International Journal of Drug Policy 14 (2003) 373–379

Impact of expanding syringe access in New York on sources of syringes

for injection drug users in Harlem and the Bronx, NYC, USA
Sherry Deren a,∗ , Crystal Fuller b,1 , Enrique R. Pouget a,2 , Shannon Blaney b,3 ,
Stephanie Tortu c,4 , Sung-Yeon Kang a,5 , James M. McMahon a,6 , Jonny F. Andia a,7 ,
Don C. Des Jarlais a,d,8 , Bruce Johnson e,9 , Andrew Rosenblum f,10 , David Vlahov b,11
a Institute for AIDS Research, Center for Drug Use and HIV Research, National Development & Research Institutes, Inc.,
71 West 23rd Street, 8th Floor, New York, NY 10010, USA
b Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029, USA
c Department of Community Health Sciences, Tulane University School of Public Health and Tropical Medicine,

1140 Canal Street, Suite 2301, New Orleans, LA 70112, USA

d The Edmond de Rothschild Foundation, Chemical Dependency Institute, Beth Israel Medical Center,

1st Avenue and 16th Street, New York, NY 10003, USA

e Institute for Special Populations Research, National Development & Research Institutes, Inc.,

71 West 23rd Street, 8th Floor, New York, NY 10010, USA

f Institute for Treatment and Services Research, National Development & Research Institutes, Inc.,

71 West 23rd Street, 8th Floor, New York, NY 10010, USA

Received 1 December 2002; received in revised form 15 March 2003; accepted 18 June 2003

Abstract

Beginning in January 2001, it became legal for pharmacies, health care facilities and certain health care providers in New York State
(NYS) to sell or provide syringes (10 maximum) without prescription. Cross-sectional survey data from three research projects recruiting
active injection drug users (IDUs) in Harlem and the South Bronx (n = 682) were analysed by calendar quarter, from January 2001 through
September 2002, to assist in an evaluation of the impact of the program, the Expanded Syringe Access Demonstration Program (ESAP). The
outcome variable examined was having used a pharmacy as the source of the last injection syringe. The percent of IDUs who knew that it
was legal to buy a syringe from a pharmacy increased over time (25–54%, P < 0.001). Pharmacy as the source of the last injection syringe
increased to approximately 20%, and syringe exchange programmes (SEPs) remained the most common source (approximately 50%). In a
multiple logistic regression analysis, IDUs who knew it was legal were more likely to have purchased their last syringe from a pharmacy
(AOR = 4.65, CI = 2.58–8.36). Pharmacies were more likely to be used by those who were younger (AOR = 0.96, CI = 0.93–0.99)
and those who were White (AOR = 2.55, CI = 1.30–5.00), and calendar quarter was a significant independent predictor of pharmacy use
(AOR = 1.22, CI = 1.06–1.40). Overall, these data indicate that: (a) knowledge about the option of purchasing syringes from a pharmacy
has increased, but enhanced dissemination efforts to IDUs, especially particular sub-groups, are needed; and (b) pharmacies were becoming
a supplemental source of syringes for active IDUs (in communities served by SEPs).
© 2003 Elsevier B.V. All rights reserved.

Keywords: Injection drug use; Pharmacy; Syringe access; AIDS; HIV; Substance use

∗ Corresponding author. Tel.: +1-212-845-4463; fax: +1-917-438-0894. 3 Tel.: +1-212-419-3541; fax: +1-212-876-6220.
E-mail addresses: deren@ndri.org (S. Deren), cfuller@nyam.org 4 Tel.: +1-504-988-4535; fax: +1-504-584-3540.
(C. Fuller), pouget@ndri.org (E.R. Pouget), sblaney@nyam.org 5 Tel.: +1-212-845-4457; fax: +1-917-438-0894.

(S. Blaney), stortu@mailhost.tcs.tulane.edu (S. Tortu), kang@ndri.org 6 Tel.: +1-212-845-4553; fax: +1-917-438-0894.

(S.-Y. Kang), McMahon@ndri.org 7 Tel.: +1-212-845-4580; fax: +1-917-438-0894.

