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The role of pharmacists in increasing syringe accessibilty

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Title:
The role of pharmacists in increasing syringe accessibilty
Creator:
White, Beth A
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
Physical Description:
ix, 124 leaves : ; 28 cm

Subjects

Subjects / Keywords:
Syringes ( lcsh )
Selling -- Syringes ( lcsh )
Needle sharing -- Colorado -- Denver Metropolitan Area ( lcsh )
Pharmacists -- Attitudes -- Colorado -- Denver Metropolitan Area ( lcsh )
Intravenous drug abuse -- Colorado -- Denver Metropolitan Area ( lcsh )
Needle exchange programs ( lcsh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 114-124).
Thesis:
Anthropology
General Note:
Department of Anthropology
Statement of Responsibility:
by Beth A. White.

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|University of Colorado Denver
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|Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
47108513 ( OCLC )
ocm47108513
Classification:
LD1190.L43 2000m .W44 ( lcc )

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Full Text
THE ROLE OF PHARMACISTS IN INCREASING
SYRINGE ACCESSIBILITY
by
Beth A. White
B.S., State University of New York at Binghamton, 1993
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Anthropology
2000


This thesis for the Master of Arts
degree by-
Beth A. White
has been approved
by
$ h^/ ao
Date


White, Beth A. (M.A. Anthropology)
The Role of Pharmacists in Increasing Syringe Accessibility
Thesis Directed by Professor Stephen K. Koester
ABSTRACT
Background: Colorado does not have a legally sanctioned needle exchange
program and is not a state which requires a prescription in order to
purchase a syringe. As a result, intravenous drug users (IDU) commonly
obtain sterile syringes by purchasing them at pharmacies.. However,
Colorado does have a paraphernalia law which makes access problematic.
The purpose of this study is to gauge the attitudes, beliefs, and experiences
of pharmacists in the Denver metro area regarding their role in providing
syringes to IDUs.
Methodology: Semi-structured interviews were conducted with 32
pharmacists in Denver concerning their attitudes toward and experience
selling syringes to IDUs. All pharmacies within study boundaries were
selected to participate in the study. Pharmacists working at both chain and
independent stores were interviewed. All interviews were confidential and
coding was done by hand.
Results: Attitudes toward syringe sales varied with three distinct categories
of pharmacists emerging; those that sold all the time, those that sold none of
the time, and those that sold some of the time. Those that sold all of the
time perceived their role in public health as one of decreasing disease
transmission by providing access to sterile injection devices. Those that
refused to sell interpreted their role as one of enhancing the health of their
111


clients and saw drug use as contradictory to that. The final group, among
whom sales were situational, expressed a continually fluctuating moral
conflict between promoting health by providing access and promoting
health by not supporting an unhealthy habit. Strategies for refusing to sell
included the request for identification to prove diabetic necessity, only
selling in bulk quantities (i.e. boxes of 100), or denying access on the basis of
store policy.
Conclusion: These attitudes have direct consequences on access to sterile
syringes and all pharmacists expressed concern about this issue. We suggest
that disease prevention efforts should work with pharmacists to increase the
sale of sterile syringes to IDUs, and that pharmacists might consider
addressing the issue of providing access to sterile syringes in their
professional organizations, in pharmacy school curriculum and in
continuing education classes.
This abstract accurately represents the content of the candidate's thesis. I
recommend its publication.
Signed
Stephen K. Koester
IV


DEDICATION
This thesis is dedicated to the memory of Alice K. White; a woman who
taught me love, courage and joy.


ACKNOWLEDGMENT
I would like to thank all those individuals who were essential in the
completion of this project. I sincerely appreciate the cooperation of the
pharmacists that took time out of their hectic schedules to participate in this
study. Great thanks goes out to Trevor Bush, whose ideas and work helped
to shape and complete this project. Dr. Stephen Koester's guidance and
advice was essential in the completion of my degree, but his passion for his
research showed me what public health is truly about. Others that
participated in the completion of this work include, but are not limited to;
David Miller, Doug Kershaw, Christy Christiansen and the entire staff at
Urban Links. I would also like to thank T. Stephen Jones at the CDC for his
unfailing commitment to this project. This work was funded through a
cooperative by the Association of Teachers for Preventative Medicine and
the Centers for Disease Control and Prevention.
My friends in Boulder and throughout the country have provided me with
endless support and encouragement. I would like to thank Jenn Shuping for
the long runs and unfailing friendship; Ralph Shuping for reminding me of
the lighter side of life; Kate Beal for her encouragement and reminders that
what I was doing was worthwhile; Michael Hammett and Kelly Riordan for
always being there for me; and all of the ultimate teams that I have been on
during the course of this degree. Thanks to you all.
My parents have always been there to support me, no matter what I was
doing at the time. Whether I was in school, traveling, or working, you have
always made me feel as if I could accomplish anything that I set my mind to.
It is because of you that I am where I am today. Thanks also goes to Erik
and Russ for providing me with constant love and support.
I cannot say enough about the love, encouragement, support and devotion
that Aaron Lewis has provided me in the years that it took to complete this
degree. Thank you for teaching me how to fly when I wasn't even sure how
to walk.


CONTENTS
Tables_______________________________________________________ ix
CHAPTER
1. INTRODUCTION___________________________________________ 1
IDU at Risk- The Dual Epidemic of HIV and HCV____ 4
Behaviors that Place IDU at Risk____________________ 6
2. THEORETICAL ORIENTATIONS._____________________________ 10
Illicit Drug Users Within our Society______________ 13
The Bio-Medical Message____________________________ 20
3. REVIEW OF THE LITERATURE______;_______________________ 22
IDU Behaviors ._______ ________________ 24
Bleach Use______________________________________ 26
Paraphernalia Laws ________;____;___________- 27
States That Have Repealed Paraphernalia and Prescription
Laws_______________:' ____________:____ 32
Needle Exchange Programs ________ '_______ 36
Syringe Disposal : ; ______________ 42
Pharmacists' Role in Syringe Accessibility_________ 45
Limitations to Access Through Pharmacies___________ 46
4. METHODOLOGY___________________:_______________________ 53
Complimentary Study________________________________ 53
Sampling Procedures________________________________ 53
Data Collection____________. 55
Question Guide_____________;_______________________ 57
Study Sample________________________________________60
Data Analysis_____________________________________ 64
5. FINDINGS______________________________________________ 65
Competing Public Health Models for Drug Users____ 66
Business Concerns_________________________________ 68
Ambiguity Regarding Legality of Syringe Sales______ 71
Image Assessment___________________________________ 74
Pharmacists' Experience with HIV+ and Injection Drug
Using Populations_______________________________ 79
Wide Spread Support for Needle Exchange Programs_ 81
vii


6. DISCUSSION________________________________ 84
7. CONCLUSION AND RECOMMENDATIONS____________ 89
Recommendations_________________________ 91
Concluding Remarks_____________________ 94
APPENDIX
A. MAIL IN SURVEY______________________________ 97
B. LETTER OF INTRODUCTION______________________ 99
C. CONSENT FORM_______________________________ 100
D. PHARMACY QUESTIONNAIRE______________________104
E. SUPPLEMENT INTERVIEW_______________________ 109
F. COLORADO PARAPHERNALIA STATUTES____________ 113
REFERENCES______________________________________ 114
viii


TABLES
Table
1. Participating Pharmacies___________________
2. Demographics of Participating Pharmacists
IX


CHAPTER I
INTRODUCTION
Currently, injection drug use is the dominant risk factor identified in
new cases of HIV and Hepatitis C in the United States, and is responsible for
over one third of all AIDS cases and over half of the Hepatitis C cases
reported in the United States. The sharing of non-sterile syringes1 and the
use of contaminated syringes during the process of preparing and injecting
drugs enables the efficient transmission of these diseases. While frequency
of use may increase an individual's risk, any person who has injected an
illicit substance using a contaminated syringe even once runs the risk of
contracting a fatal infectious disease.
Risk of disease transmission from injection drug use not only affects
injection drug users (IDUs) but their sexual partners as well. In NIDA's
triennial report to congress (NIDA 1999), summarized research indicated
that those who had used illicit drugs in the past year were more likely than
those who had not to test positive for HIV. Additionally, they reported that
illicit drug users who were surveyed were more likely than non-users to be
sexually active and to have had two or more partners within the past year.
1 Since the IDUs in the United States overwhelming use syringes with non-removable
needles, the term 'syringe' will be used to mean the syringe and the needle. In the past,
syringes with detachable needles more common.
1


Furthermore, those who reported having two or more sexual partners in the
past year were less likely to report that they always used a condom.
Subsequently, there has also been a growing number of HIV cases identified
in the sexual partners of IDUs (NIDA1999).
The only sure way to stop the spread of blood borne diseases through
injection drug use among IDUs not in treatment is to make certain that they
use a sterile syringe for every injection episode. Unfortunately, access to
sterile syringes in many states is problematic due to a mixture of contextual
factors such as paraphernalia statutes, prescription laws (requiring a
medical prescription to obtain a syringe) and the concerns of those
pharmacists who control syringe distribution. In order to increase syringe
availability and thus reduce injection risks, many areas have sanctioned
needle exchange programs that often operate on a one for one exchange
system. However, while these programs do constitute one component of a
solution to syringe access in the United States, needle exchange programs
remain sparse in the U.S.
This study is concerned with the availability of sterile syringes for
IDUs in Denver. The state of Colorado does not legally sanction needle
exchange programs, however it is also not a state that requires a
prescription in order to purchase a syringe. Consequently, Denver
pharmacies represent the most reliable source of sterile syringes for IDUs,
and are thus the primary source for distribution. However, pharmacy sales
2


are dependent on store policies and the attitudes of individual pharmacists.
Thus, it is imperative to include pharmacists in harm reduction strategies
aimed at this population. The purpose of this study was to gauge the
attitudes, beliefs, and experiences of pharmacists in the Denver metro area
regarding their role in providing syringes to IDUs.
This research was one part of a two-part study funded through a
cooperative by the Association of Teachers for Preventative Medicine
(ATPM) and the Centers for Disease Control and Prevention (CDC)2. The
other segment of the study examined the degree to which sterile syringes
are currently available to IDUs through pharmacy sales in the Denver metro
area and identified possible constraints that limit access. The research
reported here was conducted through Urban Links. Urban Links is funded
through grants from the National Institute on Health (NIH) (NIDA DA-
09232), the CDC and the state of Colorado. It is a project within the Center
for Health and Behavioral Sciences and the University of Colorado at
Denver. Dr. Stephen Koester, Urban Link's director and principal
investigator, has been funded to research individual and network HIV
interventions for IDUs.
2 Role Of Pharmacists In Increasing Syringe Accessibility. Primary Investigator: Stephen
Koester. CDC Program Officer: T. Stephen Jones, MD
3


IDUs At Risk-The Dual Epidemic
Of HIV And HCV
Injection drug use is a main risk factor for the transmission of blood
borne diseases, responsible for 35.8% (n=251,759) of all HIV/AIDS cases
(both due to and associated with injection drug use), and for 91% (n=7,828)
of all pediatric HIV/ AIDS cases (13 years and under) reported through June
of 1999 to the Centers for Disease Control and Prevention in the United
States (CDC 1998). The full force of these numbers is illuminated by the
fact that since 1996, more Americans have become infected with HIV as a
result of an infected hypodermic syringe than from an infected sexual
partner (Project Sero 1999).
HIV infection is not the only medical threat that currently confronts
IDUs: the developing epidemic of Hepatitis C (HCV) infection is a growing
concern. HCV was only recently identified in 1989, previously known as
non-A, non-B Hepatitis, and could not be detected in the blood until 1992
(NIDDK 1997). Like HTV, HCV is a blood-borne pathogen transmitted
among IDUs through the sharing of injection equipment (unlike HIV it does
not appear to be as easily transmitted sexually). There is no known cure for
HCV at this time, and while most HCV infections are transient, chronic
infections will lead to cirrhosis and hepatocellular carcinoma (Heimer et al.
1996, NIH 1997). Due to its recent identification, HCV has spread
unimpeded for decades. As a result, there are very few, if any prevention
4


programs addressing this issue among IDUs. By 1999, almost 4 million
Americans had been infected with HCV (CDC 1998). Over half of these
infections were due to injection drug use and the other half of the cases were
due to a variety of causes such as; hemophiliacs treated with products
before 1987, blood transfusions before 1990, people who engage in high risk
sexual practices, and health care workers (CDC 1998).
HCV infection is spread much more rapidly than other viral
infections such as Hepatitis B and HIV, evidenced by a fourfold increase in
HCV infection rates over HIV infection rates in young injectors (CDC 1998).
This may be due to the high prevalence of IDUs already infected with HCV
thus increasing the probability of an IDUs coming into contact with an HCV
positive individual (CDC 1998). HCV has been called the 'silent epidemic'
since individuals infected with the virus can live asymptomatic for years.
Due to this fact, many individuals who are infected may be unaware of their
status and are thus spreading the disease unknowingly. Consequently, it
has been estimated that within five years of beginning to inject, as high as
90% of IDUs may become infected with the virus. Some researchers
estimate that the death rate for HCV in the next decade will surpass that of
HIV (Mayo Health Oasis 1997).
5


Behaviors That Place IDUs At Risk
Traditionally, interventions have focused on modifying the
individual behaviors that increase risk of disease among IDUs. Injection
behaviors that facilitate transmission include the direct sharing of syringes
as well as many other less directly apparent behaviors that place IDUs at
risk for HIV/HCV infection. "Indirect sharing" occurs when syringes
become contaminated through the sharing of injection paraphernalia while
preparing and distributing the drug. This paraphernalia includes water,
cottons and cookers or mixers. The sharing of water for rinsing syringes
and/or mixing drugs, containers used to mix the drug solution, cottons for
filtering the drug as well as frontloading and backloading (methods of
transferring the drug solution from one syringe directly into another
syringe), and booting3 also place IDUs at risk of infection (Grund 1991, Zule
1992, Koester 1994, Vlahov 1996, and McCoy 1998). This risk is not as
obvious as the direct sharing of another's syringe but instead occur during
the intermediate steps in the preparation of the drug. Unfortunately, most
IDUs perceive syringe sharing as risky behavior but many do not identify
the previously mentioned practices as unsafe conduct (Koester et al. 1996).
Koester and colleagues emphasize that the percent of subjects they
3 Booting is a process that occurs after registering and administering the drug solution.
With the needle still in the vein, the individual draws the plunger back in order to fill the
barrel of the syringe with blood and then reinjects the blood. This practice allegedly
enhances the euphoria associated with the drug's effect (Normand 1995).
6


interviewed who shared rinse water, cotton filters, or cookers was more
than twice that of those who shared used syringes; resulting in a larger
population of IDUs at risk than previously estimated (Koester et al. 1996).
While Koester originally interpreted these actions as those that place
IDUs at increased risk (1990), they are only proxies for the actual risky
practice of drug sharing (Koester et al. 1996). The practice of sharing
paraphernalia while preparing the drug solution is often a result of two or
more individuals pooling their limited funds in order to purchase a small
quantity of their drug of choice. Since it can be difficult to successfully
measure out equal shares of a drug while it is in its solid form, many prefer
to measure out their share after the drug has been prepared and has become
a liquid. The processes of shared preparation and distribution represent
possible instances of risk. Thus, if a contaminated syringe is used for
preparing drugs for injection, blood-borne disease transmission can occur
even if the syringe itself is not shared.
In contrast, some behaviors that IDUs engage in may actually
decrease the chance of infection. In the western portion of the United States,
the heroin available is termed 'black tar' due to its similarity in consistency
to tar. It is unlike the easily dissolvable powder heroin available on the East
Coast and users must heat the drug in order to break it down for injection.
HIV is unable to survive the heat that occurs during this type of heroin
preparation and often dies in the drug mixture before injection (Clatts et al.
7


1999). It has been ascertained that the survival of HIV-1 in a syringe is a
function of the temperature achieved during the 'cooking' of the heroin
solution. HIV-1 has been shown to be deactivated once temperatures
reached an average of 65 C for 15 seconds or longer (Clatts et al. 1999).
However, this only pertains to those drugs that are heated before injection;
drugs such as methamphetamine and cocaine are not usually 'cooked'.
Additionally, I have observed injection episodes in which the drug solution
was heated for far less than fifteen seconds, thus decreasing the efficacy of
"cooking" as a form of harm reduction.
Research has shown that IDUs are aware of the risks associated with
injection drug use and recognize that they should use a new, sterile syringe
for each injection (Calsyn et al. 1992). Yet, injection drug use continues to be
either directly or indirectly responsible for a high proportion of all AIDS
cases, and more than half of the HCV cases. Some have stated that the
continued practice of sharing paraphernalia among IDUs is a result of
adhering to a ritual of the drug sub-culture (Howard & Borges 1972, Des
Jarlais & Friedman 1986). I would argue that the inability of IDUs to change
their injection behavior in order to decrease their risks is often a result of a
combination of obstacles to access as well as the legal repercussions of
possession of paraphernalia. These impediments can affect where, when
and how a person injects.
8


As such, in addition to educating users about these practices and the
risks they imply, it is essential to develop interventions aimed at structural
change. It is difficult for many IDUs to adhere to safe injection practices
while simultaneously being faced with structural impediments to
purchasing and possessing syringes. Unfortunately, while the number of
IDUs becoming mortality statistics grows, they remain entrenched in a
social construct for prevention of infection from a bio-medical community
that repeatedly fails to take into account the contextual factors that influence
behavior.
9


CHAPTER II
THEORETICAL ORIENTATIONS
For the purposes of this thesis, the theoretical influences that I have
incorporated include the concept of Critical Medical Anthropology (CMA),
Foucault's notion of bio-power and Bourdieu's concepts of cultural capital,
habitus and social field. The perspective that this work is grounded in is
that of CMA, a theory that is centered on the belief that "the dominant
ideological and social patterns in medical care are intimately related to
hegemonic ideologies and patterns outside of biomedicine" (Baer et al.
1997:26). This theoretical perspective is significant in that it does not
examine health issues in a vacuum but instead addresses the political and
economic factors that create and shape human behavior. In the case of
IDUs, this means that the social stigma and legal status that our culture has
associated with illicit drug use have become the primary determinants of an
IDU's treatment by the dominant society and it's representative institutions,
including medicine. A prime example of this would be the legal status
regarding possession of sterile syringes, an item that is necessary in order
for IDUs to comply with public health recommendations.
CMA has partially grown out of the ideas of Foucault, specifically the
focus on the individual's place in the realm of health care and their ability to
10


maneuver within it. Foucault theorized that humans are unable to define
and understand themselves without an awareness of the mechanisms of
power that serve to modify their behaviors and shape them as individuals
(Foucault 1983). Flis theory of power defines how the actions of individuals
in authority result in the reorder of the possible conduct of the individuals
who these actions affect. In other words, those with the power to construct
laws and create the social framework that we must live within recognize
that individuals forced to live within these boundaries are capable of
making their own decisions. Individuals either decide to comply with the
social and structural constraints placed upon them or they choose non-
compliance (Foucault 1983). For IDUs, the decision to inject illicit drugs is
the initial decision not to comply with those who deem this behavior illegal.
As a result, they have effectively lost all rights to work pragmatically within
the social structure since their first act of personal responsibility should be
to sober up. Subsequently, any choice they face concerning their drug use is
additional non-compliance.
Additionally, Foucault introduced the concept of bio-power, the idea
that historically entrenched and institutionalized forms of social control
serve to discipline individuals (Foucault 1970, Bourgois 1997). In the
context of HIV/HCV prevention, the concept of bio-power is evident in the
synergistic effects of medical guidelines regarding HIV infection, legislation
concerning drug use and paraphernalia, and the dominant but seemingly
11


contradictory policies regarding drug use. In this case, it is pharmacists that
have been unknowingly disciplined by this seemingly contradictory
institutional environment, which has thus influenced their decision to sell
sterile syringes to IDUs. IDUs themselves are similarly influenced by these
policies, as they are led to believe that they are undeserving of sterile
syringes. The combination of these factors creates an artificial scarcity of
syringes among IDUs and, ironically, increases the spread of infectious
disease, rather than preventing it.
In addition to CMA and Foucault, the work of Bourdieu provides
another perspective for understanding the role of pharmacists in selling
sterile syringes and the dilemmas they face. There are three main concepts
developed by Bourdieu that are of interest here. First, the term 'field' is
used by Bourdieu in order to describe the social arena in which individuals
maneuver (Bourdieu 1990). His use of this concept presents us with an
effective method to examine a complex social problem, the agents involved,
and the relations that exist between them. The field that is being examined
here is that of illicit drug use, which includes those involved in the
underground drug economy, drug users, and institutions developed to
prevent and/or reduce illicit drug use. Pharmacists also play a role in this
field by virtue of the fact that they dispense the syringes necessary to IDUs.
Bourdieu defines a field as a system of relations, the most important
of which are the power relations between the individual agents occupying
12


different positions within the field. Bourdieu states that "every field [is] the
locus of power relationships." (Bourdieu 1990:141). However, the amount
of power that one holds within a particular field depends upon the amount
of capital one possesses. Cultural capital is a term coined by Bourdieu to
describe the socially inherited "linguistic and cultural competence" that
allows an individual to successfully maneuver within any particular culture
(Swartz 1977, Bourdieu 1980, Robbins 1991).
Finally, Bourdieu uses the term 'habitus' to describe the perceptions
and patterns of thought and action individuals possess which have been
shaped by objective conditions (Bourdieu 1977). However, Bourdieu also
states that even when the objective conditions1 that originally shaped these
ideas have changed, individual patterns of thought and action persist. This
is significant in the case of IDUs living in the time of an HIV pandemic yet
continuing to be judged by beliefs created in a pre-HIV world.
Illicit Drug Users Within Our Society
In the beginning of the AIDS epidemic, activists could not get the
funds or the attention needed from the government and the public in order
to begin to understand and fight this disease (Shilts 1987). AIDS appeared
to be primarily affecting the homosexual community (the epidemic was
sometimes referred to as 'gay cancer'), a population that many neither
understood or approved of. It was a disease that was affecting 'them'
13


instead of 'us'. The existence of the growing epidemic was denied until it
began to infiltrate communities who had the power to make the general
public take notice. The current situation of IDUs is very similar to that of
gay men at the beginning of the AIDS epidemic. IDUs are a group who are
not well understood or approved of, often being portrayed by one of two
seemingly contradictory institutional representations: the legal view which
labels them as criminals, and the medical view which treats them as
chronically ill. This stems from the fact that the lifestyles of IDUs are vastly
different from the majority of society and as a result, they do not possess the
proper social skills necessary to fit in and are often perceived as a deviant
sub-culture. They possess their Own manner of speaking, appearance, and
behavior that is not easily transferable to the "normal social contexts" of the
dominant society. IDUs are not without cultural capital; while Bourdieu
used the term specifically for the upper classes, others such as Bourgois and
MacLeod have related this concept to the middle and lower classes
(Bourgois 1995, MacLeod 1987). The alternative knowledge or abilities that
they possess enable them to successfully maneuver within their own sub-
culture. However, cultural capital is often particular to a given social
formation, and possessing the necessary knowledge to survive or achieve in
one culture does not necessarily translate to success in another culture. As a
result, marginalized groups like IDUs are left without the specific cultural
capital necessary to succeed in the mainstream society.
14


Our culture has deemed drug use/abuse to be an illegal and self-
destructive behavior, thus making the term 'addict' seemingly
interchangeable with the term 'criminal'. This makes it easy for American
society to write these people off as undeserving of concerted public health
efforts. In order to be a productive and therefore worthy member of our
society, an addict is expected to clean up their drug use and remain sober.
Consequently, IDUs who do not or cannot obtain traditional societal goals
and thereby integrate themselves into the 'sober' world are forced to retreat
into their own world: the IDU sub-culture. Within this sub-culture they
may find the camaraderie and acceptance that they were unable to attain
within mainstream society. Their drug use, which separated them from
others, may now serve to mainstream them into a drug sub-culture, a refuge
from the pressures and judgements of the 'sober' society; but a refuge from
which escape becomes increasingly unlikely. This cultural reproduction of
the IDU's sub-culture is ultimately a self-destructive response to their own
marginalization. As Bourgois states, "self-destructive addiction is merely
the medium for desperate people to internalize their frustration, resistance,
and powerlessness" (1995:319).
Compounding this judgement from the general public, politicians as
well as health professionals have imbued society with the impression that a
massive drug epidemic is affecting the entire nation. As a result of this, the
United States has declared a 'war on drugs' (Bennet et al. 1993) in order to
15


cleanse the nation of its perceived problem. Concepts such as a 'drug
epidemic' and a 'war' in order to combat this blight on society create a
scenario in which those who use drugs are foes to be fought and conquered.
Such scenarios can result in the reproduction of ideologies within the
dominant society that regularly condemn IDUs to a stigmatized position. It
is through this cultural reproduction that many of the perceptions and thus
actions directed towards IDUs are born.
It should not be surprising that social and health services aimed at
IDUs operate from these paternalistic and contradictory notions. The
institutions and social views concerning drug use have been devised by
'hegemonic' members of our society; members of a group that has never
known poverty, homelessness, or addiction. In regards to public health
efforts aimed at this sub-culture, Bourgois states that "traditional public
health research methods reflect the class and cultural biases of academia,
medicine, and social services." (1997:16). Research surrounding deviant
behaviors such as drug use has typically been conducted through
quantitative surveys administered in research settings outside of the 'real'
world of an IDU. Since the activities of those involved in the drug economy
are often illegal and widely criticized, IDU study participants may feel the
need to give socially desirable responses that do not assist in reaching an
accurate understanding of their situation. Additionally, surveys often
cannot capture the violence, pain, sexism, and racism that influence the lives
16


of users and instead present false realities. Consequently, we are often
presented with inaccurate models of IDUs' behavior that were developed
primarily through research exclusively informed by investigators
representing the dominant cultural model. In this situation, it is the
dominant ideologies that have formulated our view of IDUs, even extending
to the quality of health care that they are perceived to deserve. In the case of
pharmacists, this translates into an unconscious negative image of an illicit
drug user that has been created by society and serves to shape the thoughts
and actions of pharmacists regarding syringe sales.
Conduct by members of the drug sub-culture is often condemned by
the dominant culture. Thus, an IDU's ability to take advantage of
opportunities that are theoretically available to all is increasingly limited.
Bourgois illustrates Bourdieu's concept of cultural capital in his
ethnography of New York crack dealers by depicting the stories of Puerto
Ricans attempting to maneuver in the American working class and through
the court system. Most of their efforts result in failure due to their inability
to act and present themselves in the manner considered acceptable to the
dominant society. In this way, they are unable to maintain employment in
the white collar working world and are seen by the court systems as
uneducated and troublesome (Bourgois 1995). MacLeod has also employed
cultural capital in reference to working-class children within our education
system (MacLeod 1987). MacLeod states that children of upper class
17


families inherit different types of cultural capital than working-class
children. However, the education system has adopted the class values and
interests of the upper classes so those students with cultural capital from the
dominant class are consistently rewarded. This results in a system that
devalues the cultural capital of the lower classes (MacLeod 1987). As
Giroux states, "students whose families have a tenuous connection to forms
of cultural capital highly valued by the dominant society are at a decided
disadvantage."(Giroux 1983:88). The situation of IDUs is similar in that by
not conforming to the norm, out of resistance and/or due to a lack of ability
resulting from limited opportunities, they are viewed as outcasts with little
or no hope for behavioral change, meaningful participation or advancement
in society. Almost all attention directed towards this group are actions
meant to condemn or prosecute them, as opposed to other intra-culture
behaviors such as friendship, philanthropy or participation. This 'negative
reinforcement' may breed contempt among IDUs for the dominant society,
possibly causing them to further retreat within their own culture.
Using Foucault's theory of power, we see that the social structural
constraints placed on such non-conformist individuals can often result in
individual failure. In the case of IDUs, the constraints in question are the
legal restrictions that limit the movements of individuals involved in an
illicit behavior such as injection drug use and the severe consequences
associated with them. These restrictions include paraphernalia laws that
18


both impede their access to syringes and make it illegal for them to carry
syringes on their person. As a result, IDUs are forced to choose between
compliance and non-compliance. Complying with these paraphernalia laws
may mean risking infection of blood borne diseases such as HIV or hepatitis.
Non-compliance with the laws creates a situation in which they rim the risk
of legal prosecution for possession of drug paraphernalia. The dichotomy
presented by this law, between a legal model and a health model, extends to
the general public as an inability to come to terms with the contradictory
messages concerning drug, use they are faced with. This conflict is manifest
in pharmacists who are faced daily with the decision to either prevent
disease transmission among IDUs by selling syringes or to refuse to support
drug use and deny IDUs sterile syringes.
Injection drug use is responsible for almost one third of all reported
AIDS cases and almost half of HCV cases. The sharing of injection
paraphernalia by IDUs is one of the most efficient methods of transmitting
HIV and HCV, yet those in this group have the least amount of political
power of all the groups at moderate to high risk for infection. As a result of
being the least socially organized as well as the group that is most easily
manipulated by the larger society, their plight goes largely
unacknowledged.
19


