National Institute for Health and Clinical Excellence. Centre for Public Health Excellence. Review decision

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1 National Institute for Health and Clinical Excellence Centre for Public Health Excellence Review decision Review of the public health guidance (PH18): Optimal provision of needle and syringe programmes (NSPs) 1 Background information Guidance issued: February 2009 Review decision: April Process for updating guidance Public health guidance is reviewed 3 years after publication to determine whether all or part of it should be updated. The process for updating NICE public health guidance is as follows: NICE convenes an expert group to consider whether any new evidence or significant changes in policy and practice would be likely to lead to substantively different recommendations. The expert group consists of selected members (including co-optees) of the original committee that developed the guidance, the review team that produced the original evidence reviews, and representatives of relevant government departments. NICE consults with stakeholders on its proposal for updating the guidance. (NSPs). Review decision April 2012 Page 1

2 NICE may amend its proposal, in light of feedback from stakeholder consultation. NICE determines where any guidance update fits within its work programme, alongside other priorities. 3 Consideration of the evidence and practice The expert group discussed published and ongoing research of relevance to the current recommendations, informed by literature searches (see below). The expert group also discussed changes to policy, legislation and organisations that might affect the recommendations. Literature searches Literature searches were conducted for papers published between January 2008 and November The original search strategies for the effectiveness and qualitative evidence review were re-run. The results of the literature searches and feedback from the expert group have been assessed to inform the proposed review decision and are summarised below. All references identified through the searches can be viewed in Appendix 1. Please note that the new pieces of public health guidance in development referred to below are listed in section 5, along with other related published NICE guidance. Policy context The expert group noted the recovery agenda started in 2008 by the UK Drug Policy Commission and supported in 2010 by the National Treatment Agency (NTA) Commissioning for Recovery document. Some members of the expert group suggested this might make it difficult for local organisations to implement the NICE recommendation about the concurrent provision of opiate substitution therapy (OST) and NSPs. (NSPs). Review decision April 2012 Page 2

3 Recommendation 1 Planning, needs assessment and community engagement It was noted by the expert group that the current recommendation was supported by evidence from Turner et al (2011) that showed high coverage NSPs can reduce transmission of the hepatitis C virus (HCV) by 50%, and that in combination with opiate substitution therapy (OST) it could reduce HCV transmission by 80%. There was no other evidence identified which was relevant to this recommendation, so the expert group suggested that there was no reason to review this recommendation. Recommendation 2 Meeting need Three studies address issues around drug related litter. de Montigny et al. (2009, 2010, 2011) report on evidence relating to IDUs conscientiousness around drug related litter and the consequent effectiveness of drop box schemes which led to reductions of up to 98% in drug related litter in a 200m circumference. Devaney and Berends (2008) support this in a study from Australia. In a multivariate analysis, Wenger et al. (2011) finds that using NSPs is protective against improper disposal. The expert group agreed that the evidence which exists supports the current recommendation, although there may be sufficient new evidence for NICE to consider drop boxes. Recommendation 3 Types of service Three studies from outside the UK (Islam 2008a, 2008b and Macdonald 2009) find that vending machines are effective for out-of-hours service. (NSPs). Review decision April 2012 Page 3

4 Two studies (Turner et al 2011, Kidorf et al 2011) find that concurrent NSP and OST provision is an effective way to reduce transmission of blood-borne viruses (BBVs). The expert group agreed that new evidence supports the current recommendation about concurrent provision of OST and NSP. However, there was new evidence from outside the UK on the effectiveness of vending machines for increasing out-of-hours access that could be considered by NICE. Recommendation 4 Equipment and advice Drach et al. (2011) found that less restrictive syringe dispensation policies are associated with increased access to clean syringes and safer injection practices. Meanwhile, providing extra syringes to NSP participants who report exchanging syringes within a social network appears to be an effective and inexpensive means of increasing access to clean syringes. Kerr et al. (2010) assess the effects of various policies for syringe distribution on HIV risk behaviour and conclude that Widespread syringe distribution appears to be a more effective SEP (Syringe Exchange Programme) policy than do more restrictive SEP policies that limit syringe access. The expert group highlighted the importance of managing secondary exchange as an opportunity for creating safe, productive peer distribution systems, especially amongst users of performance and image enhancing drugs (PIEDs). The expert group noted that the ACMD (2010a) recommended that the government reconsider their position on foil provision. The current recommendation may need some slight rewording. (NSPs). Review decision April 2012 Page 4

