Evidence-based safer injecting equipment for users of illicit drugs
Submitting InstitutionUniversity of Bath
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
The health of people who inject illicit
drugs, the formulation of harm-reduction policies, and the work of
associated businesses and social enterprises have all benefited from the
University's laboratory and practice research into the safety and efficacy
of materials and equipment used in needle-exchange programmes. The
research has informed the development of safer acids for injection
preparation, safer injecting paraphernalia (e.g., spoons and filters) and
an information film which has been distributed from needle exchanges on
DVD and viewed over 50,000 times online. The research has led to enhanced
support and protection for injecting drug misusers, and to advances in
harm reduction in the UK, France and Canada.
The key contextual information is that, according to estimates, over
300,000 people in England are dependent on opiates and/or crack cocaine (Hay,
G., Gannon, M., Casey J., Millar, T., (2010) Estimates of the prevalence
of Opiate Use and/or Crack Cocaine Use, 2009/10: Sweep 6 report. http://www.nta.nhs.uk/uploads/prevalencestats2009-10fullreport.pdf).
Many of them inject these drugs and this entails multiple risks. The road
to abstinence can be long and often requires many attempts at sustaining a
drug-free lifestyle. Harm reduction is an accepted approach that aims to
cut the damage caused by illicit drug-taking. In 2003 and 2005, UK
legislation was changed to permit the supply of injecting paraphernalia,
including acids to facilitate solubility of drugs, preparation vessels
(e.g., spoons) and filters to remove particles from injections. There is
no requirement in law for this equipment to be tested for safety or
effectiveness prior to marketing, but there are consumer protection and
moral issues around the supply of untested equipment. These are drivers of
the research at Bath.
The research underpinning the impacts described in Section 4 is a blend
of practice research and laboratory-based pharmaceutical science
In 2002-03, Dr Jennifer Scott (Senior Lecturer in Pharmacy Practice and
Medicines Use at Bath since 1999) and Rhys Ponton (Bath PhD student,
2002-06) interviewed and observed injecting drug users to establish a
reproducible method of heroin injection preparation as a basis for
scientific study. This method was built upon and expanded by Scott in
2003-04 through work undertaken in collaboration with researchers at the
University of Paisley and funded by the Scottish Executive. The work also
looked at the preparation of crack cocaine injections. The outcomes were
reproducible, controllable preparation methods for a range of illicit drug
injections, allowing detailed study in the laboratory of each aspect of
Laboratory work in 2001-03 by Scott and in 2003-05 by Scott and Ponton
using street heroin examined the use of various acids in the
injection-preparation process. These investigations included a
microbiological comparison of the use of household products with
sterilised, pharmaceutical-grade citric acid . The work also looked at
resulting drug content in prepared injections, to establish user
acceptability and aspects of injection stability. In addition, the
researchers studied the performance of filters for use by injecting drug
users (IDUs) and produced data on acceptable pore size and flow rate .
Laboratory work by Scott from 2005 to 2006, funded by the Scottish
Executive, examined the safety and effectiveness of a wider range of
filters in more detail, as well as the leakage of aluminium from
preparation vessels. The results of this work led to the development of
the aluminium-free Spoon® by Frontier Medical and modification
to the Stericup® by Association Apothicom.
Work by Scott during this time, conducted in collaboration with Bristol
Drugs Project, also focused on the microbiology of the hands of injecting
drug misusers. It compared the performance of two methods of hand
References to the research
1. Ponton, R. & Scott, J. `Injection preparation processes used by
heroin and crack cocaine injectors', Journal of Substance Use,
9(1): 7-19, 2004. DOI: 10.1080/14659890410001665041
2. Scott, J. `Laboratory Study of the Effectiveness of Filters used by
Heroin Injectors', Journal of Substance Use, 10:5, 2005. DOI:
Details of the impact
Research at Bath has had an impact on:
- Practitioners and services, evidenced by the supply of improved and
new products, literature and web information by Exchange Supplies,
Association Apothicom and Frontier Medical.
- Public policy, evidenced by the influence on the Advisory Council on
the Misuse of Drugs and subsequent health policy.
- And, through these, on the health and welfare of drug misusers.
