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Author: Nigel Brunsdon

Steroid ‘Spot Injecting’

Spot injecting is when people who use steroids inject into a smaller muscle rather than the glute or thigh. For instance injecting into the deltoid. When you ask people why they are doing this you’ll get an answer along the lines of, “I want to get my arms bigger”. A basic understanding of the human body will tell you that this isn’t how it works.

Muscle injecting

The idea of muscle injecting is to get a slow release of the injected substance (in our case the steroid). This works because deep muscle has very little blood flow to take the drug into your system. The steroid doesn’t work at the point of injection, in reality it does nothing until it’s been processed by the liver.

Shallow muscle problem

Injecting into more shallow muscles (ie spot injecting) means that drug uptake is faster than expected. This will mean that at first the user will get VERY high testosterone levels, with of course related side effects. So someone will be more likely to make snap decisions, wanting more sex and in some cases more aggressive etc.

The problem is that the drug will run out well before the next jab is due. So, testosterone levels plummet and you get the opposing symptoms. Feeling your body is horrible, crying, needing reassurance, depression.

Basically spot injecting can cause some SERIOUS mood swings.

One last point

When someone still won’t believe you that spot injecting doesn’t work even after you’ve explained the above, ask then to talk to their friends about it. Or just point out to them that if steroids worked at the point of injection then most body builders would have a backside like Jay Lo.

Injecting Without Drugs

What do you do when someone come into an NSP who isn’t injecting drugs, this week I’d like to talk a bit about someone I recently saw who has a different reason for injecting.

This person was slightly different, the woman coming into the NSP was someone who had stopped using heroin a while ago, and she wanted the needles and citric acid but not to inject drugs with.

Why?

We had a quite long chat it seems that she used injecting itself as a coping strategy for stress. She’d have a build up of feelings and emotions that would previously have lead to heroin use, but now she just injected water and citric acid, very much in the way someone with a history of self injury uses small cuts to relive stress.

We discussed what aspects of this made it help, she told me that it wasn’t really the ‘feeling’ of the injection as I would have expected but more the way it looked. Her partner (who was now also no longer using
drugs) kept encouraging her to attend a Narcotics Anonymous meeting but she didn’t like the way these worked and found they just increased her stress levels.

Other strategies

We looked at different ways this she could cope using more appropriate methods, it seems that she used to be very good at art but said that she now has no patience to draw full pictures. I talked to her about the fact that even just a few lines on a page with some colour might help (there is an old technique for working with self injury where people draw the intended wounds rather than make them).

I did talk to her about the extra risk she was adding by using an unneeded acidifier and tried to encourage her to just inject water if she felt a continued need. We also discussed using boiled water from a cold tap and allowing it to cool (our project doesn’t currently have access to water in amp form).

Self injury

She appeared to be very stable as far as her mental health is concerned, and I felt at the time that their use of injecting as a coping strategy did have some risks, both because of the injection itself and because it kept them ‘skilled’ at injecting which makes a possible relapse easier. But I do feel that this may be the most appropriate coping skill they currently had to deal with stresses and that by doing this they probably avoided doing themselves more harm either by relapsing or worse.

Risk Reduction for Sex Workers

Sex work can be a challenging line of business! First off, if you’re fortunate enough to make it through the barrage of opinion that tells you you’re in need of rescuing or rehabilitating, well done! Secondly, getting good risk reduction information in the face of punitive, contradictory laws can be really tough, however the purpose of this article is to provide a basic outline of helpful information geared at improving the general safety and well-being of (mostly) street based sex workers. Some of the information will be applicable to anyone working in the industry who is selling sex for money.

Legal issues

Firstly, let’s start with the basics… make sure you’re well informed about the current UK laws. Working outside of them can lead to inadvertent arrest or prosecution and can seriously affect your potential to earn a decent living. It can also threaten your family relationships, for example, if you work from home and live with a partner or adult child, the other person can be prosecuted for pimping even if that person is your child (over 18). For some of us, choice about working is a luxury we don’t always have. I’m not going to go into the laws here but you can find great, up-to-date advice on many websites, or if you don’t have access to the net, ask in your local sex work projects where someone should be able to help. The thing I will say is that the laws often significantly contribute to the risk taking behaviour we will engage in (or not). For example, criminalising street based clients just makes women jump into cars faster, have less time to check out the punter, less time to negotiate terms without the client getting twitchy and the job being lost. This also means we may become pressured to take more risks into having sex without condoms as clients get scared off and are fewer on the ground. What this does in real terms is put more women in more danger with yet again, the women coming off worst. Women who work from home in two’s or more can be prosecuted for running a brothel despite the fact that is obviously safer to work this way.

