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© 2006 American Public Health Association
DOI: 10.2105/AJPH.2003.032698
HEALTH POLICY AND ETHICS |
At the time of this study, Ryan J. Deibert was in the MPH program in the Health Services Department, School of Public Health and Community Medicine, University of Washington, Seattle. Gary Gold-baum and Hanne Thiede are with the Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, and with Department of Public Health—Seattle–King County, Seattle. At the time of this study, Theodore Parker was with Public Health—Seattle–King County, Seattle. Holly Hagan is with the Center for Drug Use and HIV Research, National Development and Research Institutes, New York, NY. Robert Marks and Michael Hanrahan are with Public Health—Seattle–King County, Seattle.
Correspondence: Requests for reprints should be sent to Ryan J. Deibert, Oregon Department of Human Services, 800 NE Oregon St., Suite 1105, Portland, OR 97232 (e-mail: ryan.j.deibert{at}state.or.us).
ABSTRACT
We examined pharmacists’ attitudes and practices related to syringe sales to injection drug users before and after legal reform and local programming to enhance sterile syringe access. We replicated a 1996 study by conducting pharmacist phone surveys and syringe test-buys in randomly selected pharmacies.
Test-buy success increased from 48% in 1996 to 65% in 2003 (P=.04). Pharmacists agreeing that syringes should be available to injection drug users through pharmacy purchase increased from 49% to 71% (P<.01). Pharmacy policies and pharmacist attitudes were strongly associated with syringe access. Structural changes, including policy reform and pharmacy outreach, appear to increase syringe access. Interventions should address pharmacy policies and pharmacist attitudes and policies.
INJECTION DRUG USE accounts for approximately one third of all new HIV cases and approximately 60% of hepatitis C virus (HCV) infections in the United States.1,2 Transmission of blood-borne viral infections among injection drug users (IDUs) results from shared use of drug injection equipment, including syringes, drug cookers, and filtration cotton.3,4 Access to sterile injection equipment is associated with lower frequency of unsafe injection practices and reduced risk of infections.5–10 Access to sterile syringes does not appear to increase drug use, either by increasing the number of individuals injecting drugs, or by increasing frequency of injection.11–13
Worldwide, community pharmacies contribute to blood-borne disease prevention among IDUs by dispensing controlled substances with a prescription, selling new syringes, operating needle exchange services, and disposing of used syringes.14–17 Pharmacists in Minnesota, New Hampshire, New Mexico, New York, and Washington State are partnering with public health jurisdictions to increase pharmacy access to sterile syringes, generally resulting in increased pharmacy syringe sales without prescription, decreased HIV risk behaviors among IDUs, and increased syringe disposal options.18
Although most US states have legal restrictions on the sale and possession of syringes, pharmaceutical practice guidelines often allow pharmacists discretion in syringe sales decisions; this may lead to wide variation in syringe sales by individual pharmacists and to discrimination based on gender, age, race, ethnicity, or socioeconomic status.19–23 Individual-level factors associated with pharmacists’ relative willingness to sell syringes include familiarity with customers; concerns about deception, disease transmission, improperly discarded syringes, and staff and customer safety; business concerns, including fear of theft and harassment of other customers by IDU patrons; and fear of increased drug use because of easier syringe access.24–27
Syringe Use in Seattle–King County, Washington
Approximately 15000–20000 IDUs live in King County, Washington (including Seattle, Washington); 7 needle exchange programs operate throughout the county. Only 3% of King County IDUs are HIV infected, although 86% are infected with HCV, suggesting the potential for rapid spread of HIV among IDUs.4,28 Nearly half (47%) of recently arrested King County IDUs surveyed in a current study report purchasing syringes from pharmacies (H. T., personal communication, August 2003).
From 1999 to 2002, the Washington State Board of Pharmacy and Washington State Legislature made successive reforms to state laws and regulations governing pharmacy distribution and IDU possession of syringes.29 These reforms removed legal barriers to pharmacy sales of syringes to IDUs, with the current state law specifically exempting pharmacists from any penalties associated with syringe sales and allowing individuals over 18 years of age to possess up to 10 sterile syringes.
