Who Purchases Nonprescription Syringes? Characterizing Customers of the Expanded Syringe Access Program (ESAP)

Abstract

This study represents the first attempt in the USA to survey pharmacy nonprescription syringe customers at their point of purchase. We surveyed 62 individuals purchasing nonprescription syringes in seven pharmacies located in NYC and Albany, NY, USA. Three quarters of respondents purchased for illicit use, and 36% purchased for medical use, with differences found by race and gender. Half got their syringes from pharmacies “most of the time.” Half had ever been refused a syringe purchase in a NYS pharmacy, with men, Blacks, and Hispanics reporting higher levels of refusals than women or whites. Two thirds reported syringe reuse but very few reported sharing. While approximately one quarter safely obtained and disposed of syringes “most of the time,” two thirds used both safe and unsafe methods. Pharmacy-based syringe access programs are essential in areas not served by syringe exchanges.

Background

Access to sterile injection equipment for injection drug users (IDUs) is necessary to reduce the spread of blood-borne diseases. Nonprescription syringe sales are legal in 45 states; however, little is known about individuals who purchase them.

The Expanded Syringe Access Program (ESAP), implemented in NYS in 2001, permits providers to register with the New York State Department of Health (NYSDOH) to sell/furnish ≤10 syringes per transaction without a prescription to individuals ≥18 years. ESAP supplements the work of syringe exchange programs (SEPs) by providing access to sterile syringes in areas not served by SEPs and expanded access in areas which are. There are 16 SEPs (45 sites) in NYS versus approximately 3,000 ESAP-registered pharmacies.

Most studies describing ESAP utilization have focused exclusively on IDUs, identifying them in venues where they congregate.^1–10 The current study represents the first US attempt to survey pharmacy customers at point of purchase, allowing for inclusion of non-IDU syringe users (e.g., prescription drug users) in the sample.

Methods

Ten ESAP-registered pharmacies in Albany (n = 5) and the Bronx (n = 5) who were enrolled in ESAP demonstration projects were invited to participate. All agreed, but only seven pharmacies were able to enroll customers. Each pharmacy was instructed to attempt to enroll ten customers at their store. Sixty-two customers participated from seven pharmacies (three pharmacies, 28 customers in Albany; four pharmacies, 32 customers in the Bronx). Participant demographics were as follows: 81% male, 45% Hispanic/Latino/a, 40% white, 13% Black/African American, 2% Native American, mean age 36 years (range 18–72).

This study was approved by the NYSDOH Institutional Review Board. Customers purchasing nonprescription syringes between March 2006 and January 2007 were told their purchase qualified them for a survey. Participants received a $10 pharmacy gift certificate.

The survey was one page, self-administered, anonymous, written at the 4th grade reading level, and available in English and Spanish. Topics included reason for purchase, usual source of syringes, purchasing patterns, needle sharing, usual disposal methods, and demographics.

Results

Purchase

Seventy-four percent reported purchasing syringes to inject illicit drugs, and 36% purchased to inject prescription medications (Table 1). Black (100%) and Hispanic (96%) respondents were more likely than whites (40%) to purchase for illicit use (p < 0.001). There were no differences in illicit versus prescription use by gender or age. Fifty-three percent ever tried to buy a nonprescription syringe in a NYS pharmacy and were refused. Whites were less likely than Blacks or Hispanics to have been refused (36% vs. 63% and 68%, p < 0.05); males were more likely than females to have been refused (60% vs. 25%, p < 0.05), with no significant difference by age (Table 1).

Table 1.

Study outcomes by customer demographics

	Purchased to inject illicit drugsa	Purchased to inject insulin or other prescription meds	Ever tried to purchase in NYS pharmacy and been refused	Syringe source			Syringe disposal
				Exclusively safe syringe source	Combination safe/unsafe syringe source	Exclusively unsafe syringe source	Exclusively safe disposal method	Combination safe/unsafe syringe disposal method	Exclusively unsafe disposal method
Race (n)b
White (25)	40.0 (10)	56.0 (14)	36.0 (9)	36.0 (9)	60.0 (15)	4.0 (1)	32.0 (8)	60.0 (15)	8.0 (2)
Black/African American (8)	100.0 (8)	25.0 (2)	62.5 (5)	12.5 (1)	75.0 (6)	12.5 (1)	12.5 (1)	75.0 (6)	12.5 (1)
Hispanic/Latino/a (28)	96.3 (27)	17.9 (5)	67.9 (19)	17.9 (5)	82.1 (25)	0.0 (0)	14.3 (4)	71.4 (20)	14.3 (4)
Significancec	X2 = 25.0, p < 0.0001	X2 = 6.6, p < 0.05	X2 = 7.0, p < 0.05	ns			ns
Gender (n)
Male (50)	78.0 (39)	28.0 (14)	60.0 (30)	11 (22.0)	74.0 (37)	4.0 (2)	20.0 (10)	66.0 (33)	14.0 (7)
Female (12)	58.3 (7)	66.7 (8)	25.0 (3)	5 (41.7)	58.3 (7)	0.0 (0)	33.3 (4)	66.7 (8)	0.0 (0)
Significancec	ns	ns	X2 = 4.2, p < 0.05	ns			ns
Age (n)d
34 or younger (31)	74.2 (23)	25.8 (8)	41.9 (13)	22.6 (7)	71.0 (22)	6.5 (2)	9.7 (3)	67.7 (21)	22.6 (7)
35 or older (30)	73.3 (22)	46.7 (14)	63.3 (19)	30.0 (9)	70.0 (21)	0.0 (0)	36.7 (11)	63.3 (19)	0.0 (0)
Significancec	ns	ns	ns	ns			X2 = 11.7, p < 0.01
Total (62)	74.2 (46)	35.5 (22)	53.2 (33)	25.8 (16)	71.0 (44)	3.2 (2)	22.6 (14)	66.1 (41)	11.3 (7)

