Standard Operating Procedure s15

DH June08

GENERIC STANDARD OPERATING PROCEDURE FOR THE PROVISION OF INJECTING EQUIPMENT AND PARAPHERNALIA TO DRUG USERS ( This must be modified to reflect your own pharmacy practice)

PURPOSE “To ensure the safe and efficient provision of injecting equipment and paraphernalia to drug users.

SCOPE This procedure covers the supply of injecting equipment and paraphernalia to drug users using the local pharmacy needle and exchange scheme. It includes procedures for dealing with returned used equipment but does not include the sale of injecting equipment or paraphernalia to drug users. By any suitable trained member of staff.

PROCESS/PROCEDURE The return of used equipment  Discretely identify that the client wishes to use the needle exchange service. The client may be known to you, they may catch the pharmacist’s eye, or approach the counter and ask to speak to the pharmacist or use the scheme.  Ask if the client has any equipment to return.  If the client has nothing to return you may want to ask about how they have disposed of their old injecting equipment and strongly encourage them to make returns in the future.  If the client has nothing to return, refer to the procedure for the supply of clean equipment.  If the client has used equipment to return, it should be sealed in a personal sharps container.  If the client has loose needles or used equipment in a bag, provide the client a personal sharps container and ask them to leave the shop to put the equipment in the container. Some schemes have large sharps bins on the premises suitable for accepting back loose equipment. In this case, DO NOT HANDLE loose sharps yourself ask the client to post the sharps in the Pharmacy sharps container themselves..  Client brings in equipment in bag or personal sharps container  If a member of staff must handle a bag of used equipment, instruct them to do so only by the handles of the bag or the top of the bag, ensuring there is no risk of injury if the contents were to pierce/spill from the bag. (Carry the container by the handle and well away from the body).  Retrieve the pharmacy sharps container from its storage place which is located in the room next to the entrance to the dispensary o Ask the client to place all used equipment directly into the larger pharmacy sharps container. The used equipment should preferably be sealed in a personal sharps container. (Do not touch the personal sharps container.  Thank the client for returning the equipment emphasising that this really benefits the scheme.  After disposal of the used equipment into the pharmacy sharps container, return the current sharps container to its storage place.  When returning the current sharps container to its storage place, check how full it is. Sharps containers should never be more than two thirds full. If it is nearly full check that you have more empty containers.  If there are no more empty containers and the collection date is not in the near future, contact the scheme co-ordinator (telephone number …………ask for …….. )  When full, seal the sharps containers and store in a safe place, away from empty containers, ready for collection.  Wash hands thoroughly after each exchange.  Make a record of the returns on the appropriate form which is kept at the pharmacy counter  Check that the number of returns has been correctly completed  Once the client has disposed of the used equipment, refer to the procedure for the supply of new equipment Special Circumstances

 Do not accept used equipment if all the pharmacy containers are full. Refer clients to a nearby pharmacy participating in the scheme, or refer them to either horizon house or base 25  In the event of a needle stick injury, liquid spillage, loose sharp or sharps container spillage, refer to the appropriate SOP.  Do not dispose of glass, cytotoxic or other hazardous waste in the sharps bins.

Supply of new equipment  Ensure staff are trained to treat clients with respect and in a non-judgemental way as with all the pharmacy’s customers.  Advise clients to come in alone (this is a private and confidential service), no pets, no smoking, no drinking.  Identify whether the client is over 16 years old.  If the client is under 16 years old, do not supply them with new packs. Refer them to the local young person’s drug and alcohol service -----base 25---- contact name---- Jo Flannaghan  Be alert to the possibility that a young person may be trying to obtain free condoms instead of injecting equipment.  If the client is known to you as a methadone or buprenorphine client, ask if the new equipment is for them. If the equipment is for them, encourage them to talk to their prescriber or key-worker.  If the client has no equipment to return, strongly encourage them to return their used equipment in the future.  Ask the client what equipment is needed.  Retrieve the new equipment from the storage place which is located …………………………..  If the client is behaving in a threatening manner, being verbally abusive or has been seen shoplifting, refuse to serve the client. Refer them to the local drug and alcohol service which can be contacted on 444030  In case of emergencies call the police by pressing the panic button. DEALING WITH EMERGENCIES Liquid spillages

 In the event of a spillage of blood or other bodily fluids, assign a member a staff to keep all customers away from the spillage.  Do not touch the spillage.  A fully trained member of staff should retrieve the spillage kit from its storage place which is located ……………………………  Cover any existing cuts and grazes with waterproof plasters.  Put on a pair of strong gloves and an apron  Treat the liquid spillage with the solidifying and disinfecting powder kept in the spillages kit, eg Encap.  Place the solid or semi-solid waste in a bag.  Place this bag into the sharps container.  Clean the affected area thoroughly with a disinfectant.  Dispose of the gloves and apron in the sharps container.  Wash hands thoroughly. Sharps container spillages

