Population and Public Health May 1 1 of 9 PURPOSE Engage people who may have been marginalized from mainstream services. Prevent the spread of sexually transmitted and blood-borne infections by providing information, support and harm reduction supplies target populations. Prevent overdoses. Prevent needle puncture injuries. Building and maintaining relationships between the Healthy Sexuality and Harm Reduction team and partnering sites. SCOPE & GOAL These guidelines have been developed to support agencies that partner with the WRHA in distribution of harm reduction supplies. BACKGROUND Partnership agreements A partnership agreement will be developed with each site. Regular communication with the contact-person at the HSnHR team is necessary to determine supply availability/limitations, provision of monthly statistics and ongoing support. Building relationships Building relationships and trust is an essential feature of harm reduction. Such relationships are critical to ensure a client s choice is understood, expressed and advocated. Provision of services within a welcoming context supports the development of rapport & trust. Trusting relationships can take effort and time to develop. Other aspects of relationship building within a harm reduction context include respecting client choices as to the level of interaction, being sensitive to timing of when/how information is presented and respecting the wishes of those who refuse or are not ready to accept information about their risks or health condition. Relationship building also includes continuing to provide opportunities for people to get information, to have conversations about safer drug use and to make their own choices, even when drug use or other factors may reduce a person s capacity for self-determination. It is important to be cognizant of the position of relative power in professional relationships with clients to identify and minimize sources of coercion.
Population and Public Health May 1 2 of 9 Engaging discussions and supporting behaviours to reducing harms Conversations with clients about current and safer drug use practices will support safer-use and behaviours to reduce harm, and expose opportunities for structural intervention, service improvement, and advocacy. These conversations may include types of drugs used, routes, frequency and context of drug use. Knowledge of a client s drug-use by a specific route (e.g., inhalation, injection) assists to know which supplies are necessary to reduce harm as well as support transition to less-risky drug use. Providing information and support can enable clients to act on their own behalf in meeting their health and health care needs. Access to supplies to reduce harm Access to supplies to reduce harms should extend to clients, including minors, who use drugs and take risks that potentially expose them to STBBIs and other harms. Some clients may also collect harm reduction supplies for secondary distribution which is a strategy to reach people who use drugs but not yet attend sites to obtain safer supplies. Giving consideration to keeping drug-related harm reduction supplies safely and outof-sight as much as possible can assist to avoid power-struggles and triggers. PROCEDURE 1.0 Distribution of Supplies 1.1 Provide clients with enough syringes to meet the client s needs for 1 sterile syringe per injection. 1.1.1 Returning used syringes at the same time isn t required, but encouraged. If the client does not have needles to exchange, determine how many needles the client needs and provide him/her with enough. 1.1.2 It is appropriate to provide injection supplies for the purpose of secondary distribution. Discourage resale of supplies provided. 1.1.3 Encourage clients to encourage other peers to attend for their harm reduction supplies in order to allow for opportunity for relationship building, risk-reduction counseling and education. 1.1.4 Due to risk of needle stick injury, the number of needles returned is always estimated, never counted by hand. 1.1.5 Encourage return and/or proper disposal of used needles. 1.1.6 Offer information and have discussions with clients about: Using a new syringe each time you inject.
Population and Public Health May 1 3 of 9 Correct use includes checking for burrs on needle before injecting, injecting with the bevel up, confirming needle in vein by drawing small amount of blood, pressure on puncture site after use. Risks associated with sharing syringes and drug mixing equipment. Risk of reusing your own syringes and drug mixing equipment. Disposal of used syringes. Prevention/care of skin/veins. This may include inspecting injection sites for evidence of infection or bruising, within the individual practitioner s scope of knowledge/practice. 1.2 Spoons are offered to clients who inject drugs. Provide education that: Only a single person should use one spoon. The spoon with the drug and water intended for injection should be heated to a boil to kill most germs. Washing or heating may not kill all viruses and bacteria. Hepatitis C is easily spread by sharing works such as spoons, filters, water, etc. It may be helpful to mark personal spoons in some way to reduce risk that someone else might use it. Spoons should be stored in a safe place that only you have access to. If you are unsure if others have used your spoon, discard it and use a new one. Wash spoon with soap and water or wipe with an alcohol swab before use, even the first time you use the spoon, as spoons are not sterile. If you might reuse the spoon, clean it after use to remove residue. Residue is a good place for bacteria to grow. 1.3 Sterile water is offered to clients who inject drugs. The amount distributed may be up to 1-sterile water per syringe. For client education, consider use of a Sterile Water pamphlet available from the Healthy Sexuality and Harm Reduction team. Provide education that: The vial should never be shared with anyone as this poses a risk for cross contamination. Squeeze the vial before use to make sure no water escapes. If water does leak or squeeze out of the vial, do not use it. It may no longer be sterile. Twist the cap and pull it completely off the vial. Turn the vial upside down and squeeze what you need into your spoon or cooker.
