Professor Mike Kelly, PhD, FFPH. Director, The Centre for Public Health Excellence, NICE

1. NICE Guidance on “Needle and Syringe Programmes: Providing Injecting Equipment to People who Inject Drugs”. Professor Mike Kelly, PhD, FFPH. Director, The Centre for Public Health Excellence, NICE

2. Public Health at NICE • At NICE the Centre for Public Health Excellence develops public health guidance. • Established 2005 • 31 staff based in London and Manchester, plus collaborating centres based in Sheffield, Birmingham, Exeter, London, Oxford, Liverpool and York

3. MethodologicalPrinciples

4. Methodological principles governing all NICE’s work • Base recommendations on the best available evidence. • To determine cost effectiveness using the QALY. • To be open and transparent and to involve stakeholders. • To be clear about scientific and other values • To allow contestability. • To be seen to be independent of government, the pharmaceutical industry and other vested interests.

5. Origins of this referral • NICE does not choose the topics it works on these are determined by Ministers and Officials. • Prevention of infection of blood borne viruses. • To consider optimal provision.

7. Stages in the production of guidance • Scope drafted. • Public stakeholder meeting. • Stakeholder comments received. • Final scope and responses published on the website. • Reviews of evidence undertaken. • Public Health Interventions Advisory Committee (PHIAC) reviews the evidence and drafts recommendations. • Draft recommendations published on the website and stakeholders asked to comment. • PHIAC meets to consider stakeholder comments and evidence from fieldwork. • Publication.

9. Background • 115,000 - 200,000 injecting drug users (IDUs) in England • 23% of IDUs report recently sharing needles • Over 40% of IDUs are Hepatitis C positive • IDUs are ten times more likely to die prematurely than the rest of the population • In 2006, over 1400 deaths were linked to controlled drugs

10. Scope • The optimal provision of needle exchange and syringe programmes (NSPs) for people who injectillicit substances and non-prescribed anabolic steroids • Majority of NSPs are run by pharmacies and drug services • Some NSPs offer other services such as help to stoptaking drugs • This guidance refers to people of 18 years and older

11. Recommendations

12. Aims

13. Aims • To reduce the transmission of blood borne viruses and other infections. • To get people into treatment. • To help them get off drugs. • To provide advice on safer injecting practices. • To help avoid overdoses. • Safe disposal. • Access to testing , vaccination and treatment. • Access to other welfare services.

14. Audiences • NHS and other professionals with direct responsibility for NSPs. • Drug and alcohol action teams. • Pharmacies • Local authorities. • Voluntary and community sector.

15. Target population • People over the age of eighteen who inject drugs, opioids, stimulants or in conjunction. The guidance also applies to people injecting anabolic steroids and image enhancing drugs.

16. Needs assessment • Collect and analyse data locally on: • Prevalence and incidence of drug related infections; • Demographics of users; • Coverage; • Injectors in contact with NSPs. • Make sure services meet local need. • Consult users and communities.

17. Commission services which: • Are targeted and generic and • Increase the proportion of people who have 100% coverage; • Increase proportion of people in touch with services; • Ensure syringes and needs are available in a range of sizes and locations; • Offer advice; • Encourage people to stop or switch to non-injecting methods.

18. Commissioning (cont) • Deal with safe disposal. • Encourage identification schemes. • Commission integrated care pathways. • Audit and monitor services.

19. Levels of service and availability • Levels • Distribution of equipment. • Bespoke equipment and health promotion. • As above with access to specialist services. • Co-ordinate maximum opening availability. • Ensure that opioid substitution services also offer needles and syringes.

20. Equipment and advice • Provide adequate amounts of equipment to reflect need. • Provide sharps bins. • Ensure safer injecting advice is available. • Ensure that the hazards of using long needles are made clear. • Encourage people to switch to other methods of use. • Encourage people to mark their syringes. • Encourage them to stop.

21. In the community

22. In the community • Provide sharps bins. • Ensure staff receive appropriate training in health and safety. • Ensure staff doing levels 2 and 3 have training in doing health promotion. • Ensure that Hepatitis B vaccination is available for staff.

23. Specialist services

24. Specialist services • Provide sharps bins. • Have appropriate training. • Provide the full range of equipment. • Offer comprehensive harm reduction services. • Offer help. • Opioid substitution therapy. • Treatment of site infections. • Hep A and B and tetanus vaccinations. • Testing for Hep B and C and HIV.

25. Economics • Cost effective use of resources. • Savings to both the NHS and wider society.

26. Evidence based • Reductions in risky behaviour. • Reductions in HIV infection. • Reduction in A&E admissions. • Reduction in risky injecting practices. • Reduction in incidence of Hep C. • The reductions in HIV cost effective.

27. Find out more • Visit www.nice.org.uk/PH18 for the: • guidance • quick reference guide • Costing statement and costing template • audit support • local authority planning checklist • factsheet for commissioners

28. Conclusion

30. “First come I; my name is Jowett. There’s no knowledge but I know it. I am master of this college: What I don’t know isn’t knowledge.” The Masque of Balliol Revd. H.C. Beeching

32. It is very important not to get stuck in a very narrow interpretation of what evidence based public health means. • Must not fall into the trap of assuming the evidence speaks for itself…

33. Because • All evidence requires interpretation. • Absence of evidence of effect does not necessarily mean there is no effect. • Strong evidence of effect may not relate to the important issue. • So….

34. Interpreting the evidence of complex interventions requires an assessment of: • Plausibility: a scientific assessment – biologically, organizationally, socially, psychologically. • Likelihood of success: the nature of local conditions married to tacit knowledge of practitioners

35. And it is therefore important to: • Embrace a range of evidence • Evidence from trials and from other sources of systematic investigation • Evidence from practice