Who Buys Syringes

Who Buys Syringes

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Objectives: Laws limiting access to sterile syringes impede the public health goal that injection drug users (IDUs) use a new, sterile syringe for every injection to reduce blood-borne disease transmission. We sought to determine the legality of selling or giving syringes to IDUs to prevent disease.

Design: We used standard legal research methods to identify and analyze laws and regulations influencing the distribution of syringes in the 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands.

Conclusion: Syringe access laws in most states may reasonably be interpreted to allow pharmacists to sell syringes to IDUs to prevent disease. In practice, however, unclear laws and pharmacist uncertainty as to their interpretation may constitute continuing barriers to syringe access for IDUs. A comprehensive public policy of ensuring syringe access for IDUs requires eliminating legal barriers to the sale, possession, and disposal of syringes, and educating pharmacists and law enforcement officials about the legality and public health importance of sterile syringe access.

This study was approved by the NYSDOH Institutional Review Board. Customers purchasing nonprescription syringes between March 2006 and January 2007 were told their purchase qualified them for a survey. Participants received a $10 pharmacy gift certificate.

Pharmacies, practitioners, and health care facilities that have been certified by the NYSDOH to sell or furnish new, sterile syringes through ESAP are listed by county and sorted in zip code order. Providers are encouraged to photocopy and share these listings with clients and customers to promote risk reduction. Safe disposal of residential sharps are encouraged to be photocopied and shared, as well. Please visit the New York State Safe Sharps Collection Program section.

This law, passed by the Minnesota State Legislature, began July 1, 1998. Since then, persons are able to purchase up to 10 new syringes/needles without a prescription at pharmacies that voluntarily participate with this initiative in Minnesota.

An evaluation was completed to assess the impact the syringe access initiative had on: needle sharing practices; syringe disposal practices; access to syringes; and, syringe sales at participating pharmacies.

The evaluation showed that pharmacy-based syringe purchases increased significantly while the sharing of syringes between PWID decreased during the initiative. There was no change in the frequency of safe disposal of the syringes as a result of the initiative.

Ingles CFO, Ron Freeman, said the company follows all state and federal rules regarding syringes sales but did not respond to questions about what actual policies its pharmacy staff follow in its North Carolina stores.

At Cochrane-Ridenhour Drug Co. in Montgomery County, a pharmacist, who declined to give his name, explained that the store does sell syringes over the counter without restrictions, but requested that information not be publicized.

This predicament has led some in the field to argue that rather than advocating for pharmacies to improve their syringe sale policies, resources should be focused on creating partnerships between pharmacies and syringe service programs. The service has been legal in North Carolina since 2016 and provides free syringes to anybody who wants them.

Buying syringes from pharmacies also places people who use drugs in a complicated legal situation. In North Carolina, people have to prove that they received their syringes from a syringe exchange program in order to receive immunity from prosecution under drug paraphernalia laws. People can be charged for having syringes bought from a pharmacy. Other states, such as Oregon, fully exempt needles and hypodermic syringes from its drug paraphernalia law, regardless of where they come from.

Sterile syringe access is a critical component of HIV prevention programs. Although retail pharmacies provide convenient outlets for syringe access, injection drug users (IDUs) may encounter barriers to syringe purchase even where purchase without a prescription is legal. We sought to obtain an objective measure of syringe access in Tijuana, Mexico, where IDUs report being denied or overcharged for syringes at pharmacies.

Only 46 (28.4%) of 162 syringe purchase attempts were successful. Leading reasons for unsuccessful attempts were being told that the pharmacy didn't sell syringes (35.3%), there were no syringes in stock (31.0%), or a prescription was required (20.7%). Of 136 pharmacies also surveyed by telephone, a majority (88.2%) reported selling syringes but only one-third (32.5%) had a successful mystery shopper purchase; the majority of unsuccessful purchases were attributed to being told the pharmacy didn't sell syringes. There was similar discordance regarding prescription policies: 74 pharmacies said in the telephone survey that they did not require a prescription for syringes, yet 10 of these pharmacies asked the mystery shopper for a prescription.