(J.M. McMahon), andia@ndri.org (J.F. Andia), dcdesjarla@aol.com 8 Tel.: +1-212-387-3803/845-4463;

(D.C. Des Jarlais), bruce.johnson@ndri.org (B. Johnson), fax: +1-212-387-3897/917-438-0894.

rosenblum@ndri.org (A. Rosenblum), dvlahov@nyam.org (D. Vlahov). 9 Tel.: +1-212-845-4500; fax: +1-917-438-0894.
1 Tel.: +1-212-822-7391; fax: +1-212-876-6220. 10 Tel.: +1-212-845-4528; fax: +1-917-438-0894.
2 Tel.: +1-212-845-4488; fax: +1-917-438-0894. 11 Tel.: +1-212-822-7391; fax: +1-212-876-6220.

0955-3959/$ – see front matter © 2003 Elsevier B.V. All rights reserved.
doi:10.1016/S0955-3959(03)00137-3
374 S. Deren et al. / International Journal of Drug Policy 14 (2003) 373–379
Introduction
In January 2001, as part of HIV prevention efforts in
New York State (NYS), the Expanded Syringe Access
Demonstration Program (ESAP) legislation was imple-
mented. ESAP provided for pharmacy sales of syringes (10
maximum), without prescription, to individuals who were
at least 18 years of age. Thus, although carrying a syringe
is criminalised in New York State, an exemption applies for
syringes in the possession of individuals who can prove reg-
istration at a needle exchange programme or needle posses-
sion through ESAP. The legislation also allowed for syringe
availability, without prescription, through health care facili-
ties (e.g. hospitals and clinics) and private physicians. The
legislation required that eligible providers register with the
NYS Department of Health (NYSDOH), and also mandated
an independent evaluation to assess the impact of ESAP
in regard to a wide range of possible outcomes, including
syringe sharing, substance use, pharmacy practice, acci-
dental needlestick, syringe disposal and education on safe
use and disposal (New York State Department of Health,
2001).
Regulations regarding the sale, distribution and posses-
sion of syringes exist throughout the United States (Gostin,
Lazzarini, Jones, & Flaherty, 1997). In response to the
AIDS epidemic among IDUs, several states, in addition
to New York, have recently revised or repealed laws to
permit pharmacy sales of syringes without a prescription
(i.e. Connecticut, Maine, Minnesota and Rhode Island), and
some have been evaluated (Case, Beckett, & Jones, 1998;
Groseclose et al., 1995; Singer, Baer, Scott, Horowitz, &
Weinstein, 1998; Valleroy et al., 1995). Efforts to legalise
pharmacy sales have resulted in reduced syringe sharing
(Cotton-Oldenburg, Carr, DeBoer, Collison, & Novotny,
2001; Groseclose et al., 1995), however there were indica-
tions that pharmacists had concerns about selling to IDUs
(Case et al., 1998; Wright-De Aguero, Weinstein, Jones, &
Miles, 1998).
In New York, a survey of pharmacists’ attitudes regarding
non-prescription sale of syringes, conducted prior to ESAP
implementation, indicated that 66% of pharmacies state-
wide would be likely to participate (Klein et al., 2001). By
November 2002, there were more than 2500 ESAP regis-
tered providers, consisting primarily of pharmacies (98.4%)
(New York State Department of Health, 2002). These were
estimated to represent approximately 62% of all community
pharmacies in the State. Preliminary results indicate a slow
increase in pharmacy sales since implementation, although
geographic differences in the level of use have been reported
(Des Jarlais, McKnight, & Friedmann, 2002; Fuller et al.,
2002), and no evidence of harmful effects (e.g. increases in
discarded syringes) has been found. This paper, based on
data for IDUs in communities that are served by syringe
exchange programs (SEPs), reports on changes in knowl-
edge of the ESAP provisions regarding syringe availability,
sources of syringes used, and the relationship between
socio-demographic characteristics and having purchased
the syringe used for the last injection from a pharmacy.
Methods
Recruitment
As part of the ESAP evaluation a standardised ques-
tionnaire about syringe use was incorporated into three
ongoing studies of drug risk behaviour in Harlem and the
South Bronx, two urban New York City communities. The
questionnaire included items about (a) the date of the last
injection; (b) the syringe used for the last injection (source,
disposal and cost); and (c) knowledge of the law regard-
