WATER FOR INJECTION

1
WATER FOR INJECTION

• ENGLISH WATER TORTURE?

2
BACKGROUND

• August 2003 Section 9a amended, 5 items
  legalised
• The Government will be laying a negative
  resolution statutory instrument to implement
  changes to section 9A of the Misuse of Drugs Act
  1971. With effect from 1 August 2003, it will no
  longer be an offence for doctors, pharmacists and
  drug workers to supply swabs, filters, sterile
  water, certain mixing utensils (e.g. spoons,
  bowls, cups and dishes) and citric acid to drug
  users who have obtained controlled drugs such as
  heroin and cocaine without a prescription

3
Their own words

• Water, swabs, spoons, filters, citric
• Not Vit C
• (e) ampoules of water for injection, only when
  supplied or offered for supply in accordance with
  the Medicines Act 19684 and of any instrument
  which is in force thereunder
• WFI still POM
• In effect not water either

4
June 2005

• "3A Persons employed or engaged in the provision
  of lawful drug treatment services.3A Ampoules of
  sterile water for injection containing not more
  than 2 mla of sterile water.3A The supply shall
  be only in the course of provision of lawful drug
  treatment services.".
• a -"than 2 mg of sterile water." should read
  "than 2 ml of sterile water."

5
Naloxone

• A SUMMARY OF THE COMMITTEE ON SAFETY OF MEDICINES
  MEETING HELD ON 11 MAY 2005
• However, following discussions between the Agency
  and all parties, the NPSA had withdrawn their
  objections provided appropriate systems are
  introduced by ambulance trusts to ensure
  subsequent safe practice.

6

• Spirit of law change is clearly to allow
  provision of all paraphernalia necessary in a
  comprehensive harm reducing needle exchange
• Home Office Minister, Caroline Flint said
  "Providing these items is currently illegal. We
  know that treatment workers and doctors have been
  making sensible decisions to provide equipment
  anyway, but faced the risk of prosecution. We
  have decided to change the law to help reduce the
  health risks to drug users.

7

• Pressure paid off, eventually
• However, no plastic amp is currently available
• Situation is actually worse, at least in south
  London
• Why should this matter?
• ''We have walked into shooting galleries and seen
  water that was actually pink with addicts'
  blood,''
• Published December 24, 1989

8
We always have, so we always will

• Needle Exchange Harm Reduction are pragmatic
  responses to continuing drug use
• Focus on health BBV prevention/reduction as
  well as generally
• SI amendments are in line with this
• Research clearly shows need for increased NX
  provision

9
Breaking Glass

• Assumptions glass amps inherently less safe than
  plastic?
• Cuts could pose BBV risk
• Users prefer plastic?
• Do users really need water?
• Wildlife may consume amps therefore plastic is
  safer than glass?

10

• If assumptions are followed, technically we are
  left with no WFI to supply
• PGD has been invalidated by intent of law changes
  to limit supply to 2ml
• Although police may agree prosecution isnt in
  public interest MHRA consider this their
  jurisdiction
• Interpretation locally has led to cessation of
  supply

11
Survey

• Test assumptions In April 2006 the Mainliners
  outreach team distributed 1,000 2ml glass
  ampoules and
• 100 safe snap amp snappers to injecting drug
  users as part of a pilot scheme to
• evaluate the impact and response of the
  intervention.
• Clients were surveyed at the time they were first
  given the ampoules
• they were then followed up at subsequent visit
  and asked about their use of the
  ampoules/snappers
• Mainliners had previously suspended supply of the
  5ml plastic ampoules following clarification from
  the MHRA of the legal position regarding supply
  in relation to the Medicines Act

12

• PART 1 (if youve had glass amps before, please
  go straight to part 2)
• 1. We havent been giving out water amps for a
  while what have you used in the meantime?
• (Please tick all that apply)
• boiled water from a kettle
• tap water
• bottled water
• other (please state)
• 2. Have you shared water in the last month? yes
  no
• 3. Since we stopped supplying amps have you
  shared water
• more often less often the same never
• 4. Do you think youll use the amp snapper? yes
  no dont know
• 5. Do you think mainliners supplying water amps
  will reduce water sharing amongst injectors?
• yes no dont know

