Loren Bonner
Most pharmacists fully recognize the clinical benefits of providing OTC syringes to people who use drugs, particularly in reducing transmission of HIV and hepatitis C. But according to research findings from JAPhA published July 8, 2023, pharmacists may communicate this understanding while at the same time actively creating barriers to access in their practice settings, such as unfairly interrogating patients about their need for syringes or requiring extra steps to sell them syringes.
“If we’re following the evidence—and the law—these actions don’t make any sense,” said lead author Jordan R. Covvey, PharmD, PhD, associate professor of pharmacy administration at Duquesne University School of Pharmacy.
Covvey and fellow researchers conducted a systematic review of 1,895 potentially relevant studies regarding OTC syringe sales among community pharmacy staff. A total of 36 studies spanning the last 25 years were ultimately included.
After analyzing the studies, researchers found relatively high support among respondents for harm reduction–related services within community pharmacies, but less common reports of staff engaging in said services themselves. When studies investigated the perceived positive or negative impacts of OTC syringe sales, prevention of blood-borne illness was widely understood as a benefit, while improper syringe disposal and safety of the pharmacy and its staff were commonly reported as concerns.
Stigmatizing attitudes and beliefs toward people who inject drugs were prevalent across studies, said researchers.
“One major takeaway that I hope pharmacists can use from this study is a better understanding of how stigma against people who use drugs harms patient care,” said Covvey. “Pharmacy practice aims to take the best available evidence and translate it into clinical care. While traditionally this was focused on the use of medications, our roles have expanded over time into public health as well, given our accessibility within the community setting.”
Accessible health care
Effective tools, like sterile injection equipment, that reduce morbidity and mortality from opioid misuse and abuse are greatly underused due to funding issues, politics, laws, misinformation, and stigma, according to Covvey.
“Pharmacists have this tool [sterile injection equipment] stocked in their pharmacies, which we know are one of the most accessible health care settings nationally,” she said.
Covvey said pharmacists have the opportunity to provide tools for harm reduction as well as counseling, support, and connection with a health care professional.
“It’s important that pharmacists personally interrogate the attitudes and beliefs that cause them discomfort [when] engaging with people who use drugs,” Covvey said. “We don’t need to generate more barriers for a population of patients already marginalized by health care and society, but rather [to] engage in evidence-based harm reduction whenever possible.”
Limitations and strengths
Researchers were unable to provide pooled estimates of effect for any of the outcomes they assessed, mainly due to the variation in study designs and outcomes that were identified.
Also, they were not able to comment on cause-and-effects related to any of the attitudes, beliefs, and practices identified in the studies.
“Although the majority of the studies we assessed were quantitative in nature, what I think is a great strength of our analysis was our inclusion of qualitative studies as underlying context in the domains we assessed,” said Covvey.
“These studies are where I think pharmacists can learn a lot about how OTC syringe sales really happen within practice. For me, reading quotes from interviews really helped me understand the different thought processes pharmacists have on this subject.” ■
Harm-reduction services
The studies included in this systematic review described a variety of harm-reduction services and could serve as a starting point for pharmacists, including:
- Providing information on syringe disposal and safer injection drug use
- Selling or freely providing sharps containers
- Setting up a system for sharps disposal or needle exchange within the pharmacy
- Providing brief interventions and/or referrals to SUD treatment when appropriate
APhA’s 2019 policy regarding harm reduction associated with injection use
- APhA encourages state legislatures and boards of pharmacy to revise laws and regulations to support the patient-centered care of people who inject non-medically sanctioned psychotropic or psychoactive substances.
- To reduce the consequences of stigma associated with injection drug use, APhA supports the expansion of interprofessional harm reduction education in the curriculum of schools and colleges of pharmacy, postgraduate training, and continuing professional development programs.
- APhA encourages pharmacists to initiate, sustain, and integrate evidence-based harm reduction principles and programs into their practice to optimize the health of people who inject non-medically sanctioned psychotropic or psychoactive substances.
- APhA supports pharmacists’ roles to provide and promote consistent, unrestricted, and immediate access to evidence-based, mortality- and morbidity-reducing interventions to enhance the health of people who inject nonmedically sanctioned psychotropic or psychoactive substances and their communities, including sterile syringes, needles, and other safe injection equipment, syringe disposal, fentanyl test strips, immunizations, condoms, wound care supplies, pre- and post-exposure prophylaxis medications for human immunodeficiency virus (HIV), point-of-care for HIV and hepatitis C virus (HCV), opioid overdose reversal medications, and medications for opioid use disorder.
- APhA urges pharmacists to refer people who inject non-medically sanctioned psychotropic or psychoactive substances to specialists in mental health, infectious diseases, and addiction treatment; to housing, vocational, harm reduction, and recovery support services; and to overdose prevention sites and syringe service programs.