Written by a Public Health Researcher at the request of the Needles Solutions Team
Supervisor “check your cynicism” Leopold feels that the public should not question the syringe service program (SSP) that is administered by the County Health Services Administration because it is “evidence-based”. The term “evidence-based” apparently says it all and no more discussion should be necessary from the common folk.
But what exactly is the “evidence”?
The evidence in “evidence-based” comes from research and although systematic reviews of studies, which might also include a quantitative component known as meta-analysis, have found methodological weaknesses and bias in the research on syringe service programs [1,2], there is general consensus of the obvious fact that using a clean syringe prevents the spread of disease.
But, the evidence is one-sided.
The evidence is only as useful as the research questions asked. According to one researcher who conducted a meta-analysis of research on syringe service programs, most of the studies primarily focus on information essential to demonstrate SSP effectiveness to funding sources and/or governmental units [2]. Thus, the primary focus of research on syringe programs is on benefits to people who inject drugs (PWIDs) with little or no mention of any adverse effects on the communities in which syringe programs are found.
And, few studies focus on effects of SSPs on communities where they are located.
It would be helpful if, in response to members of the public who voice concerns about the syringe service program housed at the County Health building, Supervisor Leopold would cite “evidence” from studies that look at the effect of SSPs on the community. Very few studies exist and it would be very helpful if Supervisor Leopold could locate and present these studies to the concerned public.
The studies have methodological shortcomings.
In his response to the Grand Jury report regarding the Santa Cruz County syringe service program, Dr. Arnold Leff cites a study that compared the prevalence of improperly discarded syringes in a city with SSPs (San Francisco) to one without SSPs (Miami) [3]. Although, the researchers found a higher prevalence of improperly discarded syringes in Miami, the limitations and methodological shortcomings of this study are numerous. The researchers admit that data was obtained in two different years, in 2008 in San Francisco, and 2009 in Miami. To count discarded syringes, the researchers conducted visual inspection walkthroughs of census blocks. However, in San Francisco, only one side of each randomly selected census block was inspected as compared to 4 sides of each selected census block in Miami. The researchers “mathematically adjusted” for this difference by multiplying the number of discarded syringes found in San Francisco by four. The authors of this study admit that they cannot generalize their results to other areas of each city, where behavior of PWIDs might differ.
The Needles Solutions Team has collected data but the County HSA does not consider it to be “evidence.”
Why does Dr. Leff cite a study with methodological shortcomings and issues of generalizability when we have data that was gathered in Santa Cruz County? If Supervisor Leopold and Dr. Leff care so much about evidence, why do they downplay evidence that was collected here? For over 4 and one-half years, the TBSC Needles Solution Team has carefully documented over 15,000 discarded syringes found in public. This is evidence!
Why does the Santa Cruz County SSP refuse to label the syringes they dispense even though such marking would help with research? In fact, one study, conducted in San Francisco, put color bands on syringes dispensed at exchanges so that the researchers could track them [4]. The researchers found that half of all marked syringes returned within two-weeks of being dispensed and 61% returned within the study period. The researchers also found that the rate of return of syringes varied between stationary syringe program sites and roving syringe program sites. It would be nice to obtain this kind of data right here in Santa Cruz, especially considering mobile syringe service is a local topic of discussion.
If Supervisor Leopold and Dr. Leff care so much about evidence, let’s start by working together to gather and interpret evidence where it’s highly applicable to our community, right here in Santa Cruz County.
References
[1] Fernandes, R. M., Cary, M., Duarte, G., Jesus, G., Alarcão, J., Torre, C., Carneiro, A. V. (2017). Effectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews. BMC Public Health, 17, 309. http://doi.org/10.1186/s12889-017-4210-2
[2] Ksobiech, Kate. (2004). Assessing and improving needle exchange programs: gaps and problems in the literature. Harm Reduction Journal 20041:4
[3] Tookes, H. E., Kral, A. H., Wenger, L. D., Cardenas, G. A., Martinez, A. N., Sherman, R. L., Metsch, L. R. (2012). A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs. Drug and Alcohol Dependence, 123(1-3), 255–259.
[4] Joseph Guydish, PhD, MPH, Geoge Clark Delia Garcia, Moher Downing, Patricia Case, and James L. Sorensen, PhD. (1991). Evaluating Needle Exchange: Do Distributed Needles Come Back? American Journal of Public Health; May 1991, Vol. 81, No. 5 (pp. 617-619)
