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:
- create links to other health care and social services;
- create links to substance abuse treatment; and
- open the door for doctors and patients to discuss and take action on a range of high-risk behaviors and activities.
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:
- patients are not requesting prescriptions for more syringes than they are using;
- most patients report appropriate disposal of syringes; and
- some drug-use behaviors have declined.
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:
- Prescribing syringes should be one element of a comprehensive relationship between the physician and the patient and should be done within the context of the patient's overall medical and health needs.
- Success is more likely if physicians can work with IDU patients in a non-judgmental, culturally sensitive way that includes an openness to discussing injection-related activities and a willingness to provide links to other needed programs and services.
- In these discussions, physicians should first emphasize the dangers of continued injection and urge their patients to stop injecting. Recommending reducing or stopping drug use without alienating the patient can be challenging, however. Training or continuing education may help physicians improve their skills and abilities to deal with these sensitive drug use issues.
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
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:
- believed that syringe prescription was a useful tool for preventing transmission of blood-borne infections;
- were willing to prescribe if it were clearly legal, though none had ever prescribed a syringe for the express purpose of preventing infection in an IDU; and
- had doubts about the legality of physician prescription; many expressed concern that they could lose their medical license or be sued if they prescribed syringes to IDUs.
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:
- Physician prescription of injection equipment is legal in 48 of the 52 jurisdictions (it is illegal in Delaware and Kansas). In two other jurisdictions (Ohio and Oklahoma) physicians have a "reasonable claim to legality." This means that the laws in that jurisdiction neither explicitly allow nor forbid prescribing or dispensing, so that an attorney "acting ethically and in good faith" could argue that the practice was legal.
- It is also legal for pharmacists to fill the prescriptions in 26 states (it is illegal only in Delaware, Kansas, Georgia, and Hawaii). In 22 other jurisdictions they have a "reasonable claim to legality."
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.
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:
- become willing to openly acknowledge and discuss patients' injection drug use;
- accept that syringe prescription is helpful to the patient because it can prevent disease; and
- become more knowledgeable about the issue, how to recognize patients who may be IDUs, and how to help IDU patients.
IDUs may need to:
- overcome fear and mistrust of physicians and the medical establishment and be open to developing a trusting relationship with a physician; and
- be willing to discuss their concerns about any legal ramifications of having a prescription (for example, will it help them if they are stopped by the police?).
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.
Check Out These Sources of Information
- American Medical Association (AMA). Access to sterile syringes. Chicago (IL): AMA; June 2000.
- Burris S, Lurie P, Abrahamson D, Rich JD. Physician prescribing of sterile injection equipment to prevent HIV infection: time for action. Annals of Internal Medicine 2000;133(3):218-226.
- Infectious Diseases Society of America (IDSA). IDSA public statements and positions: supporting document for IDSA's policy statement on syringe exchange, prescribing and paraphernalia laws. Alexandria (VA): IDSA; November 2000.
- Rich JD, Macalino GE, McKenzie M, Taylor LE, Burris S. Syringe prescription to prevent HIV infection in Rhode Island: a case study. American Journal of Public Health 2001;91(5):1-2.
- Rich JD, Whitlock TL, Towe CW, et al. Prescribing syringes to prevent HIV: a survey of infectious disease and addiction medicine physicians in Rhode Island. Substance Use & Misuse 2001;36(5):535-550.