5 The expert group agreed that the recommendation could be reworded to make it inclusive of foil provision should this become legal. The expert group felt that NICE should consider producing supplementary guidance to highlight the evidence-based practice with PIED users. Recommendation 5 & 6 provision in community pharmacies & specialist provision The evidence on litter summarised under recommendation 2 pertains here. The expert group highlighted a need to consider NSP provision to PIED users (for example intra-muscular (IM) needles), and NSP provision to under-18s and the special circumstances associated with that group. They also highlighted a surge in PIED use among under-18s. The expert group agreed that these recommendations did not need to change in light of new evidence, but suggested NICE may wish to consider supplementary guidance on the provision of NSPs to under- 18s. Cost effectiveness analysis Additional cost effectiveness papers were identified (Turner et al 2011, Belani et al 2008). All support the cost effectiveness of NSP. The data contained in one of the papers was already used to populate the NICE modelling in a pre-publication form. It is likely that new data would improve the cost effectiveness projections for encouraging OST use amongst NSP clients. The expert group did not feel there was any evidence to indicate the need to update the cost effectiveness analysis at this time. (NSPs). Review decision April 2012 Page 5

6 Research recommendations The expert group considered that the research recommendations are still relevant. They noted that new evidence existed that was relevant to several recommendations: 1. How can NSPs effectively and cost-effectively encourage specific populations of people who inject drugs to use their services? There is some new evidence about vending machines outside the UK see above. Some detail about PIED users as a special population in the ACMD report on steroid users (ACMD 2010b).. 2. What types of injecting and non-injecting equipment can effectively and cost effectively reduce the harm associated with injecting drug use? Some evidence on low dead space syringes reducing transmission when used for sharing (Bobashev & Zule 2010) 3. How effective and cost effective are NSPs aimed at offenders who inject drugs? Some evidence from US (Adams 2011), and from a systematic review in 2009 (Jurgens 2009). WHO advocate NSP in prisons (WHO 2005, 2007). 4. Do NSPs increase drug-related litter, crime rates or the fear of crime in the local vicinity? Evidence suggests that NSPs reduce drug related litter (Wenger at al 2011). 5. Do NSPs have an impact on the occurrence of overdose or the uptake, frequency and length of injecting drug use? No evidence was found relating to this. (NSPs). Review decision April 2012 Page 6

7 The expert group suggested that some of this evidence merited consideration by NICE. Although it was unlikely to change the current recommendations, there was new evidence that might allow NICE to better address the original referral and areas of the scope for which there was no evidence at the time of publication. Other research not mentioned in the guidance that may be relevant Pharmacy sales of needles and syringes Over a dozen papers favourably assess pharmacy sales of needles and syringes to IDUs. Mostly from the US. (Battles et al. 2009; Cooper et al. 2010; Cooper et al. 2009; Cooper et al. 2011; Costenbader et al. 2010; Garfein et al. 2010; Macalino et al. 2009; Nacopoulos et al. 2010; Riley et al. 2010; Rose and Raymond 2010; Rudolph et al. 2010; Tesoriero et al. 2009; Torre et al. 2010; Vorobjov et al. 2009a; Vorobjov et al. 2009b; Zaller et al. 2010a; Zaller et al. 2010b). Supervised injection facilities A range of reports evaluating supervised injection facilities in the US, Canada and Australia, are generally, although not universally, positive about their impact both in terms of effectiveness and cost-effectiveness. (Andresen and Boyd 2010; Bayoumi and Zaric 2008; Bravo et al. 2009; Christian 2011; DeBeck et al. 2011; Fast et al. 2008; Kral et al. 2010; Krusi et al. 2009; Millson et al. 2010; Moniruzzaman et al. 2010; Pinkerton 2010; Salmon et al. 2009; Salmon et al. 2010; Watson et al. 2010). Outreach syringe distribution Papers by two teams (Hayashi et al. 2010; Hebert et al. 2008; Heller et al. 2009) indicate that providing NSP by outreach is an effective way to engage (NSPs). Review decision April 2012 Page 7

