Needle Syringe Programs

Key Messages

• Harm reduction practices support the needs of people who use substances.
• The overall aim is to reduce the harms associated with substance use, including to prevent the transmission of blood borne infections (BBIs) such as HIV and Hepatitis C. 
• Needle Syringe Programs offer a connection to health and social services from which referrals to substance use treatment and other support services are made.

Background

Concern regarding injection drug use, in the early 1990’s, led to the formation of a steering committee composed of members from the Addiction Research Foundation, AIDS Committee of North Bay & Area (ACNBA), North Bay and District Health Unit (NBDHU), and other community partners, known as CEDACON (Clean Exchange and Disposal Committee of North Bay). Funding was provided by the Public Health Branch to carry out a needs assessment. This led to the development of a delivery model, and in March 1999, North Bay’s first site opened at ACNBA. In early 2000, the Board of Health accepted the proposal for needle exchange program development, which became known as Northern Points Exchange (NPE). Four fixed sites in North Bay were established to provide Needle Exchange Services.

Since then, the North Bay District and Parry Sound Health Units amalgamated, becoming the North Bay Parry Sound District Health Unit (NBPSDHU). Several more satellite Needle Syringe Program (NSP) sites have been established across the North Bay Parry Sound district. The term “exchange” is no longer used because the expectation of having used equipment to trade for new equipment can create barriers for people to access NSP services and can result in harm such as the reuse or sharing of used equipment.

The NBPSDHU, which serves as the core NSP site for the district, receives harm reduction supplies from the Ontario Harm Reduction Distribution Program (OHRDP), purchases the remaining equipment (e.g., sharps containers, condoms, etc.), and distributes them to the satellite sites. The NBPSDHU is responsible for the submission of NSP distribution statistics for all sites in the district for ministry reporting, inventory management, and program planning and evaluation.

Some information in this resource has been adapted from:

• Strike C, Miskovic M, Perri M, Xavier J, Edgar J, Buxton J, Challacombe L, Gohil H, Hopkins S, Leece P, Watson, T, Zurba N and the Working Group on Best Practice for Harm Reduction Programs in Canada. Best Practice Recommendations for Canadian Programs that Provide Harm Reduction Supplies to People Who Use Drugs and are at Risk for HIV, HCV, and Other Harms: 2021. Toronto, ON: Working Group on Best Practice for Harm Reduction Programs in Canada. 2021.

Becoming a Satellite NSP Distribution Site

Requests for new NSP sites are determined by consideration of various factors, which include but are not limited to:

• geographic location and proximity to other NSPs
• accessibility to clients and hours of operation
• ability of the agency to incur the costs of sharps disposal
• health unit funding availability for the purchase of supplies not provided by the OHRDP
• commitment to the provisions within the shared service agreement.

Please contact us if you are interested in learning more.

Join the Northern Points Community of Practice

All NSPs are invited to represent their agency on the Northern Points Community of Practice, formerly known as Northern Points Exchange. This Community of Practice is led by a steering committee and will be reintroducing satellite site member participation in 2024. Please contact us to discuss your interest in joining the Community of Practice.  

The Philosophy of Harm Reduction

 Harm reduction programs and services are:

• Evidence-based
• Cost-effective
• Non-judgmental
• Non-coercive
• Client-centered

Harm reduction aims to reduce the negative health, social, and economic consequences associated with drug use. It includes a wide variety of practices, programs, and services that are evidence-based, client-centered, and meet people where they are “at”. Harm reduction makes no judgments or assumptions about the moral or legal nature of drug use and recognizes that substance use is complex.

Harm Reduction Objectives

The main objectives of harm reduction practices are to reduce the individual, societal, and systemic risks associated with substance use, and optimize the health of clients. Reducing stigma associated with drug use is also an important part of harm reduction. Creating environments that foster respect and self-efficacy are conducive to individuals seeking further support and services available in the community based on personal readiness.

Examples of Harm Reduction Approaches

• Nicotine replacement therapy
• Impaired driving campaigns
• Condoms
• Overdose prevention kits (i.e., naloxone),
• Providing new drug use equipment
• Providing safer use education.

Safer handling and disposal of used equipment is an important component of safer use education.

Needle Syringe Programs

Why do we need Needle Syringe Programs?

Public Health is mandated by the Ministry of Health under the Ontario Public Health Standards (OPHS) to provide harm reduction services such as Needle Syringe Programs and naloxone.

A central aim of the Infectious and Communicable Diseases Prevention and Control Program Standard, in relation to substance use, is to ensure access to sexual health and harm reduction services and supports that reduce or prevent exposure to and transmission of sexually transmitted infections (STIs) and blood borne Infections (BBIs).