In March 2001, the Department of Public Health—Seattle–King County (PHSKC), with assistance from the Washington State Board of Pharmacy and the Washington State Pharmacy Association, began collaborating with community pharmacists to increase voluntary syringe sales to prevent blood-borne infections.30,31 Partnering pharmacies agreed to offer retail sale of sterile syringes to IDUs and provide verbal and written information to customers concerning syringe disposal, blood-borne disease prevention, substance abuse treatment, and HIV counseling and testing. PHSKC agreed to provide written materials for free distribution to customers; free, anonymous, and confidential HIV and hepatitis counseling and testing; and, if requested, free blood-borne disease prevention training for pharmacy staff. As of June 2003, 80 retail, public health, and clinical-setting pharmacies had entered partnerships.
We conducted our study to answer the following questions: (1) Did Seattle pharmacists’ reported attitudes and practices related to unrestricted syringe sales change following legal, regulatory, and syringe sales partnership interventions? (2) Did syringe availability, as measured using syringe test-buys, change following the interventions? (3) What factors may be associated with pharmacists’ reported attitudes, practices, and syringe availability? (4) Are pharmacists’ reported attitudes, practices, and syringe availability at pharmacies participating in PHSKC syringe sales partnerships different from those of pharmacists at nonparticipating pharmacies?
METHODS
We used a two-part, cross-sectional design to replicate the methods of a 1996 Seattle study.32 The 1996 study was limited to regions in Seattle; our study included those regions as well as all of King County outside of Seattle. Both studies included telephone surveys of pharmacists regarding their attitudes and practices related to pharmacy syringe sales to IDUs and syringe test-buys in selected retail pharmacies.
Pharmacist Telephone Survey
The population of interest was all full-time pharmacists engaged in pharmacy practice at eligible retail pharmacies in King County. "Full-time" was defined as practice at a given location more than 20 h per week or at least 50% of the practice’s operating time. Eligible pharmacies were all walk-up retail pharmacies, excluding pharmacies located in membership-restricted wholesale clubs, out-patient hospitals, nursing homes, and other clinical settings. We expected excluded pharmacies to be too inaccessible for many IDUs to buy syringes. Names, addresses, and phone numbers of all retail pharmacies in King County were obtained from the Washington State Board of Pharmacy.
Four researchers telephoned 280 eligible pharmacies to conduct a 20-question telephone survey with 1 eligible pharmacist at each pharmacy. All telephone surveys were conducted between 7:00 AM and 11:00 PM from February to June 2003 using a scripted survey instrument. The survey instrument was a direct replication of the one used in 1996, with 3 questions added regarding pharmacists’ awareness of recent Washington State policy changes and participation in the PHSKC syringe sales partnership program. Pharmacies selected for test-buys were not surveyed by phone until after test-buys were completed.
If an eligible pharmacy had closed, or if we were unable to reach a pharmacy by telephone, the pharmacy was excluded from analysis. If a survey was not completed in the first call, the pharmacy was called multiple times until a phone survey was completed or until an eligible pharmacist declined participation and no other eligible pharmacist at that pharmacy could be reached. If a pharmacist ended the interview before survey completion, completed answers were included in analyses, and no further calls were made.
Syringe Test-Buys
The population of interest included all pharmacies in King County eligible for inclusion in telephone surveys. Pharmacies were divided into 6 regions by ZIP code. Five regions in Seattle were defined utilizing the 1996 study methods; the sixth region included all ZIP codes in King County not included in the 1996 sampling frame. For comparative analyses and representation of results, we designated the 5 Seattle regions as "Seattle only"; we designated the sixth region as "Suburbs."
