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The most common exchange is over steroid packs and clients are far from down-and-outs. They are 30-somethings just out of the gym with top-of-the-range BMWs. But I can’t take any more of this middle-class, sharp-elbowed, self-entitled abuse, says Terry Maguire…

A needle and syringe exchange service (NSES) is not for every pharmacy. It might bring challenges; the stereotypical ‘drug-addled’ vagrant seeking ‘gear’ for his next hit, annoying customers and lowering the tone of the neighbourhood as associates congregate outside to deal in the street.

The reality is nothing like this. Those injecting narcotics, and who have indeed chaotic lives, are generally respectful and informed and come and go without hassle or disruption. This is also down to how the service is managed so that they are not unnecessarily detained or stigmatised. 

The pharmacy NSES is an important public health disease-prevention service and a key reason Northern Ireland has less prevalence of blood borne viral infections compared to other regions with similar injection drug use. 

We are noticing a change to those asking to use the service. The most common exchange now is steroid packs and the client is far from a stereotypical down-and-out, rather it’s a trendy 30-something just out of the gym, sporting a perma-tan and driving a top of the range BMW.   

A new craze of in-vogue drugs in the health and wellness arena 

We are experiencing a new craze of in-vogue drugs in the health and wellness arena that are only effective when injected. Of course, protein-based medicines mostly need to be injected. But let’s not forget that in addition to fear, pain and discomfort, injecting brings many risks, not least transmission of blood borne viral infection. 

Most hepatitis B infections are from bad injecting practice. So where is the role of the NSES in this new wellness medicine trend? Where does my needle and syringe exchange service stand in this mission creep?

A few weeks back, a client asked which needles he needed for his ‘amino-acid cocktail’ and if I could supply. He produced a small vial sealed at the top with a rubber bung and clasped at the rim by a metal surround, like the vials used for Covid vaccines.

This vial, without any markings, labels or other form of identification or instructions, contained a whitish opaque liquid. I enquired if the injection was to be intra-muscular or sub-cutaneous. He didn’t know.  Was it in-date? Was it sterile?

He seemed a shy, sensible man probably in his mid-30s and I asked where he obtained the vial. “A friend at the gym who is an agent”, he replied. “But you don’t know what it is,” I challenged. “It’s an amino-acid cocktail and everyone is using it,” he retorted. 

His attitude became assertive. Was I giving him the needles or not? I said he was welcome to the needles and syringes but I was advising him not to inject it. He became confrontational. What did I know with all the toxic medicines I hand out daily, he shouted, and stormed off.

The on-line marketing I found for amino-acid cocktails (peptides) was straight out of the para-pharmaceutical/snake oil rule book. Advertisements consist of testimonials, influencer hype and the seductive promise of turning back time.

These experimental substances operate in a medical grey zone, with unknown long-term risks, questionable manufacturing standards and in some cases, life-threatening side-effects. Two peptides, BCP-157 and TB-500, are the most frequently cited.  The appeal is understandable – who wouldn’t want faster healing and better muscle tone? 

The Golden Dose

I, and my staff, are experiencing even higher levels of aggression dealing with those trying to extract the Golden Dose (priming-dose) from their Mounjaro pens.

We are instructed by the Public Health Agency not to supply needles for this purpose. Some clients pretend to be diabetics who have run out of needles and syringes, others claim the pen is broken and they can’t get the last one or two doses out, others just explain what they are doing.

When we try to reason why we can’t supply, they flip to overt aggression and some interestingly suggest that I don’t see the irony (or is it hypocrisy on their part) in what we are doing; denying good solid citizens like them needles when we are supplying to “wastrel junkies on heroin every day of the week”. Indeed. 

Pharmacies selling/supplying GLP-1s are already alive to this trend and have in-store signage and web notices warning against attempts to extract the Golden Dose; it’s illegal to interfere with medical devices, there is a risk of underdosing with medical consequences, embolism is a possibility and legal liability is lost, etc.

This might be more to do with commercial expedience than patient safety but it’s helpful for me in making my argument to their clients. The Golden Dose is a result of bad product design and thankfully, Lilly have now agreed to redesign and reduce the amount of liquid needed to prime the device.

This happened in April, which is great news as I can’t take much more of this middle-class, sharp-elbowed and self-entitled abuse. Give me the old-fashioned drug addict any day.

Terry Maguire is a leading pharmacist in Northern Ireland.