Syringe Reuse Among People Who Inject Drugs in Rural Appalachia Kentucky

Abstract

Background:

Personal syringe reuse (i.e., reuse of one’s own syringes) can place people who inject drugs at increased risk for infectious disease but has received relatively little attention in published literature. The purpose of this study is to identify factors associated with syringe reuse among people who inject drugs in rural Kentucky.

Methods:

Participants (n=238) completed interviewer-administered questionnaires on syringe reuse and demographic, behavioral, and service access characteristics. Unadjusted negative binomial regression with cluster-robust standard errors was used to model the associations with a logged offset for number of injections in the past 30 days.

Results:

The average age of the sample was 35 and 59.7% were male. Most participants (77.7%) reused syringes at least once in the past 30 days, using each syringe a median of three times. Reuse was higher among those who were older and reported a higher street price for syringes. Syringe reuse was lower among people who were within walking distance to a syringe service program (SSP) and who obtained most of their syringes from SSPs or pharmacies.

Conclusion:

Syringe reuse among people who inject drugs in rural Kentucky is common. However, these data suggest that increased access to syringes from SSPs and pharmacies, as well as policy-level interventions that reduce street syringe price, might reduce syringe reuse and related harms.

Background

The sharp rise in injection drug use (IDU) has implications for the burden of associated infectious diseases such as hepatitis C, HIV, infective endocarditis, and osteomyelitis (Levitt et al., 2020). Policies criminalizing possession of injection supplies have limited the flow of sterile syringes through communities of people who inject drugs and helped drive injection-related infections by creating an artificial scarcity of syringes (Rich et al., 2000). The most well-studied impact has been on receptive and distributive syringe sharing. Personal syringe reuse (i.e., reuse of one’s own syringes) has received far less attention, despite data indicating that more than a third of people who inject drugs reused their needle during their last injection (Rich et al., 2022).

Syringe reuse confers risk for injection-related injury and serious bacterial infections (Levitt et al., 2020; Colledge et al., 2020). The mechanisms contributing to increased infection risk with syringe reuse are not well defined in the literature but are likely multifactorial and include injection-site injury from blunted needles otherwise designed for single-use (Harvey et al., 2022; Majcher et al., 2018), repeated introduction of skin flora, and/or bacterial colonization of syringes between uses. Few studies have explored structural, demographic, and behavioral factors associated with syringe and needle reuse. Studies in North America (Bartholomew et al., 2021; Hayashi et al., 2010; Huo & Ouellet, 2007) and Asia (Nazari et al., 2016; O’Keefe et al., 2018) found that syringe reuse is lower in areas in closer proximity to a syringe service program (SSP). Likewise, national data in the U.S. revealed that people who inject drugs using syringes from pharmacies and/or SSPs were less likely to reuse them than were those who obtained syringes from other sources (e.g., “on the street”, shooting galleries, peers, people who sell drugs; Marotta et al., 2021). Research in Rwanda revealed that syringe sharing was associated with needle reuse (Twahirwa Rwema et al., 2021). In U.S. studies, syringe reuse was associated with heroin and cocaine injection (Ropelewski et al., 2011), increased age (Ropelewski et al., 2011) and being male (Bartholomew et al., 2021), though there have been mixed findings on the latter (Rich et al., 2022).

Broadly, this exploratory study aims to build evidence to inform interventions to reduce personal syringe reuse. We focus on rural Appalachian Kentucky, a cultural region that spans 13 U.S. states along the Appalachian Mountains. Appalachia has long been among the US’s most severely impacted regions in terms of opioid use, IDU, and HCV (Zibbell et al., 2015). To date, studies on syringe reuse have been conducted primarily in urban areas with limited generalizability to rural settings. This paper characterizes the frequency of personal syringe reuse and identifies demographic and behavioral correlates to reuse in rural Appalachia.

Methods

Data were collected in an interviewer-administered questionnaire. Eligibility criteria included residency in one of five Appalachian Kentucky counties, being age 18 or older, and using opioids or injecting drugs to get high in the last 30 days. Participants (n=338) were recruited from February 2018 to March 2020 through respondent-driven sampling. Specifically, “seeds” were asked to distribute coupons to peers who may be good candidates for the study. Seeds and referred peers were reimbursed $10 per peer for up to three peers who enrolled. Given that the outcome of interest was syringe reuse, this analysis included only those who injected drugs in the past 30 days (n=238).

Measures

The outcome, syringe reuse, was captured by the question, “In the past 30 days, in general, how many times did you use each of your own syringes?” with an open-ended numeric response option accompanied by a ‘decline to answer’ option, though none declined. We examined independent variables explored in similar research, including age, sex and gender, houselessness, transportation, access to and use of SSPs and pharmacies, syringe sharing, and type of drug injected. We examined price of syringes sold by people informally in the community (hereafter “street price”) because of its positive association with strict injection paraphernalia laws criminalizing syringe possession and controlling syringe sale and distribution, like those in place in Kentucky, and those laws’ exacerbation of syringe reuse (Rich et al., 2000). Further detail on survey items and recall periods are provided in the first column of Table 1.

Table 1.