Again replicating 1996 study methods, 15 eligible pharmacies were randomly selected for test-buys within each of the 5 Seattle regions, and test-buys were conducted at the first 12 open pharmacies within each group. In the broader suburban region, addresses of pharmacies that were participating in PHSKC syringe sales partnerships, and addresses of nonparticipating pharmacies, were entered into mapping software (MapInfo 4.0; MapInfo, Troy, New York), geocoded, and plotted. To promote geographic diversity of sampling and adequate representation of pharmacies participating in syringe sales partnerships, we selected 1 participating pharmacy and the nearest 3 nonparticipating pharmacies for test-buys in 10 different suburban communities. If any of the nearest nonparticipating pharmacies had closed, the next-nearest nonparticipating pharmacy was selected for a test-buy instead.
Four test-buyers recruited from PHSKC outreach staff conducted all test-buys using a scripted protocol. Selected pharmacies were assigned to test-buyers on the basis of convenience as determined by geographic proximity. Each test-buyer wore casual dress, entered a selected pharmacy, immediately proceeded to the pharmacy counter, asked the first employee contacted if the pharmacy sold syringes, and asked to buy 10 syringes. Test-buys were successful if test-buyers were able to purchase 10 insulin or equivalent syringes without a prescription, presenting identification, or any other restriction preventing the purchase. To reflect local IDUs with respect to age, race, ethnicity, and gender, test-buyers included a 25-year-old African American male, a 29-year-old Latino male, a 36-year-old White female, and a 41-year-old White male.
Data Analyses
The 1996 study occasionally included phone survey data from multiple pharmacists at the same pharmacy. In these cases, we randomly chose the survey responses of only 1 pharmacist at each pharmacy for inclusion in our analyses. For analyses, responses "agree" and "mildly agree" were combined as "agreed," and responses "neither agree nor disagree," "mildly disagree," and "strongly disagree" were combined as "did not agree." Responses of conditional support of a survey statement were combined with nonconditional support and compared with responses of nonsupport. Responses to questions about policy or personal restrictions on sales of syringes were categorized as either "restricted" or "no restriction." All analyses related to participating versus nonparticipating pharmacies were restricted to 2003 data, as no syringe sales partnership program existed in 1996.
We used repeated-measures analysis of variance [ANOVA], 
2 tests of difference, or the 1-sided Fisher exact test (when possible) to examine differences in pharmacist attitudes and practices and test-buy success. Significance was evaluated at P 
.05; exact 95% confidence intervals (CI) were calculated for univariate odds ratios (ORs). To identify independent effects of pharmacist attitudes and practices, we compared forward and backward logistic regression models, entering factors identified as significant in univariate analyses to calculate adjusted ORs and 95% CIs. All analyses were conducted using EpiInfo 2002 (Centers for Disease Control and Prevention, Atlanta, GA) or SPSS 12.0 (SPSS Inc, Chicago, IL) statistical analysis software.
RESULTS
Changes in Pharmacist Attitudes and Practices, 1996 Versus 2003
Of 280 eligible pharmacies telephoned, 11 had closed or were otherwise unreachable. Of the remaining 269 eligible pharmacies, pharmacists at 41 pharmacies declined to participate, and 1 pharmacist ended the interview prior to completion of the survey. Surveys were completed at 227 pharmacies (overall response rate, 85%). Higher proportions of pharmacists reported practicing in corporate chain stores in 2003 than in 1996 (72% versus 58%, respectively, in Seattle [P = .03]) and in the suburban region than in Seattle (84% versus 72%, respectively, in 2003 [P = .02]). Lower proportions of pharmacists reported practicing for more than 10 years in 2003 (52%) than in 1996 (67%; P = .02). No other differences were observed among characteristics of surveyed pharmacists and their pharmacies over time and location.
Nearly all pharmacists surveyed in 2003 and 1996 agreed that pharmacists should play a part in helping to prevent the spread of HIV, hepatitis, and other blood-borne infections in the community (Table 1
). Most expressed a willingness to keep and maintain sharps containers for syringes brought in by the public.