ing syringes. Data on socio-demographic characteristics of
study participants were available from the existing ques-
tionnaires. All studies had been approved by their local
Institutional Review Boards and study participants provided
written informed consent. Only those participants who had
been interviewed since January 2001, who reported recent
(prior 30 days) injection drug use, and who provided in-
formation on the source of the syringe used for their last
injection, were included in the analyses. Subjects who
were unaware of ESAP were informed and given an ESAP
pamphlet after the interview. Individual study criteria are
described below.
The Alliance for Research in El Barrio and Bayamon
(ARIBBA, S. Deren, PI) project (Deren et al., 2003) at
National Development and Research Institutes (NDRI) in-
vestigates HIV-related risk and health behaviours of injec-
tors and crack smokers in East Harlem (and Puerto Rico).
Locations for recruitment by outreach workers were devel-
oped based on ethnographic mapping of drug “copping”
and using locations. Criteria for recruitment included: (a)
aged 18 or over, (b) self-report as Puerto Rican, (c) injected
drugs or smoked crack within the prior 30 days, and (d)
recent use of heroin or cocaine (verified by urinalysis). The
project recruited participants in 1998–1999 for a longitu-
dinal study. Cross-sectional data for the ESAP evaluation
is from the follow-up interviews conducted since January
2001 with participants in the East Harlem location.
The Couples at Risk (CAR, S. Tortu, PI) project at NDRI
(Tortu, McMahon, Hamid, & Pouget, 2002) is a cross-
sectional study of risk behaviours of women drug users in
East Harlem and their main heterosexual partners (relation-
ship duration at least 1 year). Participants are recruited us-
ing referrals and targeted sampling methods canvassing all
sectors of East Harlem. Criteria for women’s participation
include: (a) 18 years of age or older, (b) self-reported use
of crack/cocaine or heroin (injected or non-injected) in past
30 days, (c) current male sex partner identified as primary
partner for at least 1 year; (d) had unprotected vaginal or
anal sex with current partner in prior 6 months, (e) able to
enlist partner in study enrollment, (f) would not feel threat-
ened participating in the study with primary partner, and (g)
 S. Deren et al. / International Journal of Drug Policy 14 (2003) 373–379
must not have participated in HIV/AIDS-related study or
attended HIV counselling and testing session in prior year.
Male partners of eligible women must be 18 years of age
or older to participate.
The Centre for Urban Epidemiologic Studies at the New
York Academy of Medicine provided baseline data from the
Hepatitis C Cohort Study (Hep C) and data from their Urban
Research Centre (URC) Cross-sectional Survey (D. Vlahov,
PI). The cohort study targeted young (15–35 years of age)
injection drug users who reported injection three or fewer
years, and the cross-sectional study targeted drug users in-
jecting more than 3 years. Both studies street-recruited IDUs
from East/Central Harlem and the South Bronx. Each study
captured high-risk injection and sexual risk behaviours, and
data from these two data sources, Hep C and URC, were
combined for this analysis (Fuller et al., 2002).
Analysis
Data from these three studies were combined (n = 682)
and analysed by calendar quarter (based on the date of the
last injection), from January 2001 through September 2002.
The quarters were defined as follows: (1) 1 January through
9 April 2001 (this quarter is extended through 9 April be-
cause NYSDOH began distributing information regarding
registered pharmacies on 10 April, the date that implemen-
tation was considered to be in effect for the purposes of
this evaluation); (2) 10 April through 30 June 2001; (3) 1
July through 30 September 2001; (4) 1 October through
31 December 2001; (5) 1 January through 31 March 2002;
(6) 1 April through 30 June 2002; and (7) 1 July through
30 September 2002. Grouping the results by calendar quar-
ter produced roughly equal cells and facilitated analyses of
trends.
Cochran–Armitage (C–A) tests for trend (Armitage, 1955;