8 harder to reach IDU s such as those from some ethnic groups in Vancouver and Rhode Island. The expert group agreed that the sale of needles and syringes was not particularly relevant to the UK context, although they felt that online purchasing was probably common. The expert group felt that supervised injecting facilities and outreach needle and syringe distribution were both important areas that should be considered. 4 Implementation and post publication feedback The NHS Information Centre published the General Pharmaceutical Services in England to report in November This report includes data on the number and percentage of needle and syringe exchanges commissioned in England from to The results suggest that the number of needle and syringe exchanges has nearly doubled between and Table 1 Community pharmacies in contract with PCTs at 31 March, number and percentage commissioned to provide local enhanced services in England to Needle & Syringe Exchange ,061 (6.3%) 1,537 (7.3%) 1,692 (7.2%) 1,969 (7.3%) 2,048 (6.9%) The full report is available here: General_Pharmaceutical_Services_England_2000_01_to_2009_10.pdf (NSPs). Review decision April 2012 Page 8

9 5 Related NICE guidance The following NICE guidance is related to PH18: Community engagement. NICE public health guidance 9 (2008). Available from Hepatitis B and C - ways to promote and offer testing. Due December Further details at 6 Stakeholder consultation In February 2012, the proposal was made to stakeholders that the guidance should be updated in line with the suggestions above and that supplementary guidance should be produced for PIED users and for young people under-18. Fourteen organisations commented on the proposal during the two week consultation period. All stakeholders who expressed a preference (n=8) agreed that supplementary guidance for PIED users and for under-18s should be developed by NICE. All stakeholders who expressed a preference agreed that: Consideration should be given to new evidence related to dropboxes (n=4) and vending machines (n=6) The wording of the guidance should be changed to allow the possibility of foil becoming legal (n=5). Five stakeholders mentioned outreach or mobile services in a positive light. Supervised injection facilities were considered by stakeholders to be important, but several felt that they served a far broader remit than NSPs and therefore it would be inappropriate to include them in this guidance. (NSPs). Review decision April 2012 Page 9

10 Two stakeholders felt that NICE should not examine the evidence for NSP provision in prisons. One stakeholder mentioned low dead space syringes and reported that guidance may be forthcoming from the World Health Organisation. No stakeholders commented on pharmacy sales of syringes. Finally, several stakeholders supported the idea of a technical amendment to the guidance so that it reflects the possibility of a change in the law relating to providing paraphernalia, notably foils to facilitate the move from injecting to inhaling drugs. 7 Equality and diversity considerations There has been no evidence to indicate that the guidance does not comply with anti-discrimination and equalities legislation. 8 Conclusion In conclusion, no new evidence has been identified which appears to contradict the existing recommendations. Although there have been some changes to the policy context since the original guidance was published, and some new evidence is available that could add nuance to some of the recommendations, it is highly unlikely that this would invalidate or change the direction of the current recommendations. Nevertheless, there is some new evidence that relates to areas covered by the original referral and within the original scope, where NICE could partially update and extend the current guidance. There is a clear need for guidance related to working with PIED users and with under-18s who inject drugs. Evidence relating to vending machines, low dead space syringes, prisons and drop boxes could also be examined for its robustness and transferability to UK (NSPs). Review decision April 2012 Page 10

11 settings, as could data relating to supervised injecting facilities and outreach distribution schemes. 9 Review decision The guidance will be partially updated. The evidence relating to drop boxes, outreach schemes and vending machines for out-of-hours provision will be reviewed to inform potential additional recommendations. The wording of recommendation 4 will be amended to include the possibility of foil distribution (should this be made legal) in the section on dispensing paraphernalia. NICE will develop supplementary guidance on providing NSP to under-18s and to PIED users. The provision of NSPs in prisons will be considered as a topic for the recent public health referrals on offender health. Supervised injecting facilities will not be included in the update of this guidance. Centre for Public Health Excellence, April 2012 (NSPs). Review decision April 2012 Page 11

12 References not included in Appendix 1 Advisory Council on the Misuse of Drugs' (ACMD) (2010a) The consideration of the use of foil, as an intervention to reduce the harms of injecting heroin. accessed 8/2/12. Advisory Council on the Misuse of Drugs' (ACMD) (2010b) Consideration of the Anabolic Steroids. lications/alcohol-drugs/drugs/acmd1/anabolic-steroids-report/ accessed 8/2/12. Kidorf M., King V.L., Pierce Jessica. et al. (2011) Benefits of concurrent syringe exchange and substance abuse treatment participation. Journal of Substance Abuse Treatment, 40, p National Treatment Agency (2010) Commissioning for recovery. NTA: London accessed 8/2/12. Turner KM, Hutchinson S, Vickerman P et al. (2011)The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence. Addiction, 106(11): World Health Organisation (2007) Guide to starting and managing needle and syringe programmes. WHO: Geneva accessed 8/2/12 World Health Organisation (2005) Status paper on prisons, drugs and harm reduction. WHO: Geneva accessed 8/2/12. (NSPs). Review decision April 2012 Page 12