The Bio-Medical Message
When the modes of transmission for HIV became dear to health
professionals in the 1980s, a public health message was conveyed to IDUs in
an effort to make them aware of the life threatening risks that they were
engaging in as a result of sharing syringes. Messages such as 'Do not share
syringes' or 'Use a new syringe for every injection' inundated homeless
shelters, the sides of buses, substance abuse clinics, and health clinics. These
'top down' unrealistic health messages summon up Foucault's theory of
power and knowledge. The bio-medical community was relating what
appeared to be legitimate disease prevention statements, but in actuality
they were moralizing, albeit unknowingly, permissible IDUs behaviors and
thus reinforcing for street addicts that they were relegated to the category of
self-destructive behaviors (Bourgois 1997). The disease of addiction is not
well understood by many health professionals. It is a disease that is
characterized by a course of action that is motivated by emotions or real
physical needs such as craving and compulsion, a continued involvement in
activities that have adverse social, psychological or biological consequences,
and a sense that a person can no longer control their own behavior (Shaffer
1999). There are those who would address addiction as a purely biological
issue, advocating purging the body of the harmful drug under the
assumption that this would result in a healthy individual. However, when
addictive drugs seize cells in the body, they construct intense emotional
20


memories of drug experiences. As a result, these memories link the
emotions with the drug as well as the places, people, and paraphernalia
associated with them(Powledge 1999). Addicts frequently find that they are
able to rid their body of the physical addiction but are unable to stop using
due to the constant reminders of the drug use experience. As a result, many
IDUs see themselves trapped in a lifestyle that is increasingly difficult to
escape. In order to maintain their habit, many IDUs end up in a life of
homelessness and/or joblessness. While many may have the desire to
comply with public health messages calling for a new syringe for every
injection and to use only one's own injection paraphernalia, the issues of
limited funds, legal restrictions, and homelessness can make it difficult for
IDUs to participate in an injection episode free of risk. It is easy to define
another individual's responsibility, however the path towards decreasing
risk for IDUs is often lined with socially constructed boundaries and
constraints that have been created by individuals belonging to a different
social class.
21


CHAPTER III
REVIEW OF THE LITERATURE
In response to the alarming infection rates of HIV and HCV among
IDUs, harm reduction strategies have been aimed at altering the injection
behavior of IDUs in order to decrease the risks associated with injection.
The first and most obvious method of transmitting infection identified
among IDUs was through the direct sharing of contaminated syringes
during an injection episode. Needle sharing was often portrayed by health
professionals as a ritualistic behavior among members of the drug sub-
culture that demonstrated the trust that IDUs had with one another
(Howard & Borges 1972, Des Jarlais et al. 1986, Kail et al. 1995). This was in
part due to research indicating that IDUs could correctly identify their risks
concerning the transmission of HIV and were aware how to reduce their risk
(Calsyn et al. 1992). It is believed that individuals given the necessary
knowledge will alter their behavior in order to decrease their risk, yet many
IDUs continue to share paraphernalia. As a result, instead of identifying
possible structural constraints to risk reducing behavior, researchers labeled
the behavior as ritualistic.
Other researchers contend that the continued behavior of sharing
syringes among those who are aware of and understand the dangers
22


associated with injection cannot be explained simply as a matter of
strengthening social cohesion within their group or as a ritual. It is essential
to look at the broader contexts in which this behavior occurs. This includes
not only the cultural context of the IDUs social networks but also examining
the local political environment and structural impediments that hinder
syringe access to fully realize the context in which sharing occurs. It is the
summation of such barriers that contributes to the limited ability of IDUs to
sufficiently alter their behavior in order to comply with public health
recommendations (Koester 1994, Gostin 1998, Lurie & Jones 1998).
"Instead of looking for an explanation of sharing in terms of
the psycho-pathology of individual drug injectors, there is a
need to develop a theoretical schema which can explain how
the various factors identified as influencing the decision to
share may be combined in different ways and in different
situations to produce occasional or frequent sharing."
(McKeganey & Barnard 1992:46)
In fact, many researchers have demonstrated that when access
to sterile syringes for IDUs is increased or unlimited, there is a
reduction in the multi-person use of syringes (Diaz et al. 1998,
Groseclose et al. 1995, Singer et al. 1995, Vlahov et al. 1997, Watters et
al. 1994, Bluthenthal et al. 1998). Others have shown that IDUs with
unlimited access to sterile syringes (such as diabetic IDUs) have
significantly lower HIV seroprevalence rates than those without such
access (Gostin et al. 1997, Nelson et al. 1991).
23


IDU Behaviors
The sharing of injection paraphernalia represents another means for
transmitting blood borne disease. In order to more closely examine the
frequency with which IDUs engage in risky behavior while preparing drugs
for injection, McCoy and colleagues collected survey information from 19
sites in the United States that had identified a total of 12,323 active IDUs
(McCoy et al. 1998). The survey was comprised of questions concerning
their drug use and their injection behavior in the 30 days prior to the survey.
They found that a higher percentage of IDUs were engaging in unsafe
injection behavior concerning the reuse of cookers, cottons, and water than
the reuse of syringes. Almost 50% of all of the IDUs reported unsafe
behavior regarding their reuse of cookers, cottons, and water compared to
just over 40% who reported risky behavior due to the reuse of syringes.
Less than 13% of the entire sample reported use of a brand new, sterile
syringe. These statistics demonstrate the enormity of the risk behavior
occurring within the IDU community.
However, when examining risk taking behaviors among IDUs, it is
necessary to not only examine the actual risk but the use of various drugs
and their effect on behavior. It is essential to realize that individuals who
inject different drugs often exhibit varying levels of risk. Desmond and Zule
conducted a comparison of HIV risk behaviors among heroin and
methamphetamine injectors in Texas (1999). Texas law allows pharmacists
24


to sell syringes to customers using their professional judgement; the
majority of the pharmacists choose not to sell to suspected IDUs. Of the 154
heroin users and 45 methamphetamine users surveyed, 48% and 62%
respectively claimed to obtain their syringes from a pharmacy (30% of
heroin users said that they had gotten them off the street). When asked
about how often they dispose of their syringes, only 6% of heroin users
reported that they usually dispose of their needles after only one injection
compared to 40% of methamphetamine users. Additionally, 63% of the
heroin users reported that they usually used a needle more than five times
before they would dispose of it. Most of the methamphetamine users
reported that they would use a non-sterile syringe if they were forced to
choose between forgoing injecting and using a dirty syringe. Furthermore,
heroin users stated that the desire to relieve the symptoms associated with
withdrawal overrides their fear of AIDS, causing them to share syringes
without disinfecting them first (Zule & Desmond 1999). In the end, they
found that most heroin users find themselves in a situation where they are
sharing syringes more often than methamphetamine users. This is due to
more frequent injections, withdrawal symptoms, and the fear of carrying
syringes and/or bleach due to police surveillance.
25


Bleach Use
Those well acquainted with the sub-culture of drug use soon realized
the structural impediments that IDUs faced when attempting to comply
with health messages that instructed them not to share syringes. An
alternative response to the alarming infection rate was designed in order to
decrease the financial demand and thus make harm reduction techniques
more suitable for IDUs. This alternative approach advocates the use of
regular household bleach to sterilize a used syringe. However, studies
conducted on methods of bleaching syringes have revealed that the
disinfection of syringes through household bleach does not always attain
the level of sterilization necessary to avoid infection (Gershon 1998).
Furthermore, this study found that the use of bleach for sterilization "...has
unfortunately not been shown to have much impact on reducing HIV
incidence in IDUs" (Gershon 1998:23). Variables that limit the effectiveness
of bleach used for sterilization include; inadequate syringe cleaning (Vlahov
et al. 1994, Carlson et al. 1998), inadequate amount of time of contact
between bleach and syringe (Gleghorn et al. 1994), and recontamination of
syringes when cookers, cotton filters, and/or water are not cleaned or
replaced (Koester 1990). Normand (1995) recommended the use of bleach
for syringe sterilization only as a secondary option when IDUs do not have
access to sterile syringes. In addition to bleach constituting a less than
foolproof technique, bleaching syringes is not always a practical option.
26


Purchasing and carrying bottles of bleach to clean syringes is often a harm
reduction technique that is incompatible with the lifestyle of a homeless
individual.
Paraphernalia Laws
The extensive work done by Gostin details the structural
impediments to syringe access for IDUs created by the current legal
environment. He found that legal barriers to syringe access in the United
States exist in every state: 47 states have drug paraphernalia statues, 8 states
have syringe prescription statutes, and 23 states have pharmacy regulations
or practice guidelines (Gostin et al. 1998). Gostin argues that these laws
prevent health professionals such as pharmacists from participating in the
prevention of blood-borne.diseases among IDUs (Gostin 1998).
Paraphernalia statutes restrict pharmacists from selling syringes to
individuals who they suspect will use them to inject illicit substances (often
describing these people as patients without a 'legitimate medical necessity').
Additionally, paraphernalia statutes prohibit individuals without a
'legitimate medical necessity' from possessing syringes. With respect to the
paraphernalia statutes, Gostin states that police often are more likely to
search for illicit drugs once paraphernalia is found on a person. As a result
of these restrictions, IDUs often choose not to carry clean syringes in order
to avoid involvement with the police and possible prosecution. Prescription
27


requirements restrict pharmacists from selling syringes to any individual
who does not have a doctor ordered prescription. These restrictions limit the
availability of syringes through pharmacies.
Research done in Denver shows that 83% of 129 IDUs interviewed
reported sharing syringes during the 6 months prior to the interview
(Koester 1994). In order to understand the reasons behind this high rate of
syringe sharing in Denver, one must first examine the context in which it
occurs. Colorado does not have a prescription law, but it does have a
paraphernalia statute. This statute states:
"Any person who sells or delivers, possesses with intent to
sell or deliver, or manufactures with the intent to sell or
deliver equipment, products, or materials knowing, or
under circumstances where one reasonably should know,
that such equipment, products or. materials could be used
as drug paraphernalia commits a class 2 misdemeanor."
In 1979 the US Drug Enforcement Agency developed the Model Drug
Paraphernalia Act, the act which informed the above Colorado
paraphernalia statute. This act provided a definition of drug paraphernalia
that enabled states to control the sale of such items. It was written before
the proliferation of public health threats of HIV and HCV and was originally
aimed at stemming the spread of "head shops" and the overt sale of tools
used for the ingestion of illegal substances (such as bongs and water pipes).
Injection devices are mentioned under the definition of paraphernalia in the
law, however the purpose of the statute was "To protect and promote the
28


public peace, health, safety and welfare by prohibiting the possession, sale,
manufacture, and delivery or advertisement, of drug paraphernalia..." In
the midst of the current dual epidemic of HIV and HCV, it seems as if the
primary role of these laws has become to place a death sentence upon IDUs.
These laws now serve only to deter IDUs from purchasing syringes in
pharmacies and possessing them on the streets in order to avoid intrusive
questioning or legal repercussions.
In addition, Colorado's paraphernalia statute serves to deter IDUs
from carrying their own injection equipment in order to avoid incurring the
maximum $100 fine or jail time associated with possession of such
paraphernalia. As a result, users often stash their syringes in certain places
throughout the city, borrow one from a friend, or go 'dumpster diving' in
order to find a used one. Such restrictions serve to impede the efforts of
IDUs to practice the safer injection techniques that would decrease their
chances of contracting or transmitting blood borne diseases.
The paraphernalia statute is somewhat vague in its' definition of who
distributors can sell syringes to and who they can not. It states that they
should not sell to those individuals who they believe may be using the
syringe for illicit reasons such as injection drug use. However, the statute
does not provide any guidelines as to how the individual is to determine a
customer's intent and no pharmacist has ever been cited for violation of this
statute. Additionally, the Colorado Board of Pharmacy has no guidelines or
29


regulations concerning syringe sales. Therefore, unless a store has a strict
policy concerning whom to sell syringes to, pharmacists must rely on their
own discretion when making a decision to sell or not to sell. This lack of
direction leaves the decision to sell up to the pharmacist and can often lead
to the inclusion of idiosyncratic perceptions or morals on the part of the
pharmacist when it comes to syringe sales to suspected IDUs.
Paraphernalia statutes contribute to a scarcity of syringes available to
IDUs through pharmacies. Such structural impediments are in direct conflict
with recommendations issued by public health departments and others
working to decrease the transmission of blood borne diseases. These
sanctions do not act as a deterrent for individuals to inject drugs and instead
result in an increase in risk behavior among IDUs while preparing for an
injection episode. High risk injection procedures persist as a result of IDUs
attempting to elude the immediate risk of legal prosecution, thus ignoring
the larger risk of HIV/HCV infection (Koester 1994). Bluthenthal and
colleagues examined the ways in which paraphernalia restrictions affect the
habits of IDUs. His work revealed that IDUs who had previously been
arrested for carrying paraphernalia were more likely to report subsequent
sharing of syringes and other injection supplies than those who had never
been arrested for carrying paraphernalia. Additionally, he found that IDUs
concerned with being arrested while carrying drug paraphernalia were over
30


twice as likely to share syringes as other IDUs, the same being true for other
injection supplies (Bluthenthal et al. 1999).
Research by Gleghorn examined the feasibility of IDU adhering to the
U.S. Public Health Service recommendation to use a new and sterile syringe
for every injection episode. Surveys were administered to 593 active IDUs
(defined as having injected within the last 90 days) from seven U.S.
metropolitan areas (Gleghorn 1998). Less than a quarter of their sample
(23%) reported obtaining their syringe from a source that could reliably be
dispensing sterile syringes (such as a pharmacy or a needle exchange
program). Additionally, they found that 40% reported using their syringe
four or more times before disposing of it. Almost 40% of the sample
reported syringe reuse due to either the lack of funds to purchase a new
syringe, no source for obtaining a new syringe or the lack of availability of a
new syringe when needed. When asked about their perceived barriers to
syringe access, 57% said that it was lack of money and 27% said that it was
the lack of a syringe source. Nearly 40% of the IDUs surveyed reported a
difficulty in finding a reliable source for sterile syringes, limiting their
ability to comply with public health recommendations (Gleghorn 1998).
These results demonstrate the creation of an artificial scarcity of syringes
through paraphernalia statutes and pharmacy board regulations.
31


States That Have Repealed Paraphernalia
And Prescription Laws
Many states have recognized the need for changes in order to create a
legal atmosphere that is more conducive to harm reduction among IDUs.
States such as Massachusetts, Connecticut, and Maine have all amended
their legal restrictions that limit the availability of syringes to IDUs. Until
1992, Connecticut had two laws restricting access of sterile syringes for
IDUs: a syringe prescription law that required individuals to have a
prescription in order to purchase a syringe and a paraphernalia law that
made the possession or the distribution of syringes to inject illicit drugs
illegal. In 1992, Connecticut's problems with injection drug use had become
a critical issue. Half of all AIDS cases reported in Connecticut in 1992
appeared in IDUs and 60% of all AIDS cases were related to injection drug
use (Wright-De Aguero et al. 1998). In response to this growing problem,
health professionals were allowed (but not required) to sell up to 10 sterile
syringes without a medical prescription as of July 1992. An additional
partial repeal of laws concerned with possession of drug paraphernalia
accompanied it (individuals without medical purposes were allowed to
possess up to 10 syringes without drug residue). This new legislation was '
aimed at increasing the ease with which IDUs could obtain and possess
syringes, therefore decreasing the HIV infection rate.
32


A study was conducted in Connecticut in order to measure the
impact of increasing syringe accessibility through local pharmacies. Their
results showed that while pharmacists were not legally bound to sell non-
prescription syringes, 15 months after the laws were passed 83% of
pharmacists had in fact done so. In Hartford, the number of
nonprescription syringes sold increased significantly during the 12-month
surveillance period (Valleroy 1995). A second study was done during the
same time period in order to examine, the impact of the increase in syringe
accessibility on IDUs' behavior. The results showed that in the first year
after the repeal, IDUs reported more purchasing of syringes in pharmacies,
less purchasing on the street and a 30% decrease in reported syringe sharing
(Groseclose 1995). The change in the legal environment in Connecticut
directly led to the ability of IDUs to participate in safer injection practices
and therefore to a decrease in the transmission of blood borne diseases.
Research in both Maine and Massachusetts has shown that without a
total repeal of legal restrictions and the cooperation of law enforcement
officials, syringe access for IDUs can still be problematic. In 1993, Maine
amended its prescription law and made it legal for pharmacists to sell
syringes to individuals over the age of 18 without a prescription. Their
paraphernalia law remained intact, creating a contradictory environment in
which syringes could be purchased without a prescription but were illegal
for IDUs to possess. Additionally, pharmacists were not mandated to sell to
33


individuals without a prescription and were able to place additional
requirements on the sale of syringes. Case and colleagues found that fewer
than 15% of the 208 pharmacists interviewed were willing to sell syringes
without a prescription and without additional requirements (Case et al.
1998). Some pharmacists were willing to sell without a prescription but
reported other requirements as being necessary for purchase. These
requirements included knowledge of diabetes, picture identification, the
name and address of the customer, confirmation from a doctor, or a diabetic
identification card. Fewer than 9% of the pharmacists interviewed reported
negative incidents with IDUs in the two years since the law had been
repealed. While the Connecticut studies found an increase in the sale of
non-prescription syringes, Case estimated that the Maine pharmacies were
only selling 7% of the estimated number of syringes needed for IDUs. They
attribute this to the fact that Maine did not repeal their paraphernalia law as
Connecticut did. Another possible factor was that the rates of HIV infection
among IDUs are much higher in Connecticut than in Maine, perhaps
causing Maine to not take as active a role in the issue.
Also in 1993, Massachusetts amended their paraphernalia laws that
restricted access to syringes for the administration of controlled substances.
This amendment legalized possession, distribution, or exchange of syringes
as a part of a pilot needle exchange program (NEP). Additionally, eight
months later the Boston police commissioner stated that police officers
34


would not charge IDUs with possession of a syringe if they were
participating in the NEP but that those not enrolled in the program were
subject to arrest. This partial repeal of paraphernalia laws only applied to
approximately 5% of the IDUs in Massachusetts who were enrolled in the
NEP at the time of the survey. Unfortunately, even those individuals who
were enrolled in the NEP and were stopped by the police were at risk for
having their syringes confiscated by the police, putting the IDUs at future
risk for sharing syringes. In 1994, after the legal amendments, 417
individuals had been convicted of syringe possession in Massachusetts. Of
those, 41% were sentenced for incarceration, with an average incarceration
time of 5 months. The authors estimate a $1,140,183 incarceration cost
assuming that the individuals served two thirds of their incarceration time
(Case et al. 1998). The authors suggest that policies such as these that only
partially repeal legal limitations to access continue to place IDUs and their
sex partners at risk for the transmission of blood borne diseases. These law
enforcement activities often lead to an increase in multi-person use of
syringes by deterring users from carrying syringes on their person due to
fear of arrest/prosecution. Programs such as these 'top down' approaches
represent the necessity of multiple facets of access instead of partial
solutions that often result in failure.
35


Needle Exchange Programs
In 1984, the first NEP was established in Amsterdam, the Netherlands
by an advocacy group for drug injectors called Junkie Union. It was
designed to prevent an epidemic of Hepatitis B when a local pharmacist
planned to stop selling syringes to IDUs (Buning 1991). It wasn't until two
years later in the fall of 1986 that the first drug injection materials were
publicly distributed in the United States. Now, NEPs have been established
to address drug-injection risks around the world and in more than 80 cities
in 38 states in the U.S. There are currently 113 NEPs operating in the U.S.
alone. These programs were initially designed as locations where IDUs
could obtain sterile syringes arid return used injection equipment, solving
both the problems of obtaining clean syringes and of disposing used
syringes. The main objective of a NEP is not to tell people to stop injecting,
but to promote harm reduction techniques among injection drug users.
Harm reduction programs do not condone illicit drug use but instead
sanction the education of individuals concerning risk-free injection
techniques. Many exchange programs also offer substance abuse treatment
referrals for interested IDUs. NEPs may also provide other crucial services
for IDUs such as HIV/HCV testing and counseling, free condoms, bleach
kits for syringe disinfection, health pamphlets, as well as referrals to other
public health programs. One study suggests that NEPs are better equipped
36


to provide such ancillary services as well as providing a solution to the
problem of syringe disposal (Lurie 1998)
NEPs have proven to be a crucial component in the effort to increase
sterile syringe access for IDUs, demonstrating a pronounced decrease in the
rate of reusing syringes among IDUs. Heimer and colleagues conducted an
evaluation of NEPs in four different cities; San Francisco, Chicago,
Baltimore, and New Haven (Heimer et al. 1998). They measured syringe
reuse among IDUs as a method of determining whether NEPs increased
syringe availability and thus reduced the need for syringe sharing. Their
results indicated that the NEPs in all four cities appeared to decrease the
reuse of syringes. Single (non-repeating) syringe use after inception of the
NEPs increased from 10% to 29% in three years, and the NEPs also
decreased the number of injections per syringe by a range of 44% to 85%
(Heimer et al. 1998).
However, the opinions of the IDUs who purchase syringes are
essential when attempting to construct a practical solution. Junge and
colleagues examined the attitudes of IDUs participating in a NEP regarding
the prospect of pharmacy-based syringe access. Participants were
questioned as to how important different considerations where when they
were deciding where to obtain syringes. They found that 66% stated that
37


being in a hurry to relieve symptoms of dopesickness4 was 'very important'
in their decision on where to obtain syringes. Almost 54% stated that their
decision regarding where to obtain a syringe was based on how long it
would take to obtain the syringe. They found that in Baltimore, a city where
drug paraphernalia statutes exist but a prescription is not necessary for a
syringe, 80% of IDUs prefer to obtain their syringes from the needle
exchange, 15% from the street, and 5% from pharmacies Gunge et al. 1999).
In fact, in a study conducted in Baltimore earlier, Jones found that only 54%
of IDUs had ever purchased from a pharmacy and 50% of those surveyed
reported purchasing from the street as their main source of syringes Gones
et al. 1993). When asked about a hypothetical situation in which syringes
could be legally purchased over the counter, Junge and colleagues found
that the percent of IDUs who would prefer the needle exchange dropped to
48.5%, a pharmacy preference jumped to 48.5%, and street sources dropped
to almost 3%. In order to make pharmacies more appealing, 24% of IDUs
asked for a removal of the identification requirement, 22.4% asked for
syringe purchases to be made legal, and 20.7% requested that a greater
variety of syringes be made available to them Gunge et al-1999). In the
end, the researchers found an expressed interest, especially by female
injectors, to switch from a van-based needle exchange program to a
4 Dopesickness is the term used to refer to the withdrawal symptoms that individuals go
through once the effect of the drug has begun to wear off.
38


pharmacy as their main source of syringes. In order for this to occur, all
current legal restrictions to access and the identification requirement had to
be lifted. In accordance with the findings indicating the importance of
expediency in syringe access (desire to relieve withdrawal symptoms and
time required to obtain syringes), conveniently located syringe sources such
as pharmacies would be more heavily utilized than a mobile needle
exchange. The author's main conclusion was that the most effective method
of decreasing the rate of blood borne infections among active IDUs is to
offer a variety of options for syringe access.
An additional aspect to think about when considering a NEP is
whether or not the local community will be willing to support such a
program. One year after the opening Of the needle exchange program in
Baltimore and three months before a planned expansion, a household
survey was conducted in order to gauge community support. The surveyed
community was not currently served by the NEP and was not one of the
areas planned for expansion. However, there was drug traffic in the area
and the community had organized meetings in which residents expressed
strong views both for and against a needle exchange in the area. Findings
reveal that 65% of those who participated in the survey were in favor of the
NEP (Keyl et al. 1998). Of those who were not in favor, 60% felt that it
would increase the number of discarded needles on the street. Additionally,
69% of the opponents felt that the NEP would encourage injection drug use,
39


although studies have shown that the number of discarded syringes in
Baltimore since the opening of the NEP has not increased (Doherty 1995). Of
those surveyed, 47% felt that pharmacists should be allowed to sell syringes
to IDUs without a prescription and 48% disagreed with the statement (there
is no prescription law in Maryland, the question was posed in order to
ascertain whether there should be a relaxation or deregulation of
paraphernalia laws).
While there are many benefits to a NEP, they may not be the
complete solution to the dilemma in which we now find ourselves.
Although there are currently 113 known NEP in the U.S., by no means are
all operating legally. Due to the legal regulations on syringes that still exist
in some states, efforts to develop and expand NEP throughout the country
have been severely hindered. In some states they are necessarily operated
underground as a result of the existence of paraphernalia or prescription
laws. In Colorado, two recent attempts to change the State's paraphernalia
statutes were overwhelmingly defeated. When the decision was put before
the Denver city council, it was agreed to amend city ordinances, thus
allowing for a NEP. Unfortunately, since the state paraphernalia statute
takes precedence over any city ordinance, an exchange was never
implemented. In the current political environment, it is unlikely that future
legislative attempts will result in a legally sanctioned exchange in Denver.
40


Additionally, there are limitations to NEPs that illustrate the need for
securing many points of access for syringes for IDUs. Some NEPs are
mobile syringe distributors, moving around the city in a motor vehicle from
place to place. They often have a fixed schedule so that they can be at
particular locations during assigned parts of the day. This results in an
insufficient number of hours of operation in too few locations. While this is
a benefit for those with the foresight to plan their injections, it can result in .
limited access for those who are not mobile enough to get to one of the
exchange locations or find themselves needing a syringe during hours when
the NEP is not operating. Also, NEP may not represent a cost-effective
method of harm reduction. Lurie and colleagues estimated that IDUs would
require! billion syringes per year in order to have a sterile syringe for every
injection. They then estimated the cost per syringe for different distribution
strategies. The cost per syringe at a NEP was $.97 compared to $.15 for a
syringe sale through a pharmacy (Lurie et al. 1998). As a result of these
limitations as well as a current federal ban on funding, needle exchange
programs have become another aspect of the health care system that is
struggling to survive and therefore cannot be viewed as the only answer to
our current public health dilemma.
41


Syringe Disposal
Disposal is a necessary component to address when attempting to
increase syringe access for IDUs. In areas that do not have the option of
disposal through a NEP, it is important to plan a disposal program to
complement any initiative to urge greater syringe accessibility through
legislation and pharmacy sales. Many opponents to greater syringe
accessibility fear the risk of a child picking up a used syringe from the
ground or a sanitation worker possibly incurring a needlestick injury while
disposing of trash. The implementation of disposal programs may help to
create more positive attitudes towards syringe access through pharmacies.
Macalino and colleagues identified disposal programs that were in
operation throughout the world with an emphasis on those in the U.S.
(Macalino 1997). They organized a workshop in order to review public
concerns and data regarding the risk of syringe disposal as well as to assess
community based programs. They identified 15 disposal programs in the
United States, Canada, and Australia. Three of those were primarily aimed
at disposal for IDUs while the other 12 were aimed at individuals with
diabetes. There were three basic strategies used among the 15 programs;
placing syringes in puncture proof containers available in the home and
then throwing the container in the trash, drop boxes with the contents being
sent for biohazard disposal, and saving used syringes in puncture proof
42


containers and then dropping them off at sites such as pharmacies,
hospitals, and health departments.
The authors pointed out that the first strategy involves the limitation
of the use of household trash; potentially putting sanitation workers at risk
once the trash has been compacted and the syringes poke through their
containers. Furthermore, the third strategy may not be successful among
IDUs with little funds available to purchase puncture proof containers.
However, the second disposal strategy has been successfully utilized by
cities in Maryland and Florida. In 1996, the Baltimore City Health
Department initiated a pilot needle disposal program using drop boxes in
order to decrease the number of discarded syringes in areas without needle
exchanges. Surplus U.S. mailboxes were installed in an area of Baltimore,
considered to have a large number of IDUs but not served by the NEP in the
area. The boxes were emptied weekly by the city health department and
then bi-weekly after 5 months of operation. To gauge community
acceptance of the program, focus groups were conducted before the
installation of the boxes and five months after installation (Riley, 1998).
Focus groups were conducted with community residents, IDUs, and police
officers. Despite initial concern about the installation of the boxes and the
messages that they would send to the community, the post-intervention
focus groups showed more support for the disposal program and all
reported seeing fewer used syringes on the street since the inception of the
43


program. During the ten-month program, approximately 3,000 syringes
were collected in the boxes. Almost 11% of the syringes collected tested
positive for HIV, suggesting that the boxes were collecting infected syringes
that could be a possible source of infection to the public had they been
discarded in the trash or on the street.
In DeSoto County, Florida, the DeSoto Public Health Unit placed red
biohazard containers within all city and county fire departments and
police/sheriff stations in order to provide a safe disposal system for used
syringes (Toews, 1995). The annual cost for the containers was less than
$200. The program has been so successful that it has been replicated
throughout the region. However, in order for this program to be more
suitable for IDUs, it would be necessary to place the biohazard containers in
areas such as pharmacies instead of those involving law enforcement
personnel.
The importance of these programs is that they represent feasible
options for communities who do not have a local needle exchange but are
interested in increasing access to sterile syringes. Macalino and colleagues
stress the importance of including physicians, pharmacists, harm reduction
practitioners, educators who work with people who inject medications at
home, syringe producers, trash workers, medical waste and refuse
companies, organizations representing people with diabetes, persons who
44


inject illicit drugs, and public health department personnel in the creation of
any disposal program (Macalino 1997).
Pharmacists' Role in Syringe Accessibility
Until recently, the role of the pharmacist has been underutilized in
the fight against blood borne infections (Lurie et al. 1998). Pharmacists can
represent the most available health provider for IDUs in the absence of a
NEP. Due to lack of funds and insurance, IDUs often go without medical
care unless it is a medical emergency. The contact that IDUs have with
pharmacists while purchasing their syringes may present a valuable
opportunity for IDUs to obtain information concerning harm reduction,
safer sex practices, HIV/HCV transmission and other health issues of
concern. Since pharmacies are often conveniently located in a multitude of
easily accessible locations around the city and operate for longer hours than
a NEP, they have the opportunity to represent the primary syringe source
for IDUs, even in areas with a NEP. Research conducted in New Haven has
shown that pharmacies in the area sell approximately twice as many
syringes as are exchanged by their needle exchange program (Heimer et al.
1997). These findings demonstrate that pharmacy sales increase availability
of syringes during parts of the city and times of day when the NEP is not
operating.
45