ns not significant

^aIncludes purchases to inject (1) heroin, cocaine, speedballs, crystal meth., speed, ice, or other amphetamines and/or (2) nonprescription steroids. Responses to reason for purchase are not mutually exclusive

^bOne Native American individual excluded from race analysis

^cSignificance based on Pearson chi-squared tests, with Fisher’s exact tests used when cell sizes were below 5

^dOne individual who did not disclose age excluded from age analysis

Injection practice

Two thirds (66%) of participants purchased <10 syringes in the past month; 21% purchased 11–30, and 13% purchased over 30 (enough to sustain sterile injection at least once a day). Eighty percent reported injecting at least once a day. Sixty percent reported reusing the same syringe (10% always and 50% sometimes). Twenty-six percent ever shared, and 10% shared in the past month. There were no differences in sharing or reuse by race/ethnicity, gender, or age (data not displayed).

Source of syringe

Forty-four percent reported obtaining syringes through ESAP “most of the time.” Usual syringe source was divided into safe (pharmacies or SEPs), potentially unsafe (partner/family member/friend, stranger/someone they did not know, or a drug dealer), or a combination of safe/potentially unsafe. Overall, 26% indicated obtaining syringes exclusively from safe sources; 3% obtained exclusively from potentially unsafe sources, and the remainder (71%) got them from a combination. Prescription users were more likely to obtain syringes safely than illicit users (50% vs. 17%, X² = 6.9, p < 0.05, data not displayed). There were no differences by race/ethnicity, gender, or age (Table 1).

Syringe disposal

Usual disposal methods were divided into exclusively safe, exclusively unsafe, and a combination of safe (syringe disposal collection box, medical waste/fitpack container, other puncture-resistant container, SEP, or hospital/nursing home/clinic) and unsafe (throwing them loose in the trash, down a toilet or sewer/storm drain, on the ground, or selling/giving them away) disposal methods. Twenty-three percent disposed safely; 11% disposed unsafely, and 66% used a combination of methods (Table 1). Customers who purchased for prescription use were more likely to always dispose safely than those who purchased for illicit use (44% vs. 15%, X² = 5.6, p = 0.06) (data not displayed). Older participants were more likely to always dispose safely than younger participants (37% vs. 10%, p < 0.01; Table 1). There were no differences by race/ethnicity or gender.

Discussion

To our knowledge, this is the first reported description of US pharmacy-based syringe access program customers. ESAP customers are purchasing primarily to inject illicit substances; however, just over one third are purchasing to inject prescription medications. Most respondents reported purchasing fewer syringes than necessary to sustain a sterile once-a-day injection practice, and less than half acquire syringes exclusively from safe sources. Just over half had ever been refused a nonprescription syringe purchase, which was associated with both race and gender. Being refused a sale can be discouraging for someone who was already hesitant to purchase syringes. The racial and gender findings are distressing and are confounded by the fact that minority participants were more likely to purchase for illicit use. Training ESAP pharmacists to sell needles/syringes without restriction to anyone who asks would help ESAP become a more user-friendly program. In addition, educating potential customers about effective communication methods for obtaining syringes, as well as the locations of ESAP-friendly pharmacists is also encouraged.

Only one quarter of the sample reported exclusively safe disposal of their needles. NYS requires hospitals and nursing homes to operate residential sharps collection programs and has set up 100+ alternative community disposal sites across the state. Continued outreach efforts to pharmacy owners and syringe users regarding disposal activities, practices and locations are encouraged.

This study is limited by its small sample size and, therefore, results should be interpreted with caution; however, the demographics resemble IDUs in large studies conducted in NYS.^1–3,8 Conducting a survey about syringe use at the point of purchase proved to be logistically challenging. Despite this, further research is encouraged to shed light on differential sales practices of ESAP-registered pharmacists. The study is also limited by the fact that only pharmacies actively engaged with ESAP (those participating in state-funded demonstration projects to promote ESAP) were sampled. While this may not be representative of all ESAP-registered pharmacies in the state, it does allow us to view a snapshot of what is happening when the program is being implemented as intended.