The provision of safer drug use equipment and safer use education reduces the spread of BBIs, such as Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), and Hepatitis C (HCV) which otherwise can occur with sharing needles, straws, pipes, and other drug use equipment.

Needle Syringe Programs, an important component of harm reduction approaches, are evidence-based and cost-effective in reducing the financial costs on the health care system related to treating BBIs and other health outcomes that require medical attention.

The overall aim is to improve the health and well-being of individuals who use substances, increase access to services, and reduce the negative health, societal, and economic impacts of substance use.  

What are the Benefits of Offering Needle Syringe Programs?

• Information-sharing on safer substance use practices (e.g., not sharing or reusing drug use equipment) and safer sex practices.
• Reduced transmission of sexually transmitted infections (STIs) (i.e., chlamydia, gonorrhea, and syphilis) and blood borne infections (BBIs) (i.e., HIV, HBV, HCV).
• Reduced skin and soft tissue infections (e.g., abscesses) and cardiac infections.
• Reduced need for acute health care services.
• Increased access to other health and social services.
• Availability of outreach services to reach people where they are at.
• Reduced overdoses, toxicities, and deaths.
• Reduced discarded sharps in the community.
• Improved community safety and public order.
• Opportunities for empowerment and autonomy for people who use substances.
• Availability of a safe, non-judgmental environment for people who use substances to seek support and connection.

Some NSP staff refer to their program as a “hub for hope.”

Best Practice Recommendations

What are Best Practices?

Best practice recommendations apply to service design and delivery and are established by the best available evidence, and as such, are updated as new evidence emerges. The recommendations ensure that the needs of individuals who use drugs are met and that no inadvertent harm is done.

Depending on the scope or mandate of the NSP-providing agency, some services or practices are not feasible, however consideration for the expansion of services should be made when and where possible. All agencies, regardless of the NSP services provided, offer a valuable connection to other health and social services in the community.

What are the benefits of best practice recommendations?

• Improve effectiveness and ensure quality and consistency of harm reduction programs.
• Reduce transmission of infections, and reduce other harms associated with using drugs.
• Inform decisions related to policies, procedures, and supplies offered, as well as informing advocacy for appropriate harm reduction services.
• Provide benchmarks to evaluate services and identify areas of improvement at the individual program, and systems levels.

Summary of Best Practice Recommendations

• Offer a wide variety of supplies for safer sex and substance use (e.g., condoms, lubricant, pipes, straws, needles, cookers, etc.).
• Offer safer use supplies in the quantities and formats requested by clients without placing limits on the number of supplies provided.
• Encourage, but do not require, clients to return used equipment (i.e., used needles or glass pipes) in order to receive new supplies.
• One-for-one needle exchange is not recommended and can put people at risk of negative consequences from sharing or reusing substance use equipment.
• Offer education on a wide variety of harm reduction topics (e.g., safer substance use practices, overdose prevention and management, safer handling and disposal of used equipment, safer sex practices, etc.), in a variety of formats to meet the individual needs of clients (e.g., one-on-one education, workshops and group education, physical resources such as pamphlets, and peer-led education).
• Offer services using a variety of program delivery models (e.g., fixed and mobile sites) with consideration for geographic location (e.g., rural access points), hours of operation, and staff and peer-based services including outreach.
• Offer means of safe disposal of used equipment (e.g., glass pipes, needles, cookers) by offering biohazard sharps disposal containers, community sharps bins, and accepting used sharps for safe disposal, and informing clients of safe sharps disposal locations.
• Ensure safer handling, storage, transportation, and disposal of biohazardous material per local and provincial guidelines.
• Offer a wide variety of services including basic first aid, wound care, immunizations, STBBI testing and treatment (e.g., chlamydia, gonorrhea, syphilis, HIV, HCV), as well as HIV pre-exposure prophylaxis (PrEP).
• Refer clients to other agencies for health and social services (i.e., employment, mental health, housing, STBBI testing, immunizations).

Characteristics of Effective Programs

• Approachable, knowledgeable, and non-judgmental staff who communicate respectfully with individuals who use substances, and their families, to maintain dignity and sensitivity to culture, race, ethnicity, and gender. The interpersonal qualities and skills of staff and volunteers, as well as supervision, are important to establishing rapport with clients.
• Involvement of Individuals with Lived Experience of substance use, in the design, implementation, and evaluation of programs and services.
• Development of partnerships with local agencies to collaborate and coordinate services, including the development of strategies to address local substance use trends, and to ensure access to health and social services for people who use substances.
• Involving the community in planning and implementation.
• Conducting community needs assessments and feasibility studies to determine appropriate delivery and sustainability of services that meet the needs of clients.
• Advocacy and political involvement.
• Development of clearly written policies and procedures that describe the administrative and operational procedures of the NSP (e.g., offering testing, vaccines, and making referrals).