Limitations To Access Through Pharmacies
However, while pharmacies have the potential to be a dependable
syringe source, research has indicated that there are many factors that
currently hinder syringe availability for IDUs in Denver. The
complementary portion of this study involved taking eight active IDUs to
Denver pharmacies in order to purchase syringes (Bush et al. 1999).
Findings revealed that not one of the eight participating IDUs were able to
purchase syringes at all twenty-seven pharmacies, and some participants
were able to buy at more pharmacies than others were. Reasons for this
appear to be related to issues of gender, appearance and familiarity with the
pharmacy. Prices for a ten pack of syringes were inflated up to 500%
between stores (this was mainly the result of one store that charged up to
$15 for a ten pack of syringes), price fluctuation also occurred within the
same pharmacy among different.participants. Other possible constraints
affecting IDUs in general included: inconvenient hours of operation,
location, and fixed quantity sales (Bush et al. 1999). This demonstrates that
syringe sales through pharmacies are not currently dependable, creating an
unreliable outcome for IDUs trying to purchase syringes.
Additionally, limitations to access are due to the fact that it is not
mandatory for pharmacists to sell syringes to suspected IDUs, even in states
in which legal restrictions to sales have been repealed. Research has shown
that the official stance of a state may not be indicative of the actions of
46


individual pharmacists involved in selling syringes, with some pharmacies
having installed store policies designed to restrict syringe sales. Instead, it is
pharmacists' previous experiences with IDUs that has been identified as an
influential factor regarding their sales attitudes (Gleghorn 1998). Gleghom
and colleagues found that negative experiences with IDUs customers have
caused some pharmacists in Baltimore to require a prescription in order to
purchase a syringe (Gleghorn et al. 1998). Gleghorn states that:
"such attitudes may pose additional barriers to IDUs
trying to obtain sterile syringe injection equipment,
because a pharmacist can use professional discretion to
determine whether a sale takes place." (1998:90).
Other researchers have also found that there is wide variation in sales
indicating that pharmacists have concerns regarding the sale of syringes
(Compton 1992, Valleroy et al. 1995, Heimer et al. 1997, Gleghorn 1998,
Lurie & Jones 1998).
The work of various researchers has addressed current syringe access
for IDUs through Connecticut pharmacies. Through a mail in survey,
Heimer and colleagues found that 4 out of 15 pharmacies had policies
restricting the sale of sterile syringes to IDUs. Each pharmacy cited negative
incidents with IDUs as the reason for these policies (Heimer et al. 1997).
Valleroy found that the number of pharmacies selling non-prescription
syringes in the five largest cities in Connecticut had decreased from 83% in
July of 1992 to 73% in November of 1993 (Valleroy 1995). Additionally, she
47


found that 3 of the 8 Hartford pharmacies stopped selling non-prescription
syringes one year after the legal changes due to used syringes on the
premises and disruptive IDUs in the store (Valleroy et al. 1995). Through
telephone interviews, they found that 19% of pharmacists answered "yes"
when asked if there had been any negative incidents with people buying
non-prescription syringes. Incidents ranged from inappropriate behavior of
the people buying the non-prescription syringes to violent behavior on the
part of the suspected IDUs and finding drugs on store premises.
Correspondingly, Singer found that negative incidents were the primary
reason for Hartford pharmacies as well as some of the surrounding
suburban pharmacies to discontinue selling non-prescription syringes.
Their concerns included the influx of 'disreputable types', an increase in
shoplifting, and used syringes on the pharmacy premises (Singer et al. 1998).
Wright-De Aguero and colleagues' work on Connecticut pharmacists
revealed similar findings. They presented six main issues that decreased the
likelihood of a pharmacist selling non-prescription syringes; safety, context
of sale, customer-related items, perceived beneficial and detrimental effect
of the sale of syringes without a prescription on health and community well
being, and perception of peer norms and sales practices (Wright-De Aguero
et al. 1998). The only issue that was found to be independently associated
with pharmacy managers' support for non-prescription sales was their
48


perceived benefit of the sale of syringes on health and community well
being.
While many researchers have revealed that pharmacists have strong
views on this topic, others have found that it does not appear to be widely
discussed among pharmacists. Both Singer and Wright-De Aguero found
that a lack of communication exists among Connecticut pharmacists
concerning this topic. Singer found that there were instances in which the
attending pharmacist was unaware of the store policy concerning the sale of
syringes (Singer et al. 1998). Wright-De Aguero found that 40% of
pharmacists did not know what other pharmacists thought about this topic
and almost 43% did not know what action other pharmacists took when
faced with syringe sales (Wright-De Aguero et al. 1998).
In Louisiana, a state with legislation much like Colorado; there are no
prescription statutes but there are paraphernalia statutes that prohibit
individuals from possessing or distributing syringes without a medical
reason. A mail-in survey was conducted in the six most populous cities in
Louisiana to gauge the attitudes and practices of pharmacy managers
regarding syringe sales to suspected IDUs (Farley et al. 1999). Sixty-one
percent of their sample reported having sold syringes without a prescription
to individuals who they knew not to be diabetics. Of those who did not
report selling syringes, almost half believed that such sales would increase
drug use. However, the majority of the pharmacies (66%) reported never
49


selling nonprescription syringes to suspected IDUs. Sixty-four percent of
the sample was not supportive of selling syringes without a prescription
and only 26% were supportive. Many of the pharmacists reported that they
would be supportive of selling syringes without a prescription if the
customer had been referred from an outside agency or clinic. Almost one
third of all the respondents supported the idea of opening a NEP.
Additionally, they found that the individual decisions of the pharmacists
often determined whether or not a sale took place, rather than store policies.
Work regarding syringe access has also been conducted
internationally. In 1995, the needle exchange program in London surveyed
the members of the London and District Pharmacists' Association in order
to evaluate sterile syringe access for IDUs (Berry 1997). For the most part,
pharmacists ranked harm reduction and health promotion methods as more
likely to prevent the transmission of blood borne diseases than other
approaches such as law enforcement and drug treatments that emphasize
abstinence. A large portion of those surveyed (77%) stated that they deal
with syringe requests from IDUs on a regular basis. Pharmacists also
indicated that 95% of pharmacies have a policy (either written or unwritten)
that allows for the sale of syringes to non-diabetic individuals. Of the
sample, 94% reported that they would sell syringes to suspected IDUs in all
or some of the cases and 95% reported that they either agree or strongly
agree with making syringes available to IDUs. While pharmacists also
50


reported concerns regarding safety and the risk of theft, their willingness to
provide syringes to IDUs was a result of the public health threat of HIV
/AIDS (Berry 1997).
Despite pharmacists' understanding of their role in the prevention of
blood borne disease among IDUs, many have also expressed business
concerns that they feel are associated with their participation. A postal
survey of one in four in a random sample of community pharmacies in
England and Wales revealed that community pharmacists were clear on
their role in HIV prevention. However pharmacists were concerned about
the effect that IDUs would have on their business, as well as their own need
foi* training and the amount of support that would be available to them
(Sheridan et al. 1997). The authors found a significant difference between
the attitudes of syringe providers and those who did not provide syringes.
They also found a relationship between pharmacists who had received
training on this topic and their attitudes. More of those pharmacists who
were providing syringes or offering some type of needle exchange system
had taken part in training on drug misuse and HIV prevention than those
who did not distribute syringes. From the results of the survey, the authors
found that those who where providing syringes had a more positive attitude
towards sales and were less likely to believe that IDUs in their store would
have an adverse effect on their business. For those who have contact with
IDUs and are in a position to provide important health services to them, it
51


may be a good idea to provide them with service-specific training that
would address drug use and the prevention of the transmission of blood
borne diseases (Sheridan et al. 1997).
It is imperative to understand how pharmacists view their
involvement in the issue of syringe availability and fully realize their
concerns regarding sales if we wish to engage them in this public health
objective. The study presented here examines the attitudes and concerns
regarding syringe sales to suspected IDUs among pharmacists in Denver.
52


CHAPTER IV
METHODOLOGY
The Complementary Study
This research was composed of two separate components; a study
designed to gauge pharmacists attitudes and beliefs regarding syringe sales
through pharmacies to IDUs and one designed to identify actual
impediments to access from the IDUs perspective. The intent of the latter
study was to obtain the most realistic picture possible of syringe
accessibility for IDU in Denver. To accomplish this eight active IDU
(defined as having injected drugs within the last 30 days) were recruited to
attempt syringe purchases at 27 different pharmacies.
Human subject's review and approval was through the University of
Colorado at Denver Human Research Committee (HRC Protocol # 330).
Sampling Procedures
The initial component of the study consisted of a mail-in survey
distributed to the 814 recipients of the Colorado Pharmacy Association's
newsletter, an organization with statewide membership. The pharmacists
were asked to fill out the anonymous survey and return it using the
53


included postage paid envelope. The questionnaire probed members about
their views on sterile syringe sales to IDUs, regulations concerning syringes
sales, and if the HIV epidemic has effected their attitudes concerning
syringe sales (Appendix A). This was done in an effort to gauge views of
syringe access for IDUs throughout the state. However, due to a low
response rate (7%), the results of the mail in survey were considered
negligible and not considered in the data analysis.5
In order to gauge local views, pharmacies within the Denver metro
area where selected to participate in this study. The study boundaries
included Sheridan Blvd. on the west, Monaco Pkwy. on the east, 1-70 on the
north, and Evans Ave. on the south. Pharmacies were identified with the
use of the telephone directory and were comprised of both independent and
corporately owned pharmacies. There were a total of 52 eligible pharmacies
(Table 1) and 24 pharmacies agreed to participate. The study was conducted
in two stages by bisecting the metro area into East and West Sides (using I-
25 as a bisector). This was done for efficacy and so that information from
the first stage could be briefly analyzed and evaluated before moving on to
the second stage. This early analysis enables the researchers to identify gaps
in the information and then work on filling in these gaps (Miles and
Huberman 1994).
5 Of the surveys that were returned, there was one interesting aspect; respondents all
expressed strong feelings either pro or opposed to pharmacy syringe sales.
54


Data Collection
Pharmacies on the East Side were taken as the initial cohort of the
study. A letter of introduction describing the research aims of Urban Links
(the research organization through which the study was conducted) and
identifying their funding sources was sent to all twenty-seven selected
pharmacies (three of the identified pharmacies had either moved or gone
out of business). The principle investigator of the study, Dr Stephen Koester,
as well as a professor at the University of Colorado Health Sciences Center
(UCHSC) School of Pharmacy signed the letter (Appendix B). A week after
the letters were sent out, the pharmacists were individually called by the
ethnographers and asked to participate in the study. This research was
funded through a cooperative agreement by the Centers for Disease Control
and Prevention (CDC) and the Association of Teachers for Preventative
Medicine (ATPM). A sister study of pharmacists in Atlanta, GA was
conducted simultaneously by the CDC.
Semi-structured interviews were conducted with those pharmacists
who agreed to participate. Prior to the interview, the pharmacists were fully
informed about the study goals and were asked to sign a consent form
(Appendix C). Interviews were conducted in a location that was convenient
to the pharmacist (e.g. coffee shop, their pharmacy, etc.) and were recorded.
55


Interviews often took approximately one hour to complete, each pharmacist
was compensated $50 for their time.
After the 21 participating pharmacists on the East Side had been
interviewed, an initial analysis of the interviews was conducted. This was
done in an attempt to identify any recurring issues that had not initially
been a part of the question guide. This was accomplished by examining the
transcripts and identifying issues that pharmacists had repeatedly brought
up of their own accord. These domains were then added to the question
guide before the West Side pharmacists were contacted. As a result, some
domains were not as thoroughly examined with the East Side pharmacists
as they were with the West Side pharmacists. In order to make-up for this,
previously interviewed East Side pharmacists were re-contacted later for a
brief interview regarding the newly added domains.
At the completion of all of the East Side interviews and initial
analysis, we began contacting all pharmacists at the twenty-two pharmacies
on the West Side. Originally, when the West Side pharmacies were
contacted by phone following the letter of introduction, many refused to
participate. In an attempt to gain greater access, ethnographers visited the
pharmacies in order to speak with the pharmacists in person. The number
of pharmacists willing to participate increased using this more personal
approach. Eleven pharmacists from the West Side were interviewed (Table
!)
56


Question Guide
This study used qualitative research methods in order to assess the
attitudes and beliefs of pharmacists in the Denver area concerning syringe
accessibility for IDUs. Qualitative interviews, as opposed to quantitative
interviews, were chosen in order to allow for rich description through
personal perspectives in the study participant's own words. A marked
difference of quantitative and qualitative interviews exists between
standardized and reflexive interviewing (Hammersley and Atkinson 1995).
While ethnographers often have a prescribed list of issues to cover with the
interviewee, they do not know the exact questions that they will ask and do
not ask them in any particular order. Additionally, the concepts to discuss
during such interviews are not predefined, limited or taken for granted (Ely
et al. 1991). As a result, this technique may increase the possibility of
understanding issues that are latent or non-obvious to the researcher.
Qualitative interviews often resemble conversations and allow the
informant to direct the interview in a manner that seems natural. However,
similar to survey interviews, the presence of the ethnographer may effect
the validity of the information obtained in the interview. Rather than focus
on how honest the informant is being, every piece of information must be
interpreted within the context in which it was collected. In this way,
answers may reveal a subject's attitudes and perceptions as well as their
57


feelings towards their environment or life history events (Hammersley and
Atkinson 1995).
The qualitative question guide was developed in order to facilitate
the interview and ensure the collection of comparable data (Appendix D).
The guide was adapted from a survey used by researchers at the Centers for
Disease Control and Prevention who were conducting a parallel
investigation of pharmacists in Atlanta. The question guide was piloted
with two pharmacy technicians attending the UCHSC School of Pharmacy
and was then revised per their recommendations and those of the
ethnographers. The guide contained five domains;
1. Pharmacists' beliefs and attitudes concerning syringe sales
2. Practicalities and pharmacists' actions and experiences regarding lDUs.
3. Impact of Hepatitis C and HIV / AIDS on their pharmacy and on them as
pharmacists
4. Needle exchange program development issues regarding increasing
syringe access
5. Miscellaneous (included legal issues, syringe disposal, discussion of this
topic with other pharmacists, identification of an IDUs, etc.)
The first domain consisted of questions regarding syringe prices and
quantities sold as well as questions that probed the pharmacists' thoughts
concerning the sale of sterile syringes to IDUs. These latter questions
58


ascertained whether or not pharmacists felt that they should play a role in
syringe distribution. The second domain was aimed at determining
pharmacists' actions regarding syringe sales to IDUs, their concerns with
selling syringes to IDUs, their reasons for or against it, and what could alter
those views (if anything). Other questions within this domain included
establishing the quantities and prices of syringes sold in each of the
pharmacies. This domain was also aimed at understanding what the
pharmacists perceived as important issues regarding syringe access for
IDUs as well as their own past experiences with this population. The third
domain uncovered information concerning how blood borne diseases such
as HIV and HCV have impacted their pharmacy, them as pharmacists, and
them personally. This domain also gauged the amount of personal and/or
professional experience they had had with HIV+, HCV+ and IDUs
populations. The fourth examined pharmacists' thoughts on needle
exchange programs and issues they perceived as significant in the
distribution of sterile syringes by pharmacists. The final domain was
comprised of a miscellaneous group of questions ranging from how they
identify an IDUs to legal issues. Interviews were conducted by
ethnographers; all interviews were taped, transcribed, individually coded,
and then analyzed as a whole for significant themes.
In the East Side interviews, the legal issues were not addressed with
all of the study participants. As a result of a lack of information regarding
59


the pharmacists' knowledge of the legal statutes concerning syringe sales in
Colorado, a supplemental interview was created (Appendix E). The
supplement was conducted with pharmacists who had not previously
spoken about the legal restrictions in their interview. The supplement
questioned them about any knowledge that they had about the statute
concerning syringe sales, their interpretation of it, and any concerns they
had regarding the law. Additionally, the interview questioned them about
whether there were any pharmacy board regulations concerning syringe
sales and how this effected them as pharmacists.
Study Sample
From a total of fifty-two pharmacies contacted, eight pharmacies
were not eligible (seven had gone out of business and one was a natural
medicine pharmacy that did not sell syringes). Of the forty-four eligible
pharmacies, twenty-four pharmacies agreed to participate (55% refusal rate).
All licensed pharmacists at each pharmacy were asked to participate.
Twenty-one pharmacists (65.6%) were from the East Side pharmacies and
eleven pharmacists (34.4%) were from the West Side pharmacies. Of the
thirty pharmacies initially contacted on the East Side, ten pharmacies
refused to participate and six pharmacies had either moved with no
forwarding number or had gone out of business. Therefore, the twenty-one
pharmacists interviewed on the East Side were drawn from fourteen
60


pharmacies. Of the twenty pharmacies initially contacted on the West Side,
ten refused to participate, one was a natural medicine pharmacy that did not
sell syringes and was therefore not eligible, and one had gone out of
business. However, two other pharmacies were added as a result of
referrals from pharmacists resulting in eleven interviews from ten
pharmacies on the West Side. The majority of pharmacists who refused to
participate gave time constraints as their reason. Two pharmacies stated
that their manager would not allow them to participate and one pharmacist
said that they were not comfortable talking about this issue.
Pharmacists from both independent and corporate owned
pharmacies were asked to participate. This was due to the assumption that
pharmacists who worked in locally owned stores and those who worked in
corporately owned chains might have different views regarding syringe
sales.
61


Table 1
PARTICIPATING PHARMACIES
Contacted Participated
Pharmacists (East side) b 21
Pharmacists (West side) - 11
Pharmacies (East side) 30 14
Pharmacies (West side) 22 10
Pharmacists (total) - 32
6 In many cases, ethnographers were informed that none of the pharmacists at the store
were available to participate in the study. On these occasions, the number of pharmacists
working at the pharmacy was unknown to the ethnographer, making it difficult to calculate
the number of pharmacists contacted.
62


Table 2
DEMOGRAPHICS OF PARTICIPATING PHARMACISTS
Variable % n
Gender
Male 62.5% 20
Female 37.5% 12
Ethnicity
White 76% 25
Asian 15% 5
African American 6% 2
Hispanic 3% 1
Pharmacy type
Independent 49% 16
Corporate 51% 17
Mean age 40
Mean years practicing 14.4
63


The pharmacists' ages ranged from 25 to 68 with a mean age of 40.
Pharmacists had from 1.5 to 35 years of experience with a mean of 14.4 years
of experience. All individuals interviewed were practicing licensed
pharmacists.
Data Analysis
Once all of the interviews were completed, the ethnographer began
the process of coding the transcripts. This was done through a thorough
reading of the transcripts and identifying recurring concepts. Codes were
then written in the margins of the transcripts so that, the data could be
organized into categories. Some of the codes were pre-defined by the
ethnographers according to issues uncovered by the sister study conducted
by the CDC while others were defined after completion of the interviews.
These latter codes were distinguished by identifying common patterns or
themes in the interviews. All coding was manually done by one
ethnographer to ensure consistency.
64


CHAPTER V
FINDINGS
Analysis revealed three categories of pharmacists based on their
attitudes concerning syringe sales to IDUs: those who willingly sell syringes
to all of their customers (50%), those who refuse to sell unless shown
legitimate proof of diabetic necessity (34.4%), and those for whom the
decision to sell is situational (15.6%). Five common areas of concern
regarding syringe sales were identified among all three categories of
pharmacists.
1) Competing public health models for drug users
2) Business concerns
3) Legality of syringe sales
4) Pharmacists' experience with HIV+ and IDUs populations
5) Wide-spread support for needle exchange programs
The first two areas of concern appeared to be most important to
pharmacists when deciding whether to sell syringes, while the other three
themes were common secondary issues.
65


Competing Public Health Models For Drug Users
Those pharmacists who reported selling to all individuals and those
who only sold to customers exhibiting legitimate diabetic necessity had two
divergent views of their role with regards to drug use and disease
transmission. The pharmacists who sold to all customers stated that their
primary motivation was the prevention of blood borne disease transmission.
They felt that in order for this to occur, pharmacists must make sterile
syringes accessible to IDUs through the pharmacy. None of the pharmacists
in this group stated that increasing access to syringes increases drug use and
many postulated that the majority of users will not quit injecting drugs due
to an inability to purchase a syringe at a pharmacy. Pharmacists
commented that IDUs would most likely find other methods of obtaining a
syringe if they were unable to purchase them in pharmacies, such as
borrowing from somebody else or picking one up from the streets. These
pharmacists would rather provide sterile syringes than have IDUs use non-
sterile syringes. The following quote typifies these pharmacists' attitudes:
"I think syringes are accessible.... whether syringes are
available or not does not stop users from becoming an
addict. If they are going to become an addict, they are
going to become an addict anyway. Having sterile syringes
available just decreases the possibility of spreading the
disease, whether it being AIDS or hepatitis, or whatever.
So, in my opinion, if I know who uses the stuff...I know
people who are users...whether it is a good clean syringe is
not going to help them to decide whether they want to be
66


or don't want to become an addict. It is not a factor. It is
kind of after the fact."
(32 yr. old African American male, 3 years experience,
Independent store)
Some of the pharmacists who only sold to individuals with proof of
diabetic necessity asserted that the long-term goal of health care providers
should be preventing drug use and abuse. In this case, addiction is
interpreted as the disease and the transmission of blood-borne disease is
seen as a possible result of that addiction. These pharmacists maintained
that by denying syringes to IDUs they were discouraging drug use. They
argued that once a pharmacist had denied a user a syringe, the user would
be forced to rethink their addiction and possibly seek help. Many
pharmacists realized that simply denying to sell a user a syringe wouldn't
encourage a drug user to quit. However, almost half of these pharmacists
(45.4%) stated that they had no interest in supporting a behavior that was
detrimental to a person's health and therefore refused syringe sales. They
reasoned that by denying syringes they were possibly decreasing drug use
and were thus aiding in the decrease of the transmission of blood borne
diseases that resulted from risky injection practices.
"I don't think that two wrongs make a right as far as
dispensing the syringes because they'll have clean syringes
when they use their heroin so they won't share needles and
nobody will get HIV. Ideally that may be the case, but I
think there will still be sharing of needles...I don't think
you should be handing out sterile syringes and saying,
'Okay, see ya/ That's not helping anybody, not them, not
67


society, it's not helping prevention of anything, in my
opinion. I just think that's like a quick fix."
(29 yr. old White female, 6 years experience, Corporate Chain)
Those who were indecisive were caught in the middle of a conflict
between these two public health views. All the indecisive pharmacists
reported being concerned with both the addictive behavior as well as the
transmission of blood-borne diseases, resulting in an uncertainty in how to
assimilate the two public health goals. They were uncomfortable
supporting a potentially destructive addiction but they were also equally
uncomfortable knowing that denying the sale of syringes may lead to an
increase in disease transmission among this population.
"You know that's kind of a diverse role issue for us because
I don't want to spread AIDS and for part of me, turning
people down bothers me. But then I can justify it by telling
myself that if I sell this guy a 10-pack of syringes, he's
probably going to share those ten anyways. So I shouldn't
feel bad about that. But the pharmacist in me says I
shouldn't be helping them. The human being in me says I
shouldn't be letting AIDS get spread, so where do you go?
It's a tough one. And you just find ways to make it right.
You can find an excuse for why you're doing everything
you're doing, probably both directions."
(33 yr. old White female, 16 years experience, Corporate chain)
Business Concerns
The second most commonly stated reason against selling syringes
was the perceived effect on business and other clientele from having IDUs in
their pharmacy. Business concerns were the primary reported reason to
68


deny sales for 36% of those who refused to sell syringes without legitimate
proof of diabetic necessity. An additional 36% of pharmacists who refused
syringe sales mentioned business concerns as a secondary deterrent for
selling syringes to IDUs (for these pharmacists, the importance of increasing
the access of sterile syringes was clearly understood but pharmacists were
acutely aware of the detrimental effects IDUs could have on their customer
base). Pharmacists in this category were concerned about the health issues
surrounding injection drug use but their business concerns prevented them
from taking action along this avenue. Some pharmacists feared that selling
syringes to suspected IDUs would grant them a reputation of being an
IDUs-friendly pharmacy, leading to an increase in the number of users
frequenting their store. Pharmacists felt that ah influx of IDUs would make
their regular customers uncomfortable, causing them to switch to another
pharmacy. One pharmacist described their customers' reaction this way:
"I think they'd feel uncomfortable being in the store. I
think they would be uncomfortable having their
children come in to the store. I think it would be a real
deterrent for them doing business in our store."
(60 yr. old White male, 35 years experience, Independent
store)
Pharmacists stated that their position as public health role models did
not allow them to aid people in a behavior that can be detrimental to one's
health. According to some of the pharmacists, aiding IDUs in their
69


addiction could cause their other customers to question their actions and
potentially harm their reputation as health professionals.
"It just sends the wrong message to other customers in
the store, depending on appearance and attitude and
things like that. If a customer sees them in there buying
syringes and they give the appearance or have the
attitude that they're an abuser, it doesn't give the store a
very good reputation and people develop a fear to go
into places like that where they see that kind of activity
going on."
(39 yr. old White female, 15 years experience, Independent
store)
Another reported negative effect of having IDUs in the pharmacy
was the potential increase in store theft. Some pharmacists described IDUs
as 'rifraff' and 'bad clientele' who were consistently out of money,
untrustworthy, and thus more apt to shoplift than other clientele: They
were also apprehensive that IDUs could potentially vandalize the store or
possibly leave used syringes in the bathrooms and parking lots, posing a
potential threat to other customers and employees.
"...they are demanding. They are usually
untrustworthy. And usually, there is certainly more
potential to be a shoplifter than the average person,
because they are out of money usually all the time. So, I
don't have a problem with it morally. I just think that
the pharmacy isn't the place for that."
(52 yr. old White male, 25 years experience, Corporate chain)
Almost 63% of those pharmacists willing to sell syringes without
restrictions stated that the presence of IDUs in their store had little or no
70