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Significant changes over time were noted: compared with 1996, higher proportions of Seattle pharmacists surveyed in 2003 agreed that sterile syringes should be made available for purchase through pharmacies, personally felt that it is appropriate to sell sterile syringes to IDUs, reported personal policies allowing unrestricted sale of syringes, and expressed willingness to counsel IDUs regarding the hazards of illicit drug use. Despite apparent changes in pharmacist attitudes and personal policy, there was no accompanying shift in reported pharmacy policies, with fewer than half of surveyed Seattle pharmacists reporting that their pharmacy policy allowed unrestricted sale of syringes in both 2003 and 1996.
Seattle pharmacists reported different primary reasons for not selling syringes in 2003 versus 1996, with lower proportions of pharmacists expressing legal concerns in 2003 (0%) than in 1996 (18%). Business and safety concerns were the most frequently reported primary reasons for not selling syringes in both 1996 (28% business; 27% safety) and 2003 (28% business; 32% safety).
Practicing pharmacy less than 10 years was associated with willingness to counsel IDUs in 1996 ( 10 years = 85%; > 10 years = 53%; P < .01); no other responses that differed between surveyed Seattle pharmacists in 2003 versus 1996 were associated with duration of pharmacy practice. Among 2003 respondents, pharmacists in independent pharmacies were more likely than those in corporate chain pharmacies to agree that needles and syringes should be made available for IDU purchase through pharmacies (P < .01) and that it is appropriate to sell syringes to IDUs (P = .04). Among 1996 respondents, pharmacists in independent pharmacies were more willing to counsel IDUs regarding hazards of illicit drug use (P = .05). Among those interviewed in 2003, suburban pharmacists were more likely than Seattle pharmacists to report over-the-counter syringe sales in the past month; no other differences on the basis of pharmacy location were noted.
Changes in and Associations With Syringe Availability, 1996 Versus 2003
Of the test-buys conducted in 2003, 60 were in the 5 Seattle regions and 40 were in the suburban region. In Seattle, 23 test-buys (38%) were conducted by the African American male, 14 (23%) by the Latino male, 11 (18%) by the White male, and 12 (20%) by the White female. In suburbs, 7 test-buys (18%) were conducted by the Latino male, 12 (30%) by the White male, and 21 (53%) by the White female. In the 1996 Seat-tle study, 63 test-buys were conducted: 36 (57%) by an African American male and 27 (43%) by a White male. For test-buys, no significant differences in pharmacy employee characteristics (position of employment, estimated age, ethnicity, and gender) were noted in the 2003 Seattle test-buys versus the 1996 or versus the 2003 suburban test-buys. A greater percentage of Seattle test-buys (80% in 2003 versus 46% in 1996; P = .03) occurred in pharmacies owned by corporate chains.
Test-buy attempts were more successful in Seattle in 2003 than in 1996 (Table 1
). The median price per 10-pack of syringes in successful test-buys in 2003 was $3.57, with prices ranging from $1.94 to $6.51.
Telephone surveys were completed with a pharmacist at 59 of the 63 pharmacies (94%) where test-buys occurred in 1996, at 55 of the 60 pharmacies (92%) in Seattle in 2003, and at 30 of the 40 pharmacies (75%) in the suburbs in 2003. Of those pharmacies where test-buys were conducted but no phone survey was completed, 4 of 4 test-buys were unsuccessful in 1996, 5 of 5 were successful in Seattle in 2003, and 8 of 10 were successful in the suburbs in 2003. Because phone survey data were missing, these pharmacies were excluded from combined analyses.
For our univariate analyses of combined test-buy and phone survey data, factors other than test-buy year that were significantly associated with successful test-buys in Seattle were estimated age of pharmacy employee in test-buy to be less than 40 years and pharmacist reporting any of the following: agreement that syringes should be made available for IDU purchase through pharmacies; personal belief that it is appropriate to sell sterile syringes to IDUs; personal policy allowing unrestricted syringe sales; and pharmacy policy allowing unrestricted syringe sales (Table 2). In 1996, the African American test-buyer was successful in 42% of his attempts, and the White test-buyer was successful in 56% of his attempts (P = 0.20). In 2003 Seattle test-buys, African American, Latino, and White test-buyers were successful in 74%, 43%, and 70% of their attempts, respectively (P = 0.13). Test-buyer ethnicity was not significantly associated with test-buy success, nor was the position (pharmacist vs non-pharmacist) of the employee encountered for the test-buy (P = 0.12). Pharmacists’ personal policies were strongly associated with the policy of the pharmacy where they worked (P < .01).
