Best practice recommendations: development, evidence, community collaboration and uptake by needle exchanges

1. Best practice recommendations: development, evidence, community collaboration and uptake by needle exchanges Carol Strike PhD Senior Scientist, Centre for Addiction and MentalHealth Associate Professor, Dalla Lana School of Public Health

2. Team members • Carol Strike CAMH and U of Toronto • Lynne Leonard University of Ottawa • Peggy Millson University of Toronto • Shaun Hopkins The Works, Toronto Public Health • Paul Lavigne Ottawa Public Health • Don Young Superior Points, Thunder Bay • Ron Shore Street Health Centre • Susan Anstice CAMH • Natasha Berkeley CAMH • Emily Medd University of Ottawa • Tara Marie Watson CAMH

3. Outline • Needle exchange programs • Best practices – definitions and methods • Contentious programs and best practices • Best practices for needle exchange programs (NEPs) in Ontario (2006) • Challenges and solutions • Uptake by Ontario needle exchanges

4. NEPs in Ontario • Mandatory public health program • First Canadian NEPs opened in 1989 as part of a federal/provincial/local pilot project • In 2009 • 30 NEPs with over 100 satellite locations • Distributed > 3.5 million needle/syringes • OHRDP – all other injection related equipment

5. AIDS and HIV among adult IDUs Public Health Agency of Canada. I-Track: Enhanced Surveillance of of risk behaviour among injecting drug users in Canada. Phase 1 Report 2006 Public Health Agency of Canada. HIV/AIDS Epi Updates. November 2007.

6. Rationale for Ontario NEP BPs NEP managers’ goals • Use current evidence to define best practices • Use scientific evidence to defend practices • Identify and define necessary improvements • Newer/smaller programs develop their practices based on best available evidence • Define, plan, advocate for expansion of programs

7. Rationale • Increase perceived legitimacy of programs • Reduce variability in service across Ontario • Mandatory program guidelines did not provide detailed practice recommendations • Lack of leadership and focus on NEPs at the provincial level • WHO and other guides - excellent but not comprehensive or specific enough for Ontario programs

8. What are best practices? • Synthesis of scientific knowledge and rational clinical practice • Systematically developed statements to assist practitioner and patient decisions about appropriate care for specific clinical circumstances (Howard and Jensen, 1999) • Best judgement at the time based on the available information (Rush et al., 1992)

9. Best practices • Benefits • Evidence presented in an accessible manner • Reduces burden for others to find, review and assess large quantities of studies • Alleviates need for expertise in research methods, statistics etc. • Need to be updated over time • Medicine, social work, psychology, health promotion, drug treatment and rehabilitation

10. Best practice - methods • Scientific evidence-based • Extensive review and assessment of literature • Pre-determined methodological standards • Evidence ranked by strength: • RCTs, cohort studies, case control, other experiments, descriptive studies • Meta analysis – if sufficient evidence • Conducted by subject/method experts

11. Scientific evidence-based - challenges • Evidence from RCT’s not always available • RCT evidence not always generalizeable to real world settings • RCT’s not always ethical • RCT’s are not able to consider wider economic, ethical or social considerations

12. Expert-consensus model • Used when scientific model not feasible • Expert opinion fills gap in scientific evidence • Nominal group – self appointed experts • Delphi group – structured procedures • Key – selection of an unbiased, expert panel • Challenge is to define what ‘consensus’ means • All agree with every statement, or • Majority agree?

13. Consensus methods • Nominal groups • Experts privately write recommendations • With the experts, a third-party reviews (anonymous) recommendations and moderates consensus building • Delphi methods • Experts complete questionnaires with candidate best practice statements – rank or judge • Results are grouped • Questionnaire completed again to see if opinions converge • Continue until convergence

14. Consensus method - challenges • ‘Expertness’ of the experts • Evidence vs. practice • Who is an expert (inclusive vs. exclusive) • Biased opinions • Undue influence of dominant personalities • Does consensus produce accurate recommendations?

15. Contentious public health programs • Programs that are unpopular or controversial • Evidence may not be well established or there is some negative evidence • Target clients viewed as undeserving • Questioned on several grounds • Is this an issue the community needs/wants to address? • Rational (moral) expenditure of public funds • Perceived intrusion into other social service areas e.g., criminal justice, drug treatment • Other preferred models • Issues of place (ie. NIMBY issues)

16. NEP best practices • Which method is best to take? Why? • Who should be involved? Why? • Does contentious matter in this process? • What are some of the challenges likely to arise?