Population and Public Health May 1 4 of 9 Do not puncture the plastic water container with a needle to withdraw water into a syringe. Throw out any remaining water and the plastic container. Store the vials of water at room temperature. Keep them away from extreme heat and cold. Do not re-use/share used syringe or water. Water is single use only. 1.4 Filters (cotton balls) should be offered. Always wash hands with alcohol hand wash before packaging cotton balls. Educate clients as follows: Cotton balls may prevent large particles from getting into the syringe, but they will not prevent the entry of small organisms like bacteria, viruses and other small particles. Discourage reuse of filters as this practice increases risk for infection by bacteria that may grow in the wet filter. Filters should never be shared. 1.5 Alcohol swabs are offered in the quantities requested by clients, usually up to 1-alcohol swab per needle. Provide education about: Proper alcohol swab use is important to help prevent other health complications that may result from not cleaning the skin before injection such as skin and soft-tissue abscesses and other bacterial infections. Cleaning the skin with soap and water is effective but clients may not have access to soap and clean water. Using swabs on the skin before injection only; clean, dry, and absorbent pads should be used to stop blood flow after injection. Washing the injection site with soap and water is just as effective. 1.6 Sharps containers are offered to reduce risk of needle injuries. Clients are asked to fill containers to appropriate levels without overfilling. 1.7 Tourniquets are offered to reduce harm. Educate about: Correct use of single person tourniquets. Risk to tissue and veins if a quick release tourniquet is not used. Risk of bacterial and viral contamination due to shared tourniquets.
Population and Public Health May 1 5 of 9 1.8 Offer Vitamin C Ascorbic Acid powder sachets to reduce damage to muscle and vein tissue by clients who dissolve crack or certain types of heroin for injection. Ascorbic acid has been identified as a less harmful acidifier used to dissolve drugs for injecting. Offer education about and encourage client to use ascorbic acid as follows: One sachet per needle for the above drugs should be offered. Place the drug into the spoon or cooker. Add water. Rip open sachet. Tap a small amount of the ascorbic acid into the spoon/cooker (about ¼ the amount of the drug). Heat the mixture if necessary. Stir and mix as necessary to dissolve the drug. If the drug is not dissolved, add a little more ascorbic acid (avoid adding too much ascorbic acid as this will damage the veins). Some of the filler may not dissolve. This is ok. If the mixture is hot, wait 5-10 minutes before injecting. Injecting hot liquid may cause blood clotting and vein damage. Filter the drug through clean cotton before injecting. This will remove fillers that did not dissolve. The ascorbic acid powder should not be handled due to possible contamination. Using as little of the sachet as possible and discard the remainder of the open sachet. There is no known advantage in using acidifiers with pills. 1.9 Safer Crack Use Kits (SCUKs) 1.9.1 SCUKs or any components of these kits are provided to crack/meth using clients upon request for safer use of crack/meth. SCUKs are not distributed for marijuana use. 1.9.2 Number of SCUKs provided per client attending the site is based on current supplies available from the HSnHR team. Regular communication with the contact-person at the HSnHR team is necessary to determine limitations. 1.9.3 Discourage reselling of SCUKs. 1.9.4 If cracked or burned skin on the lips or fingers are observed, it is an opportunity to discuss safer use.
Population and Public Health May 1 6 of 9 1.9.5 When a client reports that the stem was broken within a week it may indicate unsafe use and reports of breakage within a week is an opportunity to review safer use. 1.9.6 Offer information and have conversations about: Risk of getting or giving communicable infections (e.g. HCV) with cuts/cracks/burns on their lips or in the mouth/throat. Risk of communicable infections if sharing glass stems and other devices for inhaling or smoking drugs. Recommended single-person use of stems to decrease risks of cuts/cracks/burns and transmission of communicable infections. This includes the assembly of the kit with the brass screens folded like an umbrella before inserting into the stem, round side down. This allows the screens to bind together when compacted so that they do not come loose and damage the client s airway. Health consequences of using products other than brass screens (e.g., Brillo brand steel wool). Harms associated with steel wool use include: toxic volatile organic carbons released when steel wool is burned. Use of steel wool is also associated with loose shards breaking off and potentially damaging the inner mouth or airway. Use of brass screens reduces these harms. If a client is unwilling to use brass screens rather than steel wool, they can be encouraged to use screens between the steel wool and the mouthpiece as a barrier for loose shards and to burn their steel wool before use. This coating can be burned off after the first use and may not be a persisting problem. Correct disposal of used glass stems and mouth pieces. 1.10 Condoms, Lube and Gloves 1.10.1 Offer condoms and water-soluble lubricant to all clients. Provide as many as requested up to an allotted limit. Each specific type of supply may have different limits, depending on availability from the HSnHR team. 1.10.2 Nitrile gloves are provided upon request for clients who engage in manual or digital-vaginal or digital-anal sex with others, or when the person s hand has cuts, sores or rashes, depending on availability from the HSnHR team. 1.10.3 Gloves are not distributed for non-sexual use such as tattooing. 1.10.4 Sex-dams may be distributed upon request with specific limits, depending on availability from the HSnHR team.