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In multivariate models, only pharmacy syringe sales policies and pharmacist attitudes regarding syringe sales to IDUs independently predicted test-buy results. In a model restricted to Seattle—and including only pharmacy policies, pharmacist attitudes, and year—pharmacy policy was strongly predictive of a successful test-buy (OR = 5.2; 95% CI = 2.1, 12.8), pharmacist attitudes were moderately predictive (OR = 2.6; 95% CI = 1.0, 6.7), and year was no longer significant (OR = 1.4; 95% CI = 0.6, 3.4). Stratified analyses revealed that pharmacy policy and pharmacist attitudes influenced test-buy outcome differently for the 2 time periods. Although the proportion of pharmacies with policies permitting sales did not change over time, the ORs for successful test-buys were high (5.7; 95% CI = 1.6, 22.0) in 1996, and even higher (7.6; 95% CI = 1.7, 46.0) in 2003. In contrast, although the proportion of pharmacists who personally felt that syringe sales were appropriate increased over time, ORs for successful test-buys declined from 6.3 in 1996 (95% CI = 1.8, 24.1) to 2.3 in 2003 (95% CI = 0.5, 11.2).
Among the 100 pharmacies where test-buys were conducted in 2003, 40 (40%) were pharmacies participating in PHSKC syringe sales partnerships and 60 (60%) were nonparticipating pharmacies. Among the 227 pharmacists surveyed in 2003, 62 (27%) practiced at participating pharmacies and 165 (73%) practiced at nonparticipating pharmacies. No significant differences in pharmacist or pharmacy characteristics were observed by program participation status, although a slightly higher percentage of pharmacists reported practicing pharmacy for less than 10 years in participating versus non-participating pharmacies (58% and 46%, respectively).
Pharmacists in both participating and nonparticipating pharmacies agreed that pharmacists should play a part in helping to prevent the spread of HIV, hepatitis, and other blood-borne infections within the community and were willing to keep and maintain a sharps container on their premises for public use, distribute written materials to IDUs, and counsel IDUs 1-on-1. However, staff at participating pharmacies more frequently sold syringes in test-buys (34 out of 40 participating pharmacies [85%] vs 29 out of 60 at nonparticipating pharmacies [48%]; P < .01); reported having attitudes, personal policies, and pharmacy policies favorable to unrestricted selling of syringes to IDUs; and making over-the-counter sales of syringes and over-the-counter sales of syringes to IDUs in the past month.
DISCUSSION
In our study, legal, regulatory, and public health interventions appear related to increases in syringe test-buy success and to changes in pharmacist attitudes and personal and pharmacy policies. Local pharmacist attitudes and personal policies regarding syringe sales to IDUs increasingly favor unrestricted sales, with pharmacist support for unrestricted syringe sales at rates as high or higher than those observed in other US cities allowing unrestricted syringe sales.26,33,34 Although pharmacy policy was most strongly related to successful syringe purchasing, pharmacist attitudes and personal policy were also important. Similar results have been observed in other cities.24–27,32,35,36
Changes in pharmacists’ attitudes and practices coincided with several important structural changes during the intervening years: progressive reform of Washington State law and regulation to allow unrestricted pharmacy syringe sales; implementation of public health programs promoting syringe sales partnerships; and expansion of community syringe disposal options. Pharmacists’ decreased legal concerns as a primary reason for not selling syringes to IDUs suggests that legal changes have successfully removed that structural barrier to syringe sales.
Differences observed in pharmacist attitudes, personal policies, and pharmacy policies at pharmacies participating in PHSKC syringe sales partnerships compared with nonparticipating pharmacies suggest that (1) pharmacists in favor of unrestricted syringe sales are willing to participate in this disease prevention partnership; (2) the targeting of pharmacists for outreach, education, and recruitment has influenced individual-level attitudes and practices and pharmacy policies; or (3) some elements of both. Increased presence of pharmacy chains versus independent pharmacies indicates opportunity for advocacy to change pharmacy policy at corporate levels, although many corporate managers approached by PHSKC allowed individual pharmacist managers to set syringe sales policies in each pharmacy.
