Canadian Public Health Association Meeting June 2008 Jane Buxton Jane.Buxton@bccdc

1. More than Just Needles:an evidence-informed approach to enhancing harm reduction supply distribution in British Columbia Canadian Public Health Association Meeting June 2008 Jane BuxtonJane.Buxton@bccdc.ca Emma Preston, Sunny Mak, Stephanie Harvard and HR committee

2. Outline • Background • What is Harm Reduction (HR)? • Current HR supplies in BC • Methods • Mapping product distribution using GIS • Qualitative interviews • Results • What can we do with this information? • Future directions and recommendations

3. Background • The BC Harm Reduction Strategies and Services (HRSS) committee • Representation for each regional health authority (5), the BC Ministry of Health, FNIH & BCCDC • The BC HRSS policy states that: • Each health authority and their community partners will provide a full range of HR services to their jurisdiction • HR products should be available to all who need them, regardless of where they live and choice of drug Are we there yet?

4. Background • Current Supply list includes varieties of: • condoms • lubricants • needles and syringes • alcohol swabs • sterile water vials • > 150 ordering sites in BC • Preliminary analysis revealed wide variations between and within HAs

6. The objective of this study is to: • 1) Analyze distribution of HR products by site using geographic information systems (GIS) • 2) Investigate the range, adequacy and methods of HR product distribution using qualitative interviews

7. MethodsSupply Distribution • The BCCDC pharmacy database tracks HR supplies distributed to health units and community agencies • A 19 month period (May 2006 - November 2007) was used to ensure inclusion of sites that placed infrequent orders • Distribution of HR supplies were calculated • All needles (with or without syringe) were collated to produce the total volume of needles distributed • Data was analyzed using GIS.

8. MethodsQualitative Interviews • Eleven face-to-face interviews were conducted in eight mainland BC communities: • Included outside Vancouver • Used an open-ended questionnaire • Questionnaire domains included: • How HR supplies are distributed • Perspectives on the adequacy of current HR products • Collection of used needles • Alternative uses of supplies • Perceived community buy-in • Themes were identified using standard iterative methods • Results were discussed with HRSS committee

9. Results Supply Distribution

10. ResultsQualitative Interviews How are HR supplies distributed? • How supplies were made available: • Privacy: separate rooms, brown paper bags • One-for-one needle exchange vs. needs based distribution • Clients required to ask for all supplies, place order in advance, basket at reception desk • Degree of client engagement • Referrals to detox, blood borne pathogen/STI testing • Secondary distribution • First Nations communities • Sex trade workers • Groups of IDUs

11. ResultsQualitative Interviews Perspectives on the adequacy of Harm Reduction products • Male condoms available at each site • Lubricated were generally preferred (~5:1) • Younger clients preferred flavoured • Female condoms not widely used • Highest distribution where actively engaged and educated the women • Needles and syringes • Most clients use 0.5 or 1 cc syringes with needles attached • Larger syringes likely used for injecting steroids • Water vials • Generally, clients are not using sterile water for every injection • One site no vials- no one asked for them • Additional requests include: • Injection: cookers, filters, tourniquets, sharps containers • Miscellaneous: brown paper bags, drinking water • Crack use: pipes, mouthpieces, screens

12. ResultsQualitative Interviews Collection of used needles • All sites reported encouraging clients to return used needles • Only one site reported trying to ensure one-for-one exchange • Some sites provided clients with individual sharps containers • Yellow biohazard container, empty rigid shampoo bottles • Requested that they be returned to the provider site when full

13. ResultsQualitative Interviews Alternate uses of HR supplies • Condoms • Non-lubricated as tourniquets • Used by crack smokers to hold exhaled smoke to share or inhale it ‘for a second take’ • Water balloons • Unusual use of female condoms and Lube • Syringes • Plungers used as a pusher for crack pipes to recover crack resin dried on the inside of the pipe as it cools • ~ 1 in 5 syringes used for this purpose as reported by Vancouver front line staff

14. ResultsQualitative Interviews Community buy in and readiness • Participants reported few community development initiatives regarding HR or pick-up of discarded needles • Perception that the HR philosophy is new to many healthcare workers and the general public • Some interviewees felt their community was ripe to hear the messages because ‘there’s been a few drug related tragedies [recently]’

15. What have we learned? • There is evidence in BC that HR supplies are not equally available throughout the province. • GIS illustrates where availability of HR supplies may be lacking • With secondary distribution, true reach and availability of supplies cannot be determined • Variations within jurisdictions • First Nations communities • No official HR distribution on First Nations reserves • Several barriers to comprehensive HR services

16. Where do we go from here? • ‘Understanding Harm Reduction’ health file developed • Health file re: ‘needle distribution vs. exchange’ in development • News letter strategies • A consultant employed to develop a ‘best practice’ document • Development of standard training and protocols within HAs • Staff to give HR advice and referrals for services and testing • Increase client awareness and engagement • Enhance profile and availability of culturally appropriate HR services for Aboriginal populations • Improve 2nd distribution date collection • Crack pipe mouthpieces and wooden push sticks are now available and distribution is being explored at local level • Different sizes of needles being rationalized • Single distributor being explored; acceptability of needles

17. With thanks to: • The interviewees who provided their valuable time, experience, and insights • Funding for this study was provided through the BC harm reduction budget

19. QUESTIONS???