detrimental effect on their other customers or on their stores. One
pharmacist observed that their present policy of selling syringes to IDUs
presented them with fewer concerns than when they had previously been
denying sales.
"It seems now that we've changed our policy and we
sell them more freely to people, we don't seem to be at
odds with the addicts. I haven't noticed any problems."
(35 White male, 10 years experience, Corporate chain)
These pharmacists often noted that when IDUs would come into the
store, they would purchase their syringes, and then leave as soon and as
quietly as possible. Due to the illegal nature of their behavior, these
pharmacists believed that most IDUs did not want to bring any undue
attention upon themselves and would therefore cause few, if any,
disturbances within the pharmacy.
Initially, it was thought that independent and corporate pharmacies
would differ on their store policies as a result of different types of business
concerns each would have. However, the type of pharmacy that the
respondent worked in did not appear to have an effect on their views.
Ambiguity Regarding Legality Of Syringe Sales
In all three groups there were pharmacists who were unaware of the
existence of a paraphernalia statute in Colorado, the only statute that could
possibly be interpreted as regulating syringe sales (Appendix F). Of the
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thirty-two pharmacists who were interviewed, 34% (11) were aware of some
type of regulation concerning the sale of syringes in Colorado (three of those
having only a vague knowledge of it) and 53% (17) were unaware of any
such regulations. The final four pharmacists were unable to be reached for
the secondary interview that concerned this issue. Five (31%) of the sixteen
pharmacists who sold syringes were aware of the statute (three in this group
were unavailable for a second interview on the topic). These pharmacists
stated that the law was ineffective in inducing fear of prosecution. In
reference to the legal restrictions one pharmacist said:
"No big deal. What are they going to do? Are they
going to fine me? I don't think so."
(29 yr. old Hispanic male, 12 yedrs experience, Independent
store)
Additionally, since there is no prescription law in Colorado and no
clear guidelines determining who pharmacists can sell to and who they can
not sell to, one pharmacist stated:
"...because if I sell someone a package of syringes and
they just don't look like a diabetic or if I just think
they're not a diabetic, they're saying we can be
prosecuted for that. I just don't see how you could be....
I just can't imagine someone coming up to you later and
trying to prosecute you because you knew that person
was a drug addict. There's just no way to know that."
(39 yr. old White male, 15 years practice, Corporate chain)
In this case, their perceived ambiguity of the statute allowed them to
continue to sell syringes to suspected IDUs without any fear of prosecution.
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On the other hand, of the eleven pharmacists who refused to sell to anybody
but diabetics, four (36%) were aware of the law and used it to strengthen
their argument to deny sales to suspected IDUs.
"So they are disguising their needs, and so technically
what we are doing is illegal by selling them to
somebody who is not a diabetic. So it takes the risk off
our back by not doing it."
(52 yr. old White male, 25 years experience, Corporate chain)
Of the five pharmacists who were indecisive, two (40%) were aware
of the statute and were unsure how to reconcile their knowledge of the
statute with their concern for the transmission of blood borne diseases.
Many stated that the ambiguity of these legal restrictions enabled them to
use their own discretion when it came to sales. In this way, they were able
to either use the statute to enforce their decision to deny a sale, or overlook
it in order to sell syringes. One pharmacist said that in certain situations she
would say:
"And I tell them, 'No, I only sell them if, supposedly by
law, you are using them for insulin.'"
(27 yr. old Asian female, 2 years experience, Corporate chain)
However when faced with another situation the same
pharmacist said:
"That's why I'm more and more lenient in selling it to
them because since the board is not so clear about it,
they didn't require a prescription for it, so I go, 'Well,
it's up to me.'"
(27 yr. old Asian female, 2 years experience, Corporate chain)
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Half of those who sold syringes were not aware of the statute. Once
they were shown the legal restrictions, they all stated that it did not change
their stance on syringe sales. However, other pharmacists who were either
unclear or unaware of the law were in search of more guidance on the issue,
wanting to know either way what they should do. Three of the five
pharmacists who were indecisive (60%) and one of the eleven who did not
sell (9%) stated that if there were a specific and clear law concerning syringe
sales, they could comfortably sell or deny a sale without any personal
conflict.
Contrary to our original hypothesis, the law did not appear to be the
primary reason for the pharmacists' decisions to sell or not to sell; only two
pharmacists mentioned it as their principal reason for not selling syringes to
suspected IDUs. However, as illustrated above, the statute did provide
pharmacists with a convenient excuse to deny sales.
Image Assessment
As a result of their feelings regarding addiction, and business and
legal concerns, some pharmacists felt it necessary to deny syringe access to
IDUs. However, since Colorado law does not require a prescription to
purchase a syringe, pharmacists have no sure way of distinguishing a
diabetic from an illicit drug user. As a result, pharmacists who deny sales to
suspected IDUs have created various strategies to assess their customers as
74


a way of separating those who possess a legitimate diabetic necessity for a
syringe from those who do not. An unconscious and almost immediate
method of evaluating a customer is by their appearance. Twenty-eight
percent of those who sold syringes, 55% of those who didn't sell syringes,
and 100% of the situational sellers felt that they could spot IDUs by the way
that they walk, their mannerisms, their thin physique, and their disheveled
and dirty appearance. One pharmacist who did not sell syringes described
IDUs in this way:
"Their physical appearance is dirty, unkempt...many
times a very strong alcoholic odor is just
permeating...the whole atmosphere. ...I would say the
majority of the ones that I can think of tend to have sort
of a oily or sweaty skin...but any how just part of the
physical appearance, it doesn't look right."
(60 yr. old White male, 35 years experience, Corporate chain)
As this next quote exemplifies, many pharmacists felt that the IDUs
entering their store are often already high and/or drunk, and thus easy to
recognize by their glassy-eyed look and nervous behavior.
"You can just tell, sometimes. Or just the way they
look, too. Sometimes you can smell alcohol on their
breath. They have that glazed over look, you can just
tell they're trying to maintain that high that they have."
(29 yr. old White female, 6 years experience, Corporate chain)
For some of the pharmacists, the individual's appearance was the
deciding factor in their decision to sell or not.
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"Sometimes, I just use my intuition, you know, they
don't have to show me any identification, I just use my
intuition and say, 'No, I'm not going to sell it to you.'"
(40 yr. old African-American, 14 years experience, Corporate
chain)
Many pharmacists noted that not all IDUs fit the stereotypical model
of a person injecting illegal drugs. For those pharmacists who sold syringes
to all of their customers and used a 'no questions asked' policy, this caused
no problem. Customers who did not look like the stereotypical IDU did
create a dilemma for pharmacists only willing to sell syringes to customers
presenting a legitimate diabetic necessity. As a result of not being able to
identify IDUs by sight, pharmacists have devised secondary strategies to
determine whether or not a customer is a diabetic. First, many felt they
!'
could tell by the way that the individual requests the syringes. 33% of those
who sold syringes, 27% of those who didn't sell syringes, and 75% of the
situational pharmacists noted that suspected IDUs are often unaware of the
exact type of syringe they require. Frequently, the person will be vague and
simply ask for a ten pack of syringes without specifying the type or the size
of syringe. Since most diabetics are generally well acquainted with this
information, pharmacists consider this perceived lack of syringe knowledge
a reliable clue that the person who they are dealing with is not a diabetic.
Additionally, pharmacists reported having a series of questions that
they would ask the customer in order to evaluate their diabetic status. 66%
76


of all pharmacists stated that they had used this strategy at one time in order
to deny sales to suspected IDUs. Once the individual has asked for the
syringes, the pharmacist will respond by asking what type of insulin they
use, in what dosage they take it, and/or if they have any diabetic
identification. Typically, pharmacists found that IDUs are not
knowledgeable about insulin types and are often unable to answer these
questions. An inability to properly respond to the questions will usually
convince the pharmacist that the customer is not going to be using the
syringes for a legitimate reason. In this case, they deny the sale.
"...and then a follow-up is, 'what type of insulin do you
use?'or'How many units do you inject?' If they can't
come up with an answer, the assumption is that they're
probably not telling the truth in the first place. So we'll
usually just stay with that approach. We might say to
that person,'Well, unless you can answer those
questions, I have a responsibility to not sell you the
syringes."
(47 yr. old White male, 8.5 years experience, Corporate chain)
Repeatedly, pharmacists stated that when confronted with these
questions, the IDU responds by saying that the syringes are not for
themselves but are for some other family member or a friend who is too sick
to pick them up. Pharmacists called this the 'grandmother excuse' due to
the fact that oftentimes an ailing diabetic grandmother was used as the
reason for buying syringes. Frequently, the pharmacist will reply that it is
necessary for them to know the patient's insulin type or some other form of
77


proper diabetic identification (like a diabetic ID card) in order to sell them a
syringe.
While the insulin questions were a fairly reliable way of identifying
an IDU and thus denying sales, pharmacists realized that there were those
IDUs who were knowledgeable enough to answer these questions.
Although they were suspicious of certain customers, pharmacists who used
this as a method of identifying IDUs maintained they would only refuse to
sell if the individual was unable to answer their questions.
"Usually from the answers to those questions, you can
ascertain whether the person is legitimate or not. Quite
honestly, if a person has an answer to those basic
questions I have no basis on which to refuse to sell them
the syringes. And so then I would [sell the syringes to
them]."
(47 yr. old White male, 8.5 years practice, Corporate chain)
Another aspect of the situation that some pharmacists took into
account when deciding whether or not to sell, was the customer's attitude at
the time of the transaction. Some explained that when an individual comes
to the counter and is rude or indignant, the pharmacist is more apt to deny
them the sale. Additionally, pharmacists reported, denying sales to
customers coming up to the counter requesting syringes as if it were their
right to purchase a sterile syringe. On the other hand, if the customer
approached them with a kind and polite manner, pharmacists would be
more likely to sell them the syringe.
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"...so most of the time I just sell it unless the person is
really rude, or aggressive or something."
(27 yr. old Asian female, 1.5 years experience, Corporate
chain)
Pharmacists' Experience With HIV+
And Injection Drug Using Populations
Pharmacists' experience with and knowledge of illegal drug users
and HIV+ populations occasionally influenced their decision to sell or not to
sell syringes to suspected IDUs. As noted earlier, essentially two public
health models with respect to drug addiction were identified; one
concerning the disease of addiction and one concerning the transmission of
blood borne diseases. Those pharmacists willing to sell to all customers
generally perceived drug addiction as a disease that could overtake any
person, displacing the physical and mental capabilities necessary to resist
such an overwhelming habit. Overall, 31% of pharmacists from this group
had extensive personal and/or professional experience with HIV+
populations while none of the pharmacists in the other groups reported any
experience. Two of pharmacists in the pro-sell group had extensive
experience with IDUs through family or friends. They stated that this
experience often contributed to their views on addiction and the sale of
sterile syringes and aided them in understanding the necessity of increasing
accessibility of syringes for injection drug users.
79


"I don't approve of the use of drugs. But then you look
at it from the other side, you can be part of prevention
in the sense that you can prevent the sharing of needles
with infected people and that's something that pushes
me more to that side in my own feeling about drug
use.... I come from a family who has that kind of
problem,... what would you do if your own brother
came in and said, 'Let me have some syringes?'...I
would not deny my brother a sterile syringe. I would
even educate him, 'Don't share anything. If you need it,
you come to me and I'll give you some syringes.' It's as
simple as that."
(29 yr. old Hispanic male, 12 years experience, Independent
store)
Another pharmacists spoke about his experiences working with
HIV+ populations and how that influenced his decision.
"And now from living in San Francisco, I don't want
them to use dirty needles. I'm not going to stop them
from using drugs and they're just going to pass on more
Hepatitis or HIV or anything using dirty needles, so I
don't have a problem giving out clean syringes."
(29 yr. old White male, 5 years experience, Independent store)
On the other hand, the group who only sold to people who could
produce legitimate proof of diabetic necessity had no reported personal
and/or professional experience with HIV+ populations. Two of the
pharmacists in this group did have experience with IDUs populations
through friends who were using drugs. These pharmacists interpreted the
situation in an alternative manner from the previous pharmacists.
"I just can't bring myself to contribute to somebody
ruining their lives potentially by using drugs because
I've seen too much of it...there were people that came
80


into the drugstore that...were nice people and they got
mixed up in drugs and ruined their lives, their family's
lives and I just couldn't handle it."
(60 yr. old White female, 39 years experience, Independent
store)
Wide Spread Support For
Needle Exchange Programs
Regardless of their stance on sales, pharmacists were supportive of
needle exchange programs. Based on the knowledge that pharmacists had
obtained through the media and from conversations with other pharmacists,
the majority of the sample perceived needle exchange programs as both a
feasible and an appropriate option for this population.
When asked about needle exchange programs, one pharmacist said:
"That's great.... if it becomes an issue, 'Well, this is my
practice. You can go here instead. I apologize but this is how
it's supposed to be.' That's an alternative... .If I should run
out, God forbid, you just tell them, 'Okay, go to this clinic and
you can get some clean syringes or exchange them.' To me,
that's great. That's something that should actually happen
around the United States."
(29 yr. old Hispanic male, 12 years experience, Independent store)
An added benefit to having needle exchange programs would be the
direct care that IDUs would be able to receive from the medical staff. Due to
the busy nature of the pharmacy, pharmacists expressed doubt that IDUs
would feel comfortable asking a pharmacist for health information that
concerns injecting illegal drugs. At a needle exchange program, a user
81


would not have to feel any inhibitions requesting information regarding
injection drug use. In this way, pharmacists stated that IDUs would be able
to access information concerning vein care, sterile injection practices, and
diseases such as endocarditis, hepatitis, and HIV /AIDS.
Pharmacists reported that the presence of needle exchange programs
would also remove the IDUs from their stores. Since IDUs were considered
by some to be untrustworthy customers with the potential to create an
uncomfortable atmosphere in the store for both the pharmacists and the
customers, this was a perceived advantage among each group of
pharmacists.
There did not appear to be any meaningful difference between why
pharmacists in the different categories supported needle exchange
programs. All three groups mentioned needle exchange programs as being
a benefit because they are a place for IDUs to have increased access to
relevant health information, a way to get the IDUs out of the store, and
provided a method of disposal for used syringes. Additionally, the
Colorado Pharmacy Board has released a statement fully supporting the
development of a legally sanctioned needle exchange in Colorado.
There were many reasons why pharmacists were in favor of
introducing needle exchange programs, one being the opportunity to supply
syringes to IDUs at no cost.
82


"...if the government or the state really wants to keep
track or to get these syringes into the hands of the
people, I don't think they should even have to pay for
them."
(52 yr. old White male, 25 years experience, Corporate chain)
Two pharmacists said that a primary reason for not selling syringes
to suspected drug users was due to the lack of proper disposal receptacles
for used syringes. Many were concerned about customers purchasing
syringes in their pharmacy, using them and then disposing of the used
syringes on pharmacy property or in another area that could prove to be
dangerous for others. Pharmacists observed that a needle exchange
program would offer a safe and comfortable option for users interested in
receiving and returning syringes. Pharmacists would be able to feel
comfortable selling syringes knowing that the needle exchange program
would present a safe disposal option for used syringes.
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CHAPTER VI
DISCUSSION
This research illuminated many of the issues that pharmacists
perceive as important when considering syringe access for IDUs. Most
importantly, it revealed that half of the pharmacists interviewed believed
that the task of decreasing disease transmission through injection drug use
is an essential and practical role for pharmacists to take on. These
pharmacists agreed that syringes should be sold without restrictions.
Importantly, many of these pharmacists could understand the views of
those who do not sell to IDUs, some of them had in fact felt that way earlier
in their career. This demonstrates that pharmacists who have denied
syringe sales to IDUs in the past have been able to come to terms with the
need to increase syringe access and have changed their behavior as a result.
The fact that half of our sample sold syringes demonstrates that this is not
an insurmountable issue among pharmacists and that many have found
methods of increasing syringe access in a manner that was not detrimental
their businesses or contradictory to their role as health professionals.
Prior to the study, the researchers postulated that the legal
restrictions placed on syringe sales would be a dominant reason for
pharmacists to deny sales to IDUs. It was presumed that the fear of
84


prosecution or the ambiguity of the law could potentially dissuade
pharmacists from selling sterile syringes to IDUs. However, we did not find
this to be the case. Only two pharmacists from our sample stated that the
legal ramifications of syringe sales were the primary reason they
discouraged sales to IDUs in their pharmacies. The statute was not the
primary stated reason for denials for the remainder of the pharmacists who
knew of it, but many used it to justify their decision not to sell. The
remaining pharmacists who did not sell to IDUs were either unclear or
unaware of the paraphernalia statute making it doubtful that it was a major
factor in their decision not to sell. Those who sold to all customers often
stated that the statute was extremely vague and expressed no concern of any
type of legal repercussions. These pharmacists reported that an increase in
syringe access was essential and that the statute was not a sufficient
deterrent to stop them from selling to IDUs.
Contrary to the original hypothesis, the most commonly stated
reason for not selling syringes to IDUs was the perception that IDUs could
have a negative effect on business and other clientele. Pharmacists were well
aware of the importance of stopping the transmission of blood borne
diseases, however, pharmacists also stated that selling syringes to IDUs
could be detrimental to business. Pharmacists may be public health
professionals, but they are also responsible for maintaining a business and
keeping other clientele and their pharmacy's reputation in mind. Their
85


principal concerns included increased theft (this included shoplifting as well
as fear of robbery of controlled substances), discarded syringes on store
premises, and IDUs creating an uncomfortable atmosphere for other
clientele. While these pharmacists understood the need for syringe access,
they also felt that syringe sales to IDUs was not something that should be
taking place within a pharmacy. This may in part explain the widespread
support for needle exchange programs that was exhibited by the majority of
the pharmacists in this study.
The other major concern for pharmacists were their moral convictions
regarding drug use. For many pharmacists, the disease in question was
drug addiction. As a consequence, they did not want to promote substance
abuse by making syringes available. Many equated treating addiction with
> .
ebbing the transmission of blood-borne diseases; by treating addiction,
injection drug use would decrease, and along with it the blood borne
diseases it facilitates. Often, pharmacists felt that by denying a syringe to a
suspected IDU, they were forcing the individual to rethink his/her position
in life and reevaluate their drug use. Unfortunately, the success rates for
drug treatment is relatively low and addiction is considered to be a chronic
condition. Thus, denying IDUs sterile syringes will rarely encourage them
to stop injecting. Instead, it may force them to use a previously used
syringe, borrow one from a friend, or find one on the streets. It is essential
86


that pharmacists understand the characteristics of addiction so that they can
be more effective in ceasing the spread of disease among IDUs.
The culmination of the previously stated concerns is that pharmacists
must be able to distinguish an IDU from an individual with a 'legitimate
medical necessity'. Without any explicit guidelines designed to determine
to whom syringes can be sold, pharmacists often stated that they were able
to first identify a user by their manner of dress or behavior. As a result,
IDUs who do not have the cultural capital necessary to successfully
assimilate into our society are often targeted for questioning by pharmacists.
They stick out because they do not have the education to know the syringe
type or the facilities and financial capital to present an orderly appearance.
They are then bombarded with questions about their diabetic status simply
because they do not have the ability to look and act like the rest of 'normal'
society. However, those who can maintain a modicum of "social
acceptability" can often play the part and get away with a successful sale
through deception. This may result in the further alienation of IDUs who
have already been marginalized due to their lack of capital, thus reinforcing
their risk taking behavior. This visual bias shows the variability in the
pharmacists' policy, creating an unreliable outcome for IDUs attempting to
purchase a syringe.
It was interesting to note that none of the pharmacists in the group
who did not sell to IDUs reported any personal and/or professional
87


experience with HIV+ populations. On the other hand, almost one third of
the group who sold to all customers reported either personal or professional
experience with HIV+ populations; experiences that often helped them to
define their current views on syringe access. Furthermore, both groups had
two individuals who reported having experience with IDUs, either through
family or friends. However, each group interpreted their experiences
differently. Those who did not sell felt that their experiences gave them an
understanding of addiction and it's destructive effects on people's lives.
The experiences of the other group gave them a sense of awareness of the
current epidemics among IDUs and a source of obligation to stop these
diseases from reaching individuals close to them who injected drugs.
Pharmacies may represent a convenient option for sterile syringes for
IDUs in Denver, but this research has demonstrated that sales through
pharmacies can often be problematic and may not represent a reliable source
for syringes. Vague legal restrictions, a lack of clear regulations or
guidelines from pharmacy associations addressing this topic, business
concerns and the incorporation of personal belief systems result in variation
of pharmacists' actions concerning sterile syringe distribution to suspected
IDUs. This places IDUs on the periphery of our health system. In an
attempt to bring IDUs into the health system, pharmacists' attitudes and
actions regarding syringe sales must be understood and addressed.
88


CHAPTER VII
CONCLUSION AND RECOMMENDATIONS
The fundamental task of stopping the transmission of diseases such
as HCV and HIV among IDUs seems basic when one looks at it strictly from
a public health perspective. However this research, as well as that of others,
has demonstrated that pharmacists have a number of concerns regarding
this issue that must be addressed if they are to become involved in the
effort. Due to the illegal and damaging nature of injection drug use, many
individuals perceive the current dilemma of IDUs as being of their own
making. It is through IDUs own lack of self-responsibility that they now
find themselves in a lifestyle that increases their risk of infection of blood
borne pathogens. Furthermore, many view any effort to increase syringe
access as a means to facilitate injection drug use thus aiding a person in the
damaging life of addiction. Consequently, the health issues of IDUs are
often times seen as a logical progression emerging from a bad life choice.
Many of the pharmacists who were interviewed expressed similar moral
concerns as well as business concerns regarding the sale of syringes to IDUs.
The concerns that were brought up by the pharmacists in the study
represented legitimate issues, however they are issues that can hopefully be
89


addressed and resolved in order to further involve pharmacists in this
public health effort.
The points brought up by pharmacists in this study were very similar
to those in existing literature (Sheridan 1997, Gleghorn et al. 1998, Singer et
al. 1998, Wright-De Aguero et al. 1998, Farley et al. 1999). Many were very
concerned with the effect that IDUs in their store would have on their
business, their customer base and their reputation as public health
professionals. These concerns lead to a broad discrepancy in syringe sales
among pharmacists and thus an uncertain outcome for IDUs when
attempting to purchase. In addition, the findings regarding the lack of
communication between pharmacists concerning syringe sales was in
agreement with that of previous researchers (Singer et al. 1998, Wright-De
Aguero et al. 1998).
In agreement with the work done by Gostin, our findings suggest
that legal restrictions were shown to limit the availability of syringes though
pharmacies (Gostin 1998). While only two pharmacists in our sample stated
that the paraphernalia statute was their primary reason to deny syringe
sales to IDUs, many other pharmacists used it to justify their actions.
However, the paraphernalia statute does not only limit access through
distribution but also restricts the actions of the IDUs by making the
possession of syringes a crime as well. Ethnographic evidence has shown
that many IDUs are reluctant to carry syringes on them because of the risk
90


of being stopped by a police officer and arrested for carrying paraphernalia
(Koester 1994). As a result, IDUs are often unprepared for an unexpected
injection episode and are forced to share syringes and other paraphernalia
with their partners. The existence of such statutes ignores the need for an
increase in syringe access as a public health requirement and relegates IDUs
into a sub-culture of individuals who are not worthy of preventative
measures. The emerging epidemic of HCV illustrates the need for the
declaration of a public health emergency and for the laws that restrict the
sale of syringes to be repealed.
Recommendations
Gostin and colleagues' findings revealed that pharmacist discretion
leads to a wide variation in the willingness to sell syringes, as a result they
presented seven legal and public health approaches to the dilemma (Gostin
et al.1997):
1. Clarify the legitimate medical purposes of sterile syringes
2. Modify drug paraphernalia laws
3. Repeal syringe prescription laws
4. Repeal restrictive pharmacy regulations and practice guidelines
5. Promote professional training
6. Permit local discretion in establishing NEP
7. Design programs for safe syringe disposal
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Full Text

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THE ROLE OF PHARMACISTS IN INCREASING SYRINGE ACCESSIBILITY by Beth A White B.S., State University of New York at Binghamton, 1993 A thesis submitted to the University of Colorado at Denver in partial fulfillment of the requirements for the degree of Master of Arts Anthropology 2000

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This thesis for the Master of Arts degree by Beth A. White has been approved by 'Da'te

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White, Beth A. (M.A. Anthropology) The Role of Pharmacists in Increasing Syringe Accessibility Thesis Directed by Professor Stephen K. Koester ABSTRACT Background: Colorado does not have a legally sanctioned needle exchange program and is not a state which requires a prescription in order to purchase a syringe. As a result, intravenous drug users (IDU) commonly obtain sterile syringes by purchasing them at pharmacies .. However, Colorado does have a paraphernalia law which makes access problematic. The purpose of this study is to gauge the attitudes, beliefs, and experiences of pharmacists in the Denver metro area regarding their role in providing syringes to IDUs. Methodology: Semi-structured interviews were conducted with 32 pharmacists in Denver concerning their attitudes toward and experience selling syringes to IDUs. All pharmacies within study boundaries were selected to participate in the study. Pharmacists working at both chain and independent stores were interviewed. All interviews were confidential and coding was done by hand. Results: Attitudes toward syringe sales varied with three distinct categories of pharmacists emerging; those that sold all the time, those that sold none of the time, and those that sold some of the time; Those that sold all of the time perceived their role in public health as one of decreasing disease transmission by providing access to sterile injection devices. Those that refused to sell interpreted their role as one of enhancing the health of their 111

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clients and saw drug use as contradictory to that. The final group, among whom sales were situational, expressed a continually fluctuating moral conflict between promoting health by providing access and promoting health by not supporting an unhealthy habit. Strategies for refusing to sell included the request for identification to prove diabetic necessity, only selling in bulk quantities (i.e boxes of 100), or denying access on the basis of store policy. Conclusion: These attitudes have direct consequences on access to sterile syringes and all pharmacists expressed concern about this issue. We suggest that disease prevention efforts should work with pharmacists to increase the sale of sterile syringes to IDUs, and that pharmacists might consider addressing the issue of providing access to sterile syringes in their professional organizations, in pharmacy school curriculum and in continuing education classes. This abstract accurately represents the content of the candidate's thesis I recommend its publication Si Stephen K. Koester lV

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DEDICATION This thesis is dedicated to the memory of Alice K. White; a woman who taught me love, courage and joy

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ACKNOWLEDGMENT I would like to thank all those individuals who were essential in the completion of this project. I sincerely appreciate the cooperation of the pharmacists that took time out of their hectic schedules to participate in this study. Great thanks goes out to Trevor Bush, whose ideas and work helped to shape and complete this project. Dr. Stephen Koester's guidance and advice was essential in the completion of my degree, but his passion for his research showed me what public health is truly about. Others that participated in the completion of this work include, but are not limited to; David Miller, Doug Kershaw, Christy Christiansen and the entire staff at Urban Links. I would also like to T. Stephen Jones at the CDC for his unfailing commitment to this project. This work was funded through a cooperative by the Association of Teachers for Preventative Medicine and the Centers for Disease Control and Prevention. My friends in Boulder and throughout; the country have provided me with endless support and encouragement. I would like to thank Jenn Shuping for the long runs and unfailing friendship; Ralph Shuping for reminding me of the lighter side of life; Kate Beal for he;r encouragement and reminders that what I was doing was worthwhile; MiChael Hammett and Kelly Riordan for always being there for me; and all of the ultimate teams that I have been on during the course of this degree. Thanks to you all. My parents have always been there to support me, no matter what I was doing at the time. Whether I was in school, traveling, or working, you have always made me feel as if I could accomplish anything that I set my mind to. It is because of you that I am where I am today. Thanks also goes to Erik and Russ for providing me with constant love and support. I cannot say enough about the love, encouragement, support and devotion that Aaron Lewis has provided me in the years that it took to complete this degree. Thank you for teaching me how to fly when I wasn't even sure how to walk.

