized intervention to improve access to syringes and services for injection drug users. Health education & behavior. 2014 Aug;41(4):397-405
[xiii] Blankenship KM, Friedman SR, Dworkin S, Mantell JE. Structural interventions: concepts, challenges and opportunities for research. Journal of Urban Health. 2006 Jan;83:59-72.
[xiv] Eldridge LA, Agley JD, Meyerson BE. Naloxone availability and dispensing in Indiana pharmacies two years after implementation of a statewide standing order. J Am Pharm Assoc (2003) 2020; 60(3): 470-474. doi: 10.1016/j.japh.2019.11.024

Please sign in or register for FREE

If you are a registered user on Research Communities by Springer Nature, please sign in

Follow the Topic

HIV infections
Life Sciences > Health Sciences > Clinical Medicine > Diseases > Immunological Disorders > Immunological Deficiency Syndromes > HIV infections
Pharmacy
Life Sciences > Health Sciences > Pharmacy
HIV infections
Humanities and Social Sciences > Society > Sociology > Health, Medicine and Society > HIV infections
Medical Law
Humanities and Social Sciences > Law > Medical Law
  • Harm Reduction Journal Harm Reduction Journal

    This journal publishes research and commentary on approaches diminishing the harm of stigmatization, marginalization and criminalization of public health, human rights and social justice issues, as well as rebuking the de facto criminalization of marginalized and stigmatized communities.

Related Collections

With collections, you can get published faster and increase your visibility.

The Need for Intersectionality in Harm Reduction and Gender-Based Violence

This special collection of the Harm Reduction Journal focuses on the significance of intersectionality in advancing understandings of how to reduce gender-based violence and other harms in social issues such as alcohol use, gambling, tobacco, sex work, the internet, human enhancement drugs, psychoactive and addictive substances, incarceration, road trauma, youth justice issues, domestic and intimate partner violence, filicide, infanticide, parental exploitation, victims and perpetrators, and law enforcement.

Contributors are encouraged to explore diverse ways in which they have addressed these social issues, upholding human rights. This collection encourages contributors to think of intersectionality with specific emphasis on marginalised and vulnerable communities, such as people living with disability, gender and sexuality diversity, religious minorities, the young and the elderly and incarcerated individuals. Addressing intersectionality in the context of institutional responses, we encourage scholars, practitioners and academics from diverse disciplines to identify alternative ways of reducing harm through allied health professions such as occupational therapy, recreational therapy, and others, and people from criminal justice/criminology/law enforcement, social work, psychology/counselling, doctors, and nurses. We encourage submissions that speak to unconventional ways of addressing the issues either through co-designed research, methodological approaches, research findings etc.

This Collection supports and amplifies research related to SDG 3, Good Health and Well-Being, SDG 5, Gender Equality, SDG 10, Reduced Inequalities, and SDG 16, Peace, Justice and Strong Institutions.

All submissions in this collection undergo the journal’s standard peer review process. Similarly, all manuscripts authored by a Guest Editor(s) will be handled by the Editor-in-Chief. As an open access publication, this journal levies an article processing fee (details here). We recognize that many key stakeholders may not have access to such resources and are committed to supporting participation in this issue wherever resources are a barrier. For more information about what support may be available, please visit OA funding and support, or email OAfundingpolicy@springernature.com or the Editor-in-Chief.

Publishing Model: Open Access

Deadline: Aug 31, 2025

The Changing Face of Harm Reduction

Harm reduction has historically been thought of in relation to drug use and originally gained traction as a movement during the HIV/AIDS epidemic, where needle exchange programs were shown to reduce the transmission of the virus without necessarily reducing the level of injection drug use. Grassroots activism and an openness to the accounts of drug users caused the harm reduction movement to grow during the so-called “War on Drugs” and the opioid crisis in the US. Later, harm reductionists took aim at tobacco and alcohol. All these topics have been covered extensively by the Harm Reduction Journal since our founding in 2004.

It has become clear that the harm reduction philosophy should be applied to other types of public health issue where ineffective policies cause excessive harm to vulnerable populations. This collection seeks to compile Harm Reduction Journal’s best content on these new frontiers and encourage further discussion. All submissions will be reviewed by the Editor-in-Chief or Deputy Editor for their suitability to this collection and will then be assigned to the relevant Section Editor for review. Articles that do not fall into the sections outlined below are still encouraged and will be handled and included at the discretion of the Editor-in-Chief.

For more information on how articles on emerging topics will be handled by the journal, take a look at our Editorial Board or Contact Us for more information.

Edited by:

Professor Nick Crofts, AM, MB, MPH, FAFPHM, University of Melbourne, Australia, Editor-in-Chief

Public health is presented with a range of new challenges in emerging areas of importance and the success of the harm reductionist approach has encouraged research into other areas. As the sole public health journal that focuses exclusively on the harm reduction philosophy, Harm Reduction Journal is acutely aware of how the field is changing and is keen to encourage further growth. The internet, human enhancement, gambling, road trauma and sex work are all key areas where we hope to see more articles. Further to this, we are looking to elevate the voices of young people and AYAs, peers and people who use(d) drugs, those involved with the justice system, under-represented and vulnerable populations, and countries in the Global South (where harm reductionism has historically been less applied). Lastly, we are seeking broader perspectives on decriminalization and how this contributes to harm or harmful behaviours.

We have compiled some of the most impactful research from our open access archive to showcase these emerging themes and encourage further submissions. Our Section Editors are actively soliciting articles and would welcome any correspondence from potential authors looking to submit.

Following an initial assessment by the Editor-in-Chief or Deputy Editor, each manuscript will be assigned to the relevant Section Editor for review.

Section Editors for Drugs and the Internet

Angus Bancroft: University of Edinburgh, United Kingdom

Aleksey Lakhov: Humanitarian Action, Russia

Section Editor for Human Enhancement Drugs

James McVeigh: Manchester Metropolitan University, United Kingdom

Section Editor for Youth, Drugs and Harm Reduction

Danya Fast: University of British Columbia, Canada

Florian Scheibein: South East Technological University, Ireland

Section Editor for Gambling Harm Reduction

Michael Egerer University of Helsinki, Finland

Other suitable papers on emerging public health issues will be handled by the Editor-in-Chief or a relevant Associate Editor.

All submissions in this collection undergo the journal’s standard peer review process. Similarly, all manuscripts authored by a Guest Editor(s) will be handled by the Editor-in-Chief. As an open access publication, this journal levies an article processing fee (details here). We recognize that many key stakeholders may not have access to such resources and are committed to supporting participation in this issue wherever resources are a barrier. For more information about what support may be available, please visit OA funding and support, or email OAfundingpolicy@springernature.com or the Editor-in-Chief.

Publishing Model: Open Access

Deadline: Ongoing