 Nominate a member of staff to keep the public well clear of the area.  If possible exclude the public from the shop until the hazard has been removed.  Do not touch any needles or syringes.  Call a suitably trained member of staff to deal with the spillage.  Put on strong, protective gloves, overalls, stout shoes, and, if necessary goggles which are located ……………………………  Use a pair of tongs or forceps to return the used equipment to a sharps container. These items are located in ……………. ……………………  Clear away the equipment as quickly and safely as possible.  Check the area thoroughly for loose sharps.  Return sharps container to its storage place.  Clean the affected area thoroughly with a disinfectant.  Remove gloves, overalls and shoes and return to their storage place. Loose sharps

 NEVER attempt to resheath a needle – this is the most common cause of needle stick injuries.  If a needle or syringe is left on the counter or accidentally dropped, do not touch it or attempt to move it.  Keep the public well away from the area.  The pharmacist or trained member of staff should deal with the needle.  Put on a pair of strong protective gloves which are located in ……………………….  Use a pair of forceps or tongs to place the loose sharps into the sharps container. These items are located in………………………..  Clean the affected area thoroughly with a disinfectant. Needle Stick Injuries

 A needle stick injury occurs when a person’s skin is punctured by an unprotected sharp.  Any needle stick injury should be reported to the pharmacist immediately.  Encourage the wound to bleed and wash it with hot running water.  Attend the nearest Accident and Emergency Department immediately (you may wish to provide details of the nearest A&E department here).  Follow current post-exposure prophylaxis guidelines (You need to check your local guidelines. You may wish to attach a copy to your SOP.) A copy of the guidelines can be found in the dedicated area for needle exchange packs. Many A & E departments have a standard procedure for dealing with needle stick injuries. Some A & E departments do not provide any treatment for needle stick injuries. Contact the scheme co-ordinator who should be able to ascertain the local procedure as well as being able to highlight that pharmacy staff operating the needle exchange scheme may be considered to be at a higher level of risk and so may be able to access post-exposure prophylaxis.  Record the accident in the pharmacy’s Accident book.  Make an initial report to the insurance company if appropriate.

KNOWN RISKS This SOP covers a number of high risk procedures and the SOP will help to avoid accidents and minimize the risks to yourself, your staff and your customers. This section should contain a description of anything you are aware of that can make the procedure more risky than usual. These are circumstances that you know can increase the likelihood of things going wrong and where you believe extra care and attention should be paid. For example, when supplying new equipment and taking back used syringes and needles, known risks might include:

 Equipment returned in bags  New staff, locums etc  New clients, unfamiliar with the service  Clients bringing in loose needles for return  Over filling sharps containers  Untrained staff  Client behaving in an unacceptable manner. What is the law on supplying injecting paraphernalia?

Under the Misuse of Drugs Act 1971 Section 9A, it was an offence for pharmacists to supply any of the paraphernalia which may be associated with the illegal administration of drugs, eg citric acid, sterile swabs, filters, sterile water etc.

Many doctors, pharmacists and health workers made the decision to supply these items anyway, but faced the risk of prosecution. The Government recognised the role of such items in reducing the health risk to drug users and in 2003, changed the law accordingly.

From 1 August 2003, it is not an offence for pharmacists, doctors and drug treatment workers to supply the following five items to help prevent disease and infection: ampoules of water for injections, swabs, utensils for the preparation of a Controlled Drug (spoons, bowls, cups and dishes), citric acid and filters. However, remember that water for injection is still a prescription only medicine*.

* The MHRA is currently consulting on whether people working in drug treatment services should be able to supply Water for Injections without prescription.

Can I sell injecting equipment without having arrangements in place to take back used equipment?

The RPSGB code of ethics states:

“Only in exceptional circumstances should pharmacists supply clean injecting equipment for drug misusers if the pharmacy has no arrangements for taking back contaminated equipment. Purchasers of injecting equipment should be advised of the availability of disposal facilities at the pharmacy and should always be encouraged to dispose of used syringes and needles safely.”

If you are not participating in an official needle exchange scheme but you are selling needles and syringes to drug misusers, you MUST have a properly designed sharps container in your pharmacy for the disposal of used equipment. Contact the NPA for a list of suppliers of sharps boxes which meet the required British Standard BS7320.

If you currently have no facilities for taking back used equipment but are asked to sell needles and syringes, consider joining a local needle and syringe scheme. Sharps boxes are usually supplied by the organizers of the scheme. They also arrange for the collection and destruction of the main sharps container on a regular basis. If you decide not to join the scheme, or are unable to, find out where the nearest participating pharmacy is located. Refer any requests for needle and syringes to the nearest participating pharmacy.

It is worth contacting the local Needle exchange scheme co-ordinator if returned injecting equipment is common as they may be willing to provide the pharmacy with a sharps bin and waste collection service as part of the needle exchange scheme.