Achieving optimal, inclusive, and quality services

• Tailor services to meet the specific needs of sub-populations of people who use substances (e.g., youth, women, and ethno-cultural groups).
• Collaborate with local agencies and organizations (e.g., pharmacies) to provide no-cost NSP services in rural, underserviced, and/or high-needs areas.
• Provide on-going training and support to staff, peer workers, volunteers, and anyone involved in offering NSP services and interacting with clients.

Safer Substance Use Equipment, Supplies and Distribution

The items currently available to established satellite sites are found on the most recent NSP Supply Order Form. The order form is updated as the availability of supplies changes.

NSP Supply Order Form

Descriptions of the safer drug use equipment, and their purpose, are available in the Connecting Guide.

Satellite sites are provided premade kits (e.g., injection, crystal meth, inhalation kits, etc.) or as bulk items. Standardized premade kits provide consistency and familiarity across the district although the contents may be changed by the core site based on local trends and client needs.

It is recommended that NSPs provide supplies for safer sex practices, including:  

• lubricated and non-lubricated condoms
• insertive condoms
• dental dams
• personal lubricant

Pre-made Kits

Satellite sites in the North Bay Parry Sound District who order premade kits from the Health Unit, can expect to receive kits with the following counts and types of items depending on the kit type. The configuration of the kits is in the “background” of NEO, therefore when you track a premade kit, it counts all of the items contained in that kit. Bundles of the different coloured bags (empty) can be ordered in case your agency wishes to assemble some, although any changes to the contents should be discussed with your Health Unit contact person beforehand.

• Crystal Meth Kits – Green zipper seal bag:

  • 1 Bowl pipe
  • 4 Vinyl mouth pieces*
  • 4 Alcohol wipes
  • 2 Latex lubricated condoms, 2 Lubricant packets

• Inhalation Kits – Blue zipper seal bag:

  • 2 Glass straight stems
  • 4 Vinyl mouth pieces*
  • 4 pack of (5) screens
  • 2 Push sticks
  • 2 Alcohol wipes
  • Matches
  • 2 Latex lubricated condoms
  • 2 Lubricant packets

• Injection Kits (SHORTS) – Yellow tie-up bags:

• • 10 1cc syringes with needles (short)
  • 10 Tourniquets
  • 10 Cookers with filters
  • 10 Sterile water ampules
  • 10 Alcohol wipes
  • 5 Latex lubricated condoms
  • 5 Lubricant packets

• Injection Kits (LONGS) – Black tie-up bags:

  • 10 1cc syringes with needles (long)
  • 10 Tourniquets
  • 10 Cookers with filters
  • 10 Sterile water ampules
  • 10 Alcohol wipes
  • 5 Latex lubricated condoms
  • 5 Lubricant packets

• Snorting Kits: Orange zipper seal bag:

  • 4 coloured straws
  • 1 cutting card
  • 6 Alcohol wipes
  • 2 Sterile water ampules
  • 2 Latex lubricated condoms
  • 2 Lubricant packets

*Please note that the tubing for the mouthpieces for the straight stems and the bulb pipes are not the same size; be careful to keep them with their respective pipe type.

Distribution of Safer Substance Use Equipment and Supplies

NSP supplies for people who use substances are offered in the quantities needed, wherever possible. Some of the supplies provided by NSPs are in high demand and we recognize that people, needing needles and sharps containers for medical injections, may struggle to find affordable or no-cost supplies. NSPs are funded only for supporting the needs of people who use substances. We respectfully direct people seeking medical supplies to their pharmacies, primary Health Care Providers, and specialty clinics for help with meeting their needs.

Locations across Ontario that offer Needle Syringe Programs and community sharps bins can be found on the OHRDP’s Find Supplies map.

Naloxone is distributed to individuals who use substances, or their family or friends across Ontario.

Refer to this list of agencies that distribute naloxone in your community.   

Education and Other Services

Safer Drug Use Education for Clients

Safer substance use education is an important part of harm reduction services. Providing new equipment and education on safer use practices go hand-in-hand. Safer use education should be offered in a variety of formats, wherever possible. This includes one-on-one education, workshops and group education, skill-building sessions, information pamphlets, instructional videos, demonstrations, targeted educational interventions (e.g., injection drug use, crack cocaine smoking) and other formats deemed necessary. Peer-delivered, brief interventions, and longer interventions should be offered to reach a broad range and diversity of clients.

