This case highlights the important role that pharmacies play in providing access to sterile syringes and that limiting access to sterile syringes in pharmacies can have considerable, albeit often unintended, consequences to syringe purchasers in the community. With the change in policy at her local pharmacy, this patient started reusing syringes without cleaning them because she did not perceive that her used syringes were unsanitary or potentially dangerous. These unsafe injection practices most likely caused her MRSA infection. Although the pharmacy policy change did not directly cause the MRSA infection, the patient’s unsafe injection practices were adversely influenced by the change in syringe sales. Results from a modified Naranjo scale (Appendix 1 in the electronic version of this article, available online at www.japha.org
) indicated that the patient’s use of an unsterile syringe was “probably related” to her MRSA infection.
For many pharmacists, both perceived and real concerns exist regarding sale of syringes to IDUs. As a response, some community pharmacists and store managers may opt to sell syringes in large quantities only, at prices that can be prohibitive to most IDUs, in order to deter syringe sales and associated problems. However, this practice is highly variable, and the decision to sell syringes in specific quantities is left to the discretion of individual pharmacists and pharmacy managers. Further, pharmacy staff, including technicians and interns on different shifts at the same store, may have inconsistent syringe-selling practices, including refusal to sell or selling in quantities not consistent with established store policy.
Rhode Island and many other states’ laws allow individuals to possess hypodermic syringes without a prescription and permit pharmacists to sell nonprescription syringes.9
In Rhode Island, the law does not, however, set guidelines for quantities or accessibility and does not require
pharmacists to sell over-the-counter syringes or refer patients to another pharmacy. In this instance, although the patient could have attained sterile syringes from other nearby pharmacies, we believe that she should have been able to access sterile syringes in affordable and manageable quantities at any
In community chain pharmacies, store policy is not only determined by the pharmacist, pharmacy manager, and store manager, as described above; it is also influenced by state law, law enforcement officials, corporate policy, and district managers. In areas with a high prevalence of injection drug use, some pharmacists have found a great challenge with foot traffic, inappropriate syringe disposal, and shoplifting.10,11
Other pharmacists fear that syringe sales will be bad for business.12,13
For the pharmacist who is willing to sell syringes, acquiring and maintaining adequate on-site syringe disposal can pose a great financial and logistical challenge. Further, formal education of pharmacists on illicit injection drug use and addiction is limited.14
In spite of these problems (and often in response to local need), many pharmacists understand the public health importance of access to sterile syringes and sell syringes in single packs or packs of 10.
Despite the challenges of syringe sales in community pharmacies, many positive reasons exist for pharmacist sale of syringes in lower quantities, such as single syringes or packs of 10. Such sales are a harm-reduction measure used to encourage safe injection practices among IDUs. This measure can be beneficially bolstered by discussions of preparation, safe injection practices, and safe and appropriate disposal of injection equipment. Pharmacists and pharmacy staff who sell syringes to IDUs are presented with a unique opportunity that has the potential to develop into a therapeutic relationship that could lead to safer injection behavior, referral to medical care, social services, and/or addiction treatment and even discontinuation of drug injection. These services have already been shown to be critical secondary benefits of syringe exchange programs and may be replicable in the community pharmacy setting.15
Discussion of access to clean syringes for IDUs often centers on transmission of HIV or HCV—costly and dangerous infections that may take years to fully realize their devastating effects. Consideration, however, must also be given to the immediate danger inherent in a lack of access to clean syringes. The use of unsafe syringes can easily result in abscesses or other perilous infections,16,17
such as the near-fatal MRSA infection described here. Perhaps more importantly, the case described in the current work sheds light on the complexity surrounding access to clean syringes. For this patient, the local pharmacy was central to her safe injection practices, as she had no knowledge of the state’s syringe exchange program and did not find a new reliable source of clean and affordable syringes. Although the specific situation of this patient may indeed be unique, it nevertheless provides an opportunity to raise general awareness of the implications of syringe sale policies.