Needle and syringe programmes

Selecting relevant studies

For the assessment of effectiveness: systematic reviews of experimental and observational studies, randomised controlled trials, controlled non-randomised studies, controlled and uncontrolled before and after studies, cross-sectional studies, cohort studies, case-control studies and ecological studies were eligible for inclusion.

For the assessment of cost effectiveness: economic evaluations conducted alongside trials, intervention studies, modelling studies and analyses of administrative databases were eligible.

Qualitative research was excluded because there was no indication from intelligence gathering that views and experiences of service users and providers of services had changed substantially. Qualitative research in this area would therefore be unlikely to impact on the current recommendations.

Collating and analysing data on drug use

An expert stated that Public Health England (PHE) no longer has a needle exchange activity monitoring system available nationally. Concern was also expressed about the collection of evidence from needle exchanges in England. A suggestion was made to consider a more strongly worded recommendation on the use of a database such as 'Pharmoutcomes' to enable more detailed analysis on drug use. However, further feedback indicated that PHE does have sentinel surveillance through the unlinked anonymous monitoring survey included in People who inject drugs: infection risks, guidance and data. Data are also available via the national drug treatment monitoring system. As such, there is unlikely to be an impact on the guideline because the issues remain addressed in recommendation 2. However, this area may be explored further in a planned workshop for discussing the broader care pathway for the management of drug misuse.

Commissioning both targeted and generic services to meet local need

Experts stated that recommendation 3 advice for hepatitis testing could be strengthened given improvements in testing (particularly blood spot testing) and treatment. Treatment for hepatitis C in particular was considered to have been improved since the guideline was published. However, no evidence was cited or identified in the surveillance review that showed an impact on the recommendation, which is likely to remain valid. A cross reference will be made to the Department of Health and Social Care's Drug misuse and dependence: UK guidelines on clinical management to align with current national advice. The NICE Pathway on needle and syringe programmes will also link to the hepatitis section of the NICE Pathway on liver conditions, to cover hepatitis B and C testing and treatment technology appraisal guidance. This area may also be explored further in a planned workshop for discussing the broader care pathway for the management of drug misuse.

Use of low dead space equipment (LDS)

Recommendation 3 advises that services offer, and encourage the use of LDS injecting equipment. Recommendation 7 advises that needle and syringe programme providers should, where possible, make needles available in a range of lengths and gauges, provide syringes in a range of sizes and offer LDS equipment. New evidence highlighted by topic experts on LDS equipment supports the gradual implementation of this equipment, offered alongside existing equipment and supported by training and education. This is consistent with the NICE guideline and no impact is anticipated.

Provision of equipment and advice to people who inject image- and performance-enhancing drugs (IPED)

Topic experts highlighted data from PHE's Shooting Up: infections among people who inject drugs in the UK. However, this was limited to prevalence data, and the lack of evidence on the effectiveness of needle and syringe programmes for IPED users means there is unlikely to be any impact.

Experts indicated that there may be new evidence in the following areas, but did not cite any studies:

New evidence identified through the surveillance review in these areas was considered to be consistent with current recommendations, or would need to be substantiated by further, higher quality or more directly relevant studies to have a potential impact on the NICE guideline.

Detachable LDS syringes

A stakeholder commented that the guideline recommendations should distinguish between LDS fixed all-in-one needle and syringes, and detachable needle and syringes. Although recommendations 3 and 7 in the NICE guideline, do not distinguish detachable from fixed needle and syringes, they do highlight the importance of LDS injecting equipment provision. This advice is consistent with the recently updated Department of Health and Social Care's Drug misuse and dependence: UK guidelines on clinical management, which advises clinicians who work with people who inject drugs to offer and encourage the use of LDS injecting equipment to reduce infection and transmission risk.

Supervised consumption rooms (SCRs)

A stakeholder commented that the guideline should take account of new evidence supporting SCRs, to address the needs of people who inject drugs and are at risk of very high levels of mortality and morbidity. Recommendation 7 advises provision of equipment to people who inject drugs, and to encourage people who inject drugs to use other services as well as needle and syringe programmes. New review evidence indicates the potential value of SCRs, but was from non-UK settings and was limited by indirectness to England. A stakeholder submitted additional evidence applicable to Scotland. However, the UK government position is that there is no legal framework for the provision of SCRs in the UK and there are no plans to introduce them. As such, the guideline will not be extended to include SCRs at this time.

Additional areas

Stakeholders highlighted areas that they considered to be insufficiently covered by the guideline recommendations. This included the provision of take-home naloxone, hepatitis C testing, and advising against sharing needles and syringes when discussing harm reduction with service users. A cross reference will be added to the NICE guideline to the Department of Health and Social Care's Drug misuse and dependence: UK guidelines on clinical management, which provides national advice in these areas (see editorial amendments). An editorial correction is also proposed to ensure that the NICE Pathway on needle and syringe programmes will link to the hepatitis section of the NICE Pathway on liver conditions, to cover hepatitis B and C testing and treatment technology appraisal guidance.

Additional areas that stakeholders suggested for inclusion in the guideline were general health; involvement of nursing staff; skin infections; dental complications; sexualised drug use, sexual health and referral; and mobile needle and syringe units. However, because no evidence was provided in these areas, there is no impact on the guideline recommendations.

See appendix B for full details of stakeholders' comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

Recommendation 1

The cross reference to the NICE guideline on community engagement should be updated to the NICE guideline on community engagement: improving health and wellbeing and reducing health inequalities.

Recommendation 3

The cross reference to the Department for Environment, Food and Rural Affairs' Tackling drug-related litter (2005) should be replaced by Tackling drug related litter: guidance and good practice (2013). The existing link is still correct in directing to the replacement guidance and only the text needs updating.

Recommendation 6

The link is broken and the document has been archived in the recommendation 'Ensure services offering opioid substitution therapy also make needles and syringes available to their service users, in line with the National Treatment Agency Models of care for treatment of adult drug misusers: update (2006)'.

The text should be amended to state:

'Ensure services offering opioid substitution therapy also make needles and syringes available to their service users.'

Short version of the NICE guideline

The following text should be added to the end of the section on what is this guidance about?

See also the Department of Health and Social Care's Drug misuse and dependence: UK guidelines on clinical management, also known as the 'Orange Book', which provides advice to healthcare professionals on the delivery and implementation of a broad range of interventions for drug misuse, including those interventions covered in the present guideline.

Overview page of the guideline

A link should be added to NICE's quality standard on drug use disorders in adults.

NICE Pathway

Links should be inserted in the NICE Pathway on needle and syringe programmes to:

Social care

The following text should be inserted at the start of the recommendations section of the NICE guideline as per newer NICE guidelines: