Public Health Considerations for Non-Prescription Syringe Sales in NC

 

North Carolina and the rest of the United States are currently experiencing a health crisis related to rapidly rising rates of heroin and injection drug use, and consequently, increases in HIV and hepatitis C transmission through shared syringes. Nationally, the death rate from heroin overdose has quadrupled in the past decade [1], while the number of acute hepatitis C cases has grown 273 percent from 2009 to 2013 [2] (Figure 1).

In North Carolina, heroin deaths have risen 565% over the past four years [3](Figure 2) while acute hepatitis C cases have more than doubled [4](Figure 3). The cost of treating Medicaid patients with chronic hepatitis C rose from around 8 million dollars in 2013 to over 50 million in 2014 [5](Figure 4). Currently, HCV and HIV/AIDS treatment costs more per member per year (PMPY) than any other disease treatment covered under North Carolina Medicaid as well as all other state Medicaid programs [6].

Lack of access to sterile syringes is a significant driver of hepatitis C and HIV transmission, with over 50% of new hepatitis C cases [7] and 8% of new HIV cases [8] attributed to the practice of sharing syringes among people who inject drugs (PWID). North Carolina law allows the purchase and sale of syringes from a pharmacy without a prescription. However, because North Carolina statute on drug paraphernalia prohibits the distribution or sale of syringes if it is known that such items will be used for illicit drug purposes, the decision of whether or not to sell syringes is essentially left up to the discretion of pharmacists and pharmacies [9].

Relying on pharmacist discretion regarding syringe sales puts undue burden on the pharmacist and often leads to discriminatory practices: studies show that blacks, Hispanics, and men are less likely to be sold syringes than white or female customers [10]. Additionally, a North Carolina study published by RTI International in 2009 demonstrated that black injection drug users were five times less likely to use pharmacies as a source for syringes than white injection drug users [11].

Decades of empirical evidence on syringe access and injection drug use demonstrates that syringe access lowers the incidence of PWID sharing syringes and decreases the transmission of HIV and hepatitis C substantially [12]. Furthermore, increased syringe access does not lead to negative effects such as increases in improperly discarded syringes or drug use [13].

The risk of negative impacts for nonprescription syringe sales on pharmacies and pharmacists are likewise very low. A national search of reported cases found no instance in which a pharmacist had been prosecuted under a paraphernalia law or pharmacy regulation for selling a syringe that was later used to inject drugs [14]. Additionally, scientific studies from other states have demonstrated that the proportion of improperly discarded syringes at or around pharmacies did not increase after the nonprescription sale of syringes from pharmacies was legalized [15].

The unrestricted sale of syringes is supported by the American Pharmacists Association, whose statement reads: “APhA encourages state legislatures and boards of pharmacy to revise laws and regulations to permit the unrestricted sale or distribution of sterile syringes and needles by or with the knowledge of a pharmacist in an effort to decrease the transmission of blood-borne diseases. [16]” Likewise, a recent study of 146 pharmacies and staff reported that 87% of participating pharmacists support the unrestricted sale of syringes as a disease reduction method [17].

Pharmacists are a trusted, accessible source of health information indispensible to providing North Carolinians with accurate education and useful tools to reduce disease transmission and improve community well-being. Considering the devastating effects of increases in injection drug use, hepatitis C and HIV, as well as the financial toll on North Carolina Medicaid costs, NC pharmacies should consider selling syringes without regard to intended use in an effort to reduce rising rates of blood borne disease transmission. Pharmacies play an absolutely critical role in this effort.

Hep C US v NC

[2] CDC Viral Hepatitis Statistics and Surveillance: http://www.cdc.gov/hepatitis/statistics/index.htm.

[3] NC Injury Prevention Branch.  

[4] NC Department of Health and Human Services surveillance data

[5] NC Department of Health and Human Services surveillance data

[6] NC Department of Health and Human Services Medicaid department

[8] CDC: HIV and Drug Use in the United States: http://www.cdc.gov/hiv/riskbehaviors/idu.html

[9] NC Statute 90-113-21. Article 5B Drug Paraphernalia: General Provisions

[10] Janulis, Patrick. Pharmacy nonprescription syringe distribution and HIV/AIDS: A review. J Am Pharm Assoc. 2012;52:787–797.

[11] Costenbader E, Zule W, Coomes C. Racial differences in acquisition of syringes from pharmacies under conditions of legal but restricted sales. Int J Drug Policy. 2010:425–8.

[12] Wodak A, Cooney A.  Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug users. (Evidence for action technical papers). Geneva, 2004.

[13] Fuller C, Ahern J, Vadnai L, et al. Impact of increased syringe access: preliminary findings on injection drug user syringe source, disposal, and pharmacy sales in Harlem, New York. J Am Pharm Assoc. 2002;42:77–82.

[14] Burris S, Welsh J, Ng M, Li M, Ditzler A. State syringe and drug possession laws potentially influencing safe syringe disposal by injection drug users. J Am Pharm Assoc (Wash). 2002 Nov-Dec;42(6 Suppl 2):S94-8.

[15] Cotten-Oldenburg NU, Carr P, DeBoer JM, et al. Impact of pharmacy-based syringe access on injection practices among injecting drug users in Minnesota, 1998 to 1999. J Acquir Immune Defic Syndr. 2001;27:183–92.

[16] American Pharmacists Association 1999 policy statement. (JAPhA 39(4): 447 July/August 1999)(Reviewed 2003)(Reviewed 2006)(Reviewed 2008)(Reviewed 2009)(Reviewed 2014).

[17] Zaller N, Jeronimo A, Bratberg J, et al. Pharmacist and pharmacy staff experiences with non-prescription (NP) sale of syringes and attitudes toward providing HIV prevention services for injection drug users (IDUs) in Providence, RI. J Urban Health. 2010;87:942–53.