Cochran, 1954), using calendar quarter as an ordinal vari-
able (i.e. 1–7), were used to assess the significance of
changes over time in knowledge of the law and syringe
sources. Chi-square tests were conducted to assess the rela-
tionships between selected socio-demographic characteris-
tics and pharmacy use. Variables significant at P < 0.05 in
bivariate analyses were entered into a multiple logistic re-
gression model. In the multivariate model, age was entered
as a continuous variable and calendar quarter was coded as
an ordinal variable.
Results
The socio-demographic characteristics of participants
from each of the three projects are consistent with the
particular aims of the individual projects (Table 1). Thus,
while males constitute approximately three quarters of the
participants in ARIBBA and URC, they are approximately
one-half of the CAR sample. The ARIBBA sample is 100%
Latino, and Latinos represent the largest category in the
375
other two samples. The total sample is approximately 68%
Latino, 20% Black and 9% White. Approximately, one-half
of all participants were at least 40 years of age, and the av-
erage number of years injecting was 17. In all three studies,
the mean number of days since last injection was less than
seven.
The percent of IDUs who knew that it was legal to buy a
syringe from a pharmacy increased over time from 25% (in
the first quarter of 2001) to 54% by the last period exam-
ined, and this increase was significant (C–A = −4.72, P <
0.001) (see Table 2). This increase primarily occurred be-
tween the first two periods (when approximately 25% knew
it was legal) and the last five periods (when this knowledge
was reported by about 50% of all participants). Knowledge
that it was legal to get a needle from a clinic showed a signif-
icant increase over time (C–A = −2.17, P < 0.05). Knowl-
edge that it was legal to obtain syringes from a hospital or
private doctor did not significantly change over time. Par-
ticipants were also asked if it was legal to carry a syringe,
and approximately 35–50% reported that it was legal during
each time period. The use of a pharmacy as the source of
the last syringe used remained relatively stable for the first
five quarters, reported by 3–11% of IDUs, and increased to
20–22% during the final two periods (C–A = −4.39, P <
0.001) (Table 3). SEPs remained the most frequent sources
of the last syringe used during all quarters (approximately
50%), but showed a significant decline over the study time
periods (C–A = 2.86, P < 0.01). The use of health care
facilities as a source of the last syringe used was not re-
ported until 2002. Although relatively few participants re-
ported this source, it resulted in a significant increase over
time (C–A = −2.84, P < 0.01). Friend/family was the sec-
ond most frequently cited source, with over 20% identifying
it as a source through five of the seven quarters; it dropped
below 20% during the fifth and sixth quarters, however, no
statistically significant change over time was found.
An examination of socio-demographic characteristics re-
lated to pharmacy use indicated that both male and female
IDUs were equally likely to report obtaining their last sy-
ringe from a pharmacy (Table 4). Pharmacy users were
younger (16% of those aged under 30 reported pharmacy
use, compared to 12 and 8% of those 30–39 and over 39,
respectively (χ2 = 6.6, d.f. = 2, P < 0.05). There was also
a significant difference by race/ethnicity (χ2 = 25.4, d.f. =
3, P < 0.01), with Whites more likely to report pharmacy
use for the syringe used at the last injection (30%) than all
other race/ethnic groups. Those who knew it was legal to
purchase syringes from pharmacies were more likely to have
purchased their last syringe from a pharmacy (20% versus
5%, χ2 = 39.6, d.f. = 1, P < 0.001).
The three variables significant in the bivariate analyses
(age, race/ethnicity, knowledge of the pharmacy legality),
and the variable representing number of calendar quarters
since inception of ESAP, were entered into a multiple lo-
gistic regression to assess their independent contribution to
predicting pharmacy use (Table 5). Knowledge of the legal-
376 S. Deren et al. / International Journal of Drug Policy 14 (2003) 373–379