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CONTENTS Tables ix CHAPTER 1. INTRODUCTION 1 IDU at RiskThe Dual Epidemic of HIV and HCV__ 4 Behaviors that Place IDU at Risk 6 2. THEORETICAL ORIENTATIONS 10 Illicit Drug Users Within our Society 13 The Bio-Medical 20 3. REVIEW OF THE LITERATURE 22 IDU Behaviors 24 Bleach Use 26 Paraphernalia Laws 27 States That Have Repealed Paraphernalia and Prescription Laws 32 Needle Exchange Programs 36 Syringe Disposal 42 Pharmacists' Role in Syringe Accessibility 45 Limitations to Access Through Pharmacies 46 4. METHODOLOGY 53 Complimentary Study 53 Sampling Procedures 53 Data Collection 55 Question Guide 57 Study Sample 60 Data Analysis 64 5. FINDINGS 65 Competing Public Health Models for Drug Users 66 Business Concerns 68 Ambiguity Regarding Legality of Syringe Sales 71 Image Assessment 7 4 Pharmacists' Experience with HIV + and Injection Drug Using Populations 79 Wide Spread Support for Needle Exchange Programs_ 81 Vll

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6. DISCUSSION ______________ 7 CONCLUSION AND RECOMMENDATIONS ____ Recommendations ___________ Concluding Remarks __________ APPENDIX A. MAILINSURVEY _____________ B. LETTER OF INTRODUCTION _________ C. CONSENTFORM. ____________ _ D. PHARMACY QUESTIONNAIRE. _________ E. SUPPLEMENT INTERVIEW __________ F. COLORADO PARAPHERNALIA STATUTES ____ REFERENCES _________________ ,, viii 84 89 91 94 97 99 100 104 109 113 114

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TABLES Table 1. Participating Pharmacies ______________ 62 2. Demographics of Participating Pharmacists _______ 63 ix

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CHAPTER I INTRODUCTION Currently, injection drug use is the dominant risk factor identified in new cases of HIV and Hepatitis C in the United States, and is responsible for over one third of all AIDS cases and over half of the Hepatitis C cases reported in the United States. The sharing of non-sterile syringes1 and the use of contaminated syringes during the process of preparing and injecting drugs enables the efficient transmission of these diseases. While frequency of use may increase an individual's risk, any person who has injected an illicit substance using a contaminated syringe even once runs the risk of contracting a fatal infectious disease. Risk of disease transmission from injection drug use not only affects injection drug users (IDUs) but their sexual partners as well. In NIDA's triennial report to congress (NIDA 1999), summarized research indicated that those who had used illicit drugs in the past year were more likely than those who had not to test positive for HIV. Additionally, they reported that illicit drug users who were surveyed were more likely than non-users to be sexually active and to have had two or more partners within the past year. 1 Since the IDUs in the United States overwhelming use syringes with non-removable needles, the term 'syringe' will be used to mean the syringe and the needle. In the past, syringes with detachable needles more common 1

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Furthermore, those who reported having two or more sexual partners in the past year were less likely to report that they always used a condom. Subsequently, there has also been a growing number of HN cases identified in the sexual partners of IDUs (NIDA 1999). The only sure way to stop the spread of blood borne diseases through injection drug use among IDUs not in treatment is to make certain that they use a sterile syringe for every injection episode. Unfortunately, access to sterile syringes in many states is problematic due to a mixture of contextual factors such as paraphernalia statutes, prescription laws (requiring a medical prescription t? obtain a syringe) and the concerns of those pharmacists who control syringe distribution. In order to increase syringe availability and thus reduce iri.jection risks, many areas have sanctioned needle exchange programs that often operate on a one for one exchange system. However, while these programs do constitute one component of a solution to syringe access in the United States, needle exchange programs remain sparse in the U.S. This study is concerned with the availability of sterile syringes for IDUs in Denver. The state of Colorado does not legally sanction needle exchange programs, however it is also not a state that requires a prescription in order to purchase a syringe. Consequently, Denver pharmacies represent the most reliable source of sterile syringes for IDUs, and are thus the primary source for distribution. However, pharmacy sales 2

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are dependent on store policies and the attitudes of individual pharmacists. Thus, it is imperative to include pharmacists in harm reduction strategies aimed at this population. The purpose of this study was to gauge the attitudes, beliefs, and experiences of pharmacists in the Denver metro area regarding their role in providing syringes to IDUs. This research was one part of a two-part study funded through a cooperative by the Association of Teachers for Preventative Medicine (ATPM) and the Centers for Disease Control and Prevention (CDCf The other segment of the study examined the degree to which sterile syringes are currently ava1lable to IDUs through pharmacy sales in the Denver metro area and identified possible constraints that limit access. The research reported here was conducted through Urban Links. Urban Links is funded through grants from the National Institute on Health (NIH) (NIDA DA09232), the CDC and the state of Colorado. It is a project within the Center for Health and Behavioral Sciences and the University of Colorado at Denver. Dr. Stephen Koester, Urban Link's director and principal investigator, has been funded to research individual and network HIV interventions for IDUs. 2 Role Of Pharmacists In Increasing Syringe Accessibility. Primary Investigator: Stephen Koester. CDC Program Officer: T. Stephen Jones, MD 3

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IDUs At Risk-The Dual Epidemic Of HIV And HCV Injection drug use is a main risk factor for the transmission of blood borne diseases, responsible for 35.8% (n=251,759) of all HIV I AIDS cases (both due to and associated with injection drug use), and for 91% (n=7,828) of all pediatric HIV I AIDS cases (13 years and under) reported through June of 1999 to the Centers for Disease Control and Prevention in the United States (CDC 1998). The full force of these numbers is illuminated by the fact that since 1996, more Americans have become infected with HIV as a result of an infected hypodermic syringe than from an infected sexual partner (Project Sero 1999). HIV infection is not the only medical threat that currently confronts IDUs: the developing epidemic of Hepatitis C (HCV) infection is a growing concern. HCV was only recently identified in 1989, previously known as non-A, non-B Hepatitis, and could not be detected in the blood until1992 (NIDDK 1997). Like HIV, HCV is a blood-borne pathogen transmitted among IDUs through the sharing of injection equipment (unlike HIV it does not appear to be as easily transmitted sexually). There is no known cure for HCV at this time, and while most HCV infections are transient, chronic infections will lead to cirrhosis and hepatocellular carcinoma (Heimer et al. 1996, NIH 1997). Due to its recent identification, HCV has spread unimpeded for decades. As a result, there are very few, if any prevention 4

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programs addressing this issue among IDUs. By 1999, almost 4 million Americans had been infected with HCV (CDC 1998). Over half of these infections were due to injection drug use and the other half of the were due to a variety of causes such as; hemophiliacs treated with products before 1987, blood transfusions before 1990, people who engage in high risk sexual practices, and health care workers (CDC 1998). HCV infection is spread much more rapidly than other viral infections such as Hepatitis Band i-IIV, evidenced by a fourfold increase in HCV infection rates over HIV infection rates in young injectors (CDC 1998). This may be due to the high prevalence of IDUs already infected with HCV thus increasing the probability of an IDUs coming into contact with an HCV positive individual (CDC 1998). HCV has been called the 'silent epidemic' since individuals infected with the virus can live asymptomatic for years. Due to this fact, many individuals who are infected may be unaware of their status and are thus spreading the disease unknowingly. Consequently, it has been estimated that within five years of beginning to inject, as high as 90% of IDUs may become infected with the virus. Some researchers estimate that the death rate for HCV in the next decade will surpass that of HIV (Mayo Health Oasis 1997). 5

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Behaviors That Place IDUs At Risk Traditionally, interventions have focused on modifying the individual behaviors that increase risk of disease among IDUs. Injection behaviors that facilitate transmission include the direct sharing of syringes as well as many other less directly apparent behaviors that place IDUs at risk for HIV /HCV infection. "Indirect sharing" occurs when syringes become contaminated through the sharing of injection paraphernalia while preparing and distributing the drug. This paraphernalia includes water, cottons and cookers or mixers The sharing of water for rinsing syringes and/or mixing drugs, containers used to mix the drug solution, cottons for filtering the drug as well as frontloading and backloading (methods of tranSferring the drug solution from one syringe directly into another syringe), and also place IDUs at risk of infection (Grund 1991, Zule 1992, Koester 1994, Vlahov 1996, and McCoy 1998). This risk is not as obvious as the direct sharing of another's syringe but instead occur during the intermediate steps in the preparation of the drug. Unfortunately, most IDUs perceive syringe sharing as risky behavior but many do not identify the previously mentioned practices as unsafe conduct (Koester et al. 1996). Koester and colleagues emphasize that the percent of subjects they 3 Booting is a process that occurs after registering and administering the drug solution. With the needle still in the vein, the individual draws the plunger back in order to fill the barrel of the syringe with blood and then reinjects the blood. This practice allegedly enhances the euphoria associated with the drug's effect (Normand 1995). 6

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interviewed who shared rinse water, cotton filters, or cookers was more than twice that of those who shared used syringes; resulting in a larger population of IDUs at risk than previously estimated (Koester et al. 1996). While Koester originally interpreted these actions as those that place IDUs at increased risk (1990), they are only proxies for the actual risky practice of drug sharing (Koester et al. 1996). The practice of sharing paraphernalia while preparing the drug solution is often a result of two or more individuals pooling their limited funds in order to purchase a small quantity of their drug of choice. Since it can be difficult to successfully measure out equal shares of a drug while it is in its solid form, many prefer to measure out their share after the drug has been prepared and has become a liquid. The processes of shared preparation and distribution represent possible instances of risk. Thus, if a contaminated syringe is used for preparing drugs for injection, blood-borne disease transmission can occur even if the syringe itself is not shared. In contrast, some behaviors that IDUs engage in may actually decrease the chance of infection. In the western portion of the United States, the heroin available is termed 'black tar' due to its similarity in consistency to tar. It is unlike the easily dissolvable powder heroin available on the East Coast and users must heat the drug in order to break it down for injection. HIV is unable to survive the heat that occurs during this type of heroin preparation and often dies in the drug mixture before injection (Clatts et al. 7

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1999). It has been ascertained that the survival of HIV-1 in a syringe is a function of the temperature achieved during the 'cooking' of the heroin solution. HIV -1 has been shown to be deactivated once temperatures reached an average of 65 C for 15 seconds or longer (Clatts et al. 1999). However, this only pertains to those drugs that are heated before injection; drugs such as methamphetamine and cocaine are not usually 'cooked'. Additionally, I have observed injection episodes in which the drug solution was heated for far less than fifteen seconds, thus decreasing the efficacy of "cooking" as a form of harm reduction. Research has shown that IDUs are aware of the risks associated with injection drug use and recognize that they should use a new, sterile syringe for each injection (Calsyn et al. 1992). Yet, injection drug use continues to be either directly or indirectly responsible for a high proportion of all AIDS cases, and more than half of the HCV cases. Some have stated that the continued practice of sharing paraphernalia among IDUs is a result of adhering to a ritual of the drug sub-culture (Howard & Borges 1972, Des Jarlais & Friedman 1986). I would argue that the inability of IDUs to change their injection behavior in order to decrease their risks is often a result of a combination of obstacles to access as well as the legal repercussions of possession of paraphernalia. These impediments can affect where, when and how a person injects. 8

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As such, in addition to educating users about these practices and the risks they imply, it is essential to develop interventions aimed at structural change. It is difficult for many IDUs to adhere to safe injection practices while simultaneously being faced with structural impediments to purchasing and possessing syringes. Unfortunately, while the number of IDUs becoming mortality statistics grows, they remain entrenched in a social construct for prevention of infection from a bio-medical community that repeatedly fails to take into account the contextual factors that influence behavior. 9

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CHAPTER II THEORETICAL ORIENTATIONS For the purposes of this thesis, the theoretical influences that I have incorporated include the concept of Critical Medical Anthropology (CMA), Foucault's notion of bio-power and Bourdieu's concepts of cultural capital, habitus and social field. The perspective that this work is grounded in is that of CMA, a theory that is centered on the belief that "the dominant ideological and social patterns in medical care are intimately related to hegemonic ideologies and patterns outside of biomedicine" (Baer et al. 1997:26). This theoretical perspective is significant in that it does not examine health issues in a vacuum but instead addresses the political and economic factors that create and shape human behavior. In the case of IDUs, this means that the social stigma and legal status that our culture has associated with illicit drug use have become the primary determinants of an IDU's treatment by the dominant society and it's representative institutions, including medicine. A prime example of this would be the legal status regarding possession of sterile syringes, an item that is necessary in order for IDUs to comply with public health recommendations. CMA has partially grown out of the ideas of Foucault, specifically the focus on the individual's place in the realm of health care and their ability to 10

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maneuver within it. Foucault theorized that humans are unable to define and understand themselves without an awareness of the mechanisms of power that serve to modify their behaviors and shape them as individuals (Foucault 1983). His theory of power defines how the actions of individuals in authority result in the reorder of the possible conduct of the individuals who these actions affect. In other words, those with the power to construct laws and create the social framework that we must live within recognize that individuals forced to live within these boundaries are capable of making their own decisions. Individuals either decide to comply with the social and structural constraints placed upon them or they choose non compliance (Foucault 1983) For IDUs, the decision to inject illicit drugs is the initial decision not to comply with those who deem this behavior illegal. As a result, they have effectively lost all rights to work pragmatically within the social structure since their first act of personal responsibility should be to sober up. Subsequently, any choice they face concerning their drug use is additional non-compliance. Additionally, Foucault introduced the concept of bio-power, the idea that historically entrenched and institutionalized forms of social control serve to discipline individuals (Foucault 1970, Bourgois 1997). In the context of HN /HCV prevention, the concept of bio-power is evident in the synergistic effects of medical guidelines regarding HN infection, legislation concerning drug use and paraphernalia, and the dominant but seemingly 11

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contradictory policies regarding drug use. In this case, it is pharmacists that have been unknowingly disciplined by this seemingly contradictory institutional environment, which has thus influenced their decision to sell sterile syringes to IDUs. IDUs themselves are similarly influenced by these policies, as they are led to believe that they are undeserving of sterile syringes. The combination of these factors creates an artificial scarcity of syringes among IDUs and, ironically, increases the spread of infectious disease, rather than preventing it. In addition to CMA and Foucault, the work of Bourdieu provides another perspective for understanding the role of pharmacists in selling sterile syringes and the dilemmas they face. There are three main concepts developed by Bourdieu that are of interest here. First, the term 'field' is \ used by Bourdieu in order to describe the social arena in which individuals maneuver (Bourdieu 1990). His use of this concept presents us with an effective method to examine a complex social problem, the agents involved, and the relations that exist between them. The field that is being examined here is that of illicit drug use, which includes those involved in the underground drug economy, drug users, and institutions developed to prevent and/ or reduce illicit drug use. Pharmacists also play a role in this field by virtue of the fact that they dispense the syringes necessary to IDUs. Bourdieu defines a field as a system of relations, the most important of which are the power relations between the individual agents occupying 12

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different positions within the field. Bourdieu states that "every field [is] the locus of power relationships." (Bourdieu 1990:141). However, the amount of power that one holds within a particular field depends upon the amount of capital one possesses. Cultural capital is a term coined by Bourdieu to describe the socially inherited "linguistic and cultural competence" that allows an individual to successfully maneuver within any particular culture (Swartz 1977, Bourdieu 1980, Robbins 1991). Finally, Bourdieu uses the term 'habitus' to describe the perceptions and patterns of thought and action individuals possess which have been shaped by objective conditions (Bourdieu 1977). However, Bourdieu also states that even when the objective conditions : that originally shaped these ideas have changed, individual patterns of thought and action persist. This is significant in the case of IDUs living in the time of an HIV pandemic yet continuing to be judged by beliefs created in a pre-HIV world. Illicit Drug Users Within Our Society In the beginning of the AIDS epidemic, activists could not get the funds or the attention needed from the government and the public in order to begin to understand and fight this disease (Shilts 1987). AIDS appeared to be primarily affecting the homosexual community (the epidemic was sometimes referred to as 'gay cancer'), a population that many neither understood or approved of. It was a disease that was affecting 'them' 13

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instead of 'us'. The existence of the growing epidemic was denied until it began to infiltrate communities who had the power to make the general public take notice. The current situation of IDUs is very similar to that of gay men at the beginning of the AIDS epidemic. IDUs are a group who are not well understood or approved of, often being portrayed by one of two seemingly contradictory institutional representations: the legal view which labels them as criminals, and the medical view which treats them as chronically ill. This stems from the fact that the lifestyles of IDUs are vastly different from the majority of society and as a result, they do not possess the proper social skills necessary to fit in and are often perceived as a deviant sub-culture. They possess their own manner of speaking, appearance, and behavior that is not easily transferable to the "normal social contexts" of the dominant society. IDUs are not without cultural capital; while Bourdieu used the term specifically for the upper classes, others such as Bourgois and MacLeod have related this concept to the middle and lower classes (Bourgois 1995, MacLeod 1987) The alternative knowledge or abilities that they possess enable them to successfully maneuver within their own sub culture. However, cultural capital is often particular to a given social formation, and possessing the necessary knowledge to survive or achieve in one culture does not necessarily translate to success in another culture. As a result, marginalized groups like IDUs are left without the specific cultural capital necessary to succeed in the mainstream society. 14

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Our culture has deemed drug use/abuse to be an illegal and self destructive behavior, thus making the term 'addict' seemingly interchangeable with the term 'criminal'. This makes it easy for American society to write these people off as undeserving of concerted public health efforts. In order to be a productive and therefore worthy member of our society, an addict is expected to clean up their drug use and remain sober. Consequently, IDUs who do not or cannot obtain traditional societal goals and thereby integrate themselves into the 'sober' world are forced to retreat into their own world: the IDU sub-culture. Within this sub-culture they may find the camaraderie and acceptance that they were unable to attain within mainstream society: Their drug use, which separated them from others, may now serve to mainstream them into a drug sub-culture, a refuge from the pressures and judgements of the 'sober' society; but a refuge from which escape becomes increasingly unlikely. This cultural reproduction of the IDU's sub-culture is ultimately a self-destructive response to their own marginalization. As Bourgois states, "self-destructive addiction is merely the medium for desperate people to internalize their frustration, resistance, and powerlessness" (1995:319). Compounding this judgement from the general public, politicians as well as health professionals have imbued society with the impression that a massive drug epidemic is affecting the entire nation. As a result of this, the United States has declared a 'war on drugs' (Bennet et al. 1993) in order to 15

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cleanse the nation of its perceived problem. Concepts such as a 'drug epidemic' and a 'war' in order to combat this blight on society create a scenario in which those who use drugs are foes to be fought and conquered. Such scenarios can result in the reproduction of ideologies within the dominant society that regularly condemn IDUs to a stigmatized position. It is through this cultural reproduction that many of the perceptions and thus actions directed towards IDUs are born. It should not be surprising that social and health services aimed at IDUs operate from these paternalistic and contradictory notions. The institutions and social views concerning drug use have been devised by 'hegemonic' members of our society; members of a group that has never known poverty, homelessness, or addiction. In regards to public health efforts aimed at this sub-culture, Bourgois states that "traditional public health research methods reflect the class and cultural biases of academia, medicine, and social services." (1997:16). Research surrounding deviant behaviors such as drug use has typically been conducted through quantitative surveys administered in research settings outside of the 'real' world of an IDU. Since the activities of those involved in the drug economy are often illegal and widely criticized, IDU study participants may feel the need to give socially desirable responses that do not assist in reaching an accurate understanding of their situation. Additionally, surveys often cannot capture the violence, pain, sexism, and racism that influence the lives 16

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of users and instead present false realities. Consequently, we are often presented with inaccurate models of IDUs' behavior that were developed primarily through research exclusively informed by investigators representing the dominant cultural model. In this situation, it is the dominant ideologies that have formulated our view of IDUs, even extending to the quality of health care that they are perceived to deserve. In the case of pharmacists, this translates into an unconscious negative image of an illicit drug user that has been created by society and serves to shape the thoughts and actions of pharmacists regarding syringe sales. Conduct by members of the drug sub-culture is often condemned by the dominant culture. Thus, an IDU's ability to take advantage of opportunities that are theoretically available to all is increasingly limited. Bourgois illustrates Bourdieu's concept of cultural capital in his ethnography of New York crack dealers by depicting the stories of Puerto Ricans attempting to maneuver in the American working class and through the court system. Most of their efforts result in failure due to their inability to act and present themselves in the manner considered acceptable to the dominant society. In this way, they are unable to maintain employment in the white collar working world and are seen by the court systems as uneducated and troublesome (Bourgois 1995). MacLeod has also employed cultural capital in reference to working-class children within our education system (MacLeod 1987). MacLeod states that children of upper class 17

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families inherit different types of cultural capital than working-class children. However, the education system has adopted the class values and interests of the upper classes so those students with cultural capital from the dominant class are consistently rewarded. This results in a system that devalues the cultural capital of the lower classes (MacLeod 1987). As Giroux states, "students whose families have a tenuous connection to forms of cultural capital highly valued by the dominant society are at a decided disadvantage."(Giroux 1983:88). The situation of IDUs is similar in that by not conforming to the norm, out of resistance and/ or due to a lack of ability resulting from limited opportunities, they are viewed as outcasts with little or no hope for behavioral change, meaningful participation or advancement in society. Almost all attention directed towards this group are actions meant to condemn or prosecute them, as opposed to other intra-culture behaviors such as friendship, philanthropy or participation. This 'negative reinforcement' may breed contempt among IDUs for the dominant society, possibly causing them to further retreat within their own culture. Using Foucault's theory of power, we see that the social structural constraints placed on such non-conformist individuals can often result in individual failure. In the case of IDUs, the constraints in question are the legal restrictions that limit the movements of individuals involved in an illicit behavior such as injection drug use and the severe consequences associated with them. These restrictions include paraphernalia laws that 18

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both impede their access to syringes and make it illegal for them to carry syringes on their person. As a result, IDUs are forced to choose between compliance and non-compliance Complying with these paraphernalia laws may mean risking infection of blood borne diseases such as HIV or hepatitis. Non-compliance with the laws creates a situation in which they run the risk of legal prosecution for possession of drug paraphernalia. The dichotomy presented by this law, between a legal model and a health modet extends to the general public as an inability to come to terms with the contradictory messages concerning drug. use they are faced with. This conflict is manifest in pharmacists who are faced daily with the decision to either prevent disease transmission among IDUs by selling syringes or to refuse to support drug use and deny IDUs sterile syringes. Injection drug use is responsible for almost one third of all reported AIDS cases and almost half of HCV cases. The sharing of injection paraphernalia by IDUs is one of the most efficient methods of transmitting HIV and HCV, yet those in this group have the least amount of political power of all the groups at moderate to high risk for infection. As a result of being the least socially organized as well as the group that is most easily manipulated by the larger society, their plight goes largely unacknowledged. 19

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The Bio-Medical Message When the modes of transmission for HIV became clear to health professionals in the 1980s, a public health message was conveyed to IDUs in an effort to make them aware of the life threatening risks that they were engaging in as a result of sharing syringes. Messages such as 'Do not share syringes' or 'Use a new syringe for every injection' inundated homeless shelters, the sides of buses, substance abuse clinics, and health clinics. These 'top down' unrealistic health messages summon up Foucault's theory of power and knowledge. The bio-medical community was relating what appeared to be legitimate disease prevention statements, but in actuality they were moralizing, albeit unknowingly, permissible IDUs behaviors and thus reinforcing for street addicts that they were relegated to the category of self-destructive behaviors (Bourgois 1997). The disease of addiction is not well understood by many health professionals. It is a disease that is characterized by a course of action that is motivated by emotions or real physical needs such as craving and compulsion, a continued involvement in activities that have adverse social, psychological or biological consequences, and a sense that a person can no longer control their own behavior (Shaffer 1999). There are those who would address addiction as a purely biological issue, advocating purging the body of the harmful drug under the assumption that this would result in a healthy individual. However, when addictive drugs seize cells in the body, they construct intense emotional 20

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memories of drug experiences. As a result, these memories link the emotions with the drug as well as the places, people, and paraphernalia associated with them(Powledge 1999). Addicts frequently find that they are able to rid their body of the physical addiction but are unable to stop using due to the constant reminders of the drug use experience. As a result, many IDUs see themselves trapped in a lifestyle that is increasingly difficult to escape. In order to maintain their habit, many IDUs end up in a life of homelessness and/ or joblessness. While many may have the desire to comply with public health !Ilessages calling for a new syringe for every injection and to use only one's own injection paraphernalia, the issues of limited funds, legal restrictions, and homelessness can make it difficult for IDUs to participate in an injection episode free of risk. It is easy to define another individual's responsibility, however the path towards decreasing risk for IDUs is often lined with socially constructed boundaries and constraints that have been created by individuals belonging to a different social class. 21

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CHAPTER III REVIEW OF THE LITERATURE In response to the alarming infection rates of HIV and HCV among IDUs, harm reduction strategies have been aimed at altering the injection behavior of IDUs in order to decrease the risks associated with injection. The first and most obvious method of transmitting infection identified among IDUs was through the direct sharing of contaminated syringes during an injection episode. Needle sharing was often portrayed by health professionals as a ritualistic behavior among members of the drug sub culture that demonstrated the trust that IDUs had with one another (Howard & Borges 1972, DesJarlais et al. 1986, Kail et al. 1995). This was in part due to research indicating that IDUs could correctly identify their risks concerning the transmission of HIV and were aware how to reduce their risk (Calsyn et al. 1992). It is believed that individuals given the necessary knowledge will alter their behavior in order to decrease their risk, yet many IDUs continue to share paraphernalia. As a result, instead of identifying possible structural constraints to risk reducing behavior, researchers labeled the behavior as ritualistic. Other researchers contend that the continued behavior of sharing syringes among those who are aware of and understand the dangers 22

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associated with injection cannot be explained simply as a matter of strengthening social cohesion within their group or as a ritual. It is essential to look at the broader contexts in which this behavior occurs. This includes not only the cultural context of the IDUs social networks but also examining the local political environment and structural impediments that hinder syringe access to fully realize the context in which sharing occurs. It is the summation of such barriers that contributes to the limited ability of IDUs to sufficiently alter their behavior in to comply with public health recommendations (Koester 1994, Gostin 1998, Lurie & Jones 1998). "Instead of looking for an explanation of sharing in terms of the psycho-pathology of individual drug injectors, there is a need to develop a theoretical schema which can explain how the various factors identified as influencing the decision to share may be combined in different ways and in different situations to produce occasional or frequent sharing." (McKeganey & Barnard 1992:46) In fact, many researchers have demonstrated that when access to sterile syringes for IDUs is increased or unlimited, there is a reduction in the multi-person use of syringes (Diaz et al. 1998, Groseclose et al. 1995, Singer et al. 1995, Vlahov et al. 1997, Watters et al. 1994, Bluthenthal et al. 1998). Others have shown that IDUs with unlimited access to sterile syringes (such as diabetic IDUs) have significantly lower HN seroprevalence rates than those without such access (Gostin et al. 1997, Nelson et al. 1991). 23

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IDU Behaviors The sharing of injection paraphernalia represents another means for transmitting blood borne disease. In order to more closely examine the frequency with which IDUs engage in risky behavior while preparing drugs for injection, McCoy and colleagues collected survey information from 19 sites in the United States that had identified a total of 12,323 active IDUs (McCoy et al. 1998). The survey was comprised of questions concerning their drug use and their injection behavior in the 30 days prior to the survey. They found that a higher percentage of IDUs were engaging in unsafe injection behavior concerning the reuse of cookers, cottons, and water than the reuse of syringes. Almost 50% of all of the IDUsreported unsafe behavior regarding their reuse of cookers, cottons, and water compared to just over 40% who reported risky behavior due to the reuse of syringes. Less than 13% of the entire sample reported use of a brand new, sterile syringe. These statistics demonstrate the enormity of the risk behavior occurring within the IDU community. However, when examining risk taking behaviors among IDUs, it is necessary to not only examine the actual risk but the use of various drugs and their effect on behavior. It is essential to realize that individuals who inject different drugs often exhibit varying levels of risk. Desmond and Zule conducted a comparison of HIV risk behaviors among heroin and methamphetamine injectors in Texas (1999). Texas law allows pharmacists 24

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to sell syringes to customers using their professional judgement; the majority of the pharmacists choose not to sell to suspected IDUs. Of the 154 heroin users and 45 methamphetamine users surveyed, 48% and 62% respectively claimed to obtain their syringes from a pharmacy (30% of heroin users said that they had gotten them off the street). When asked about how often they dispose of their syringes, only 6% of heroin users reported that they usually dispose of their needles after only one injection compared to 40% of methamphetamine users. Additionally, 63% of the heroin users reported that they usually used a needle more than five times before they would dispose of it. Most of the methamphetamine users reported that they would use a non-sterile syringe if they were forced to choose between forgoing injecting and using a dirty syringe. Furthermore, heroin users stated that the desire to relieve the symptoms associated with withdrawal overrides their fear of AIDS, causing them to share syringes without disinfecting them first (Zule & Desmond 1999). In the end, they found that most heroin users find themselves in a situation where they are sharing syringes more often than methamphetamine users. This is due to more frequent injections, withdrawal symptoms, and the fear of carrying syringes and/ or bleach due to police surveillance. 25

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Bleach Use Those well acquainted with the sub-culture of drug use soon realized the structural impediments that IDUs faced when attempting to comply with health messages that instructed them not to share syringes. An alternative response to the alarming infection rate was designed in order to decrease the financial demand and thus make harm reduction techniques more suitable for IDUs. This alternative approach advocates the use of regular household bleach to sterilize a used syringe. However, studies conducted on methods of bleaching syringes have revealed that the disinfection of syringes through household bleach does not always attain the level of sterilization necessary to avoid infection (Gershon 1998). Furthermore, this study found that the use of bleac;:h for sterilization" ... has unfortunately not been shown to have much impact on reducing HN incidence in IDUs" (Gershon 1998:23). Variables that limit the effectiveness of bleach used for sterilization include; inadequate syringe cleaning (Vlahov et al. 1994, Carlson et al. 1998), inadequate amount of time of contact between bleach and syringe (Gleghorn et al. 1994), and recontamination of syringes when cookers, cotton filters, and/ or water are not cleaned or replaced (Koester 1990). Normand (1995) recommended the use of bleach for syringe sterilization only as a secondary option when IDUs do not have access to sterile syringes. In addition to bleach constituting a less than foolproof technique, bleaching syringes is not always a practical option. 26

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Purchasing and carrying bottles of bleach to clean syringes is often a harm reduction technique that is incompatible with the lifestyle of a homeless individual. Paraphernalia Laws The extensive work done by Costin details the structural impediments to syringe access for IDUs created by the current legal environment. He found that legal to syringe access in the Unit-ed States exist in every state: 47 states have drug paraphernalia statues, 8 states have syringe prescription statutes, and 23 states have pharmacy regulations or practice guidelines (Costin et al. 1998). Costin argues that these laws prevent health professionals such as pharmacists from participating in the prevention of blood-borne.diseases among IDUs (Costin 1998). Paraphernalia statutes restrict pharmacists from selling syringes to individuals who they suspect will use them to inject illicit substances (often describing these people as patients without a 'legitimate medical necessity'). Additionally, paraphernalia statutes prohibit individuals without a 'legitimate medical necessity' from possessing syringes. With respect to the paraphernalia statutes, Costin states that police often are more likely to search for illicit drugs once paraphernalia is found on a person. As a result of these restrictions, IDUs often choose not to carry clean syringes in order to avoid involvement with the police and possible prosecution. Prescription 27

