Monday, November 1, 2010

Tonight's heroin

I'd like a pack of insulin syringes. Thirty-one gauge. One-hundred cc's.

She almost had it right. Units, not cc's. Units.

If you've been in pharmacy for more than fifteen minutes, you know that this patient/customer isn't diabetic. She's injecting illicit drugs.

One of my technicians knew of her. Said she was busted for crack several years ago. From her looks and actions tonight, I'd say that she was messing with heroin now.

This is a situation that pharmacists face day-in, day-out. Do we or do we not sell syringes to injection drug users? My employer does not have a clear policy on the matter, so it falls on the individual pharmacist to make the call.

A few weeks ago I was reading the September/October issue of the Journal of the American Pharmacists Association. There was a case study on a female prostitute who developed a case of MRSA after reusing syringes because the pharmacy where she usually bought her individual packs of syringes changed their policy to sell only full boxes. No more packs to sell to the drug users. The prostitute's MRSA hospitalized her for six or seven weeks. And we can assume that the hospital or the taxpayers of the state ended up footing the bill.

There were two other articles in that issue that discussed syringe sales and syringe access programs. That got me thinking....

One of the arguments in favor of supplying clean syringes to injection drug users is that it decreases the transmission risk of certain diseases (hepatitis, HIV). By ensuring that injection drug users have clean needles, we are protecting public health.

Sounds like a good role for pharmacists... preventing disease transmission.

But I'm a pharmacist. It's my job to monitor the use of controlled substances and try to keep people from abusing them. Last time I looked, heroin was a Schedule I controlled substance. The worst of the worst.

If I sell syringes to this junkie, I'm enabling the abuse of this controlled substance. In my state, I have to report the sales of all C-IIs thru C-Vs to my state's prescription drug monitoring program. We try to control the abuse of narcotics by monitoring their sales. As a responsible pharmacist, I can't enable the abuse of C-Is when I must report the sales of other controlled substances.

If I sell the syringes and the drug user ODs, am I liable for supplying the syringes to them?

If I don't sell the syringes and the person contracts a blood-borne disease because they reused dirty syringes, have I protected the public health?

By selling syringes to injection drug users, will I attract more users to my pharmacy? Do I put my staff at risk by having more drug abusers come to my pharmacy to get their needles?

These are questions that pharmacists have every day when the question of selling syringes to injection drug users is posed.

I don't have an answer for this question. The arguments for both sides of the issue make perfect sense to me. Down in my gut, I don't want to sell the syringes. I can't justify the enabling of the abuser's addiction. But then I think, what if somebody I know gets HIV because this person used a dirty needle? I could have prevented that.

Like I said, I don't have an answer for this dilemma. But why does it have to be a dilemma? Why is this something that falls into the hands of the pharmacist to decide?

From the articles I've read, the consensus seems to be in favor of syringe exchange programs. I'm cool with that. But let's not put the pharmacists in the middle of this public health issue. We always hear about expanding access to care. This is one area where I wouldn't mind seeing the access to care expanded to include the local Circle-K or any other retailer.


pharmacy chick said...

I would rather not sell syringes to abusers. they just tell their friends and they come in, leave their syringes in our bathroom, parkinglot etc. I used to sell by the box only until our company sent out a directive that we have to sell by the bag.. Some stores sell them by the bag...10 bucks a bag. Since that time, we find them in the garbage, parking lot and toilet again. Honestly, I dont care what they die of. Sorry, that sounds crass, but its true.

lovinmyjob said...

The state where I practice kind of answered this by making it the law that anyone wanting to buy syringes has to show "a legitimate need". This usually translates that they have to have some medication on their profile that requires syringes for injection. Or if they use insulin they have to be able to produce the insulin bottle for the pharmacist to varify need. I have seen some of the oldest, funkiest bottles of insulin produced to "prove" need. Obviously these people are turned away. I had one chick that kept bringing me the same bottle of b-12 each time she wanted syringes so I finally marked the bottle with a line to show where the medication was, when she came back the next time and no medication had been removed from the bottle she was turned away. The really funny thing is that anyone can go into the local farmer's co-op and buy syringes without any proof of anything! They are the same syringes that we sell! Go figure!