13 Appendix 1 relevant papers from searches Adams, J., Nowels, C., Corsi, K., Long, J., Steiner, J.F., & Binswanger, I.A HIV risk after release from prison: A qualitative study of former inmates. Journal of Acquired Immune Deficiency Syndromes, 57, (5) Andresen, M.A. & Boyd, N A cost-benefit and cost-effectiveness analysis of Vancouver's supervised injection facility. International Journal of Drug Policy, 21, (1) Battles, H.B., Rowe, K.A., Ortega-Peluso, C., Klein, S.J., & Tesoriero, J.M Who purchases nonprescription syringes? Characterizing customers of the Expanded Syringe Access Program (ESAP). Journal of Urban Health, 86, (6) Bayoumi, A.M. & Zaric, G.S The cost-effectiveness of Vancouver's supervised injection facility. CMAJ Canadian Medical Association Journal, 179, (11) Belani, H.K. & Muennig, P.A Cost-effectiveness of needle and syringe exchange for the prevention of HIV in New York City. [References]. Journal of HIV/AIDS & Social Services, 7, (3) Bobashev, G.V. & Zule, W.A Modeling the effect of high dead-space syringes on the human immunodeficiency virus (HIV) epidemic among injecting drug users. Addiction, 105, (8) Bravo, M.J., Royuela, L., de la Fuente, L., Brugal, M.T., Barrio, G., Domingo- Salvany, A., & Itinere Project Group Use of supervised injection facilities and injection risk behaviours among young drug injectors. Addiction, 104, (4) Christian, G The Sydney injecting centre-assessing the evidence-base. Journal of Global Drug Policy and Practice, 5, (1) (NSPs). Review decision April 2012 Page 13

14 Cooper, E.N., Dodson, C., Stopka, T.J., Riley, E.D., Garfein, R.S., & Bluthenthal, R.N Pharmacy participation in non-prescription syringe sales in Los Angeles and San Francisco counties, Journal of Urban Health, 87, (4) Cooper, H.L., Bossak, B.H., Tempalski, B., Friedman, S.R., & Des Jarlais, D.C Temporal trends in spatial access to pharmacies that sell over-thecounter syringes in New York City health districts: relationship to local racial/ethnic composition and need. Journal of Urban Health, 86, (6) Cooper, H.L., Des Jarlais, D.C., Ross, Z., Tempalski, B., Bossak, B., & Friedman, S.R Spatial access to syringe exchange programs and pharmacies selling over-the-counter syringes as predictors of drug injectors' use of sterile syringes. American Journal of Public Health, 101, (6) Costenbader, E.C., Zule, W.A., & Coomes, C.C Racial differences in acquisition of syringes from pharmacies under conditions of legal but restricted sales. International Journal of Drug Policy, 21, (5) de Montigny, L., Vernez, M.A., Leigh, B., & Kim, S.Y Assessing a drop box programme: a spatial analysis of discarded needles.[erratum appears in Int J Drug Policy Jul;21(4):333 Note: Young, Kim [corrected to Kim, Sun Young]]. International Journal of Drug Policy, 21, (3) de Montigny, L., Vernez, M.A., Leigh, B.C., & Kim, S.-Y A spatial analysis of the physical and social environmental correlates of discarded needles. Health and Place, 17, (3) de Montigny, L Discarded needles and the urban environment: A spatial analysis of attractors, deterrents and disposal options. de Montigny. DeBeck, K., Kerr, T., Bird, L., Zhang, R., Marsh, D., Tyndall, M., Montaner, J., & Wood, E Injection drug use cessation and use of North America's first medically supervised safer injecting facility. Drug & Alcohol Dependence, 113, (2-3) (NSPs). Review decision April 2012 Page 14