Table 1
Socio-demographic characteristics and drug use behaviours among Harlem and Bronx IDUs, by project, 1 January 2001–30 September 2002 (n = 682)
ARIBBA (n = 110) CAR (n = 173) URC/Hep C (n = 399) Total (n = 682)

Gender (% male) 77.3 48.0 73.8 67.7

Ethnicity (%)
Black 24.9 23.7 20.2
Latino 100.0 49.1 66.4 67.5
White 22.5 5.6 9.0
Other 3.5 4.3 3.4
Age (% within group)
Under 30 7.3 12.7 22.0 17.2
30–39 34.5 35.8 36.9 36.2
40 and older 58.2 51.4 41.2 46.5
Age [mean (S.D.)] 41.2 (8.1) 39.4 (7.9) 37.0 (8.7) 38.3 (8.6)
Education
Less than H.S. grad. 60.9 49.1 54.9 54.4
H.S. grad. or GED 9.1 27.7 14.7 17.1
More than H.S. 30.0 23.1 30.4 28.5
Years injecting [mean (S.D.)] 20.5 (11.0) 16.6 (11.0) 16.3 (10.0) 17.1 (10.6)
Days since last injection [mean (S.D.)] 2.5 (3.9) 4.2 (5.8) 6.1 (8.7) 5.0 (7.6)
Note. Data were missing for 3 subjects for age and ethnicity, 4 subjects for education, 10 subjects for years injecting, and 7 subjects for gender. Also, 3
subjects indicated transgender or other gender and are not included in analyses of gender.

Table 2
Knowledge of the law by quarter among Harlem and Bronx IDUs, 1 January 2001–30 September 2002 (n = 675)
Percent who 1 January 2001–9 10 April 2001–30 1 July 2001–30 1 October 1 January 1 April 2002–30 1 July 2002–30
knew that it April 2001 June 2001 September 2001 2001–31 2002–31 March June 2002 September 2002
was legal to: (n = 68) (n = 136) (n = 106) December 2001 2002 (n = 110) (n = 81)
(n = 79) (n = 95)
Buy a needle from 25.0 27.9 45.3 46.8 46.3 48.2 54.3
a pharmacy∗∗∗
Get a needle from 19.1 8.8 14.2 12.7 8.4 15.6 17.5
a hospital
Get a needle from 10.3 10.3 15.1 13.9 12.6 16.4 21.3
a clinic∗
Get a needle from 8.8 9.6 13.2 10.1 7.4 14.5 11.3
a private doctor
Carry a needle 47.1 43.4 51.9 34.2 42.1 35.5 41.3
Note. For all items except “Buy a needle from a pharmacy”, one response was missing in the final (seventh) quarter.
∗ P < 0.05.
∗∗∗ P < 0.001.

Table 3
Source of syringe used for the last injection by quarter among Harlem and Bronx IDUs, 1 January 2001–30 September 2002 (n = 682) (percentage)
Source 1 January 2001–9 10 April 2001–30 1 July 2001–30 1 October 1 January 1 April 2002–30 1 July 2002–30
April 2001 June 2001 September 2001 2001–31 2002–31 March June 2002 September 2002
(n = 70) (n = 139) (n = 107) December 2001 2002 (n = 95) (n = 110) (n = 81)
(n = 80)
SEP∗∗ 54.3 66.2 56.1 43.8 57.9 48.2 43.2
Friend or family 27.1 20.9 24.3 30.0 17.9 13.6 24.7
member
Pharmacy∗∗∗ 10.0 2.9 7.5 11.3 6.3 21.8 19.8
Drug/needle 8.6 10.1 12.1 15.0 15.8 11.8 11.1
dealer
Health care 0.0 0.0 0.0 0.0 2.1 4.5 1.2
facilitya ,∗∗
aNo subjects indicated a private doctor as the source for their last syringe used.
∗∗ P < 0.01.
∗∗∗ P < 0.001.
 S. Deren et al. / International Journal of Drug Policy 14 (2003) 373–379 377