Demographic and behavioral characteristics of sample and their association with syringe reuse, with an offset for frequency of recent injection drug use (n = 238)

Characteristic	n	%	RR	95% CI	P-value
Number of times reused syringes in past 30 days (n=238), median (IQR)	3	2–10	--	--	--
Gender
Female	96	40.3	Ref		0.218
Male	142	59.7	1.23	0.89, 1.71
Agea, median (IQR) (Unit for RR: 10 years)	35	29 – 41	1.29	1.09, 1.53	0.003
Unable to do something that needed to be done due to lack of transportation in the past 6 months
No	94	39.5	Ref		0.471
Yes	144	60.5	1.15	0.79, 1.66
Unstably houseda in the past 6 months	92	38.7	0.87	0.59, 1.27	0.468
Drugs injected in past 30 days (n = 232)
Opioidsb only	38	16.4	Ref		0.132
Stimulantsc only	30	12.9	0.77	0.49, 1.19
Opioids and stimulantsb,c	164	70.7	0.71	0.50, 0.99
Number of times injected in past 30 days, median (IQR)	60	22 – 90	--	--	--
Number of people shared equipment with in past 30 days, median (IQR) (n=236)	1	0 – 3	0.98	0.95, 1.00	0.070
Number of times injected with a syringe used by someone else in past 30 days, median (IQR)	0	0 – 4	0.98	0.96, 1.01	0.153
Where most syringes were obtained in the last 30 days
Pharmacy or SSP	99	41.6	Ref		0.003
Someone who obtained them from an SSP	30	12.6	2.44	1.22, 4.88
Family, friend, or found them	82	34.5	1.90	1.35, 2.68
Person who sells drugs and/or needles	27	11.3	1.65	1.18, 2.31
Current street price of one syringe in community (n = 227)d
Less than $3 USD	33	14.5	Ref		<0.001
$3 to $4.99 USD	46	20.3	1.56	1.01, 2.41
$5 USD or more	148	65.2	2.82	1.82, 4.37
Current distance from residence to nearest SSP (n = 237)
Within walking distance	65	27.4	Ref		0.002
Less than a 30-minute drive	147	62.0	1.47	1.17, 1.85
More than a 30-minute drive	25	10.6	1.55	1.01, 2.37

IQR: interquartile range; SSP: syringe service program; USD: U.S. dollar

^aDefined in survey as “living from place-to-place, ‘couch-surfing,’ on the street, in a car, park, abandoned building, tent, campsite, squat or shelter.”

^bOpioids queried include heroin, fentanyl, opioid painkillers, methadone, buprenorphine, and synthetic opioids

^cStimulants queried include cocaine, crack, amphetamine, and methamphetamine

^dOpen-ended, numeric responses were categorized into given categories due to skew

Analyses

All analyses were exploratory and conducted using SAS 9.4 (SAS Institute Inc., Cary, NC, USA). The associations between the number of times a participant had reused their own syringe with demographic and substance use-related predictors were estimated using individual bivariate and multivariable negative binomial regressions. Multivariable models were estimated by adding variables to the model by domain. Given the lack of underlying theory, these models should be considered exploratory. All models were estimated as generalized estimating equations in PROC GENMOD to account for non-independence within recruitment chains by assuming exchangeability within recruitment seed. To account for the differential frequency of IDU that might drive associations, all models use a logged offset for the number of times a participant injected in the past 30 days. All models were estimated as complete case analyses as the highest missingness rate was less than 5%.

Results

The sample is described in Table 1 [n=238]. The average age was 35 [SD=8.5] and 59.7% were male. Over one-third [38.7%] had recently been unstably housed and 60.5% lacked reliable access to transportation. The median number of times participants injected in the past 30 days was 60 [interquartile range (IQR): 22–90]. Most participants [70.7%] reported injecting both stimulants and opioids. Only 41.6% reported that most of their syringes came from a pharmacy or SSP and 72.6% reported not being within walking distance of the nearest SSP. Street syringe price was high, with nearly two-thirds [65.2%] reporting that syringes were $5 USD or more each.

Most participants [77.7%] reported reusing syringes at least once in the past 30 days. Participants used their syringes a median of three times [IQR: 2–10, range: 1–95]. Nearly half (49%) of the sample used their syringes more than three times and 18% used them more than 10 times. Rates of syringe reuse increased by nearly 30% for each 10-year increase in age [RR: 1.29, 95% CI: 1.09–1.53]. Compared to participants who obtained the majority of their syringes from an SSP or pharmacy, those whose main source of syringes were secondary exchange [RR: 2.44, 95% CI: 1.22–4.88], people who sell drugs or needles [RR: 1.65, 95% CI: 1.18–2.31], and family, friends, or having found them [RR: 1.90, 95% CI: 1.35–2.68] reported higher rates of syringe reuse. Participants who lived further from an SSP had higher rates of syringe reuse, including those who lived beyond walking distance but within a 30-minute drive [RR: 1.47, 95% CI: 1.17–1.85] and further than a 30-minute drive [RR: 1.55, 95% CI: 1.01–2.37]. Finally, those who reported higher street prices for syringes were more likely to reuse syringes [RR: 1.56, 95% CI: 1.01–2.41 for those reporting a price of $3 USD to $4.99 USD, and RR: 2.82, 95% CI: 1.82–4.37 for those reporting a price of $5 USD or greater compared to those who reported a price of less than $3 USD]. Notably, there was no statistically significant difference in the rate of syringe reuse by sex, access to transportation, houselessness, drug injected, or frequency of injection equipment sharing. Adjusted models revealed similar results (Appendix A).