Safer Substance Use Education

Safer use of substances and equipment reduces the risk of bacterial infections and transmission of HIV, HBV, and HCV. Safer use education should include:

• substance preparation practices
• safer injection practices
• the use of different needles/syringes.
• the use of sterile water and acidifiers, including the amount needed to dissolve the drug.
• the areas of the body that are safer to inject and which to avoid.
• risk of fungal infections associated with spore-contaminated lemon juice and other acids like acetic acid.
• use of a quick-release tourniquet to reduce vein damage and impairment of blood circulation.
• use of a new small-pore filter, rather than a cigarette filter, to reduce risks of deep vein thrombosis (DVT).
• wiping the injection site with an alcohol swab and using a post-injection dry swab to prevent infections.
• use of a new sterile needle for each injection (e.g., one-time use only).
• not sharing needles or syringes for injecting, piercing, or tattooing (including ink pots).
• risks of frontloading and backloading.
• the risks of BBIs from sharing needles, cookers, and filters (including making ‘washes’ from residue).
  • safer inhalation practices
  • the use of brass screens, rather than steel wool or scrubbing pads.
  • the use of vinyl mouthpieces to protect the lips from burns, cuts, and pathogens.
    • the risks of sharing multi-dose vials or ampoules of anabolic steroids.
    • recognizing damage to skin and veins and seeking appropriate medical attention.

Handling and Disposal of Used Equipment

Education on safer handling and disposal of used equipment includes placing sharps in a hard-sided container with a tight-fitting lid such as a bleach bottle, coffee tin, or plastic pop bottle when a biohazardous waste container is not available. All other waste should be disposed of in garbage receptacles out of reach of children and pets. There is more information on sharps handling and disposal on our health unit website. Staff at NSPs should consider the following when receiving used sharps and drug use equipment for disposal:

• do not handle, sort, or separate used from unused equipment.
• visually estimate the number of returned sharps or ask the client for an estimate.
• have clients place their own sharp returns into the bin.
• never recap a needle.
• do not bend, break, or force needles or glass stems into full sharps containers.

Accidental Sharps Injury

NSPs should have their own occupational health and safety response plans related to accidental sharps injuries. Some information is available about sharps injuries, however advice from a medical professional should be sought for assessment and recommendations related to post-exposure prophylaxis (PEP).

Education and Training for Staff at Needle Syringe Programs

NSP staff are foundational to offering warm, welcoming, and non-judgmental settings for clients. Understanding and consistently representing the principles of harm reduction are important to working with people who use substances and other marginalized populations. Reliable sources for learning and for professional development include:

• Harm Reduction Fundamentals: A toolkit for service providers
• Connecting Guide
• Best Practice Recommendations for Canadian Programs that Provide Harm Reduction Supplies

Other Harm Reduction Programs and Services

Opioid Overdose/Toxicity Response

Naloxone is distributed at some NSP sites. Please see the Ontario Naloxone Program (ONP) website for information on eligibility criteria. Our health unit website also has general information on naloxone as well as information for ONP Distributing Agencies and First Responders.

Used in the Development of this Resource

• Strike C, Hopkins S, Watson TM, Gohil H, Leece P, Young S, Buxton J, Challacombe L, Demel G, Heywood D, Lampkin H, Leonard L, Lebounga Vouma J, Lockie L, Millson P, Morissette C, Nielsen D, Petersen D, Tzemis D, Zurba N. 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: Part 1. Toronto, ON: Working Group on Best Practice for Harm Reduction Programs in Canada. 2013.
• Strike C, Leonard L, Millson M, Anstice S, Berkeley N, Medd E. Ontario needle exchange programs: Best practice recommendations. Toronto, ON: Needle Exchange Coordinating Committee. 2006.
• Strike C, Miskovic M, Perri M, Xavier J, Edgar J, Buxton J, Challacombe L, Gohil H, Hopkins S, Leece P, Watson, T, Zurba N and the Working Group on Best Practice for Harm Reduction Programs in Canada. Best Practice Recommendations for Canadian Programs that Provide Harm Reduction Supplies to People Who Use Drugs and are at Risk for HIV, HCV, and Other Harms: 2021. Toronto, ON: Working Group on Best Practice for Harm Reduction Programs in Canada. 2021.
• Strike C, Watson TM, Gohil H, Miskovic M, Robinson S, Arkell C, Challacombe L, Amlani A, Buxton J, Demel G, Gutiérrez N, Heywood D, Hopkins S, Lampkin H, Leonard L, Lockie L, Millson P, Nielsen D, Petersen D, Young S, Zurba N. The 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: Part 2. Toronto, ON: Working Group on Best Practice for Harm Reduction Programs in Canada. 2015.

Additional Resources

• Centre for Addiction and Mental Health. Harm Reduction Best Practices: Partner Resources. Needle Syringe Program Community of Practice. 2023.
• Understanding Needle Syringe Programs