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requirements restrict pharmacists from selling syringes to any individual who does not have a doctor ordered prescription. These restrictions limit the availability of syringes through pharmacies. Research done in Denver shows that 83% of 129 IDUs interviewed reported sharing syringes during the 6 months prior to the interview (Koester 1994). In order to understand the reasons behind this high rate of syringe sharing in Denver, one must first examine the context in which it occurs. Colorado does not have a prescription law, but it does have a paraphernalia statute. This statute states: "Any person who sells or delivers, possesses with intent to sell or deliver, or manufactures with the intent to sell or deliver equipment, products, or materials knowing, or under circumstances where one reasonably should know, that such equipment, products or materials could be used as drug paraphernalia commits a class 2 misdemeanor." In 1979 the US Drug Enforcement Agency developed the Model Drug Paraphernalia Act, the act which informed the above Colorado paraphernalia statute. This act provided a definition of drug paraphernalia that enabled states to control the sale of such items. It was written before the proliferation of public health threats of HIV and HCV and was originally aimed at stemming the spread of "head shops" and the overt sale of tools used for the ingestion of illegal substances (such as bongs and water pipes). Injection devices are mentioned under the definition of paraphernalia in the law, however the purpose of the statute was "To protect and promote the 28

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public peace, health, safety and welfare by prohibiting the possession, sale, manufacture, and delivery or advertisement, of drug paraphernalia ... In the midst of the current dual epidemic of HIV and HCV, it seems as if the primary role of these laws has become to place a death sentence upon IDUs. These laws now serve only to deter IDUs from purchasing syringes in pharmacies and possessing them on the streets in order to avoid intrusive questioning or legal repercussions. In addition, Colorado's paraphernalia statute serves to deter IDUs from carrying their own injection equipment in order to avoid incurring the maximum $100 fine or jail time associated with possession of such paraphernalia. As a result; users often stash their syringes in certain places throughout the city, borrow one from a friend, or go 'dumpster diving' in order to find a used one. Such restrictions serve to impede the efforts of IDUs to practice the safer injection techniques that would decrease their chances of contracting or transmitting blood borne diseases. The paraphernalia statute is somewhat vague in its' definition of who distributors can sell syringes to and who they can not. It states that they should not sell to those individuals who they believe may be using the syringe for illicit reasons such as injection drug use. However, the statute does not provide any guidelines as to how the individual is to determine a customer's intent and no pharmacist has ever been cited for violation of this statute. Additionally, the Colorado Board of Pharmacy has no guidelines or 29

PAGE 39

regulations concerning syringe sales. Therefore, unless a store has a strict policy concerning whom to sell syringes to, pharmacists must rely on their own discretion when making a decision to sell or not to sell. This lack of direction leaves the decision to sell up to the pharmacist and can often lead to the inclusion of idiosyncratic perceptions or morals on the part of the pharmacist when it comes to syringe sales to suspected IDUs. Paraphernalia statutes contribute to a scarcity of syringes available to IDUs through pharmacies. Such struG:tural impediments are in direct conflict with recommendations issued by public health departments and others working to decrease the transmission of blood borne diseases. These sanctions do not act as a deterrent for individuals to inject drugs and instead result in an increase in risk behavior among IDUs while preparing for an injection episode. High risk injection procedures persist as a result of IDUs attempting to elude the immediate risk of legal prosecution, thus ignoring the larger risk of HIV /HCV infection (Koester 1994). Bluthenthal and colleagues examined the ways in which paraphernalia restrictions affect the habits of IDUs. His work revealed that IDUs who had previously been arrested for carrying paraphernalia were more likely to report subsequent sharing of syringes and other injection supplies than those who had never been arrested for carrying paraphernalia. Additionally, he found that IDUs concerned with being arrested while carrying drug paraphernalia were over 30

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twice as likely to share syringes as other IDUs, the same being true for other injection supplies (Bluthenthal et al. 1999). Research by Gleghorn examined the feasibility of IDU adhering to the U.S. Public Health Service.recommendation to use a new and sterile syringe for every injection episode. Surveys were administered to 593 active IDUs (defined as having injected within the last 90 days) from seven U.S. metropolitan areas (Gleghorn 1998). Less than a quarter of their sample (23%) reported obtaining their syringe from a source that could reliably be dispensing sterile syringes (such as a pharmacy or a needle exchange program). Additionally, they found that 40% reported using their syringe fotiror more times before disposing of it. Almost 40% of the sample reported syringe reuse due to either the lackof funds to purchase a new syringe, no source for obtaining a new syringe or the lack of availability of a new syringe when needed. When asked about their perceived barriers to syringe access, 57% said that it was lack of money and 27% said that it was the lack of a syringe source. Nearly 40% of the IDUs surveyed reported a difficulty in finding a reliable source for sterile syringes, limiting their ability to comply with public health recommendations (Gleghorn 1998). These results demonstrate the creation of an artificial scarcity of syringes through paraphernalia statutes and pharmacy board regulations. 31

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States That Have Repealed Paraphernalia And Prescription Laws Many states have recognized the need for changes in order to create a legal atmosphere that is more conducive to harm reduction among IDUs. States such as Massachusetts, Connecticut, and Maine have all amended their legal restrictions that limit the availability of syringes to IDUs. Until 1992, Connecticut had two laws restricting access of sterile syringes for IDUs: a syringe prescription law that required individuals to have a prescription in order to purchase a syringe and a paraphernalia law that made the possession or the distribution of syringes to inject illicit drugs illegal. In 1992, Connecticut's problems with injection drug use had become a critical issue. Half of all AIDS cases reported in Connecticut in 1992 appeared in IDUs and 60% of all AIDS cases :were related to injection drug use (Wright-De Aguero et al. 1998). In response to this growing problem, health professionals were allowed (but not required) to sell up to 10 sterile syringes without a medical prescription as of July 1992. An additional partial repeal of laws concerned with possession of drug paraphernalia accompanied it (individuals without medical purposes were allowed to possess up to 10 syringes without drug residue). This new legislation was aimed at increasing the ease with which IDUs could obtain and possess syringes, therefore decreasing the HIV infection rate. 32

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A study was conducted in Connecticut in order to measure the impact of increasing syringe accessibility through local pharmacies. Their results showed that while pharmacists were not legally bound to sell non prescription syringes, 15 months after the laws were passed 83% of pharmacists had in fact done so. In Hartford, the number of nonprescription syringes sold increased significantly during the 12-month surveillance period (Valleroy 1995). A second study was done during the same time period in order to examine.the impact of the increase in syringe accessibility on IDUs' behavior. The results showed that in the first year after the repeal, IDUs reported more pilrchasing of syringes in pharmacies, less purchasing on the street and a 30% decrease in reported syringe sharing (Groseclose 1995). The change in the legal environment in Connecticut directly led to the ability of IDUs to participate in safer injection practices and therefore to a decrease in the transmission of blood borne diseases. Research in both Maine and Massachusetts has shown that without a total repeal of legal restrictions and the cooperation of law enforcement officials, syringe access for IDUs can still be problematic In 1993, Maine amended its prescription law and made it legal for pharmacists to sell syringes to individuals over the age of 18 without a prescription. Their paraphernalia law remained intact, creating a contradictory environment in which syringes could be purchased without a prescription but were illegal for IDUs to possess Additionally, pharmacists were not mandated to sell to 33

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individuals without a prescription and were able to place additional requirements on the sale of syringes. Case and colleagues found that fewer than 15% of the 208 pharmacists interviewed were willing to sell syringes without a prescription and without additional requirements (Case et al. 1998). Some pharmacists were willing to sell without a prescription but reported other requirements as being necessary for purchase. These requirements included knowledge of diabetes, picture identification, the name and address of the customer, confirmation from a doctor, or a diabetic identification card. Fewer than 9% of the pharmacists interviewed reported negative incidents with IDUs in the two years since the law had been repealed. While the Connecticut studies found an increase in the sale of non-prescription syringes, Case estimated that the Maine pharmacies were only selling 7% of the estimated number of syringes needed for IDUs. They attribute this to the fact that Maine did not repeal their paraphernalia law as Connecticut did. Another possible factor was that the rates of HN infection among IDUs are much higher in Connecticutthan in Maine, perhaps causing Maine to not take as active a role in the issue. Also in 1993, Massachusetts amended their paraphernalia laws that restricted access to syringes for the administration of controlled substances. This amendment legalized possession, distribution, or exchange of syringes as a part of a pilot needle exchange program (NEP). Additionally, eight months later the Boston police commissioner stated that police officers 34

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would not charge IDUs with possession of a syringe if they were participating in the NEP but that those not enrolled in the program were subject to arrest. This partial repeal of paraphernalia laws only applied to approximately 5% of the IDUs in Massachusetts who were enrolled in the NEP at the time of the survey. Unfortunately, even those individuals who were enrolled in the NEP and were stopped by the police were at risk for having their syringes confiscated by the police, putting the IDUs at future risk for sharing syringes. In 1994, after the legal amendments, 417 individuals had been convicted of syringe possession in Massachusetts. Of those, 41% were sentenced for incarceration, with an average incarceration time of 5 months. The authors estimate a $1,140,183 incarceration cost assuming that the individuals served two thirds of their incarceration time (Case et al. 1998). The authors suggest that policies such as these that only partially repeal legal limitations to access continue to place IDUs and their sex partners at risk for the transmission of blood borne diseases. These law enforcement activities often lead to an increase in multi-person use of syringes by deterring users from carrying syringes on their person due to fear of arrest/prosecution. Programs such as these 'top down' approaches represent the necessity of multiple facets of access instead of partial solutions that often result in failure. 35

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Needle Exchange Programs In 1984, the first NEP was established in Amsterdam, the Netherlands by an advocacy group for drug injectors called Junkie Union. It was designed to prevent an epidemic of Hepatitis B when a local pharmacist planned to stop selling syringes to IDUs (Buning 1991). It wasn't until two years later in the fall of 1986 that the first drug injection materials were publicly distributed in the United States. Now, NEPs have been established to address drug-injection risks around the world and in more than 80 cities in 38 states in the U.S. There are currently 113 NEPs operating in the U.S. alone. These programs were initially designed as locations where IDUs could obtain sterile syringes and return used injection equipment, solving both the problems of obtaining .dean syringes and of disposing used syringes. The main objective of a NEP is not to tell people to stop injecting, but to promote harm reduction techniques among injection drug users. Harm reduction programs do not condone illicit drug use but instead sanction the education of individuals concerning risk-free injection techniques. Many exchange programs also offer substance abuse treatment referrals for interested IDUs. NEPs may also provide other crucial services for IDUs such as HIV /HCV testing and counseling, free condoms, bleach kits for syringe disinfection, health pamphlets, as well as referrals to other public health programs. One study suggests that NEPs are better equipped 36

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to provide such ancillary services as well as providing a solution to the problem of syringe disposal (Lurie 1998) NEPs have proven to be a crucial component in the effort to increase sterile syringe access for IDUs, demonstrating a pronounced decrease in the rate of reusing syringes among IDUs. Heimer and colleagues conducted an evaluation of NEPs in four different cities; San Francisco, Chicago, Baltimore, and New Haven (Heimer et al. 1998). They measured syringe reuse among IDUs as a method of determining whether NEPs increased syringe availability and thus reduced the need for syringe sharing. Their results indicated that the NEPs irt all four cities appeared to decrease the reuse of syringes. Single (non-repeating) syringe use after inception of the NEPs increased from 10% to 29% in three years, and the NEPs also decreased the number of injections per syringe by a range of 44% to 85% (Heimer et al. 1998). However, the opinions of the IDUs who purchase syringes are essential when attempting to construct a practical solution. Junge and colleagues examined the attitudes of IDUs participating in a NEP regarding the prospect of pharmacy-based syringe access. Participants were questioned as to how important different considerations where when they were deciding where to obtain syringes. They found that 66% stated that 37

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being in a hurry to relieve symptoms of dopesickness4 was 'very important' in their decision on where to obtain syringes. Almost 54% stated that their decision regarding where to obtain a syringe was based on how long it would take to obtain the syringe. They found that in Baltimore, a city where drug paraphernalia statutes exist but a prescription is not necessary for a syringe, 80% of IDUs prefer to obtain their syringes from the needle exchange, 15% from the street, and 5% from pharmacies Ounge et al. 1999). In fact, in a study conducted in Baltimore earlier, Jones found that only 54% of IDUs had ever purchased from a pharmacy and 50% of those surveyed reported purchasing from the street as their main source of syringes (Jones et al. 1993). When asked about a hypothetical situation in whichsyringes could be legally purchased over the counter; Junge and colleagues found that the percent of IDUs who would prefer the needle exchange dropped to 48.5%, a pharmacy preference jumped to 48.5%, and street sources dropped to almost 3%. In order to make pharmacies more appealing, 24% of IDUs asked for a removal of the identification requirement, 22.4% asked for syringe purchases to be made legat and 20.7% requested that a greater variety of syringes be made available to them Ounge et al. 1999). In the end, the researchers found an expressed interest especially by female injectors, to switch from a van-based needle exchange program to a 4 Dopesickness is the term used to refer to the withdrawal symptoms that individuals go through once the effect of the drug has begun to wear off. 38

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pharmacy as their main source of syringes. In order for this to occur, all current legal restrictions to access and the identification requirement had to be lifted. In accordance with the findings indicating the importance of expediency in syringe access (desire to relieve withdrawal symptoms and time required to obtain syringes), conveniently located syringe sources such as pharmacies would be more heavily utilized than a mobile needle exchange. The author's main conclusion was that the most effective method of decreasing the rate of blood borne infections among active IDUs is to offer a variety of options for syringe access. An additional aspect to think about when considering a NEP is whether or not the local community will be willing support such a program. One year after the opening of the needle exchange program in Baltimore and three months before a planned expansion, a household survey was conducted in order to gauge community support. The surveyed community was not currently served by the NEP and was not one of the areas planned for expansion. However, there was drug traffic in the area and the community had organized meetings in which residents expressed strong views both for and against a needle exchange in the area. Findings reveal that 65% of those who participated in the survey were in favor of the NEP (Keyl et al. 1998). Of those who were not in favor, 60% felt that it would increase the number of discarded needles on the street. Additionally, 69% of the opponents felt that the NEP would encourage injection drug use, 39

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although studies have shown that the number of discarded syringes in Baltimore since the opening of the NEP has not increased (Doherty 1995). Of those surveyed, 47% felt that pharmacists should be allowed to sell syringes to IDUs without a prescription and 48% disagreed with the statement (there is no prescription law in Maryland, the question was posed in order to ascertain whether there should be a relaxation or deregulation of paraphernalia laws). While there are many benefits to a NEP, they may not be the complete solution to the dilei1Ulla in which we now find ourselves. Although there are currently 113 known NEP in the U.S., by no means are all operating legally. Due to the legal regulations on syringes that still exist in some states, efforts to develop and expand NEP throughout the country have been severely hindered; In some states they are necessarily operated underground as a result of the existence of paraphernalia or prescription laws. In Colorado, two recent attempts to change the State's paraphernalia statutes were overwhelmingly defeated. When the decision was put before the Denver city council, it was agreed to amend city ordinances, thus allowing for a NEP. Unfortunately, since the state paraphernalia statute takes precedence over any city ordinance, an exchange was never implemented. In the current political environment, it is unlikely that future legislative attempts will result in a legally sanctioned exchange in Denver. 40

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Additionally, there are limitations to NEPs that illustrate the need for securing many points of access for syringes for IDUs. Some NEPs are mobile syringe distributors, moving around the city in a motor vehicle from place to place. They often have a fixed schedule so that they can be at particular locations during assigned parts of the day. This results in an insufficient number of hours of operation in too few locations. While this is a benefit for those with the foresight to plan their injections, it can result in limited access for those who are not mobile enough to get to one of the exchange locations or find themselves needing a syringe during hours when the NEP is not operating. Also, NEP may not represent a cost-effective inethod of harm reduction. Lurie and colleagues estimated that IDUs would require 1 billion syringes per year in orderto have a sterile syringe for every injection. They then estimated the cost per syringe for different distribution strategies. The cost per syringe at a NEP was $.97 compared to $.15 for a syringe sale through a pharmacy (Lurie et al. 1998). As a result of these limitations as well as a current federal ban on funding, needle exchange programs have become another aspect of the health care system that is struggling to survive and therefore cannot be viewed as the only answer to our current public health dilemma. 41

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Syringe Disposal Disposal is a necessary component to address when attempting to increase syringe access for IDUs. In areas that do not have the option of disposal through a NEP, it is important to plan a disposal program to complement any initiative to urge greater syringe accessibility through legislation and pharmacy sales. Many opponents to greater syringe accessibility fear the risk of a child picking up a used syringe from the ground or a sanitation worker possibly incurring a needlestick injury while disposing of trash. The implementation of disposal programs may help to create more positive attitudes towards syringe access through pharmacies. Macalino and colleagues identified disposal programs that were in operation throughout the world with an emphasis on those in the U S (Macalino 1997). They organized a workshop in order to review public concerns and data regarding the risk of syringe disposal as well as to assess community based programs. They identified 15 disposal programs in the United States, Canada, and Australia. Three of those were primarily aimed at disposal for IDUs while the other 12 were aimed at individuals with diabetes. There were three basic strategies used among the 15 programs; placing syringes in puncture proof containers available in the horne and then throwing the container in the trash, drop boxes with the contents being sent for biohazard disposal, and saving used syringes in puncture proof 42

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containers and then dropping them off at sites such as pharmacies, hospitals, and health departments. The authors pointed out that the first strategy involves the limitation of the use of household trash; potentially putting sanitation workers at risk once the trash has been compacted and the syringes poke through their containers. Furthermore, the third strategy may not be successful among IDUs with little funds available to purchase puncture proof containers. However, the second disposal strategy has been successfully utilized by cities in Maryland and Florida. In 1996, the Baltimore City Health Department initiated a pilot needle disposal program using drop boxes in order to decrease the number of discarded syringes in areas without needle exchanges. Surplus U.S. mailboxes were installed in an area of Baltimore, considered to have a large number of IDUs but not served by the NEP in the area. The boxes were emptied weekly by the city health department and then bi-weekly after 5 months of operation. To gauge community acceptance of the program, focus groups were conducted before the installation of the boxes and five months after installation (Riley, 1998). Focus groups were conducted with community residents, IDUs, and police officers. Despite initial concern about the installation of the boxes and the messages that they would send to the community, the post-intervention focus groups showed more support for the disposal program and all reported seeing fewer used syringes on the street since the inception of the 43

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program. During the ten-month program, approximately 3,000 syringes were collected in the boxes. Almost 11% of the syringes collected tested positive for HIV, suggesting that the boxes were collecting infected syringes that could be a possible source of infection to the public had they been discarded in the trash or on the street. In DeSoto County, Florida, the DeSoto Public Health Unit placed red biohazard containers within all city and county fire departments and police/ sheriff stations in order to provide a safe disposal system for used syringes (Toews, 1995). The annual cost for the containers was less than $200. The program has been so successful that it has been replicated throughout the region. However, in order for" this program to be more .suitable for IDUs, it would: be necessary to place the biohazard containers in areas such as pharmacies instead of those involving law enforcement personnel. The importance of these programs is that they represent feasible options for communities who do not have a local needle exchange but are interested in increasing access to sterile syringes. Macalino and colleagues stress the importance of including physicians, pharmacists, harm reduction practitioners, educators who work with people who inject medications at home, syringe producers, trash workers, medical waste and refuse companies, organizations representing people with diabetes, persons who 44

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inject illicit drugs, and public health department personnel in the creation of any disposal program (Macalino 1997). Pharmacists' Role in Syringe Accessibility Until recently, the role of the pharmacist has been underutilized in the fight against blood borne infections (Lurie et al. 1998). Pharmacists can represent the most available health provider for IDUs in the absence of a NEP. Due to lack of funds and insurance, IDUs often go without medical care unless it is a medical emergency. The contact that IDUs have with pharmacists while purchasing their syringes may present a valuable opportunity for IDUs to obtain information concerning harm reduction, safer sex practices, HIV /HCV transmission and other health issues of concern. Since pharmacies are often conveniently located in a multitude of easily accessible locations around the city and operate for longer hours than a NEP, they have the opportunity to represent the primary syringe source for IDUs, even in areas with a NEP. Research conducted in New Haven has shown that pharmacies in the area sell approximately twice as many syringes as are exchanged by their needle exchange program (Heimer et al. 1997). These findings demonstrate that pharmacy sales increase availability of syringes during parts of the city and times of day when the NEP is not operating. 45

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Limitations To Access Through Pharmacies However, while pharmacies have the potential to be a dependable syringe source, research has indicated that there are many factors that currently hinder syringe availability for IDUs in Denver. The complementary portion of this study involved taking eight active IDUs to Denver pharmacies in order to purchase syringes (Bush et al. 1999). Findings revealed that not one of the eight participating IDUs were able to purchase syringes at all twenty-seven pharmacies, and some participants were able to buy at more pharmacies than others were. Reasons for this appear to be related to issues of gender, appearance and familiarity with the pharmacy. Prices for a ten pack of syringes were inflated up to 500% between stores (this was mainly the result of one store that charged up to $15 for a ten pack of syringes), price fluctuation also occurred within the same pharmacy among differentparticipants: Other possible constraints affecting IDUs in general included: inconvenient hours of operation, location, and fixed quantity sales (Bush et al. 1999). This demonstrates that syringe sales through pharmacies are not currently dependable, creating an unreliable outcome for IDUs trying to purchase syringes. Additionally, limitations to access are due to the fact that it is not mandatory for pharmacists to sell syringes to suspected IDUs, even in states in which legal restrictions to sales have been repealed. Research has shown that the official stance of a state may not be indicative of the actions of 46

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individual pharmacists involved in selling syringes, with some pharmacies having installed store policies designed to restrict syringe sales. Instead, it is pharmacists' previous experiences with IDUs that has been identified as an influential factor regarding their sales attitudes (Gleghorn 1998). Gleghorn and colleagues found that negative experiences with IDUs customers have caused some pharmacists in Baltimore to require a prescription in order to purchase a syringe (Gleghorn et al. 1998). Gleghorn states that: "such attitudes may pose barriers to IDUs trying to obtain sterile syringe injection equipment, because a pharmacist can use professional discretion to determine whether a sale takes place." (1998:90). Other researchers have also found that there is wide variation in sales indicating that pharmacists have concerns regarding the sale of syringes (Compton 1992, Valleroy et al. 1995, Heimer et al. 1997, Gleghorn 1998, Lurie & Jones 1998). The work of various researchers has addressed current syringe access for IDUs through Connecticut pharmacies. Through a mail in survey, Heimer and colleagues found that 4 out of 15 pharmacies had policies restricting the sale of sterile syringes to IDUs. Each pharmacy cited negative incidents with IDUs as the reason for these policies (Heimer et al. 1997). Valleroy found that the number of pharmacies selling non-prescription syringes in the five largest cities in Connecticut had decreased from 83% in July of 1992 to 73% in November of 1993 (Valleroy 1995). Additionally, she 47

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found that 3 of the 8 Hartford pharmacies stopped selling non-prescription syringes one year after the legal changes due to used syringes on the premises and disruptive IDUs in the store (Valleroy et al. 1995). Through telephone interviews, they found that 19% of pharmacists answered "yes" when asked if there had been any negative incidents with people buying non-prescription syringes. Incidents ranged from inappropriate behavior of the people buying the non-prescription syringes to violent behavior on the part of the suspected IDUs and finding drugs on store premises. Correspondingly, Singer found that negative incidents were the primary reason for Hartford pharmacies as well as some of the surrounding suburban pharmacies to discontinue selling non-prescription syringes. Their concerns included the influx of 'disreputable types', an increase in shoplifting, and used syringes on the pharmacy premises (Singer et al. 1998). Wright-De Aguero and colleagues' work on Connecticut pharmacists revealed similar findings. They presented six main issues that decreased the likelihood of a pharmacist selling non-prescription syringes; safety, context of sale, customer-related items, perceived beneficial and detrimental effect of the sale of syringes without a prescription on health and community well being, and perception of peer norms and sales practices (Wright-De Aguero et al. 1998). The only issue that was found to be independently associated with pharmacy managers' support for non-prescription sales was their 48

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perceived benefit of the sale of syringes on health and community well being. While many researchers have revealed that pharmacists have strong views on this topic, others have found that it does not appear to be widely discussed among pharmacists. Both Singer and Wright-De Aguero found that a lack of communication exists among Connecticut pharmacists concerning this topic. Singer found that there were instances in which the attending pharmacist was unaware of the store policy concerning the sale of syringes (Singer et al. 1998). Wright-De Aguero found that40% of pharmacists did not know what other pharmacists thought about this topic and almost 43% did not know what action other pharmacists took when faced with syringe sales (Wright-De Aguero etal. 1998). In Louisiana, a state with legislation much like Colorado; there are no prescription statutes but there are paraphernalia statutes that prohibit individuals from possessing or distributing syringes without a medical reason A mail-in survey was conducted in the six most populous cities in Louisiana to gauge the attitudes and practices of pharmacy managers regarding syringe sales to suspected IDUs (Farley et al. 1999). Sixty-one percent of their sample reported having sold syringes without a prescription to individuals who they knew not to be diabetics. Of those who did not report selling syringes,_ almost half believed that such sales would increase drug use. However, the majority of the pharmacies (66%) reported never 49

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selling nonprescription syringes to suspected IDUs. Sixty-four percent of the sample was not supportive of selling syringes without a prescription and only 26% were supportive. Many of the pharmacists reported that they would be supportive of selling syringes without a prescription if the customer had been referred from an outside agency or clinic. Almost one third of all the respondents supported the idea of opening a NEP. Additionally, they found that the individual decisions of the pharmacists often determined whether or not a.sa1e took place, rather than store policies. Work regarding syringe access has also been conducted internationally. In 1995, the needle exchange program in London surveyed the members of the London and DistriCt Pharmacists' Association in order to evaluate sterile syringe access for IDUs (Berry 1997). For the most part, pharmacists ranked harm reduction and health promotion methods as more likely to prevent the transmission of blood borne diseases than other approaches such as law enforcement and drug treatments that emphasize abstinence. A large portion of those surveyed (77%) stated that they deal with syringe requests from IDUs on a regular basis. Pharmacists also indicated that 95% of pharmacies have a policy (either written or unwritten) that allows for the sale of syringes to non-diabetic individuals. Of the sample, 94% reported that they would sell syringes to suspected IDUs in all or some of the cases and 95% reported that they either 'agree' or 'strongly agree' with making syringes available to IDUs. While pharmacists also 50

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reported concerns regarding safety and the risk of theft, their willingness to provide syringes to IDUs was a result of the public health threat of HIV I AIDS (Berry 1997). Despite pharmacists' understanding of their role in the prevention of blood borne disease among IDUs, many have also expressed business concerns that they feel are associated with their participation. A postal survey of one in four in a random sample of community pharmacies in England and Wales revealed that community pharmacists were clear on their role in HIV prevention. However pharmacists were concerned about the effect that IDUs would have on their business, as well as their own need for training and the amount of support that would be available to them (Sheridan et al. 1997). The authors foimd a significant difference between the attitudes of syringe providers and those who did not provide syringes. They also found a relationship between pharmacists who had received training on this topic and their attitudes. More of those pharmacists who were providing syringes or offering some type of needle exchange system had taken part in training on drug misuse and HIV prevention than those who did not distribute syringes. From the results of the survey, the authors found that those who where providing syringes had a more positive attitude towards sales and were less likely to believe that IDUs in their store would have an adverse effect on their business. For those who have contact with IDUs and are in a position to provide important health services to them, it 51

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may be a good idea to provide them with service-specific training that would address drug use and the prevention of the transmission of blood borne diseases (Sheridan et al. 1997). It is imperative to understand how pharmacists view their involvement in the issue of syringe availability and fully realize their concerns regarding sales if we wish to engage them in this public health objective. The study presented here examines the attitudes and concerns regarding syringe sales to suspected IDUs among pharmacists in Denver. 52

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CHAPTER IV METHODOLOGY The Complementary Study This research was composed of two separate components; a study designed to gauge pharmacists attitudes and beliefs regarding syringe sales through pharmacies to IDUs and one designed to identify actual impediments to access from the IDUs perspective. The intent of the latter study was to obtain the most realistic picture possible of syringe accessibility for IDU in Denver. To accomplish this eight active IDU (defined as having injected drugs within the last 30 days) were recruited to attempt syringe purchases at 27 different pharmacies. Human subject's review and approval was through the University of Colorado at Denver Human Research Committee (HRC Protocol# 330). Sampling Procedures The initial component of the study consisted of a mail-in survey distributed to the 814 recipients of the Colorado Pharmacy Association's newsletter, an organization with statewide membership. The pharmacists were asked to fill out the anonymous survey and return it using the 53

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included postage paid envelope. The questionnaire probed members about their views on sterile syringe sales to IDUs, regulations concerning syringes sales, and if the HIV epidemic has effected their attitudes concerning syringe sales (Appendix A). This was done in an effort to gauge views of syringe access for IDUs throughout the state However, due to a low response rate (7%), the results of the mail in survey were considered negligible and not considered in the data analysis.5 In order to gauge local views, pharmacies within the Denver metro area where selected to participate in this study. The study boundaries included Sheridan Blvd. on the west, Monaco Pkwy. on the east, 1-70 on the north, and Evans Ave. on the south. Pharmacies were identified with the use of the telephone directory and were comprised of both independent and corporately owned pharmacies. There were a total of 52 eligible pharmacies (Table 1) and 24 pharmacies agreed to participate. The study was conducted in two stages by bisecting the metro area into East and West Sides (using 1-25 as a bisector). This was done for efficacy and so that information from the first stage could be briefly analyzed and evaluated before moving on to the second stage. This early analysis enables the researchers to identify gaps in the information and then work on filling in these gaps (Miles and Huberman 1994). 5 Of the surveys that were returned, there was one interesting aspect; respondents all expressed strong feelings either pro or opposed to pharmacy syringe sales. 54