Table 4 Discussion
Bivariate associations with pharmacy source for last syringe used among
Harlem and Bronx IDUs, 1 January 2001–30 September 2002 (n = 682)
Within the first 2 years of ESAP implementation, it ap-
Pharmacy source for last pears that knowledge about the legality of purchasing sy-
syringe used (%) ringes from pharmacies has increased, however, only half of
Gender the IDUs enrolled in the most recent period were aware of
Male 11.0
legal non-prescription pharmacy syringe sales. In addition,
Female 9.7
knowledge about availability of syringes from other new
Age∗ (categories) legal sources, health care facilities and private physicians,
Under 30 16.2
30–39 11.8
was not widespread. Further dissemination of information
40 and older 7.9 regarding the needle deregulation is needed. Initial efforts to
implement ESAP by the NYSDOH focused on registering
Age∗∗ (continuous)
Pharmacy mean (S.D.) 35.4 (8.4) pharmacies, and more recent efforts have begun to address
Non-pharmacy mean (S.D.) 38.6 (8.5) the expansion of ESAP providers. Continued monitoring of
Race/ethnicity∗∗∗
knowledge of these sources is needed as these expansion
Black 7.3 efforts are developed.
Latino 9.2 Although NYS Public Health Law states that persons
White 29.5 legally possessing syringes (e.g. through SEPs or ESAP) are
Other 13.0 not subject to arrest or prosecution, the fact that syringe pos-
Knowledge of pharmacy legality∗∗∗ session remains a criminal offence in the New York Penal
Knew it was legal 19.9 Law (220.45) (Penal Law of the State of New York, 2001),
Did not know 4.6
may still influence participation levels. The data showed that
Note. Data were missing for 7 subjects for gender, 3 subjects for age approximately one-third to one-half of the IDUs participat-
and ethnicity, and 7 subjects for knowledge of pharmacy legality. Also, ing thought that carrying a needle was either illegal or they
3 subjects indicated transgender or other gender and are not included in
were unsure about its legal status, and this remained rela-
analyses of gender.
∗ P < 0.05. tively constant over the study periods. The perceived crimi-
∗∗ P < 0.01. nality or uncertainty regarding criminality is likely to reduce
∗∗∗ P < 0.001.
the level of participation in ESAP as well as other efforts
to increase availability of sterile syringes. Furthermore, al-
though persons can legally possess syringes under certain
ity of pharmacy sales was the best predictor of having pur-
circumstances, implementation has often been inconsistent.
chased the last syringe from a pharmacy, with odds of pur-
Only recently (Weiser, 2002) being arrested for drug pos-
chasing their last syringe from a pharmacy almost five times
session as a result of drug residue left in a syringe was al-
greater for those who knew it was legal (AOR = 4.65, 95%
lowed until a judge ruled that this was not the “intention” of
CI = 2.58–8.36). Race/ethnic group and age remained sig-
increased access syringe laws (e.g. SEPs or ESAP). Knowl-
nificant predictors of pharmacy use: Whites were more likely
edge of this new ruling, however, may not be widespread
to report pharmacy use than the other race/ethnic groups
among IDUs and fear of arrest likely remains.
(AOR = 2.55, 95% CI = 1.30–5.00), and those who were
The finding that men and women were equally likely to
younger were more likely to have reported pharmacy use
report obtaining their last syringe from a pharmacy is en-
(AOR = 0.96, 95% CI = 0.93–0.99). Calendar quarter re-
couraging. Research on SEPs has indicated that women are
mained a significant independent predictor of pharmacy use
under-represented in terms of SEP use (Lurie, 1993), and
(AOR = 1.22, CI = 1.06–1.40).
thus pharmacies may provide an important alternative for
new syringes for women who prefer not to use SEPs.
Table 5 There are some limitations to these data. The question
Multivariate logistic regression predicting pharmacy use among Harlem was based on the last syringe used, therefore the distribution
and Bronx IDUs (n = 672) of sources of syringes for those using multiple sources was
Independent variable Adjusted odds 95% CI not available. The data were collected after a period of de-
ratio clining HIV incidence and prevalence among IDUs in New
Age∗ 0.96 0.93–0.99 York (Des Jarlais et al., 2000; Maslow, Friedman, Perlis,
White∗∗ 2.55 1.30–5.00 Rockwell, & Des Jarlais, 2002), and thus may not apply to
Black, Latino, other = 0 communities in which seroprevalence has stabilised or is in-
White = 1
creasing. In addition, these three projects may not represent
Knowledge of pharmacy legality∗∗∗ 4.65 2.58–8.36