Limitations
Exact replication of 1996 sample populations was impossible, because links between pharmacy identifiers and data were destroyed following the 1996 study. Differences in test-buyer characteristics between the 1996 study and the current study may confound results, although the lack of association between test-buy success and test-buyer characteristics suggests that this is unlikely. For 2003 syringe test-buys, pharmacies were assigned to test-buyers by convenience (including test-buyer schedule availability), rather than random assignment; therefore, impacts of test-buyer characteristics (including ethnicity) and pharmacy location in test-buy success cannot be directly distinguished. The lack of a control city with no similar interventions further restricts clear causal inference. Although willingness of pharmacists to counsel and distribute written information to IDUs was measured, no attempt was made to determine the efficacy of such interventions. Further study may be useful in this area.
Several steps were taken to minimize the influence of these limitations on study results. By replicating 1996 methods, attempting phone surveys at all pharmacies in King County, and achieving a very high response rate, researchers minimized bias based on pharmacy location, relative IDU density, and other unmeasured variables. Lack of correlation in attitudes between individual pharmacists and their coworkers in the same pharmacy is a potential source of bias. However, the lack of association between position of employee encountered in test-buys and test-buy success, and strong association between pharmacists’ personal policies and the policy of the pharmacy where they worked suggests that practices of pharmacists and coworkers agree with store policy.
Conclusions
Public health policymakers view pharmacies as important components in broader strategies to improve access to sterile syringes. Studies on behalf of the US government conducted by the National Commission on AIDS,37 the University of California and the Centers for Disease Control and Prevention,38 the National Academy of Science,39 and the Office of Technology Assessment40 all concluded that syringe prescription and drug paraphernalia laws should be overturned or modified to allow IDUs to purchase, possess, and exchange sterile syringes. Modifying or repealing laws and regulations prohibiting syringe sales have been proposed to allow for public health disease control measures, such as needle exchange programs and pharmacy syringe sales to IDUs.19,41,42 Pharmacies are typically located throughout communities, and have extended operating hours. The flexibility and scale of pharmacy infrastructure could conceivably help meet substantial need for sterile syringes.
Structural changes, including legal and regulatory reform, removed legal barriers to syringe sales and likely contributed to increased syringe access in Seattle. Although pharmacy policies seem to play a significant role in determining pharmacy access to syringes, ultimately individual pharmacists choose whether to sell syringes or not. Interventions should target pharmacy policy and pharmacist attitudes and practices while responding to perceived barriers to unrestricted syringe sales. The collaboration between PHSKC and community pharmacists likely facilitated changes in pharmacist attitudes and practices and pharmacy policies. This intervention should be continued, and similar programs may increase syringe access in other cities.
Acknowledgments
This research was jointly funded by a grant from the US Centers for Disease Control and Prevention and the Association of Schools of Public Health (grant S1832-21/22).
The authors thank Bob Wood, AIDS Control Officer for King County, who provided general administrative oversight to the project, and Clarence Spigner, of the Department of Health Services at the University of Washington School of Public Health and Community Medicine, who reviewed initial drafts of the article.
Footnotes
Contributors
R. J. Deibert wrote the study protocol, conducted and supervised all 2003 data collection and analyses, and led the writing. G. Goldbaum was principle investigator and supervised and contributed to all aspects of study design, implementation, and analysis. T.R. Parker designed data collection instruments and sampling methods and conducted all 1996 data collection. H. Hagan originated the study and contributed to the writing. R. Marks contributed to study design and recruited pharmacies. M. Hanrahan contributed to study design and supervised pharmacy recruitment. H. Thiede contributed to study design, data collection, and analysis. All authors helped to conceptualize ideas, interpret findings, and review drafts of the article.
Accepted for publication October 9, 2005.
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