During my time as a community pharmacist in Maryland, I often encountered individuals who would approach the pharmacy in search of syringes. Although they would try to disguise their intentions by stating that they needed it for someone else or for an animal, it was apparent why they were there; they were going to use heroin, and they wanted clean syringes to prevent an infection. When I first encountered this scenario, I polled my colleagues to see what they thought about selling them. The response I received was varied. Some were in favor, stating the obvious public health benefits. Others were against, saying that it was illegal to do so. Further, some indicated that they needed to have a prescription for insulin. Why did I receive so many different responses? The answer: the law was ambiguous.
According to Maryland law, pharmacists can sell needles and syringes to patients who show proper identification and indication of need. This leaves significant room for interpretation, which is why my colleagues gave me different answers. In 2007 the state Board of Pharmacy voted to approve that the prevention of disease is an acceptable indication of need [PDF]. However, as demonstrated by my own experience, the language of the law continues to cause confusion even today.
The sale of nonprescription syringes should be widely available, and the laws should be explicit in their support of the practice. Unfortunately, the laws governing the sale of nonprescription syringes vary by state, with some more restrictive than others. This presents a significant challenge as we seek to prevent the spread of disease from injection drug use amidst a growing opioid epidemic.
The opioid epidemic is one of the most significant public health challenges the United States is facing. According to the Centers for Disease Control and Prevention (CDC), 115 Americans die every day from an opioid overdose, and the death toll continues to climb yearly.
Although much of the focus of the epidemic has been directed towards prescription opioids, heroin use is also on the rise. Indeed, the CDC estimates that its use has more than doubled among young adults over the last decade. Furthermore, according to the National Center for Health Statistics, the number of overdose deaths from heroin has risen from 3,036 in 2010 to 12,989 in 2015, a greater than 400% increase in 5 years.
Injection drug users (IDUs) increase their risk of contracting HIV, hepatitis, and other blood-borne infections when they engage in practices like sharing needles. The CDC estimates that 9% of HIV diagnoses were among IDUs in 2014. Although progress has been made in preventing disease through the use of interventions like needle exchange programs, the decline in HIV diagnoses has slowed and may be poised to increase once again. In fact, the country is already seeing this occur with hepatitis. Between the years of 2010 and 2015, there was a 294% increase in hepatitis C [PDF] incidence among IDUs. Fortunately, this trend can be reversed by expanding access to clean syringes — and pharmacies may be just the place to do it.
Expanding access to syringes sales and/or exchanges at pharmacies has several advantages. Pharmacies are conveniently located and have convenient hours. In many locations, they may even be the only site available for someone to purchase clean syringes. They are also staffed by pharmacists, who can play a meaningful role in educating IDUs about safe injection practices and directing them towards other services, like substance abuse treatment. However, before states can begin leveraging the potential of their pharmacies, they need to update their laws.
A review of the topic identifies several areas to be addressed when considering expanding access to nonprescription sales of needles. From the IDUs’ perspective, the laws need to decrease barriers to purchase. This includes allowing them to purchase syringes in small quantities and removing requirements that demand proof of medical need or identification. From the pharmacists’ perspective, the laws need to be unambiguous, as ambiguity decreases the likelihood of the sale. Laws should be specific about what pharmacists are allowed to do. Ideally, sales of syringes should be accompanied by additional resources, such as assistance with needle disposal and continuing education in harm reduction.
For an example of successful policy, states can look to California. In 2005, the state implemented a law that allows pharmacies to sell syringes without a prescription while also removing barriers to sale. A survey conducted in San Francisco, a year after the law took effect, evaluated pharmacists’ perspectives. The majority of pharmacies who participated reported none or very few problems with the sale of syringes. Most of them also reported accepting used syringes, with 67% collecting more than 400. Another study evaluating pharmacy participation in Los Angeles and San Francisco demonstrated that 42% of pharmacies participated in syringe sales, with more than 13 thousand sold between the two cities.
These results demonstrate the feasibility of including pharmacies in efforts to increase access to clean syringes and the importance of changing our laws to support the practice. Pharmacies have an essential role to play in the opioid epidemic, from the provision of naloxone to the sale of clean syringes. However, to do so, they must first have the support of the law. If we do not act to update our laws, we risk leaving injection drug users vulnerable to infection and adding an additional layer of complexity to the opioid epidemic as we struggle to care for patients who acquire these severe infections. Through pharmacies, states can begin to increase access to clean syringes in more communities, including those without access to exchange programs, and prevent the spread of disease.