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Physician Prescription of Sterile Syringes to Injection Drug Users

December 2005

Injection drug users (IDUs) who continue to inject can substantially reduce their risk of acquiring or transmitting HIV, hepatitis B and C, and other blood-borne infections if they use sterile syringes. Physician prescription of syringes is one way to improve IDUs' access to sterile injection equipment. It also can help IDUs obtain medical services and substance abuse treatment.

Injection Drug Users Are at High Risk of HIV and Hepatitis. They Also Need Medical Care and Substance Abuse Treatment

HIV and hepatitis B and C can be transmitted directly when infected IDUs share syringes with others. These viruses can also be transmitted when infected IDUs jointly prepare and use drugs and share other drug injection equipment. As a result, the U.S. Public Health Service and other scientific and governmental agencies have recommended that IDUs who continue to inject should always use sterile syringes and use them only once. This recommendation is a central strategy in the effort to prevent HIV and other blood-borne diseases. However, IDUs often have difficulty obtaining sterile syringes because of laws, regulations, and pharmacy and prescription rules that limit the sale and possession of syringes.

Many IDUs also suffer from other serious problems, including drug overdoses, sexually transmitted diseases (STDs), liver disease, tuberculosis, abscesses, bacterial infections, mental illness, and violence.

Because of the illicit nature of their drug use and the stigma attached to it, IDUs often fear and mistrust health care providers and have few or no links to regular health care or social services. This reduces their chances to obtain needed medical care and enter substance abuse treatment.

Physician Prescription of Sterile Syringes Can Help IDUs in Several Important Ways

Because physicians are key gatekeepers to syringe access, efforts to encourage them to prescribe syringes to IDUs will help ensure that those who continue to inject can legally obtain sterile syringes. Involving physicians also illustrates the medical rationale for increasing IDUs' access -- that improving access to sterile syringes has a legitimate medical purpose in preventing disease.

Physician prescription on its own may not have a large-scale public health impact, but it adds another valuable option to efforts to improve IDUs' access to sterile syringes.

Encouraging physician involvement in syringe prescription has another important benefit -- it provides a way for programs and providers to reach out to high-risk and stigmatized individuals. Placing syringe prescription within a broader physician-patient relationship can:

The Rhode Island Experience

Currently, few physicians in the United States prescribe syringes to IDUs. However, a research study in Rhode Island is examining the feasibility of physician prescription in a community care setting, with promising results.

In the spring of 1999, the state's Department of Health, with the support of the Rhode Island Medical Society, the Rhode Island Pharmacists' Association, the Rhode Island Board of Medical Licensure and Discipline, the Rhode Island State Board of Pharmacy, and others, invited all the state's physicians to participate in a clinical program to prescribe sterile syringes to IDUs. In her letter of invitation, the director of the Health Department informed physicians that syringe prescription was legal.

This pilot program now operates at two locations and includes a staff of four physicians, one substance abuse referral specialist, one nurse, one interviewer, and one administrator. To date, the clinic has prescribed more than 60,000 syringes to 350 participants. Participants who have received syringe prescriptions have also received basic clinical exams, medical care, tests for HIV and viral hepatitis, hepatitis A and B immunizations, and links to substance abuse treatment and social services. The services are provided free of charge. An in-depth evaluation of the program is underway. Preliminary findings indicate that:

Economic studies have concluded that Syringe Exchange Programs (SEPs) are also cost effective. At an average cost of $0.97 per syringe distributed, SEPs can save money in all IDU populations where the annual HIV seroincidence exceeds 2.1 per 100 person years.

Fostering Physician Prescription Requires Work on a Community and Individual Level

The Community Level

As the Rhode Island experience shows, communities that are working to encourage physician prescription can help the process by obtaining the support of the state and local health departments, pharmacy boards, medical boards, and other key stakeholders. Formal endorsement and promotion of this practice by these bodies can do much to reassure physicians that this activity is both legal and a legitimate medical practice.

Communities also should act to educate and persuade physicians, pharmacists, and other health providers about the public health and individual benefits of prescribing sterile syringes to IDUs and how it should be done within the medical care setting. Education about how to help patients dispose of syringes appropriately and safely should also be included. Establishing regular communication among interested physicians, through periodic meetings or a newsletter, may stimulate physicians' willingness and ability to work with IDUs. Tracking physician prescription activity, evaluating its outcomes, and publishing these data can be another important way to cultivate support.

The Individual Level

Individual physicians who wish to prescribe sterile syringes to IDU patients should first know the legal status in their community of prescribing syringes to IDUs. Other important recommendations include:

Physicians should document in the patient's medical record the recommendation to stop injecting and the need and rationale for the decision to prescribe syringes (similar to that done for any other prescription). Physicians should also record alternative options that have been explored, such as referrals to substance abuse treatment.

Physician Prescription of Syringes to IDUs Is Feasible but It Faces Challenges

Legal Issues

In 1999, at the start of the Rhode Island study, the investigators conducted a survey of all the state's infectious disease and addiction medicine physicians on their attitudes toward and practices in prescribing syringes to IDUs. The responses of these physicians may well echo those of others around the country. Responding physicians:

Prescribing and dispensing sterile injection equipment is governed principally by state law. An analysis (see Burris et al., 2000) of the laws in all 50 states, the District of Columbia, and Puerto Rico showed that prescribing and dispersing injection equipment to patients as a means of preventing disease transmission during drug use is clearly legal in most states:

The authors of this analysis note that although states differ, physicians generally have broad discretion to prescribe drugs and devices that they believe are medically beneficial for their patients. Several major medical and legal societies, including the American Medical Association, the Infectious Diseases Society of America, and the American Bar Association all support efforts to improve IDUs' access to sterile syringes, including physician prescription.

Attitudinal Issues

For physician prescription to become more common, both physicians and IDU patients may need to gain a greater understanding of the issues facing people who inject and how to address health behaviors that might be changed. Physicians may need to:

IDUs may need to:

To Learn More About This Topic

Read the overview fact sheet in this series on interventions regarding IDUs' access to sterile syringes -- Access to Sterile Syringes. It provides basic information, links to the other fact sheets in this series, and links to other useful information.

Visit these Web sites of the Centers for Disease Control and Prevention to get:

Visit the Web site of Law, Policy and Public Health at Temple University's Beasley School of Law. This site provides an analysis of the legality of prescribing and dispensing of sterile injection equipment to injection drug users who cannot or will not enter drug treatment.

See the Winter 2001 issue of Health Matrix: Journal of Law-Medicine. A special feature entitled "Symposium: Legal and Ethical Issues of Physician Prescription and Pharmacy Sale of Syringes to Patients Who Inject Illegal Drugs" includes five papers that present the rationale for physician prescription of syringes and explore related legal and ethical issues. Health Matrix: Journal of Law-Medicine 2001:11(1):1-147.

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