17. Our approach • Combined scientific/consensus approach • Mindful of opposing arguments and how these might be addressed • Mindful of biases in the literature (some strong advocates and strong detractors) • Balance of certitude, humility and reflexivity

18. BP NEP Team • Researcher team • Strike, Leonard, Millson, Anstice, Berkeley & Medd • From CAMH, U of Toronto and U. of Ottawa • Long history of epidemiological and social science research regarding NEPs and people who use drugs • NEP manager team • Hopkins, Lavigne, Young and Shore • Current and long-term NEP managers with extensive experience working with and for IDUs in Ontario • Nursing, counselling, peer, social service experience

19. BP development process • Collaboration of research and managers • Define the scope and timeframe • Solicited opinions of other NEP managers • Within and across teams to develop consensus • Format, style, language • Content • Scope • Extensive literature review, summary, synthesis • Extensive web-search and solicitation of reports

20. Best practices for NEPs in Ontario • Mid-way review by manager team and other Ontario NEP managers • Table of contents • Format, language, style • Existing sections • Final review: • scientific (US and Australia) • service provider experts (Alberta & Nova Scotia)

21. Start-up tasks NEP effectiveness Needles and other injection equipment Safer handling and disposal Glass stems Program models Education Safer injection education Safer sex education Overdose prevention Services Referrals and counselling Methadone maintenance treatment Primary care Primary care First aid for abscesses and skin problems Vaccinations Testing services Relationships with law enforcement Program evaluation Other considerations NEP Best Practice – Chapters

22. Example - needle distribution • Previously used needles can serve as a reservoir and vector for transmission of HIV, HCV, HBV and other blood borne pathogens • Injection with a previously used needle can lead to transmission of HIV, HBV, HCV and other blood borne pathogens • Re-use of needles can lead to skin and vein problems from bacteria and dull needles

23. Needle distribution • IDUs re-use, share and borrow* needles and syringes but on the decline in Ontario • 42% in 1991 • 24% in 2003 (Millson et al., 2005) • Variation across Canadian cities (average 25%) • Regina 16.5% (I-Track; HC 2004) • Toronto 24.% (I-Track; HC 2004) • Sudbury 26.6% (I-Track; HC 2004) • Victoria 30.7 % (I-Track; HC 2004) • Ottawa men 43%; women 34.7% (Leonard et al. 2005) * last 6 months

24. Needle distribution • IDUs who have difficulty acquiring needles are more likely to share needles, equipment, drugs etc. (Wood et al., 2002) • NEPs reduce: • Sharing (OR 0.4; Wood et al., 2002) • HIV transmission (hazard ratio 3.35; DesJarlais and Marmor, 1996) • HCV transmission but evidence is mixed

25. Needle distribution • NEPs are cost effective • Over 5 years, Hamilton NEP prevent 24 infections and avoid $1.3 million in health care (Gold et al, 1997) • $145,000 of lifetime medical costs averted for every infection prevented (Anderson 2000)

26. To prevent the transmission of HIV, HBV, HCV and other bloodborne pathogens: • Provide needles • In the quantities requested by clients: • Without requiring clients to return used needles • With no limit on the number of needles provided • With encouragement to return used needles • Offer all other injection equipment with each needle provided

27. To prevent the transmission of HIV, HBV, HCV and other bloodborne pathogens: cont. • Educate clients about the risks of re-using non-sterile needles and injection equipment • Educate clients about the correct use and disposal of equipment

28. Dissemination • English and French version • Pre-release presentations to all Ontario NEP managers – paper and electronic • Workshops by NEP managers • OHTN Think Tank/Launch • Sleeping giant video – distributed; OHTN film festival • Presentations • OACHA, OHTN, CAHR, Int’l AIDS Conf, Int’l HR Conf • Dr. Sheila Basrur & face to face meeting • Kaiser Foundation Award for Leadership in HR

29. BP challenges - evidence • Mountains of paper in 3 sites (~ 550 references) • No RCT’s but lot of epidemiological evidence about behaviour and outcome • Limited evidence about specific program components • Lots of extensive practice experience about day to day operations and issues Solutions • Hierarchy of evidence • Identify – contrary evidence, gaps, opinions

30. Evidence hierarchy • Well designed and published studies • Quantitative • Qualitative evidence – processes, organization • Other reviews and guidelines from scientific or highly respected sources WHO • ‘Grey’ literature – reports etc. • Ontario-specific, Canadian and then Western European and Australia – similarities in public health, health care, social service, legal systems and drug consumption

31. BP challenges - evidence • Solutions - continued • Introduced a Considerations section • To fill gaps in scientific literature • Expert practice based knowledge from managers • Needle types • Estimating number of needles returned • Identify emerging issues or concerns • Contentiousness of NEPs • Mindful of opposing arguments and how to address • Mindful of biases in the literature (some strong advocates and strong detractors)

32. BP challenges – timeliness • Big project; small budget • Table of contents (handout) Solutions • Begged and borrowed extra staff/students • Rigid timelines in a collegial manner • Hierarchy of evidence

33. BP challenges - audience • Service providers – staff and volunteers • Med. Officers of Health and Exec. Directors • Politicians, City Councellors, Policy Makers • Researchers Solution - two versions (hand-out) • In brief – one page, quick read • In detail – many pages and includes accessible technical language

34. BP challenges – best vs feasible Should we recommend practices that many cannot provide? • With every needle give all other injection equipment (now OHRDP) • Varied service models? Solution • Yes – best (not second best) practices • Programs can identify service goals • Advocacy tool

35. Lessons learned • Takes more time and money than anticipated • To ensure rigorous process, need someone dedicated to searching, pulling, collating and tracking the literature • Negotiating edits – time consuming • Allow plenty of opportunities for feedback from other NEP managers and researchers • Expect debate re content, format/style, opinion, feasibility, etc. • Audience: being able to take on the perspective of a practitioner

36. Do needle exchange programs (NEPs) distribute needles and other harm reduction equipment according to best practice recommendations? Strike C, Watson TM, Hopkins S, Lavigne P, Shore R, Young D, Leonard L, Millson M.