Calendar quarter∗ 1.22 1.06–1.40 all IDUs in the communities studied, nor all IDUs in NYS.
∗
In fact, the wide availability of SEPs serving the commu-
P < 0.05.
∗∗ nities in which these participants were recruited is atypical
P < 0.01.
∗∗∗ P < 0.001. for most communities.
378 S. Deren et al. / International Journal of Drug Policy 14 (2003) 373–379
Nonetheless, some important implications regarding
ESAP implementation emerge from these data. Although
knowledge about the ESAP pharmacy syringe sales was
increasing, additional efforts to disseminate information
about the various aspects of ESAP are needed. Enhanced
dissemination efforts to IDUs, either in locations where they
are likely to be found (e.g. SEPs, drug treatment programs)
or through service providers who have been able to contact
them in the past (e.g. HIV prevention outreach workers)
are needed. This appears to be particularly important for
the groups that have thus far under-utilised the availability
of needles from pharmacies, including minority IDUs and
older IDUs. To some extent, there may be a self-selection
process operating in terms of utilisation of pharmacy-
based programs: different syringe availability programs
(e.g. SEPs, pharmacy) may appeal to consumers with dif-
ferent demographic characteristics (Obadia, Feroni, Perrin,
Vlahov, & Moatti, 1999). Furthermore, a qualitative study
of pharmacist practices during the first year of ESAP noted
that pharmacists were equally likely to sell syringes to a
diverse group of purchasers (Finkelstein, Tiger, Greenwald,
& Mukherjee, 2002), implying that differential utilisation of
pharmacies may be based on choices of the potential con-
sumers rather than the pharmacists. Given the slow start of
the implementation and utilisation of the changes brought
about by the ESAP regulations (e.g. only about one-half of
IDUs are aware that needles can be legally purchased from
pharmacies more than 1 year after ESAP implementation),
the need to continue monitoring and evaluating the program,
with a particular emphasis on understanding the reasons for
under-utilisation among particular subgroups, is warranted.
The data also indicate that pharmacies were likely to be-
come a supplemental syringe source for active IDUs in com-
munities with SEPs, such as those in which the participat-
ing studies were conducted. Syringes were typically sold
in pharmacies as 10-packs for US$ 2–8, or for US$ 0.50
each when sold singly (Finkelstein et al., 2002; Fuller et al.,
2002). The availability of free needles at SEPs, often with
the addition of other harm reduction supplies and health-
related services (e.g. free condoms and referrals to health
and human services), is likely to result in the continuation
of SEPs as the main source of syringes. Nonetheless, even
in those communities well-served by SEPs, pharmacies may
play an important role in providing syringes for those IDUs
who: (a) may prefer to use SEPs but need to obtain syringes
during hours when the SEPs are not operating or (b) choose
not to use SEPs, and are willing to pay for syringes for rea-
sons of convenience or privacy.
Studies of the range of needle sources used by IDUs are
needed. Although the data indicate that an increase in phar-
macy use may be associated with a decline in SEP use,
an examination of IDUs’ sources of syringes over a longer
time period (not simply the last injection episode) can reveal
changes in the frequency of use among the various sources.
Longitudinal research is needed to determine whether those
who would normally get syringes from unsafe sources would
be likely to begin using pharmacies or those who tradition-
ally use SEP are likely to access syringes through pharma-
cies as well.
As pharmacy use increases, it may also be possible to
enhance services provided through pharmacies. For exam-
ple, recent research indicates that while needle reuse has
declined, the sharing of injection-related paraphernalia (in-
cluding cookers and cottons) remains high (Deren et al.,
2003). The very positive response of the majority of phar-
macies in NYS to ESAP indicates that the possibility of
expanding pharmacy service provision to IDUs, including
provision of harm reduction-related equipment and other
health-related services, should be assessed.
Acknowledgements
This study was supported by NIDA grant numbers
R01DA10424 (S. Deren, PI), P30DA11041 (S. Deren, PI),
R01DA12805 (S. Tortu, PI), R01DA14219 (D. Vlahov,
PI), and CDC grant number U48/CCU209663 (D. Vla-
hov, PI). The authors also acknowledge the assistance and
co-operation of Susan J. Klein of the NYS Department of
Health, AIDS Institute.
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