Population and Public Health May 1 7 of 9 1.10.5 Offer education to clients regarding: Risk of HIV, HBV and other STIs through oral, vaginal and anal penetration as well as cunnilingus and anilingus. Safer sex with every sexual partner. Use of water or silicone-based lubricants. Discourage use of oil-based products when using latex condoms which weaken the condom and cause it to break. Those wearing lipstick or using lip balm may be reminded that oil-based products weaken and break latex. Correct condom use. Demonstration should be offered to all clients as required. 2.0 Overdose Prevention. Create opportunities to encourage overdose prevention. Recommendations Rationale Avoid mixing drugs with similar effects Drugs with similar effects when combined can increase the risk of overdose When tolerance is lower (e.g., after drug treatment or Lowered tolerance can increase the risk of release from jail): overdose o Use a smaller amount of drugs than before o Smoke or snort drugs to reduce the speed of absorption into the body o Use with someone else present or let someone know to check Take care when using drugs from a new and/or Using drugs of unknown potency can increase unknown source: the risk of overdose o Inject a test shot to test potency o Ask others about the potency Buy drugs from a regular and trusted source Know how to recognize symptoms of overdose in self Early intervention during an overdose can and others increase survival rates Know what to do, and what not to do, if you or someone else shows symptoms of overdose Call for assistance if you or someone else is overdosing Do not leave someone who is overdosing alone Early intervention during an overdose can increase survival rates and reduce victimization Ontario Needle Exchange Programs: Best Practice Recommendations (2006). Strike, C., Leonard, L., Millson, M., Anstice, S., Berkeley, N. & Medd, E. http://www.ohtn.on.ca/nep.htm.
Population and Public Health May 1 8 of 9 3.0 Needle-Puncture Injury Prevention 3.1 Staff Follow Workplace Health and Safety guidelines Staff must not accept hand-to-hand offers of used sharps. Staff will ask people dropping off sharps containers to engage the locking mechanism in order to reduce risk of accidental opening of the sharps container. If the sharps are not already in an approved sharps container, ask clients to put all used sharps directly into an approved sharps container. Spills of used needles will be dealt with by securing the area. Make it safe for yourself and others. Pick-up needles safely at a comfortable, easy pace. When clients exchange needles, offer and provide sharps containers. Large sharps containers should be changed when they are 2/3 full. At that time, secure the lid to the container. 3.2 Clients Clients are encouraged to use sharps containers with a non-removable lid. The container must be capable of withstanding the weight of the biomedical waste without tearing, cracking or breaking. When sharps containers are not available, encourage clients to place used equipment in a rigid, plastic container with a tight fitting lid such as a bleach bottle, fabric softener bottle, or plastic soda pop bottle. Encourage clients to write SHARPS DO NOT RECYCLE on containers without such markings. To prevent injuries to themselves and others encourage clients to: o Return sharps containers before they are overfilled. o Locate sharps containers close to the area of use. o Dispose of used equipment immediately. o Never recap a needle. o When using or exchanging needles with other people, ask them to deposit them in a sharps container. o Do not bend or break a needle. o Engage the locking mechanism on sharps containers when they are full.
Population and Public Health May 1 9 of 9 4.0 Support appropriate immunization. 4.1 Support and encourage clients to get vaccinated against Hepatitis and other vaccines for which they are eligible. 4.2 Refer to Provincial guidelines RECOMMENDED READING Canadian HIV/AIDS Legal Network (2008). Distributing safer crack use kits in Canada http://www.aidslaw.ca/publications/interfaces/downloadfile.php?ref=1390 Strike et al. (2006). Ontario needle exchange programs: Best practice recommendations http://www.health.gov.on.ca/english/providers/pub/aids/reports/ontario_needle_exchang e_programs_best_practices_report.pdf WRHA (2007). Position Statement on Harm Reduction http://www.wrha.mb.ca WRHA (2008). What do I do if I find a used needle of syringe? http://www.wrha.mb.ca