Impact on practitioners and services
Exchange Supplies is a social enterprise, formed in 2001, which
provides products, information and services that reduce the harms of
illicit drug use. Dr. Scott has been collaborating with Exchange to
examine the use of various acids in the injection-preparation process and
the resulting drug content in prepared injections. An important impact of
this research was its crucial influence on the development by Exchange
Supplies of Citric and VitC acidifier sachets, which are much safer than
alternatives, such as lemon juice, often used by injecting drug users. The
Managing Director of Exchange Supplies has remarked , "We have had
a long association with Dr Jenny Scott at the University of Bath, whose
understanding of the chemistry of illicit drug injection process is
second to none. When we were first establishing the business, and
developing our first product (a single use sachet of citric acid to be
added to heroin or crack cocaine as a safer alternative to vinegar or
lemon juice) the advice we received from Dr Scott was invaluable. Her
research provided a scientific rationale for the amount, and type, of
acid we should supply in the sachet. The positive impact of launching
the product on the basis of a solid scientific foundation in its
subsequent success cannot be underestimated".
The move to evidence-based provision of the products manufactured by
Exchange Supplies by most NHS services in the UK has been the foundation
upon which the company has been built and transformed into a thriving
social enterprise, turning over almost £3 million per year, and employing
15 people. The Exchange team includes current and former drug users for
whom paid, flexible and supportive employment, and additional training
opportunities, are provided .
The Managing Director further notes that , "Dr Scott's expert
evidence to the Advisory Council on the Misuse of Drugs was a
significant causal factor in them recommending amendments to the Misuse
of Drugs Act so that acids, spoons, filters and foil could be legally
provided. This combination of impact on injecting drug users technique,
drug worker practice, and UK public policy have combined to achieve
significant impact on the health and welfare of injecting drug users
both in the UK and worldwide".
Correct use of the Citric product was encouraged via the production of a
collaborative film by Dr Scott and Exchange Supplies in 2006 . This
demonstrated in the laboratory the correct use of Citric with street
heroin, and addressed concerns that injectors had been using the whole
sachet rather than the correct amount, an error which could (and did)
result in vein damage. The DVD was distributed to needle exchanges, it was
shown in waiting rooms, and handed out free to IDUs. In 2008, a drug user
activist posted the film on YouTube, prompting Exchange Supplies to launch
a YouTube channel and publish the film in HD format. Total YouTube views
for both versions of the film currently stand at over 50,000.
Association Apothicom (France), a not-for-profit association
created in 1992 for information and prevention, conducts public health
research programmes and develops tools for drug use-related harm
reduction. Apothicom created and developed a unique prevention
kit, Steribox™, and invested considerable effort to make it
available to illicit drug users. Subsequently, Stericup®
and Sterifilt®, single-use cup and filter,
respectively, completed the kit. Today, Steribox2™, which
contains these prevention tools, is supplied by pharmacies, syringe
exchange programmes and automatic vending and dispensing machines. The
founder of Apothicom, has stated , "Dr Scott's efforts were pivotal
in the early 2000s in convincing the U.K. Home Office to change its
position on harm reduction tools for illicit drug users (specifically,
the supply of acidifying agents and the provision of sterile filters).
Evidence presented by Dr Scott to the U.K. Advisory Council on the
Misuse of Drugs (ACMD) informed subsequent legislation changes on
paraphernalia supply. In turn, this convinced the French authorities
that the supply of harm reduction tools for drug users was warranted.
Further, Dr Scott alerted Apothicom in 2008 of a possible risk
associated with the metal composition of our Stericup®,
a problem which has now been resolved such that 50,000 drug users are
now using this tool every day".
As further examples of the reach of Dr Scott's research and its impact in
the REF period, in 2009, Apothicom and the Centre de Biologie Médicale
Spécialisée de l'Institute Pasteur, Paris, sought permission from the
Scottish Executive to translate the `Study of Safety, Risks and Outcomes
from the Use of Injecting Paraphernalia'  into French, to inform French
policy on needle exchange equipment supply. Apothicom's founder also notes
that, "Jenny Scott's report, `Study of the Safety, Risks and Outcomes
from the Use of Injecting Paraphernalia' (Edinburgh: Scottish Executive,
March 2008) is a reference work for French decision makers, and greatly
influenced our document, "Référentiel de Réduction des Risques". Her
work has contributed to best practice recommendations and to ensure that
harm reduction supplies are available to public health services in many
countries. For example, her studies are often cited when a choice
between acidifiers or other materials is to be made; as an illustration,
see Best Practice Recommendations for Canadian Harm Reduction Programs
That Provide Service to People Who Use Drugs and Are AT Risk For HIV,
HCV, and Other Harms (2013)". 