15 Devaney, M. & Berends, L Syringe disposal bins: The outcomes of a free trial for city traders in an inner-city municipality Australia. Substance Use and Misuse, 43, (1) Drach, L., Guernsey, J., Maher, J.E., Rumptz, M., Stark, M., Pranian, K., & Casciato, C Should we move from syringe exchange to distribution? [References]. American Journal of Public Health, 101, (3) Fast, D., Small, W., Wood, E., & Kerr, T The perspectives of injection drug users regarding safer injecting education delivered through a supervised injecting facility. Harm Reduction Journal, 5, Article Number: 32. Date of Publication: 29 Oct 2008., Garfein, R.S., Stopka, T.J., Pavlinac, P.B., Ross, A., Haye, B.K., Riley, E.D., & Bluthenthal, R.N Three years after legalization of nonprescription pharmacy syringe sales in California: where are we now? Journal of Urban Health, 87, (4) Gillies, M., Palmateer, N., Hutchinson, S., Ahmed, S., Taylor, A., & Goldberg, D The provision of non-needle/syringe drug injecting paraphernalia in the primary prevention of HCV among IDU: a systematic review. [Review]. BMC Public Health, 10, 721 Hayashi, K., Wood, E., Wiebe, L., Qi, J., & Kerr, T An external evaluation of a peer-run outreach-based syringe exchange in Vancouver, Canada. International Journal of Drug Policy, 21, (5) Hebert, M.R., Caviness, C.M., Bowman, S.E., Chowdhury, S.P., Loberti, P.G., & Stein, M.D Backpack needle exchange: background, design, and pilot testing of a program in Rhode Island. Journal of Addictive Diseases, 27, (3) 7-12 Heller, D.I., Paone, D., Siegler, A., & Karpati, A The syringe gap: An assessment of sterile syringe need and acquisition among syringe exchange program participants in New York City. Harm Reduction Journal, 6, Article Number: 1. Date of Publication: 12 Jan 2009., (NSPs). Review decision April 2012 Page 15

16 Islam, M., Stern, T., Conigrave, K.M., & Wodak, A. 2008a. Client satisfaction and risk behaviours of the users of syringe dispensing machines: a pilot study. Drug & Alcohol Review, 27, (1) Islam, M., Wodak, A., & Conigrave, K.M. 2008b. The effectiveness and safety of syringe vending machines as a component of needle syringe programmes in community settings. [Review] [34 refs]. International Journal of Drug Policy, 19, (6) Islam, M.M., Conigrave, K.M., & Stern, T Staff perceptions of syringe dispensing machines in Australia: a pilot study. Substance Use & Misuse, 44, (4) Jurgens, R., Ball, A., & Verster, A Interventions to reduce HIV transmission related to injecting drug use in prison. [Review] [125 refs]. The Lancet Infectious Diseases, 9, (1) Kerr, T., Small, W., Buchner, C., Zhang, R., Li, K., Montaner, J., & Wood, E Syringe sharing and HIV incidence among injection drug users and increased access to sterile syringes. American Journal of Public Health, 100, (8) Kral, A.H., Wenger, L., Carpenter, L., Wood, E., Kerr, T., & Bourgois, P Acceptability of a safer injection facility among injection drug users in San Francisco. Drug and Alcohol Dependence, 110, (1-2) Krusi, A., Small, W., Wood, E., & Kerr, T An integrated supervised injecting program within a care facility for HIV-positive individuals: a qualitative evaluation. AIDS Care, 21, (5) Macalino, G.E., Sachdev, D.D., Rich, J.D., Becker, C., Tan, L.J., Beletsky, L., & Burris, S A national physician survey on prescribing syringes as an HIV prevention measure. Substance Abuse Treatment, Prevention, & Policy, 4, 13 (NSPs). Review decision April 2012 Page 16