Kevin Clauson said...

Eric - I think your post does an excellent job conveying one of the (seemingly) mundane challenges a pharmacist faces every day that is in reality more complex. I similarly don't have the answer to this dilemma. It does make me think back to a pharmacy I worked at where one pharmacist decided to sell syringes based loosely on the idea of supporting public health and the other pharmacist chose not to for fear it would encourage drug abusers to visit en masse.

The one sentiment I disagree with is ‘not to put pharmacists in the middle of this public health issue’. I think perhaps it may be valid in the current state of things (i.e., minimal support/guidance on a store/corporate/association level), but it seems like an opportunity for pharmacists to be more educated and involved in public health. I don't think every pharmacist needs to be a specialist nor am I advocating 'one more thing' dumped on pharmacists to do, but you've illustrated the perfect type of scenario to at least explore for the profession.

As for the commenter's "I dont care what they die of". It is not crass. It is a repugnant statement for a healthcare professional to make. I get that being a pharmacy manager is tough, but letting it beat the tolerance and humanity completely out of you? I certainly say and post things that I later regret and make plenty of mistakes. But to post "I would pray that everything I say and do would be to your Glory and Blessing" ( and then make that comment's discouraging.

Anonymous said...

My concern is where are the drug users disposing of their needles? We give them a nice shiney needle and they use it. Now Im sure it doesnt get put in a nice sharps container and sent away to stericycle... instead it ends up on the park bench, public restroom, etc. Now that clean needle I supplied is a dirty needle and a bigger public health concern.

I require proof of need (show me your meter, insulin vial, pump, CMN whatever).

Oh, and dont try to buy 2 X 48 ct box of sudafed at the same time. Lil tip!

Unknown said...

I can definitely understand your hesitance to give needles to people who you think are going to use them to inject illegal substances. But here's the thing. You keep calling it enabling when it really isn't. An addict never put off injecting because they couldn't find a clean syringe. They will always be able to find SOMETHING to inject with. Syringe access programs have pretty conclusively been proven to not increase injection frequency, which means it is reasonable to assume that you cannot prevent any injections by refusing to sell syringes. Isn't it then your duty to try and prevent the spread of communicable disease?

Also, in response to the "I don't care how they die" comment, it is not only repugnant, it is horribly ignorant. You might not care if a drug user has HIV. But what about the people they pass it on to through sex? And the people those people pass it on to? Most cases of HIV have injection drug use somewhere in their line of transmission, imagine what could have been if that had been prevented?

Eric Durbin, RPh said...

Kevin, I think you hit it on the head with the "one more thing dumped on pharmacists" comment. If our time wasn't divided doing twenty other tasks (most of which are not utilizing our professional skills), community pharmacists might welcome the role in public health. Perhaps if more members of management in the chains were actual practicing pharmacists there may be some corporate direction.

And Patrick, maybe enabling isn't the right word, but if I give the abuser the syringe I am implying that I, at the least, don't disapprove of the behavior.

We are trained to watch for signs of abuse for the controlled substances that we dispense. We don't let people get their legal prescriptions for controlled substances early. Heaven forbid that they OD and their family comes back to sue us. But we should just hand over the tools to use the illegal drugs? What happens when these people OD and the family finds the receipt for the syringes in their pocket? It would take about 8 seconds to figure out which pharmacist sold the syringes. Can we be held liable then?

I think we agree, there's not a simple answer. Just throwing out some different ideas to think about.

Jeremy said...

I always had the same mixed feelings. Should I give them their "clean needles?" or prevent their "drug abuse?" It's a lose/lose situation really... :(

The Ole' Apothecary said...

If the user contracts HIV because he/she used a dirty needle to inject heroin, in my opinion the proximate cause of the infection (duh!!) is the USER, NOT THE PHARMACIST!