Discussion

This study explored factors linked to syringe reuse among people who inject drugs in Appalachian Kentucky. Findings revealed frequent syringe reuse in this rural sample, where more than three in every four participants reused their syringes at least once in the past 30 days. Participants who were older, reported a higher street syringe price, obtained the majority of their syringes from sources other than SSPs and pharmacies, and lived further from an SSP had higher rates of syringe reuse.

The prevalence of syringe reuse in this study approaches that of a hospital-based study of people who inject drugs diagnosed with injection-related infections in rural Maine, wherein 81% had reused their syringes (Thakarar et al., 2021). That the prevalence of syringe reuse in our community-based sample rivals that of a sample of hospitalized with injection-related infections is alarming. Of further concern, participants reused their syringes multiple times; nearly half reported using each of their syringes more than three times and nearly one-fifth used each syringe more than 10 times. Similarly, the frequency of reuse is alarming: needles are designed for single-use; they become dull within two to three uses, and are blunt by the fourth or fifth use (Majcher et al., 2018), potentially elevating risk for bacterial infection (Harvey et al., 2022).

In this study, participants who obtained most of their syringes directly from programs (i.e., SSPs and pharmacies) had far lower rates of syringe reuse than those who obtained most of their syringes from other sources. These findings add to the body of evidence from Canada (Hayashi et al., 2010), Iran (Nazari et al., 2016), Myanmar (O’Keefe et al., 2018), and the U.S. (Huo & Ouellet, 2007; Marotta et al., 2021) demonstrating that SSP use is associated with decreased syringe reuse. Of note, this finding was driven by SSP use, as 17% reported SSPs as their primary source of syringes and only 1% reported pharmacies as their primary source of syringes. This is unsurprising given pharmacy-level barriers to syringe access in Kentucky: individuals without a prescription are required to self-pay, and at the time of data collection, pharmacies were required to maintain a detailed log of syringe sales to individuals without a prescription. Additionally, there were higher rates of syringe reuse among those living further from an SSP. Previous research from the U.S. highlights distance as a constraint to SSP utilization in rural communities (Thakarar et al., 2021). Expanding services to mobile SSPs and mail delivery options may overcome distance as a barrier to obtaining sterile syringes.

This study is one of the first to reveal an association between street syringe price and syringe reuse. Previous research has shown that in areas with strictly enforced injection paraphernalia laws, the street price of syringes is significantly more expensive (Rich et al., 2000), with decreased access to sterile syringes (Rich et al., 2000). This study extends this research by revealing an association between syringe price and reuse, potentially suggesting that syringe price may be an intermediary in the association between strict paraphernalia laws and reuse. Of note, syringes sold on the streets may not always be sterile, making it critical for people who inject drugs to have access to reliable resources for obtaining syringes (Rich et al., 2000).

While this study had many strengths, there were limitations. The wording of the outcome question asked about “syringe reuse”. While local people who inject drugs use “syringe” and “needle” synonymously and most studies refer to “syringe reuse” (Marotta et al., 2021; Nazari et al., 2016; Rich et al., 2000), syringe and needle reuse are technically different and may confer different risks for infection creating a challenge for interpretation. Also, some recall periods (i.e., houselessness and access to transportation) were assessed over a 6-month timeframe while the outcome variable examined past 30-day behavior. Finally, causality and temporality cannot be inferred due to the cross-sectional nature of the study.

This study is the first to our knowledge to examine syringe reuse in a community-recruited sample of rural people who inject drugs. Syringe reuse was common, but these data suggest that increased access to syringe SSPs might reduce syringe reuse and related harms. Likewise, policy changes to loosen paraphernalia laws around injection supply possession might reduce street syringe price (Rich et al., 2000) and syringe reuse (Rich et al., 2000). In all efforts, it is critical that relevant interventions incorporate the perspectives of people who inject drugs and leverage salient reasons for wanting to reduce reuse, including venous care and injection site pain. Finally, in the context of limited access to or direct utilization of SSPs or pharmacies for syringes, harm reduction efforts should promote bleaching syringes and needles between repeated uses while ensuring that clients understand that these are not failsafe approaches.

Highlights.

• Research on repeated use (reuse) of syringes for injection drug use is limited.

• Reuse of one’s own syringes can confer risk for major bacterial infections.

• Syringe reuse is highly prevalent in this rural sample of people who inject drugs.

• Nearly half the sample reported using each syringe more than three times.

• Use of and proximity to syringe service programs were associated with less reuse.

Abbreviations

IDU

injection drug use

SSP

syringe service program

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to the highly sensitive nature of the data but may be available from the corresponding author upon reasonable request.