13

• PART 2
• If youve had glass water amps before
• 1. Did you use the water amps? yes no
• 2. How do you normally dispose of your amps?
• 3. Have you shared water since you were given the
  amps? yes no
• 4. Do you want water amps this time? yes no
• 5. Did you use the amp snapper always sometimes
  never
• 6. Did you (or anyone else) cut yourself with any
  of the amps? yes please give details no

14

• Results do support assumptions, but not those
  supposed
• what other sources of water have you used since
  Mainliners stopped supplying 5ml plastic
  ampoules?
• boiled water from a kettle 0
• tap water 11
• bottled water 13
• toilet water 2
• puddle water 2

15
Sharing without amps

• Shared in last month - 17 - said Yes, while
  just 6 said no
• Shared since supply stopped - More often 16
• the same 2
• less often 0
• never 5

16
Amps

• Do you think youll use the amp snapper?
• 22 said yes
• none said no
• 1 said dont know
• Do you think that supplying water amps will
  reduce water sharing amongst injectors?
• 22 yes
• 1 no.

17

• Did you use the water amps? 
• yes 18
• no 5
• how did you dispose of the amps?
• Sharps bin 13 
• Domestic waste 8
• Tin can 1

18
Sharing with amps

• Do you think that supplying water amps will
  reduce water sharing amongst injectors?
• 22 saying yes
• just 1 no.
• Have you shared water since you were given the
  amps?
• 8 yes
• 13 no
• 9 of the 17 who had shared water in the previous
  month at first interview, said had not shared
  water since they were given the ampoules

19
Safety

• did you use the amp snapper?
• always 16 
• sometimes 6
• never 1
• did you (or anyone else) cut themselves on the
  amps?
• 100 NO!

20

• Where next?
• Supply of water is more than good practice
  plenty of research to show sharing message
  needs to be more than just syringes
• Needle supply remains paramount, but of
  additional paraphernalia water supply is
  potentially next greatest hazard

21
From NIDA NOTES March/April 1997

• The researchers used HIV's distinctive genetic
  structure, its DNA, as a marker to detect its
  presence in the injection paraphernalia. They
  found evidence of HIV DNA in up to 85 percent of
  contaminated needles collected from shooting
  galleries and in up to 36 percent of cotton
  swabs, 54 percent of cookers, and 67 percent of
  rinse water samples.

22
Where next

• NEEDLE EXCHANGE WATER FOR INJECTION SUPPLY
• This petition has been compiled by the Mainliners
  SMART Service user group with regards to the
  following concern. If you require any further
  information please do not hesitate to contact us
  on Tel [phone] Fax [phone]. Our
  office is at 9b Mitcham Lane, Streatham, London,
  SW16 6LG
• Water used for injecting is an integral part of
  Intravenous Drug Use. This means that users may
  resort to unhygienic and non-sterile practices to
  obtain water. Sterile injecting water has been
  available in the past, which is why we are now
  campaigning for its return. It is essential in
  Harm Reduction relating to reduce the risk and
  spread of Blood Borne Viruses.
• Please register your concerns regarding this by
  signing the petition below. This petition will be
  brought to the attention of the National
  Treatment Agency as it is a very serious issue
  that needs to be addressed quickly, as well as
  locally to the funding bodies responsible
• DateNameSignatureServiceOccupation(NFA)

23
Alternatives

• Other WFI options - ? None of sufficient quality
• Increased information on safe water use
• - hierarchy of risks (boiled, tap etc.)
• - dont use same bottle for more than a day
• - always pour, never dip
• - dont use communal glasses (rinsing or
  cooking)
• - dont assume water is clean (or any
  paraphernalia)
• - dispose of anything sharp responsibly
• - DONT SHARE ANYTHING

24
Ignorance can be bliss

• Whats the situation elsewhere?