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Data Collection Pharmacies on the East Side were taken as the initial cohort of the study. A letter of introduction describing the research aims of Urban Links (the research organization through which the study was conducted) and identifying their funding sources was sent to all twenty-seven selected pharmacies (three of the identified pharmacies had either moved or gone out of business). The principle investigator of the study, Dr Stephen Koester, as well as a professor at the University of Colorado Health Sciences Center (UCHSC) School of Pharmacy signed the letter (Appendix B). A week after the letters were sent out, the pharmacists were individ:ually called by the ethnographers and asked to participate in the study. This research was funded through a cooperative agreement by the Centers for Disease Control and Prevention (CDC) and the Association of Teachers for Preventative Medicine (ATPM). A sister study of pharmacists in Atlanta, GA was conducted simultaneously by the CDC. Semi-structured interviews were conducted with those pharmacists who agreed to participate. Prior to the interview, the pharmacists were fully informed about the study goals and were asked to sign a consent form (Appendix C). Interviews were conducted in a location that was convenient to the pharmacist (e.g. coffee shop, their pharmacy, etc.) and were recorded. 55

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Interviews often took approximately one hour to complete, each pharmacist was compensated $50 for their time. After the 21 participating pharmacists on the East Side had been interviewed, an initial analysis of the interviews was conducted. This was done in an attempt to identify any recurring issues that had not initially been a part of the question guide. This was accomplished by examining the transcripts and identifying issues that pharmacists had repeatedly brought up of their own accord. These domains were then added to the question guide before the West Side pharmacists were contacted. As a result, some domains were not as thoroughly examined with the East Side pharmacists as they were with the West Side pharmacists; In order to make-up for this, previously interviewed East Side pharmacists were re-contacted later for a brief interview regarding the newly added domains. At the completion of all of the East Side interviews and initial analysis, we began contacting all pharmacists at the twenty-two pharmacies on the West Side. Originally, when the West Side pharmacies were contacted by phone following the letter of introduction, many refused to participate. In an attempt to gain greater access, ethnographers visited the pharmacies in order to speak with the pharmacists in person. The number of pharmacists willing to participate increased using this more personal approach. Eleven pharmacists from the West Side were interviewed (Table 1). 56

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Question Guide This study used qualitative research methods in order to assess the attitudes and beliefs of pharmacists in the Denver area concerning syringe accessibility for IDUs. Qualitative interviews, as opposed to quantitative interviews, were chosen in order to allow for rich description through personal perspectives in the study participant's own words. A marked difference of quantitative and qualitative interviews exists between standardized and reflexive interviewing (Hammersley and Atkinson 1995). While ethnographers often have a prescribed list of issues to cover with the interviewee, they do not know the exact questions that they will ask and do not ask them in any particular order. Additionally, the concepts to discuss during such interviews are not predefined, limited or taken for granted (Ely et al. 1991). As a result, this technique may increase the possibility of understanding issues that are latent or non-obvious to the researcher. Qualitative interviews often resemble conversations and allow the informant to direct the interview in a manner that seems natural. However, similar to survey interviews, the presence of the ethnographer may effect the validity of the information obtained in the interview. Rather than focus on how honest the informant is being, every piece of information must be interpreted within the context in which it was collected. In this way, answers may reveal a subject's attitudes and perceptions as well as their 57

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feelings towards their environment or life history events (Hammersley and Atkinson 1995). The qualitative question guide was developed in order to facilitate the interview and ensure the collection of comparable data (Appendix D). The guide was adapted from a survey used by researchers at the Centers for Disease Control and Prevention who were conducting a parallel investigation of pharmacists in Atlanta. The question guide was piloted with two pharmacy technicians attending the UCHSC School of Pharmacy and was then revised per their recommendations and those of the ethnographers. The guide contained five domains; 1. Pharmacists' beliefs and attitudes concerning syringe sales 2. Practicalities and pharmacists' actions and experiences regarding lDUs. 3. Impact of Hepatitis C and HIV I AIDS on their pharmacy and on them as pharmacists 4. Needle exchange program development issues regarding increasing syringe access 5. Miscellaneous (included legal issues, syringe disposal, discussion of this topic with other pharmacists, identification of an IDUs, etc.) The first domain consisted of questions regarding syringe prices and quantities sold as well as questions that probed the pharmacists' thoughts concerning the sale of sterile syringes to IDUs. These latter questions 58

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ascertained whether or not pharmacists felt that they should play a role in syringe distribution. The second domain was aimed at determining pharmacists' actions regarding syringe sales to IDUs, their concerns with selling syringes to IDUs, their reasons for or against it, and what could alter those views (if anything). Other questions within this domain included establishing the quantities and prices of syringes sold in each of the pharmacies. This domain was also aimed at understanding what the pharmacists perceived as important issues regarding syringe access for IDUs as well as their own past experiences with this population. The third domain uncovered information concerning how blood borne diseases such as HIV and HCV have impacted their pharmacy, them as pharmacists, and them personally. This domain also gauged the amount of personal and/ or professional experience they had had with HIV +, HCV + and IDUs populations. The fourth examined pharmacists' thoughts on needle exchange programs and issues they perceived as significant in the distribution of sterile syringes by pharmacists. The final domain was comprised of a miscellaneous group of questions ranging from how they identify an IDUs to legal issues. Interviews were conducted by ethnographers; all interviews were taped, transcribed, individually coded, and then analyzed as a whole for significant themes. In the East Side interviews, the legal issues were not addressed with all of the study participants. As a result of a lack of information regarding 59

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the pharmacists' knowledge of the legal statutes concerning syringe sales in Colorado, a supplemental interview was created (Appendix E). The supplement was conducted with pharmacists who had not previously spoken about the legal restrictions in their interview. The supplement questioned them about any knowledge that they had about the statute concerning syringe sales, their interpretation of it, and any concerns they had regarding the law. Additionally, the interview questioned them about whether there were any pharmacy board regulations concerning syringe sales and how this effected them as pharmacists. Study Sample From a total of fifty-two pharmacies contaCted, eight pharmacies were not eligible (seven had gone out of business and one was a natural medicine pharmacy that did not sell syringes). Of the forty-four eligible pharmacies, twenty-four pharmacies agreed to participate (55% refusal rate). All licensed pharmacists at each pharmacy were asked to participate Twenty-one pharmacists (65.6%) were from the East Side pharmacies and eleven pharmacists (34.4%) were from the West Side pharmacies. Of the thirty pharmacies initially contacted on the East Side, ten pharmacies refused to participate and six pharmacies had either moved with no forwarding number or had gone out of business. Therefore, the twenty-one pharmacists interviewed on the East Side were drawn from fourteen 60

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pharmacies. Of the twenty pharmacies initially contacted on the West Side, ten refused to participate, one was a natural medicine pharmacy that did not sell syringes and was therefore not eligible, and one had gone out of business. However, two other pharmacies were added as a result of referrals from pharmacists resulting in eleven interviews from ten pharmacies on the West Side. The majority of pharmacists who refused to participate gave time constraints as their reason. Two pharmacies stated that their manager would not allow them to participate and one pharmacist said that they were not comfortable talking about this issue. Pharmacists from both independent and corporate owned pharmacies were asked to participate. This was due to the assumption that pharmacists who worked in locally owned stores and those who worked in corporately owned chains might have different views regarding syringe sales. 61

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Table 1 PARTICIPATING PHARMACIES Contacted Participated Pharmacists (East side) 6 21 Pharmacists (West side) 11 Pharmacies (East side) 30 14 Pharmacies (West side) 22 10 Pharmacists (total) 32 6 In many cases, ethnographers were informed that none of the pharmacists at the store were available to participate in the study. On these occasions, the number of pharmacists working at the pharmacy was unknown to the ethnographer, making it difficult to calculate the number of pharmacists contacted 62

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Table 2 DEMOGRAPHICS OF PARTICIPATING PHARMACISTS Variable % n Gender Male 62.5% 20 Female 37.5% 12 Ethnicity White 76% 25 Asian 15% 5 African American 6% 2 Hispanic 3% 1 Pharmacy type Independent 49% 16 Corporate 51% 17 Mean age 40 Mean years practicing 14.4 63

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The pharmacists' ages ranged from 25 to 68 with a mean age of 40. Pharmacists had from 1.5 to 35 years of experience with a mean of 14.4 years of experience. All individuals interviewed were practicing licensed pharmacists. Data Analysis Once all of the interviews were completed, the ethnographer began the process of coding the transcripts This was done through a thorough reading of the transcripts and identifying recurring concepts. Codes were then written in the margins of the transcripts so that the data could be organized into categories. Some of the codes were pre-defined by the ethnographers according to issues uncovered by the sister study conducted by the CDC while others were defined after completion of the interviews. These latter codes were distinguished by identifying common patterns or themes in the interviews All coding was manually done by one ethnographer to ensure consistency. 64

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CHAPTERV FINDINGS Analysis revealed three categories of pharmacists based on their attitudes concerning syringe sales to IDUs: those who willingly sell syringes to all of their customers (50%), those who refuse to sell unless shown legitimate proof of diabetic necessity (34. 4%), and those for whom the decision to sell is situational (15.6%). Five common areas of concern regarding syringe sales were identified among all three categories of pharmacists. 1) Competing public health models for drug users 2) Business concerns 3) Legality of syringe sales 4) Pharmacists' experience with HIV + and IDUs populations 5) Wide-spread support for needle exchange programs The first two areas of concern appeared to be most important to pharmacists when deciding whether to sell syringes, while the other three themes were common secondary issues. 65

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Competing Public Health Models For Drug Users Those pharmacists who reported selling to all individuals and those who only sold to customers exhibiting legitimate diabetic necessity had two divergent views of their role with regards to drug use and disease transmission. The pharmacists who sold to all customers stated that their primary motivation was the prevention of blood borne disease transmission. They felt that in order for this to occur, pharmacists must make sterile syringes accessible to IDUs through the pharmacy. None of the pharmacists in this group stated that increasing access to syringes increases drug use and many postulated that the majority of users will not quit injecting drugs due to an inability to purchase a syringe at a pharmacy. Pharmacists commented that IDUs would most likely find other methods of obtaining a syringe if they were unable to purchase them in pharmacies, such as borrowing from somebody else or picking one up from the streets. These pharmacists would rather provide sterile syringes than have IDUs use nonsterile syringes. The following quote typifies these pharmacists' attitudes: "I think syringes are accessible .... whether syringes are available or not does not stop users from becoming an addict. If they are going to become an addict, they are going to become an addict anyway. Having sterile syringes available just decreases the possibility of spreading the disease, whether it being AIDS or hepatitis, or whatever. So, in my opinion, if I know who uses the stuff .. .! know people who are users ... whether it is a good clean syringe is not going to help them to decide whether they want to be 66

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or don't want to become an addict. It is not a factor. It is kind of after the fact." (32 yr. old African American male, 3 years experience, Independent store) Some of the pharmacists who only sold to individuals with proof of diabetic necessity asserted that the long-term goal of health care providers should be preventing drug use and abuse. In this case, addiction is interpreted as the disease and the transmission of blood-borne disease is seen as a possible result of that addiction. These pharmacists maintained that by denying syringes to IDUs they were discouraging drug use. They argued that once a pharmacist had denied a user a syringe, the user would be forced to rethink their addiction and possibly' seek help. Many pharmacists realized that simplydenying to sell a user a syringe wouldn't encourage a drug user to quit. However, almost half of these pharmacists (45.4%) stated that they had no interest in supporting a behavior that was detrimental to a person's health and therefore refused syringe sales. They reasoned that by denying syringes they: were possibly decreasing drug use and were thus aiding in the decrease of the transmission of blood borne diseases that resulted from risky injection practices. "I don't think that two wrongs make a right as far as dispensing the syringes because they'll have clean syringes when they use their heroin so they won't share needles and nobody will get HIV. Ideally that may be the case, but I think there will still be sharing of needles .. .! don't think you should be handing out sterile syringes and saying, 'Okay, see ya.' That's not helping anybody, not them, not 67

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society, it's not helping prevention of anything, in my opinion. I just think that's like a quick fix." (29 yr. old White female, 6 years experience, Corporate Chain) Those who were indecisive were caught in the middle of a conflict between these two public health views. All the indecisive pharmacists reported being concerned with both the addictive behavior as well as the transmission of blood-borne diseases, resulting in an uncertainty in how to assimilate the two public health goals. They were uncomfortable supporting a potentially destructive addiction but they were also equally uncomfortable knowing that denying the sale of syringes may lead to an increase in disease transmission among this population. "You know that's kind of a diverse role' issue for us because -I don't want to spread AIDS and for part of me; turning people down bothers me. But then I can justify it by telling myself that if I sell this guy a 10-pack of syringes, he's probably going to share those ten anyways. So I shouldn't feel bad about that. But the pharmacist in me says I shouldn't be helping them. The human being in me says I shouldn't be letting AIDS get spread, so where do you go? It's a tough one. And you just find ways to make it right. You can find an excuse for why you're doing everything you're doing, probably both directions." (33 yr. old White female, 16 years experience, Corporate chain) Business Concerns The second most commonly stated reason against selling syringes was the perceived effect on business and other clientele from having IDUs in their pharmacy. Business concerns were the primary reported reason to 68

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deny sales for 36% of those who refused to sell syringes without legitimate proof of diabetic necessity. An additional36% of pharmacists who refused syringe sales mentioned business concerns as a secondary deterrent for selling syringes to IDUs (for these pharmacists, the importance of increasing the access of sterile syringes was clearly understood but pharmacists were acutely aware of the detrimental effects IDUs could have on their customer base). Pharmacists in this category were concerned about the health issues surrounding injection drug use but their business concerns prevented them from taking action along this avenue. Some feared that selling syringes to suspected IDUs would grant them a reputation of being an IDUs-friendly pharmacy, leading to an in the number of users frequenting their store. Pharmacists felt that an influx of IDUs would make their regular customers uncomfortable, causing them to switch to another pharmacy. One pharmacist described their customers' reaction this way: "I think they'd feel uncomfortable being in the store. I think they would be uncomfortable having their children come in to the store. I think it would be a real deterrent for them doing business in our store." ( 60 yr. old White male, 35 years experience, Independent store) Pharmacists stated that their position as public health role models did not allow them to aid people in a behavior that can be detrimental to one's health. According to some of the pharmacists, aiding IDUs in their 69

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addiction could cause their other customers to question their actions and potentially harm their reputation as health professionals. "It just sends the wrong message to other customers in the store, depending on appearance and attitude and things like that. If a customer sees them in there buying syringes and they give the appearance or have the attitude that they're an abuser, it doesn't give the store a very good reputation and people develop a fear to go into places like that where they see that kind of activity going on." (39 yr. old White female, 15 years experience, Independent store) Another reported negative effect of having IDUs in the pharmacy was the potential increase in store theft. Some pharmacists described IDUs as 'rifraff' and 'bad clientele' who consistently out of money, untrustworthy, and thus inore apt to shoplift than other clientele: They were also apprehensive that IDUs could potentially vandalize the store or possibly leave used syringes in the bathrooms and parking lots, posing a potential threat to other customers and employees. ... they are demanding. They are usually untrustworthy. And usually, there is certainly more potential to be a shoplifter than the average person, because they are out of money usually all the time. So, I don't have a problem with it morally. I just think that the pharmacy isn't the place for that." (52 yr. old White male, 25 years experience, Corporate chain) Almost 63% of those pharmacists willing to sell syringes without restrictions stated that the presence of IDUs in their store had little or no 70

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detrimental effect on their other customers or on their stores. One pharmacist observed that their present policy of selling syringes to IDUs presented them with fewer concerns than when they had previously been denying sales. "It seems now that we've changed our policy and we sell them more freely to people, we don't seem to be at odds with the addicts. I haven't noticed any problems." (35 White male, 10 years experience, Corporate chain) These pharmacists often noted that when IDUs would come into the store, they would purchase their syringes, and then leave as soon and as quietly as possible. Due to the illegal nature of their behavior, these pharmacists believed that most IDUs did not want to bring any undue attention upon themselves and would therefore cause few, if any, disturbances within the pharmacy. Initially, it was thought that independent and corporate pharmacies would differ on their store policies as a result of different types of business concerns each would have. However, the type of pharmacy that the respondent worked in did not appear to have an effect on their views. Ambiguity Regarding Legality Of Syringe Sales In all three groups there were pharmacists who were unaware of the existence of a paraphernalia statute in Colorado, the only statute that could possibly be interpreted as regulating syringe sales (Appendix F). Of the 71

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thirty-two pharmacists who were interviewed, 34% (11) were aware of some type of regulation concerning the sale of syringes in Colorado (three of those having only a vague knowledge of it) and 53% (17) were unaware of any such regulations. The final four pharmacists were unable to be reached for the secondary interview that concerned this issue. Five (31 %) of the sixteen pharmacists who sold syringes were aware of the statute (three in this group were unavailable for a second interview on the topic). These pharmacists stated that the law was ineffective in inducing fear of prosecution. In reference to the legal restrictions one pharmacist said: "No big deal. What are they going to do? Are they going to fine me? I don't think so." (29 yr. old Hispanic niale, 12 years experiencei Independent store) Additionally, since there is no prescription law in Colorado and no clear guidelines determining who pharmacists can sell to and who they can not sell to, one pharmacist stated: ... because if I sell someone a package of syringes and they just don't look like a diabetic or if I just think they're not a diabetic, they're saying we can be prosecuted for that. I just don't see how you could be .... I just can't imagine someone coming up to you later and trying to prosecute you because you knew that person was a drug addict. There's just no way to know that." (39 yr. old White male, 15 years practice, Corporate chain) In this case, their perceived ambiguity of the statute allowed them to continue to sell syringes to suspected IDUs without any fear of prosecution. 72

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On the other hand, of the eleven pharmacists who refused to sell to anybody but diabetics, four (36%) were aware of the law and used it to strengthen their argument to deny sales to suspected IDUs. "So they are disguising their needs, and so technically what we are doing is illegal by selling them to somebody who is not a diabetic. So it takes the risk otf our back by not doing it." (52 yr. old White male, 25 years experience, Corporate chain) Of the five pharmacists who were indecisive, two (40%) were aware of the statute and were unsure how to reconcile their knowledge of the statute with their concern for the transmission of blood borne diseases. Many stated that the ambiguity of these legal restrictions enabled them to use their own discretion when it came to sales. In this way, they were able to either use the statute to enforce their decision to deny a sale, or overlook it in order to sell syringes. One pharmacist said that in certain situations she would say: "And I tell them, 'No, I only sell them if, supposedly by law, you are using them for insulin."' (27 yr. old Asian female, 2 years experience, Corporate chain) However when faced with another situation the same pharmacist said: "That's why I'm more and more lenient in selling it to them because since the board is not so clear about it, they didn't require a prescription for it, so I go, 'Well, it's up to me."' (27 yr. old Asian female, 2 years experience, Corporate chain) 73

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Half of those who sold syringes were not aware of the statute. Once they were shown the legal restrictions, they all stated that it did not change their stance on syringe sales. However, other pharmacists who were either unclear or unaware of the law were in search of more guidance on the issue, wanting to know either way what they should do. Three of the five pharmacists who were indecisive (60%) and one of the eleven who did not sell (9%) stated that if there were a specific and clear law concerning syringe sales, they could comfortably sell or deny a sale without any personal conflict. Contrary to our original hypothesis, the law did not appear to be the primary reason for the pharmacists' decisions to sell or not to sell; only two pharmacists mentioned it as their principalreason for not selling syringes to suspected IDUs. However, as illustrated above, the statute did provide pharmacists with a convenient excuse to deny sales. Image Assessment As a result of their feelings regarding addiction, and business and legal concerns, some pharmacists felt it necessary to deny syringe access to IDUs. However, since Colorado law does not require a prescription to purchase a syringe, pharmacists have no sure way of distinguishing a diabetic from an illicit drug user. As a result, pharmacists who deny sales to suspected IDUs have created various strategies to assess their customers as 74

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a way of separating those who possess a legitimate diabetic necessity for a syringe from those who do not. An unconscious and almost immediate method of evaluating a customer is by their appearance. Twenty-eight percent of those who sold syringes, 55% of those who didn't sell syringes, and 100% of the situational sellers felt that they could spot IDUs by the way that they walk, their mannerisms, their thin physique, and their disheveled and dirty appearance, One pharmacist who did not sell syringes described IDUs in this way: ,. "Their physical appearance is d:irty, unkempt...many times a very strong alcoholic odor is just permeating ... the whole atmosphere .... 1 would say the majority of the ones that I can think oftend to have sort of a oily or sweaty skin ... but any how jtist part of the physical appearance, it doesn't look right." ( 60 yr. old White male, 35 years experience, Corporate chain) As this next quote exemplifies, many pharmacists felt that the IDUs entering their store are often already high and/ or drunk, and thus easy to recognize by their glassy-eyed look and nervous behavior. "You can just tell, sometimes. Or just the way they look, too. Sometimes you can smell alcohol on their breath. They have that glazed over look, you can just tell they're trying to maintain that high that they have." (29 yr. old White female, 6 years experience, Corporate chain) For some of the pharmacists, the individual's appearance was the deciding factor in their decision to sell or not. 75

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"Sometimes, I just use my intuition, you know, they don't have to show me any identification, I just use my intuition and say, 'No, I'm not going to sell it to you."' (40 yr. old African-American, 14 years experience, Corporate chain) Many pharmacists noted that not all IDUs fit the stereotypical model of a person injecting illegal drugs. For those pharmacists who sold syringes to all of their customers and used a 'no questions asked' policy, this caused no problem. Customers who did not look like the stereotypical IDU did create a dilemma for pharmacists only' willing to sell syringes to customers presenting a legitimate diabetic necessity. As a result of not being able to identify IDUs by sight pharmacists have devised secondary strategies to determine whether or not a customer is a diabetic. First, many felt they I could tell by the way that the individual requests the syringes. 33% of those who sold syringes, 27% ofthose who didn't sell syringes, and 75% of the situational pharmacists noted that suspected'IDUs are often unaware of the exact type of syringe they require. Frequently, the person will be vague and simply ask for a ten pack of syringes without specifying the type or the size of syringe Since most diabetics are generally well acquainted with this information, pharmacists consider this perceived lack of syringe knowledge a reliable clue that the person who they are dealing with is not a diabetic. Additionally, pharmacists reported having a series of questions that they would ask the customer in order to evaluate their diabetic status. 66% 76

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of all pharmacists stated that they had used this strategy at one time in order to deny sales to suspected IDUs. Once the individual has asked for the syringes, the pharmacist will respond by asking what type of insulin they use, in what dosage they take it, and/ or if they have any diabetic identification. Typically, pharmacists found that IDUs are not knowledgeable about insulin types and are often unable to answer these questions. An inability to properly respond to the questions will usually convince the pharmacist that the cust omer is not going to be using the syringes for a legitimate reason. In this case, they deny the sale. ... and then a follow-up is, 'what type of insulin do you use?' or 'How many units do you inject?' Ifthey can't come up with an answer, the assumption is that they're probably not telling the truthin the first place. So we'll usually just stay with that approach. We might say to that person, 'Well, unless you can answer those questions, I have a responsibility to not sell you the syringes." (47 yr old White male, 8 5years experience, Corporate chain) Repeatedly, pharmacists stated that when confronted with these questions, the IDU responds by saying that the syringes are not for fhemselves but are for some other family member or a friend who is too sick to pick them up. Pharmacists called this the 'grandmother excuse' due to the fact that oftentimes an ailing diabetic grandmother was used as the reason for buying syringes. Frequently, the pharmacist will reply that it is necessary for them to know the patient's insulin type or some other form of 77

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proper diabetic identification (like a diabetic ID card) in order to sell them a syringe. While the insulin questions were a fairly reliable way of identifying an IDU and thus denying sales, pharmacists realized that there were those IDUs who were knowledgeable enough to answer these questions. Although they were suspicious of certain customers, pharmacists who used this as a method of identifying IDUs maintained they would only refuse to sell if the individual was unable to ans"\'Ver their questions. "Usually from the answers to those questions, you can ascertain whether the person is legitimate or not. Quite honestly, if a person has an answer to those basic questions I have no basis on which to refuse to sell them the syringes. And so then I would [sell the syringes to them]." ( 47 yr. old White male, 8.5 years practice, Corporate chain) Another aspect of the situation that some pharmacists took into account when deciding whether or not to sell, was the customer's attitude at the time of the transaction: Some explained that when an individual comes to the counter and is rude or indignant, the pharmacist is more apt to deny them the sale. Additionally, pharmacists reported. denying sales to customers coming up to the counter requesting syringes as if it were their right to purchase a sterile syringe. On the other hand, if the customer approached them with a kind and polite manner, pharmacists would be more likely to sell them the syringe. 78

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" ... so most of the time I just sell it unless the person is really rude, or aggressive or something." (27 yr. old Asian female, 1.5 years experience, Corporate chain) Pharmacists' Experience With HIV + And Injection Drug Using Populations Pharmacists' experience with and knowledge of illegal drug users and HIV + populations occasionally influenced their decision to sell or not to sell syringes to suspected IDUs. As noted earlier, essentially two public health models with respect to drug addiction were identified; one concerning the disease of addiction and one concerning the transmission of blood borne diseases. Those pharmacists willing to sell to a:ll customers generally perceived drug addiction as a disease that could overtake any person, displacing the physical and mental capabilities necessary to resist such an overwhelming habit. Overall, 31% of pharmacists from this group had extensive personal and/ or professional experience with HIV + populations while none of the pharmacists in the other groups reported any experience. Two of pharmacists in the pro-sell group had extensive experience with IDUs through family or friends. They stated that this experience often contributed to their views on addiction and the sale of sterile syringes and aided them in understanding the necessity of increasing accessibility of syringes for injection drug users. 79

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"I don't approve of the use of drugs. But then you look at it from the other side, you can be part of prevention in the sense that you can prevent the sharing of needles with infected people and that's something that pushes me more to that side in my own feeling about drug use .... I come from a family who has that kind of problem, ... what would you do if your own brother came in and said, 'Let me have some syringes?' .. .! would not deny my-brother a sterile syringe. I would even educate him, 'Don't share anything. If you need it, you come to me and I'll give you some syringes.' It's as simple as that." (29 yr. old Hispanic male, 12 years experience, Independent store) Another pharmacists spoke about his experiences working with HIV+ populations and how that influenced his decision. "And now from living in San Francisco, I don't want them to use dirty needles. I'm not going to stop them from using drugs and the-y're just going to pass on more Hepatitis or HIV or anything using dirty needles, so I don't have a problem giving out clean syringes." (29 yr. old White male, 5 years experience, Independent store) On the other hand, the group who only sold to people who could produce legitimate proof of diabetic necessity had no reported personal and/ or professional experience with HIV + populations. Two of the pharmacists in this group did have experience with IDUs populations through friends wli.o were using drugs. These pharmacists interpreted the situation in an alternative manner from the previous pharmacists. "I just can't bring myself to contribute to somebody ruining their lives potentially by using drugs because I've seen too much of it...there were people that came 80

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into the drugstore that...were nice people and they got mixed up in drugs and ruined their lives, their family's lives and I just couldn't handle it." ( 60 yr. old White female, 39 years experience, Independent store) Wide Spread Support For Needle Exchange Programs Regardless of their stance on sales, pharmacists were supportive of needle exchange programs. Based on the knowledge that pharmacists had 'il. obtained through the media and froi:n conversations with other pharmacists, the majority of the sample perceived needle exchange programs as both a feasible and an appropriate option for population. When asked about needle exchange programs, one pharmacist said: "That's great. .. if it becomes a:riissue, 'Well, this is my practice You can go here instead. I apologize but this is how it's supposed to be:' That's an alternative ... .If I should run out, God forbid, you just tell them, 'Okay, go to this clinic and you can get some clean syringes or exchange them.' To me, that's great. That's something that should actually happen around the United States." (29 yr. old Hispanic male, 12 years experience, Independent store) An added benefit to having needle exchange programs would be the direct care that IDUs would be able to receive from the medical staff. Due to the busy nature of the pharmacy, pharmacists expressed doubt that IDUs would feel comfortable asking a pharmacist for health information that concerns injecting illegal drugs. At a needle exchange program, a user 81

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would not have to feel any inhibitions requesting information regarding injection drug use. In this way, pharmacists stated that IDUs would be able to access information concerning vein care, sterile injection practices, and diseases such as endocarditis, hepatitis, and HIV I AIDS. Pharmacists reported that the presence of needle exchange programs would also remove the IDUs from their stores. Since IDUs were considered by some to be untrustworthy customers with the potential to create an uncomfortable atmosphere in the store for both the pharmacists and the customers, this was a perceived advantage among each group of pharmacists. There did not appear to be any meaningful difference between why pharmacists in the different categories supported needle exchange programs. All three groups mentioned needle exchange programs as being a benefit because they are a place for IDUs to have increased access to relevant health information, a way to get the IDUs out of the store, and provided a method of disposal for used syringes. Additionally, the Colorado Pharmacy Board has released a statement fully supporting the development of a legally sanctioned needle exchange in Colorado. There were many reasons why pharmacists were in favor of introducing needle exchange programs, one being the opportunity to supply syringes to IDUs at no cost. 82

