Although the importance of pharmacies as a syringe source has been documented elsewhere, many previous studies reported findings from urban areas with good SEP coverage. Here, we report the findings from RI, a geographic location with an accessible (but likely underutilized) SEP, and southeastern MA, a location without an SEP. In both locations, pharmacies were the most common source of syringes. The overall utilization of pharmacies as a syringe source was slightly higher in MA, although the difference between locations was not significant. These findings suggest that IDUs will utilize pharmacies as a syringe source in locations with and without SEP coverage, and reinforce findings from other authors that non-prescription syringe sales in pharmacies compliment the activities of SEPs.1,15
Legislative and regulatory changes in the past 10 years have increased access to syringes in both RI and MA while simultaneously lessening the legal repercussions for syringe possession. The success of these changes is reflected in our results, as the vast majority of our participants (91%) reported being able to obtain all of the syringes that they have needed for the past 6 months.
Both RI and MA legalized the purchase of non-prescription syringes in pharmacies; however, each state did so 6 years apart. Thus, in the current study, we expected prior differences between the sites to be diminished, and we also expected syringe accessibility to be increased in MA, in comparison to the 2001–2003 study by our research group. We also anticipated a difference in SEP utilization between MA and RI participants, since there is no SEP in southeastern MA, but decent statewide SEP coverage in RI. Both of these hypotheses proved accurate.
In comparison to the 2001–2003 study by our research group, we noted some important changes in the differences between MA and RI participants’ syringe acquisition and syringe use behaviors. In 2001–2003, only 32% of MA and 79% of RI participants had purchased syringes from pharmacies in the past 6 months. In the current study, the portion of RI residents purchasing syringes at pharmacies was similar (78%), but 87% of MA participants reported using pharmacies as a syringe source. Rates of SEP utilization were also different from the 2001–2003 study, with 11% of RI and 6% of MA participants reporting SEPs as a syringe source in that study, compared with 28% of RI and 1% of MA participants in the current sample. Also, when asked if they were able to obtain all of the syringes needed in the past 6 months, only 79% of MA participants from the prior study answered in the affirmative, whereas 91% of MA participants in the current sample were able to obtain all of the syringes they needed (prior 6 months, change in RI respondents between studies was small). We also observed a decrease in the percentage of MA participants who reported “always” using injection equipment previously used by someone else, with 10% of MA participants in the 2001–2003 study reporting that answer, compared to only 1.6% in the current sample (prior 30 days, RI rates were similar for both study periods). These data highlight the success of legalizing non-prescription syringes sales in pharmacies as a way to increase access to sterile syringes and decrease the rate of high-risk injection practices among IDUs.
In the current study, in both MA and RI, less than one quarter of participants reported a pharmacist ever declining to sell them a syringe; however, more than two thirds of our sample reported ever feeling uncomfortable or slightly uncomfortable while buying syringes in a pharmacy. While our findings demonstrate the importance of pharmacies as a source of syringes for IDUs, they also suggest that negative interactions between IDUs attempting to purchase sterile syringes and pharmacists can pose a critical barrier to syringe access in pharmacy settings. IDUs are a highly stigmatized population and any stigma or unfair treatment—perceived or experienced—during the process of syringe acquisition in a pharmacy may cause IDUs to become reluctant to utilize pharmacies as a syringe source and may limit the opportunity for pharmacy staff to engage IDUs in important health services. The high prevalence of individuals reporting uncomfortable experiences indicates a need for continuing education among pharmacists and pharmacy staff regarding the medical basis of addiction and the public health and medical benefits of accessible, sterile syringes for IDUs. Further research is still needed to understand pharmacists’ interest and willingness to engage in the pharmacy-based provision of health-related services to IDUs. Our findings, however, highlight the importance of integrating legalization efforts with interventions to better adapt harm reduction initiatives to pharmacy settings and to more effectively engage this group of health care providers in HIV prevention efforts.
In our assessment of syringe acquisition behaviors, we also examined issues regarding SEP utilization. Surprisingly, less than one fifth of our sample reported acquiring syringes from a SEP in the previous 6 months, with only one person from MA reporting SEPs as a syringe source. The benefits of SEPs, such as the ability of SEP staff to form productive relationships with clients, are well established and the low rates of SEP utilization in our sample suggest possible significant barriers to accessing SEPs among IDUs in both states. Although we identified some possible barriers to SEP utilization, including a lack of program awareness among IDUs (reported by 27% of respondents) and SEPs being located too far away (22%), the impact of these and other barriers on SEP utilization is still unclear. Although there are no data available to determine whether SEPs in MA and RI currently reach the majority of IDUs, we believe, based on current and prior research, that SEPs cover the majority of locations where IDU densities are high in RI, but not in southeastern MA.
Finally, it is notable that many respondents in our sample reported risk factors for HIV infection (Table ). Despite the existence of SEPs and the non-prescription sale of syringes in both MA and RI, nearly half of our sample reported sharing syringes and/or injection equipment in the past 6 months. While non-prescription syringes may be available at most pharmacies in MA and RI, some pharmacies may only sell syringes in larger quantities at costs that make them inaccessible to many IDUs.21
This finding has important policy implications as it suggests that, even with expansion of syringe access to pharmacy settings, important barriers exist to utilizing these new venues that must be better understood. In particular, research should examine how legalization policies and cost-related barriers associated with non-prescription syringe purchase impact syringe accessibility and HIV risk behaviors among IDUs.
The generalizability of our findings is limited by our sampling of IDUs undergoing inpatient detoxification, which may not be representative of all IDUs in RI or southeastern MA. Selection bias may have occurred, but was likely avoided by recruiting at an acute detoxification center that accepts uninsured patients. Self-report and recall biases are possible, although they were likely avoided by using lifetime or short, recent time frames for most survey questions. Prior research has validated the accuracy of self-report among IDUs.22,23
Our relatively small sample size also limited the statistical power of our analyses. Since this was a cross-sectional survey, we cannot infer causality for any of the outcomes. Additionally, we did not assess place of residency, and instead used the location where individuals spent most of their time as a proxy for geographic location. Since SEPs are concentrated in urban areas of MA and RI, it would have been useful to compare place of residence with SEP availability and utilization. Finally, data from the 2007 paper are no longer available, precluding concurrent statistical analyses of the two samples to determine statistical significance for the differences observed. Despite these limitations, our findings highlight a critical shift in syringe acquisition behaviors among IDUs. The sale of non-prescription syringes in pharmacies has resulted in many IDUs in both RI and MA accessing their syringes in pharmacies, and our study provides empirical evidence for this shift.