37. Background • Only resource of its kind in Canada • Evaluated uptake 2 years after release • Identify facilitators and modifiable • Key recommendations: • needle and syringe exchange • injection-related equipment • safer inhalation equipment • relationships with police

38. Methods • Invited all Ontario NEP managers to participate • 32 core NEP managers • 99 satellite NEP managers (partner agencies) • On-line survey • 20 to 30 minutes to complete • Response rate (98 of 131 NEPs) • 100% for core programs • 67% for satellite programs • Analyzable data n = 94

39. Core NEPs Satellite NEPs 2006 (#) 2008(#) 2006 (#) 2008 (#) Distributed needles without requiring clients to return used needles 94% (30) 94% (30) 93% (55) 95% (58) Followed a 1-for-1 exchange policy 3% (1) 0% (0) 0% (0) 2% (1) Imposed a cap on the number of needles given to clients who did not have any to return 13% (4) 3% (1) 7% (4) 11% (6) Distributed needles with no limit on the number provided 84% (27) 91% (29) 75% (44) 86% (50)* * p  .05 Needle & syringe exchange

40. Core NEPs Satellite NEPs 2006 2006 (#) 2008 (#) 2006 (#) 2008 (#) Distributed cookers 13% (4) 88% (28)* 34% (21) 84% (52)* Provided cookers with no limit on the number provided 75% (3) 100% (28) 95% (20) 85% (44) * p  .001 Cookers Containers used to prepare drugs

41. Core NEPs Satellite NEPs 2006 (#) 2008 (#) 2006 (#) 2008 (#) • Distributed recommended type(s) • - Distributed in different packaging or volumes • - Did not distribute 13% (4) 16% (5) 72% (23)  84% (27) 0% (0) 16% (5)*  31% (19) 18% (11) 52% (32) 76% (47) 10% (6) 15% (9)* Provided acidifiers with no limit on the number provided 100% (9) 96% (26) 83% (25) 87% (46) * p  .001 Acidifiers Convert insoluble drugs into water-soluble form.

42. Sterile Water Used to mix and dissolve drugs prior to injection Core NEPs Satellite NEPs 2006 (#) 2008 (#) 2006 (#) 2008 (#) Distributed sterile water 66% (21) 100% (32)* 84% (52) 97% (60)** Provided ampoules with no limit on the number provided 86% (18) 94% (30) 87% (45) 92% (54) * p  .001 ** p  .01

43. Safer Inhalation Equipment

44. Safer Inhalation Equipment Glass stems heat drugs and direct drug vapors toward the mouth. Mouth pieces protect the lips from burns when using a pipe. Brass screens hold rock-type drugs in place in pipes. Core NEPs Satellite NEPs 2006 (#) 2008 (#) 2006 (#) 2008 (#) Distributed glass stems 3% (1) 16% (5) 33% (20) 44% (27)* Distributed mouth pieces 3% (1) 16% (5) 25% (15) 38% (23)* Distributed brass screens 3% (1) 13% (4) 28% (17) 41% (25)* * p  .05

45. Facilitators • The Ontario Harm Reduction Distribution Program (OHRDP) • The Ontario Needle Exchange Programs: Best Practice Recommendations • Decisions by NEP managers • Decisions by the local MOH/Executive Director

46. Barriers For safer injection equipment distribution: • Lack of funding • Senior management and political decision-making, particularly by the local MOH/Executive Director For safer inhalation equipment distribution: • Lack of approval • Opposition from law enforcement

47. Recommendations Policy and practice: • Include in the Mandatory Health Programs and Services Guidelines (OMHLTC) a stipulation that NEPs must distribute all injection-related equipment • Develop provincial-level policies to approve a program to distribute safer inhalation equipment Funding: • Develop a funding mechanism to ensure that the OHRDP can distribute safer inhalation equipment Best practices: • Develop a plan and identify a funding source to update the Best Practice Recommendations, particularly the evidence regarding safer inhalation equipment

48. Next steps - National • Desire to update BP’s • New evidence • New issues – Rx opioids, buprenorphine • Users outside of Ontario • Strike and Leonard • Update BP for crack smoking • National advisory committee • Funding search • Strike and Hopkins– co-PIs • Discussion with potential funders • Expansion of team to members outside of Ontario • Development of proposal

49. Acknowledgements • NEP managers for their suggestions, time and efforts on behalf of the BP team • Funding • Recommendations - Health Canada • Think Tank/Launch – OHTN • Evaluation – OHTN • Salary infrastructure for Strike – Ministry of Health and Long Term Care • Student support - CAMH • Salary support for Leonard – OHTN • Download the BP Recommendations & Evaluation Report at: www.ohrdp.ca