Frontier Medical Group (Wales) provides a range of safe and
appropriate products (usually distributed through pharmacies) for the
prevention of harm in intravenous drug users. One of Frontier's products
was an aluminium cup in which IV drug users dissolved heroin in water,
typically adding an acidifier and applying heat. Scott undertook research
to address a concern that there was a risk that aluminium from the cup
might contaminate the "hit" and cause harm to the user. Although this work
revealed that the cups were in fact quite safe, and that the release of
aluminium was unlikely to pose a health risk, Frontier decided, on the
basis of Scott's results, to develop its own brand stainless steel spoon
that is now a highly successful product, millions of which have been sold
throughout the world .
Bristol Drugs Project (BDP). Scott's work  with BDP included a
focus on the microbiology of the hands of injecting drug misusers. A
comparison of the performance of two methods of hand cleansing resulted in
the crafting and distribution of an advice pamphlet for intravenous drug
users. Subsequently, in collaboration with Scott, BDP introduced Safer
Injecting Workshops with four main foci: (a) use of a clean needle for
each injection, (b) rotatable sites, (c) good technique for preparation
and injecting, and (d) hygiene (including hand washing). As BDP's former
Harm Reduction Team Leader notes : "... as a result of [Scott's]
initial research, all washing facilities were revamped and hand-washing
Gel dispensers were liberally installed around [BDP's] buildings and
mobile units for clients to use".
Impact on policy
Professor David Nutt, past chair of Advisory Council on the Misuse of
Drugs (ACMD), invited Dr Scott to give evidence to this group on three
occasions. The first two presentations informed the 2003 and 2005 changes
in legislation on paraphernalia supply. The third gave an overview of
research conducted for the Scottish Executive, which is cited in a 2009
ACMD report  which informs current policy on hepatitis C prevention.
Funding from the Scottish Executive and the publication on the Internet
in 2008 of the report called `Study of the Safety, Risks and Outcomes from
the Use of Injecting Paraphernalia'  led to a change in policy, not
only in the UK but also in France and Canada during the REF period .
The 2011 Harm Reduction Training Manual published by the British Columbia
Harm Reduction Strategies and Services department, part of the British
Columbia Harm Reduction Program, used Scott's research findings to
evidence their advice on paraphernalia use .
Health and welfare of drug users
The Managing Director of Exchange Supplies affirms that Scott's research,
expert advice and advocacy: "on injecting drug users' technique, drug
worker practice, and UK public policy have combined to achieve
significant impact on the health and welfare of injecting drug users in
the UK and worldwide" . This view is fully endorsed by the
Programmes Coordinator of the International Network of People who Use
Drugs (INPUD, a global network that seeks to represent current and former
drug users in international agencies, e.g., the UN, and those undertaking
international development work), who states , "[Scott] has been
active in training practitioners working with drug treatment
organisations... [her] involvement has reduced significant harm to many
of the drug using communities".
Thus, in summary, the main beneficiaries of this research are:
- Injecting drug users, who now have access to a range of sterile,
fit-for-purpose equipment that has been tested for theoretical safety
despite no legal requirement to do so. This has benefited their
individual health. The supply of equipment has attracted IDUs into
needle exchange services, which by proxy is thought to have contributed
to the control of blood-borne viruses such as HIV and hepatitis C.
- Policymakers and harm-reduction agencies in a number of countries have
been able to develop their thinking and their practical approaches in
the light of scientific evidence from Bath.
- Companies that manufacture and distribute injecting paraphernalia,
including Exchange Supplies and Association Apothicom have benefited
from the provision of scientific data that has guided product
development, contributing to the uptake of new products by health
professionals and injecting drug users.
Sources to corroborate the impact
- Letter from the Managing Director of Exchange Supplies (UK).
- Letter from the Secrétaire General, Association Apothicom (France).
- J. Scott, "Safety, Risks and Outcomes from the Use of Injecting
Paraphernalia", (final report of the findings of a study into the impact
of providing paraphernalia to injecting drug users), Scottish Government
Social Research, 2008,
- `Harm Reduction Training Manual' (for frontline staff involved in
harm-reduction strategies and services). Vancouver: British Columbia
Harm Reduction Strategies and Services. January 2011. Available online:
- Letter from the Group Managing Director, Frontier Medical Group
- Email from the former (now retired) Harm Reduction Leader (until
2013), Bristol Drugs Project.
- `The Primary Prevention of Hepatitis C Among Injecting Drug Users'.
Advisory Council on the Misuse of Drugs, London: Home
Office, February 2009. (research referenced on pages 22 and 35).
- Letter from the Programmes Coordinator of INPUD.