Please, please---can we not place responsibility where it lies instead of making up some phony egalitarianism that excuses the addict's addiction? Better that the pharmacist gives out information about methods of recovery instead of more death needles.

Yes, I am my brother's keeper, but only if my brother wants a life.

Anonymous said...

As pharmacists...we do not aid and abet an addiction. Stated in law. Which supports moral grounds if feel so inclined.

Anonymous said...

My concern is as the healthcare provider in the scenario.

As a pharmacist, I am the gatekeeper (even if the syringes CAN be obtained elsewhere...if the patient comes to me to get a supply of needles and syringes, it's my say 'No way! Not from me, go to the public health agency or bring me a script.' (and, let some other 'healthcare professional' work on taking care of the patient's addiction--Isn't this why public health clinics in Holland provide free supplies?)

I have an obligation to provide proper health care.

Say, I'm working in the ER that particular day when the CODE cart comes back contaminated with HCV or HIV or HBV, or CMV, etc. and I contract the virus from its presence on the tray or other equipment, is it my concern that the patient contracted the viruses because they used dirty needles because I didn't provide clean ones from the pharmacy?

Kiwipharmer said...

Do you now have needle exchange programmes in the US? We have a well run needle exchange programme in New Zealand. They run out of needle exchange centres (where they provide info on treating addiction etc too) and out of pharmacies.

In pharmacy there are two levels - one where you provide a '10 pack' with 10 syringes, needles, sharps container, lube, condom, education material, alcohol swabs and the other where they can purchase individual needles etc. These are EXCHANGE - so bring back old and we sell you new ones.

They are run with the same philosophy as the methadone maintenance programme - to reduce harm. Harm to the individual (infections etc) & harm to society - encourage safe use, safe disposal, etc etc.

So although as health profs we have obligations to prevent misuse of meds, I feel we have obligations to inform and prevent harm to others also. And if it means that our playgrounds/toilets/gardens are free of used needles etc then I think that is a benefit to us all. said...

It cannot have effect in actual fact, that is exactly what I think.

Anonymous said...

Hello, I found your site on google, I am an IV heroin user, and I have been able to buy needles over the counter here in Oregon where I live for several years, there were even a few pharmacy's that would sell single needles on the counters for .25 and I am grateful that it is this way here.

I have had many friends and adequateness die of HIV, Hep C and other really nasty things, these folks have cost tax payers millions of dollars in medical care because they didn't have insurance. and a .25 cent needle could of prevented their death.

If you are worried about people littering your parking lots with used needles please ask them to not leave them around with they are done with them, addicts are people too, they are in pain, and if you treat them with respect they will reciprocate, there are bad people in all walks of life and if someone chooses do put an illicit chemical into their bodies that doesn't make them a bad person, they have feelings too.

thank you for a great article, and I wish that everyone reading this can be compassionate to the addict that comes in to buy needles, they are people, they could be your son or daughter sister or brother.


Jimbo said...

I used to think like the other poster who said "I don't care what they die of" until a good friend's son died of an overdose. Easy access to syringes just makes it easier for kids to start using. Heroin used to be the big bad drug of hardcore addicts but now it's a common recreational drug among high school and college kids. I blame the fact that we are forced to sell these kids needles in our pharmacies, no questions asked. Our profession has been ruined by govt. regulations and the big 3 pharmacy corporations who only care about making a buck.

Anonymous said...

We could argue ethics here all day long. But from a business perspective it is fairly straightforward. IDUs are low-profit, high-risk customers. No, thanks.

Anonymous said...

I assure you that not selling syringes does NOT stop people from using. It stops them from using SAFELY. I would challenge you to find one study that says otherwise.

If people can get illegal drugs, they can get syringes, but not having access to clean syringes is just going to make them share needles or use dirty ones. I lost a good friend to AIDS after the pharmacy in my area changed their policy, a friend that likely infected dozens of other people unknowingly. How many lives are destroyed needlessly because of pharmacists with their heads up their ass about this issue? Take an honest look at the data (any needle exchange program will have a wealth of resources showing you everything I just said), and think before you make self-righteous judgements about other people.