IDUs in Tijuana have limited access to syringes through retail pharmacies and policies and practices regarding syringe sales are inconsistent. Reasons for these restrictive and inconsistent practices must be identified and addressed to expand syringe access, reduce syringe sharing and prevent HIV transmission.

Injection drug users (IDUs) are at high risk of infection with HIV, hepatitis C (HCV) and other blood-borne pathogens transmitted by sharing syringes and other injection equipment. Globally, almost 20% of the world's 15.9 million IDUs are infected with HIV [1] and in some studies HCV prevalence among IDUs is >90% [2].

Transmission of these pathogens can be prevented by eliminating syringe sharing among IDUs. This requires that sterile syringes be available at appropriate times and in sufficient quantities to supply a sterile syringe for each injection. In most settings, IDUs' avenues for obtaining sterile syringes are limited to syringe exchange programs (SEPs) and pharmacies. SEPs have proven effective in reducing syringe sharing [3], but the number of these programs - and the overall number of syringes they distribute - is not sufficient to provide IDUs with a sterile syringe for each injection. In Latin America, for example, only 5 of 20 countries are known to have implemented SEPs, which serve only approximately 2% of the region's IDUs [4].

Pharmacies can provide a more comprehensive and convenient source of syringes for IDUs, as they generally exceed SEPs in number of locations and hours of operation. In some areas, however, pharmacy-based syringe access is hampered by laws requiring a prescription for purchase. Allowing purchase without a prescription has been shown to increase the number of syringes sold and reduce sharing among IDUs. In the United States, for example, where syringe access laws vary by state, Connecticut and Minnesota saw substantial increases in the number of IDUs who reported pharmacy purchase of syringes and decreases in syringe sharing following repeal of syringe prescription laws [5, 6]. Similarly, in New York City, an Expanded Syringe Access Demonstration Program (ESAP) was associated with a significant increase in the proportion of IDUs who obtained syringes from pharmacies, and these IDUs were less likely than others to report syringe sharing [7].

In Mexico, where syringe purchase without a prescription is also legal, IDUs report being refused or overcharged for syringes at retail pharmacies and link these refusals directly with syringe sharing [13, 14]. In Tijuana, a northwestern Mexico border city adjacent to San Diego, California, 59% of IDUs report receptive syringe sharing in the past 6 months and HCV prevalence is 96% [15, 16]. HIV prevalence among Tijuana's male IDUs, female IDUs and female IDUs who engage in sex work is 4%, 10%, and 12%, respectively [17, 18] and as many as one in 125 persons aged 15-49 in the city are estimated to be HIV-positive [19]. We undertook this study to obtain an objective measure of barriers to pharmacy-based syringe purchase among IDUs in Tijuana and assess the need for pharmacy-based HIV prevention interventions.

Between September 2009 and February 2010, the same pharmacies were contacted by telephone by a female project staffer. The person who answered the phone was asked whether they sold 1 cc insulin syringes and, if so, how much they cost and whether a prescription was required for purchase. These data were recorded on a standardized form and entered into the same Excel database for analysis. Although the telephone survey was conducted after the mystery shopper visits were completed, the mystery shopper study and its results had not yet been shared with health departments, pharmacy associations or pharmacy staff; therefore, the risk of the telephone survey responses being influenced by knowledge of the mystery shopper data collection was minimal.

Data from mystery shopper purchase attempts were tabulated to determine the percentage of successful syringe purchases and reasons for failed purchases. We also identified factors associated with purchase outcome by comparing the characteristics of successful versus unsuccessful purchase attempts using Wilcoxon rank-sum tests for continuous variables and the Pearson's chi-square test for categorical variables. Data from the telephone survey were similarly tabulated to determine the percentage of pharmacies that reported selling syringes and the percentage that required a prescription for purchase. These results were then compared with data from the mystery shopper purchase attempts to identify discrepant findings.

Only 46 (28.4%) of the 162 eligible mystery shopper purchase attempts were successful. The median price per syringe purchased was 7 pesos (IQR: 5-10). Table 1 compares the characteristics of successful and unsuccessful purchase attempts. There were no statistically significant differences between the pharmacies where syringes were successfully purchased and