17 McDonald, D The evaluation of a trial of syringe vending machines in Canberra, Australia. International Journal of Drug Policy, 20, (4) Millson, P., Jairam, J., Challacombe, L., Hopkins, S., Strike, C., & Bayoumi, A Where injection drug use and crack smoking occur: Implications for safer consumption sites in Toronto. Canadian Journal of Infectious Diseases and Medical Microbiology, Conference: 19th Annual Canadian Conference on HIV/AIDS Research: New Challenges, New Commitments, CAHR 2010 Saskatoon, SK Canada. Conference Start: Conference End: Conference Publication: (var.pagings) 70B Moniruzzaman, A., Thomas, V., Patel, S., Pearce, M.E., Schechter, M.T., & Spittal, P.M The cedar project: longitudinal analysis of accessing vancouver's safe injection site among young aboriginal people who use injection drugs. Canadian Journal of Infectious Diseases and Medical Microbiology, Conference: 19th Annual Canadian Conference on HIV/AIDS Research: New Challenges, New Commitments, CAHR 2010 Saskatoon, SK Canada. Conference Start: Conference End: Conference Publication: (var.pagings) 64B Nacopoulos, A.G., Lewtas, A.J., & Ousterhout, M.M Syringe exchange programs: Impact on injection drug users and the role of the pharmacist from a U.S. perspective. [Review] [50 refs]. Journal of the American Pharmacists Association: JAPhA, 50, (2) Pinkerton, S.D Is Vancouver Canada's supervised injection facility cost-saving? Addiction, 105, (8) Pizzey, R. & Hunt, N Distributing foil from needle and syringe programmes (NSPs) to promote transitions from heroin injecting to chasing: An evaluation. Harm Reduction Journal, 5, Article Number: 24. Date of Publication: 21 Jul 2008., Riley, E.D., Kral, A.H., Stopka, T.J., Garfein, R.S., Reuckhaus, P., & Bluthenthal, R.N Access to sterile syringes through San Francisco (NSPs). Review decision April 2012 Page 17

18 pharmacies and the association with HIV risk behavior among injection drug users. Journal of Urban Health, 87, (4) Rose, V.J. & Raymond, H.F Evaluation of nonprescription syringe sales in San Francisco. Journal of the American Pharmacists Association: JAPhA, 50, (5) Rudolph, A.E., Crawford, N.D., Ompad, D.C., Benjamin, E.O., Stern, R.J., & Fuller, C.M Comparison of injection drug users accessing syringes from pharmacies, syringe exchange programs, and other syringe sources to inform targeted HIV prevention and intervention strategies. Journal of the American Pharmacists Association: JAPhA, 50, (2) Salmon, A.M., Dwyer, R., Jauncey, M., van, B., I, Topp, L., & Maher, L Injecting-related injury and disease among clients of a supervised injecting facility. Drug & Alcohol Dependence, 101, (1-2) Salmon, A.M., van, B., I, Amin, J., Kaldor, J., & Maher, L The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia. Addiction, 105, (4) Tesoriero, J.M., Battles, H.B., Klein, S.J., Kaufman, E., & Birkhead, G.S Expanding access to sterile syringes through pharmacies: assessment of New York's Expanded Syringe Access Program. Journal of the American Pharmacists Association: JAPhA, 49, (3) Torre, C., Lucas, R., & Barros, H Syringe exchange in community pharmacies--the Portuguese experience. International Journal of Drug Policy, 21, (6) Vorobjov, S., Uuskula, A., Abel-Ollo, K., Talu, A., & Jarlais, D.D. 2009a. Should pharmacists have a role in harm reduction services for IDUs? A qualitative study in Tallinn, Estonia. Journal of Urban Health, 86, (6) Vorobjov, S., Uuskula, A., Abel-Ollo, K., Talu, A., Ruutel, K., & Des Jarlais, D.C. 2009b. Comparison of injecting drug users who obtain syringes from (NSPs). Review decision April 2012 Page 18

19 pharmacies and syringe exchange programs in Tallinn, Estonia. Harm Reduction Journal, 6, Article Number: 3. Date of Publication: 20 Feb 2009., Watson, T.M., Strike, C., Kolla, G., Jairam, J., Luce, J., Degani, N., O'Campo, P., Millson, P., & Bayoumi, A Smoke over here, inject over there: Identifying Challenges for the design of supervised consumption sites (SCSS) for crack smoking. Canadian Journal of Infectious Diseases and Medical Microbiology, Conference: 19th Annual Canadian Conference on HIV/AIDS Research: New Challenges, New Commitments, CAHR 2010 Saskatoon, SK Canada. Conference Start: Conference End: Conference Publication: (var.pagings) 87B-88B Wenger, L.D., Martinez, A.N., Carpenter, L., Geckeler, D., Colfax, G., & Kral, A.H Syringe disposal among injection drug users in San Francisco. American Journal of Public Health, 101, (3) Zaller, N., Jeronimo, A., Bratberg, J., Case, P., & Rich, J.D. 2010a. 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. Journal of Urban Health, 87, (6) Zaller, N.D., Yokell, M.A., Jeronimo, A., Bratberg, J.P., Case, P., & Rich, J.D. 2010b. Adverse event associated with a change in nonprescription syringe sale policy. Journal of the American Pharmacists Association: JAPhA, 50, (5) (NSPs). Review decision April 2012 Page 19