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" .. .if the government or the state really wants to keep track or to get these syringes into the hands of the people, I don't think they should even have to pay for them." (52 yr. old White male, 25 years experience, Corporate chain) Two pharmacists said that a primary reason for not selling syringes to suspected drug users was due to the lack of proper disposal receptacles for used syringes. Many were concerned about customers purchasing syringes in their pharmacy, using them and then disposing of the used syringes on pharmacy property or in another area that could prove to be dangerous for others. Pharmacists observed that a needle exchange program would offer a safe and comfortable option for users interested in . receiving and returning syringes, Pharmacists would be able to feel comfortable selling syringes knowing that the needle exchange program would present a safe disposal option for used syringes. 83

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CHAPTER VI DISCUSSION This research illuminated many of the issues that pharmacists perceive as important when considering syringe access for IDUs. Most importantly, it revealed that half of the pharmacists interviewed believed that the task of decreasing disease transmission through injection drug use is an essential and practical role for pharmacists to take on. These pharmacists agreed that syringes should be sold without restrictions. Importantly, many of these pharmacists could understand the views of those who do not sell to IDUs, some .of them had in fact felt that way earlier in their career. This demonstrates thatpharmacists who have denied syringe sales to IDUs in the past have been able to come to terms with the need to increase syringe access and have changed their behavior as a result. The fact that half of our sample sold syringes demonstrates that this is not an insurmountable issue among pharmacists and that many have found methods of increasing syringe access in a manner that was not detrimental their businesses or contradictory to their role as health professionals. Prior to the study, the researchers postulated that the legal restrictions placed on syringe sales would be a dominant reason for pharmacists to deny sales to IDUs. It was presumed that the fear of 84

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prosecution or the ambiguity of the law could potentially dissuade pharmacists from selling sterile syringes to IDUs. However, we did not find this to be the case. Only two pharmacists from our sample stated that the legal ramifications of syringe sales were the primary reason they discouraged sales to IDUs in their pharmacies. The statute was not the primary stated reason for denials for the remainder of the pharmacists who knew of it, but many used it to justify their decision not to sell. The remaining pharmacists who did not, sell to IDUs were either unclear or unaware of the paraphernalia statute making it doubtful that it was a major factor in their decision not to sell. Those who sold to all customers often stated that the statute was extremely vague and expressed no concern of any type of legal repercussions. These pharmacists reported that an increase in syringe access was essential and that the statute was not a sufficient deterrent to stop them from selling to IDUs. Contrary to the original hypothesis, the most commonly stated reason for not selling syringes to IDUs was the perception that IDUs could have a negative effect on business and other clientele. Pharmacists were well aware of the importance of stopping the transmission of blood borne diseases, however, pharmacists also stated that selling syringes to IDUs could be detrimental to business. Pharmacists may be public health professionals, but they are also responsible for maintaining a business and keeping other clientele and their pharmacy's reputation in mind. Their 85

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principal concerns included increased theft (this included shoplifting as well as fear of robbery of controlled substances), discarded syringes on store premises, and IDUs creating an uncomfortable atmosphere for other clientele. While these pharmacists understood the need for syringe access, they also felt that syringe sales to IDUs was not something that should be taking place within a pharmacy. This may in part explain the widespread support for needle exchange programs that was exhibited by the majority of the pharmacists in this study. The other major concern for pharmacists were their moral convictions regarding drug use. For many pharmacists, the disease in question was drug addiction. As a consequence, they did no.t want to promote substance abuse by making syringes available. Many equated treating addiction with ebbing the transmission of blood-borne diseases; by treating addiction, injection drug use would decrease, and along with it the blood borne diseases it facilitates. Often, pharmacists felt that by denying a syringe to a suspected IDU, they were forcing the individual to rethink his/her position in life and reevaluate their drug use. Unfortunately, the success rates for drug treatment is relatively low and addiction is considered to be a chronic condition. Thus, denying IDUs sterile syringes will rarely encourage them to stop injecting. Instead, it may force them to use a previously used syringe, borrow one from a friend, or find one on the streets. It is essential 86

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that pharmacists understand the characteristics of addiction so that they can be more effective in ceasing the spread of disease among IDUs. The culmination of the previously stated concerns is that pharmacists must be able to distinguish an IDU from an individual with a 'legitimate medical necessity' Without any explicit guidelines designed to determine to whom syringes can be sold, pharmacists often stated that they were able to first identify a user by their manner of dress or behavior As a result, IDUs who do not have the cultural capital necessary to successfully assimilate into our society are often targeted for questioning by pharmacists. They stick out because they do not have the education to know the syringe type or the facilities and financial capital to present an orderly appearance. They are then bombarded with questions about. their diabetic status simply because they do not have the ability to look and act like the rest of 'normal' society However, those who can maintain a modicum of "social a-cceptability" can often play the part and get away with a successful sale through deception. This may result in the further alienation of IDUs who have already been marginalized due to their lack of capital, thus reinforcing their risk taking behavior. This visual bias shows the variability in the pharmacists' policy, creating an unreliable outcome for IDUs attempting to purchase a syringe. It was interesting to note that none of the pharmacists in the group who did not sell to IDUs reported any personal and/ or professional 87

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experience with HIV + populations. On the other hand, almost one third of the group who sold to all customers reported either personal or professional experience with HIV + populations; experiences that often helped them to define their current views on syringe access. Furthermore, both groups had two individuals who reported having experience with IDUs, either through family or friends. However, each group interpreted their experiences differently Those who did not sell felt that their experiences gave them an understanding of addiction and it's c;l, estructive effects on people's lives. The experiences of the other group gave them a sense of awareness of the current epidemics among IDUs and a source ofobligation to stop these from reaching individuals close to them who injected drugs. Pharmacies may represent a convenient option for sterile syringes for IDUs in Denver, but this research has demonstrated that sales through pharmacies can often be problematic and may not represent a reliable source for syringes. Vague legal restrictions, a lack of clear regulations or guidelines from pharmacy associations addressing this topic, business concerns and the incorporation of personal belief systems result in variation of pharmacists' actions concerning sterile syringe distribution to suspected IDUs. This places IDUs on the periphery of our health system. In an attempt to bring IDUs into the health system, pharmacists' and actions regarding syringe sales must be understood and addressed. 88

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CHAPTER VII CONCLUSION AND RECOMMENDATIONS The fundamental task of stopping the transmission of diseases such as HCV and HIV among IDUs seems basic when one looks at it strictly from a public health perspective. However this research, as well as that of others, has demonstrated that pharmacists have a number of concerns regarding this issue that must be addressed if 'tfiey are to become involved in the effort. Due to the illegal and damaging nature of injection drug use, many individuals perceive the current dilemma of IDUs as being of their own : ., making. It is through IDUs own lack of self-responsibility that they now find themselves in a lifestyle that increases their risk of infection of blood borne pathogens. Furthermore, many view any effort to increase syringe access as a means to facilitate injection drug use thus aiding a person in the damaging life of addiction. Consequently, the health issues of IDUs are often times seen as a logical progression emerging from a bad life choice. Many of the pharmacists who were interviewed expressed similar moral concerns as well as business concerns regarding the sale of syringes to IDUs. The concerns that were brought up by the pharmacists in the study represented legitimate issues, however they are issues that can hopefully be 89

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addressed and resolved in order to further involve pharmacists in this public health effort. The points brought up by pharmacists in this study were very similar to those in existing literature (Sheridan 1997, Gleghorn et al. 1998, Singer et al. 1998, Wright-De Aguero et al. 1998, Farley et al. 1999). Many were very concerned with the effect that IDUs in their store would have on their business, their customer base and their reputation as public health professionals. These concerns lead to a broad discrepancy in syringe sales among pharmacists and thus an uncertain outcome for IDUs when attempting to purchase. In addition, the findings regarding the lack of communication between pharmacists concerning syringe sales was in . agreement with that of previous researchers (Singeret al. 1998, Wright-De Aguero et al. 1998). In agreement with the work done by Costin, our findings suggest that legal restrictions were shown to limit the availability of syringes though pharmacies (Costin 1998). While only two pharmacists in our sample stated that the paraphernalia statute was their primary reason to deny syringe sales to IDUs, many other pharmacists used it to justify their actions. However, the paraphernalia statute does not only limit access through distribution but also restricts the actions of the IDUs by making the possession of syringes a crime as well. Ethnographic evidence has shown that many IDUs are reluctant to carry syringes on them because of the risk 90

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of being stopped by a police officer and arrested for carrying paraphernalia (Koester 1994). As a result, IDUs are often unprepared for an unexpected injection episode and are forced to share syringes and other paraphernalia with their partners. The existence of such statutes ignores the need for an increase in syringe access as a public health requirement and relegates IDUs into a sub-culture of individuals who are not worthy of preventative measures. The emerging epidemic of HCV illustrates the need for the declaration of a public health emergency and for the laws that restrict the sale of syringes to be repealed. Recommendations Costin and coneagues' findings revealed that pharmacist discretion leads to a wide variation in the willingness to sell syringes, as a result they presented seven legal and public health approaches to the dilemma (Costin et al.1997): 1. Clarify the legitimate medical purposes of sterile syringes 2. Modify drug paraphernalia laws 3. Repeal syringe prescription laws 4. Repeal restrictive pharmacy regulations and practice guidelines 5. Promote professional training 6. Permit local discretion in establishing NEP 7. Design programs for safe syringe disposal 91

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Their paper calls for a complete repeal of all prescription statutes and pharmacy regulations as well as a modification of drug paraphernalia statutes in order to enable pharmacists to play an active role in increasing syringe accessibility. In so doing, the state would be removing an obstacle to providing the syringes necessary to comply with public health recommendations. For a comprehensive plan to not only increase access but prevent the spread of infection and assist IDUs in changing their behavior, this deregulation must be coupled wjth education, testing, treatment and counseling. However, it is not only pharmacists' attitudes and legal restrictions that limit syringe access, additionally, there are certain structural limitations to access through pharmacies. One of these barriers is that pharmacies are open fixed hours and only on certain days of the week. This creates a problem for the IDU who is in need of a sterile syringe during the hours that the pharmacies are not open. During these times, IDUs may be forced to reuse or borrow a syringe to inject with at the time rather than wait until a store opens for the day. A reasonable solution to this health dilemma would be to institute needle exchange programs that would be available to exchange syringes during all times of the day and night. In this way, IDUs would be able to access syringes through pharmacies during regular working hours and could then turn to NEP if the pharmacy was unable to provide them with a syringe. This would be more suitable for the lifestyle 92

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of a user and would therefore increase the chances of IDUs using sterile syringes during an injection episode. Traditionally, it has been the behavior of the IDUs that has been the focus of HIV /HCV interventions, yet this research demonstrates that such interventions should also address pharmacists and others who control access to the sterile syringes necessary for IDUs to make these changes. Without any pharmacy board regulations and with only an ambiguous paraphernalia law concerning sales, pharmacists often rely on their .. own discretion regarding syringe sales. Pharmacists should be encouraged to sell syringes to all customers regardless of diabetic necessity. In order for this to occur, pharmacists .should be involved in efforts to amend the legal restrictions placed on sale and possession of sterile syringes. Additionally, a method ofdisposal for used syringes needs to be put in place. At the pharmacists' request, there needs to be a development of continuing educational programs to provide information on the lifestyles of IDUs, drug use and addiction, and the importance of sterile syringes in decreasing the transmission of blood-borne diseases. The first necessary step in changing this situation is to examine the issue and attempt to understand it. This research was successful in identifying some of the issues surrounding sterile syringe access for IDUs through pharmacies. Not all of the issues brought up by the pharmacists in this study can be easily addressed. However, this is only the beginning of 93

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involving pharmacists in the quest for increased syringe access for IDUs. The goal now is to take this information and transform it into practical knowledge. The findings of Sheridan and colleagues have demonstrated that education regarding drug misuse and HIV prevention can have a positive effect on pharmacists in terms of providing syringes to IDUs. In hopes of similar results, the findings of this research were presented to undergraduate and graduate students in the School of Pharmacy at the University of Colorado Health ScieJ)Fes Center. This was done in an attempt to increase awareness and generate discussion among tomorrow's pharmacists Additionally, these same researchers are currently working with the American Pharmacists' Association (APhA) to create a nationwide course regarding this issue to be used as a continued education course for pharmacists. The first class is scheduled for September, 2000. Concluding Remarks It is the individual pharmacist who must be the focus of today' s debate regarding more complete syringe access. In the end, the pharmacist makes a decision as to what action to take during a potential sale, their individual views and concerns result in a wide variation in sales policies. If the goal is reliable, consistent access to sterile syringes, we feel that pharmacists must be informed of the benefits and consequences of their choices regarding syringe sales. By encouraging a structured information 94

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system for pharmacists through continuing education courses we can raise awareness and bridge the cultural gap between the 'standard' society of which pharmacists are a part and the drug sub-culture to which IDUs belong. Knowledge about the spread of HIV /HCV among IDUs, and the effectiveness of increasing syringe access, in conjunction with the legal sanctioning of syringe sales, may create a suitable environment for pharmacists to take a leading role in halting the spread of HIV and HCV A pharmacist education effort such as this maybe a far better use of public funds than the current attempts at winning the 'war on drugs'. The longer the government funnels money into a losing battle, the greater the number of HIV /HCV.infections resulting from injection drug use will be. For those who fail to understand why w e should help individuals who are participating in illegal activities ; they should be aware that there will be a financial cost to their ignorance. Studies have shown that addressing the issue of sterile syringe access for IDUs is much more cost effective than the possible alternative. Holtgrave's analysis revealed that the funding of programs aimed at increasing syringe access and syringe disposal for IDUs would be an efficient use of public funds. Their results indicated that for each year that goes by without increasing syringe access for IDUs, as many as 12,350 individuals will become infected with HIV, incurring an estimated $1.3 billion in future medical costs for these people (Holtgrave et al. 1998). Our failure to act now will exact a growing 95

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economic toll in the years to come. 96

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APPENDIX A Pharmacies are cited as enhancing the accessibility of sterile syringes to injecting drug users for the purpose of preventing the transmission of HIV and other blood-borne pathogens. This survey, designed by Urban Links at the University of Colorado at Denver, gives pharmacists an opportunity to share their thoughts, beliefs and attitudes concerning pharmacies' involvement in making sterile syringes more accessible. Please fill out the survey and return in the enclosed stamped, self-addressed envelope, or fax to 303-294-5275. Your responses are confidential. Please read the following statements. Circle the response that best reflects your opinion using the following scale: SD= strongly disagree, D= disagree, N= neither agree nor disagree, A= agree, SA= strongly agree 1. Increasing the accessibility of sterile syriJ:lges to injection 2. drug users is an effective means of reducing the spread of blood-borne viruses (i.e. HIV anci Hepatitis C). 3. Increasing syringe accessibility promotes drug abuse. 4. There are legal constraints on the sale of syringes by pharmacists. SO D N A SA SD D N A SA SD D N A SA 5. It is acceptable for pharmacists to sell syringes to someone SD D N A SA they suspect may use them to inject illegal drugs. 6. Pharmacists are an effective means of promoting increased SD D N A SA access to sterile syringes for injection drug users. 7. Increasing sterile syringe access to injection drug users is important, but pharmacists should not be involved. 8. It is acceptable for pharmacists to refuse to sell syringes to someone they suspect may use them to inject illegal drugs. SD D N A SA SD D N A SA 9. Local commnnity efforts to encourage the sale, distribution SD D N A SA and exchange of sterile syringes by pharmacists are important public health measures. 10. Pharmacies should be involved in a comprehensive program to increase drug users' access to sterile syringes. SD D N A SA 11. Increasing syringe accessibility to injection drug users is not SD D N A SA a concern of mine. The following demographic information is optional. 12. What type of pharmacy do you work in? (Check all that apply) Hospital Corporate owned Privately owned Other: 13. Is the pharmacy you work in open past 6:00p.m. on weekdays? Yes No 14. Is the pharmacy you work in open on Snndays and/ or holidays? Yes No 15. In what county in Colorado is the pharmacy you work in located? 16. Which of the following best describes the area in which the pharmacy is located? Urban/ metropolitan Suburban Tourist economy Rural/ agricultural Other ___ 97

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Thank you for completing this survey. If you have any questions or comments, please contact Dr. Stephen Koester at 303-294-5274 or e-mail to skoester@carbon.cudenver.edu . ,, . . . 98

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APPENDIXB January 22,1999 Dear colleague, Urban Links is a research project of the Health and Behavioral Sciences Program at the University of Colorado Denver, and is also affiliated with the Department of Psychiatry at the University of Colorado Health Sciences Center. As an organization, we are dedicated to involving a broader spectrum of public health professionals in disease prevention and health promotion. Currently, we are conducting a study funded by the Centers for Disease Control and Prevention (CDC) examining the role of :in HIV and Hepatitis B&C prevention. As part of this study, we are conducting qualitative interviews with pharmacists in Denver We would like to invite you to participate in this study. It is our intent to conduct interviews with approx:iinately 36 pharmacists practicing in Denver. As highly respected, front line public health professionals, pharmacists play an important role in meeting the everyday health needs of the public. As such, we would like to discuss your perspectives .regard,ing commt.mity-level HIV prevention; and particularly your regarding HIVamong jnjection drtig users. The interview will take approximately one hour of your time. We will schedule it at your convenience and at a location you choose. You will receive $50 in compensation for your time and assistance. As with all of our research, the interview will be completely confidential The data collected is for research purposes only. Your contribution is very important to us. In talking with you and your colleagues, we will be able to coordinate more closely the fields of public health, pharmacology and medicine in fuhrre efforts to prevent blood borne viral transmission. Your insight and experience will make a significant contribution to our effort. We will contact you within two weeks to schedule a time for the interview. We look forward to meeting with you. Please feel free to call us for more information (294-5274 or 294-5277). Thank you for your consideration. Sincerely, Stephen Koester, Ph.D. Associate Professor Principal Investigator 99 David Elm, Ph.D. Associate Professor School of Pharmacy

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APPENDIXC COLORADO MULTIPLE INSTITUTIONAL REVIEW BOARD SUBJECT CONSENT FORM FOR The Role of Pharmacists in Increasing Syringe Accessibility Ethnographic (face-to-face) Interview Urban Links Center for Research in the Health and Behavioral Sciences University of C olorado at Denver Version Date 7/7/99 Project Description: You have been asked to participate in a research project, funded by the National Institute on Drug Abuse, aimed at to reduce the risk of contracting infectious blood-borne diseases, primarily HIV. You are being invited to do this because you are a pharmacist in a neighborhood of Denver where high concentrations of injection drug users are known to live. .Procedures Involved: If you choose to participate 'in this study; y9u wili be given a face-toface interview . by a research professional. These interviews will w::t information about your role i . and attitudes towards selling syringes to IDUs, your experi'erices selling syringes to .. JDUs, and what issues and concerns you have with regard to selling syringes to IDUs. These interviews will be informal. They will be conducted in a private setting. Each interview usually requires at ieast 15 minutes, but not more than 30 minutes of your time. You will be compensated for your time with a payment of twenty dollars ($20). Discomfort and Risks: Sqme ofthe questions may cause some anxiety. You may choose not to answer any question that you feel uncomfortable answering. Benefits: There are no known benefits to you for being in this study. Treatments/ Alternative Treatments: No treatments are being provided Funding: Funding for this project comes from a grant from the National Institute on Drug Abuse. Initials -----100

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Cost to you: There is not cost to you, other than your time, for participation in this study. Study Withdrawal: You may withdraw from this study at any time without affecting your use of the University of Colorado at Denver's programs. You will be withdrawn from the study if you are abusive to any staff personnel. If you are withdrawn from this study you will still be able to continue participation in any of the University of Colorado at Denver's programs. Invitation for Questions: Please feel free to ask questions about any aspect of this research or this consent form. Ifyou have more questions about this study at a later date, you can telephone Dr. Stephen Koester, the director of the project, at 303.294.5273. In addition, if you questions regarding your rights as a human subject participating in this research project, please call the Office of Academic and Student Affairs, at 303.556.2550. You will get a copy ofthis consent form. Confidentiality: These interviews may be audiotape recorded for puiposes only. By signing form you give permission for taping : The : tap;;s will be erased once the irtter\riew sessions are transcribed and anaiyzed. Ounng the transcription of the ali' names will be replaced with pseudonyms to protect your 'identity. To minimize any risk to you, all of the information that you provide is kept in a locked file and your name will not be associated with any of the interview data. All signed consent forms will be kept in a locked file at the research All accompanying research data will be kept in locked files. All staff will be thoroughly trained in these procedures. You will not be identified by name in any reports or publications based on this study. Initials ----101

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Authorization: I have read this consent form, or it was read to me. I know the possible positive and negative aspects of this research. I know what will happen during this study. All of my questions about this study have been answered to my satisfaction. I agree to participate in this study. I understand that I may choose not to answer any questions and stop being in the study at any time without losing access to University of Colorado at Denver programs or services. I will get a copy of this consent form. I also know that I will be given fifty dollars ($50) to complete this interview. Subject's Signature Date . Interviewer's Name (Please print) ... .' 102

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The Role of Pharmacists in Increasing Syringe Accessibility Ethnographic (face-to-face) Interview Urban Links Center for Research in the Health and Behavioral Sciences University of Colorado at Denver Version Date 2/17/98 Receipt of Payment I acknowledge receipt of fifty ($50) dollars for my participation in this interview. Subject's Signature Date Interviewer's Name (Please print) 103

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APPENDIXD PHARMACY QUESTIONNAIRE INTRODUCTION The following study has been funded by the CDC and A TPM and seeks to assess the viewpoints of pharmacists in the Denver area concerning sterile syringe accessibility for intravenous drug users. The assessment is for public health information only and in no way seeks to be suggestive of project implementation. The study consists of two sets of 15 qualitative interviews pharmacists in both East and West Denver neighborhoods. DOMAIN 1: Beliefs and Attitudes Recently, the US Public Health Service published a public health bulletin suggestion that the only sure way to prevent blood borne viral transmission among injecting drug users not in treatment is to increase their access to sterile syringes. -What are your thoughts concerning this statement? -What role do you think pharmacists/pharmacies should play in providing IDUs with sterile syringes? -What role do you see pharmacists playing in public health issues? 104

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DOMAIN II: Practicalities and Pharmacists' Actions and Experiences -What quantity do you sell syringes in? (singles, ten-packs, boxes) -What are the prices of them? -Where are they located in the store (counter, pharmacy)? -Does your pharmacy have a position or policy on the sale of syringes without a prescription? -If YES, what is it? Have you ever felt conflicted when complying with this policy? Can you describe such a situation and how you handled it? Is this policy just for your store or the entire chain of stores (if it is a chaip pharmacy)? -If NO, would it be easier if there was? Why? Do you have a personal position on this issue? -Describe a scenario (and the procedure) in which a customer wants to buy a syringe. -Tell me about a time that sticks out inyour mind where you sold syringes, or observed someone syringes, to suspected IDUs. -What, if any, information do you ask customers for on why they need syringes? Do you require proof? -Do you ever refuse people? Why? -What strategy do you use to refuse people or deter them from attempting to purchase syringes at your pharmacy? 105

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-If you do not sell to IDUs, what would it take for you to sell to them? What would make it easier for you? -Have you ever worked in another store where the policy was different or it was a different situation than where you work now? -Do you ever talk to your other colleagues about this issue? Is it ever addressed in pharmacy journals? -Do you think that syringe sales to IDUs should occur in a pharmacy setting qr elsewhere? -Have you ever had a bad experience with a suspected IDUs? If so, could you explain it to me? ,DOMAIN III: Impact of Hepatitis C and HIV/AIDS -How does Hep C and HIV I AIDS impact your pharmacy and you as a pharmacist? -How have they impacted you personally? -How do you perceive the pharmacist s role in HIV /HCV prevention? -Do you have any HIV + patients that fill their medications at your pharmacy? 106

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DOMAIN IV: Program Development Issues -What are the issues that you perceive around pharmacies' participation in the distribution of sterile syringes to IDUs? -What are the barriers for pharmacists? -What are the facilitators for pharmacists? -Is a pharmacy led program to promote sterile syringe accessibility feasible? Why /Why not? -What might such a program look like? -How much would you suggest selling syringe for and where would you suggest putting them? -What about disposal of syringes? Does that issue ever. present itself in your pharmacy? Have you ever had a person come to you with a dirty syringe to dispose of? What happened? -Do you see any problems with such a program? Benefits? -Do you think that any of your colleagues would be interested in participating in this study? Can I use your name as a referral? DOMAIN V: Miscellaneous Questions -What do you think is the prevalence of IDUs in the area of the pharmacy? -Approximately how many IDUs come in here on a weekly basis looking for syringes? 107

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-Do you sell liquor? -Who is able to sell syringes in the pharmacy (pharmacy techs, clerks, etc.)? -Is age ever an issue when you are deciding whether or not to sell a syringe to somebody? -Do you get a lot of repeat clientele that are suspected IDUs? -Have you ever heard of a diabetic card? What is it? -What are some distinguishing characteristics that tip you off that somebody might be an IDUs? there any legalities regarding this situation (only probe if interviewee has brought it up)? -Where is this law written? -Would you be more willing to if the w,as referred from a n l . . outside agency or clinic? -Do you think that the position that the pharmacist is in when deciding whether or not to sell a syringe to a customer is a difficult one? . -How do you integrate the two issues of the health benefits of providing syringes with the detrimental issues of drug use/ abuse? 108

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APPENDIXE Pharmacy Supplement Interview Protocol Focused interviews concerning legalities of syringe sales, thoughts on recent policy statements by leading public health institutions, and recent personal or store policy changes will be conducted with 14 of the previously interviewed pharmacists. Eleven of the 14 pharmacists were chosen due to the lack of content concerning the legalities of syringe sales in their first interview. The remaining 3 were chosen due to recent findings that suggest policies, con<;:erning syringe sales at their respective stores; have been changed. The focused interviews are projected to last 20-30 minutes and will be conducted in person. Interviews will include the following questions: 1. Since our last interview has your personal and/ or store policy changed? If yes, why and for how long has this been in place? Colorado Statute Awareness 2. Are you aware of any Colorado statute/law concerning syringe sales? 109

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If No, skip to #6 If yes continue to #3 3. What is your interpretation of that law as it pertains to pharmacists/ pharmacies? 4. Has it or does it have any effect on your personal actions? On your store policy? What or how? 5. Do you or your pharmacy have any concerns with regards to this statute? Colorado Board of Pharmacy Regulation Awareness 6. Are you aware of any Colorado Board of Pharmacy regulation concerning syringe sales? If No, skip to #11 If yes continue to #7 7. What is your interpretation of that regulation? 8. Has it or does it have any effect on your personal actions? On your store policy? What or how? 9. Do you or your pharmacy have any concerns with regards to this regulation? 110

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10. With regards to the state law and/or board regulation, which weighs more heavily in dictating your actions? 11. If the state law and/ or the pharmacy board regulation was/were amended or interpreted to ensure that pharmacists are exempt from possible prosecution or professional censure, would you be more willing to sell syringes? Other Policy/Legal Issues 12. What would you identify a, s the primary motivations for your or your store's policy on syringe sales? 13. Are there any other legal issues that are of a concern when dealing with this population? APhA Policy Statement 14. Are you aware of the policy statement recently put forth by the American Pharmacy Association concerning syringe sales? If No, present the statement and continue In 1999, the American Pharmaceutical Association (APhA) adopted an official policy towards the sale of sterile syringes stating that: "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 111

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effort to decrease the transmission of blood borne diseases." 15. Has it or will it effect your personal and/ or your store policy? If so, how? *Pharmacists will be compensated $20 for their time. 112

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APPENDIXF COLORADO STATUTE -18 428. Possession Of Drug Paraphernalia Penalty 1A person commits possession of drug paraphernalia if he possesses drug paraphernalia and knows or reasonably should know that the drug paraphernalia could be used under circumstances in violation of the laws of this state. 2-Any person who commits possession of drug paraphernalia commits a class 2 petty offense and, upon conviction thereof, shall be punished by a fine of not more than one hundred dollars. Repealed and reenacted by laws 1992, 110.92-1015, 1, eff. July 1,1992 18 18 429. Manufacture, Sale, Or Delivery Of Drug Paraphernalia Penalty Any person who sells or delivers, possesses with intent to sell or deliver, or manufactures with intent to sell or deliver equipment, products, or materials knowing, or under circumstances where one reasonably should know, that such equipment, products, or materials could be used as drug paraphernalia commits a class 2 misdemeanor. Repealed and reenacted by laws 1992, R.B.92 1015, 1, eff. July 1, 1992. 113

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