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Needles and hearts


Pharmacy-based needle exchange programmes – a gamble into the unknown?

Brian Edwards
Emeritus Professor of Healthcare Development
University of Sheffield

Former President
HOPE (European Hospital and Healthcare Federation)
Brussels, Belgium

Pharmacy-based needle exchange programmes are now common in Europe but are not expanding at the rate some predicted. Needle exchange started in the 1980s as a public health intervention to limit the spread of HIV infection. Exchange implies changing old needles for new ones although in some countries this requirement appears to have been dropped. These programmes appear to work and the evidence seems to suggest that they do not stimulate increased drug use. An international review by the World Health Organisation confirmed their effectiveness.

Limiting the spread of Hepatitis C virus has been added to the public health agenda in recent years but some experts
think that the current level of needle exchange is not enough to contain it. Evidence from the US suggests that one-fifth
of all new HIV infections and the vast majority of Hepatitis C infections are the result of injection drug use.

The community pharmacist can add counselling and support to clients using the exchange so they are considered a valuable vehicle. They are almost certainly better than vending machines trialled in Australia (although they did seem to have some value).There is however a number of barriers to further expansion and these were explored in a recent UK study funded by the Pharmacy Practice Research Trust.[1] Remuneration is clearly an issue but so is fear for the safety of staff from a client group that can be unpredictable. Interestingly, the supply of methadone appears to be more attractive financially and produces less trouble from clients. Well-trained staff experience fewer problems from clients and are confident in dealing with the client group.

The larger high-street pharmacies have not been prominent in needle exchange programmes and there may be a link with staff reward. The staff take the risk and the company gets the reward. Many injection drug users are of course unidentifiable in the pharmacy and do not fit the stereotype of a junkie. Adequate funding that provides for investment in training would seem to be the key.

In a recent ruling the European Commission (EC) has given the French government permission to invest EU33 million in an attempt by a group of private companies led by Carmat, to develop an artificial heart that is fully implantable together with the associated electrical supply and telediagnostic systems. The programme will focus on patients suffering from advanced heart failure who cannot undergo transplantation and who have exhausted all the available options regarding drug treatment. The implantable Carmat heart will be cheaper than transplantation. The EC explains that the free market would never provide the spontaneous investment needed in what is a high-risk venture with a very uncertain outcome. Given the recent world banking crisis, letting governments undertake high-risk ventures will raise some eyebrows. What next an EU multibillion Euro initiative to develop new antibiotics?

Like the economic justification for spaceships to the moon there might be important scientific spin-offs for French industry. It might turn out to be a profitable gamble with public money… but gamble it is.

1. Pharmacy Practice Research Trust. Why is pharmacy-based needle exchange failing to expand and how can this be
overcome. Jenny Scott. University of Bath.

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