If you are arrested, know your rights. You have the right to know why you’re being arrested and the right to remain silent. You have the right to read the police codes of conduct and to have someone notified of your arrest. You have the right to see your solicitor in private. There is NO SUCH THING as an ‘off the record’ chat! If you need medical help whilst you’re under arrest, a police surgeon must be called to assess whether you’re fit to be interviewed. Unless you’re arrested for drink driving or suspected of a serious crime, enforced blood or DNA testing is not lawful.

Lots of street workers get a bad rap from local communities who feel hassled by kerb crawlers or fed up with associated criminal activity in their area. They often report finding discarded condoms, needles or other drug paraphernalia too and whilst none of these activities are necessarily anything to do with street sex workers, it makes sense to be discreet and take care of your stuff in order to avoid the finger of prejudice pointing directly at you. Work away from the busiest residential areas but don’t affect your safety in doing so. Encourage your punters to be discreet too.

Handy hints

Keep tissues or small plastic bags in your bag or pockets and wrap used condoms in them to dispose of later. If you use needles, make sure you take them back to your local needle programme. If you don’t want your clients to know about your habit, you have 2 options:

  1. Don’t take needles out with you and make sure you know you’re not going to ‘rattle’ whilst you’re out, or
  2. Consider smoking on foil as an alternative whilst you’re at work. It’s much easier to conceal your use and much safer to dispose of the things you need…clients can get really freaked out by needles and evidence of hard drug use, and a freaked out client makes for a nervous client makes for potential trouble.

If you do need to take pins out with you, keep only the number you need on your person, re-cap them after use and dispose of them SAFELY in a designated sharps container and return them to the needle programme.

If you do inject, try to rotate injecting sites and use salves and creams to help healing. Never get so high that you can’t see properly at night and remember too that heroin raises your body temperature and masks the effects of the cold, but you can still be affected by the cold so wear layers and keep warm. Make yourself as safe as possible by becoming informed about these risks and take pride in your health and wellbeing. A healthy hooker is a happy hooker!

Another really important thing to remember is that mixing drugs = recipe for trouble. Poly drug use as it’s called is more likely to create situations where you’re out of control than single use because of the way different drugs react with each other in your body. Speed-balling for example can create multiple problems as the additional cocaine numbs the injection site and masks other symptoms of pain, leaving you less likely to be aware of any problems. It’s probably obvious but let’s say it anyway, working under the influence of alcohol or other depressant drugs as will slow down your ‘flight or fight’ responses and you could really be putting yourself in danger by being too stoned to size up risk or get out of a tricky situation.

Never underestimate the power of the ‘word on the street’ …pass on information about dodgy punters, what the police are up to, gangs making trouble or other points of concern and make sure you keep an eye out for each other.

Tips of the trade

Looking after your health
  • Try to insist a punter uses a condom even if just for oral as HIV and other STI’s can still be passed on this way
  • If you do take risks, gargle with antiseptic and DON’T brush your teeth straight away as small cuts could then transmit infection
  • Use water based lube with condoms as oils can rot the rubber. Better to use spit than the wrong kind of lube. DON’T use baby oil
  • If you do anal, use extra strength condoms and lubricate really well to avoid tears. Sitting on top of your client lets you control the contact more
  • Don’t go from anal to vaginal without changing condoms
  • Use dental dams for analingus (licking around the asshole) or for oral a customer does on you. If you don’t have them, you can cut up a condom or a piece of non-microwaveable cling film. You can get HepA from licking around the asshole
  • Learn how to put on condoms with your mouth!
  • Drink lots of water and pee regularly to help flush out infection
  • Too much sugar, coffee, tea, cocaine or speed increase the chance of you getting bladder infections
  • If you work when on a period, use a diaphragm as well or if you use sponges, rinse them out really well between clients
  • Pregnancy can be immuno-suppressive so if you work when pregnant
    • try only selling hand and mouth work
    • If you do have vaginal sex, use condoms, good lube and avoid deep penetration
    • Be alert for signs of infection and treat immediately
  • Check your breasts and get cervical smears regularly (Research shows that there is an increased chance of getting cervical cancer the more sexual partners a woman has. Cervical smears are vital in preventing this.)
  • Know what to look for in the following: crabs (pubic lice), chlamydia, herpes, thrush, warts, PID (pelvic inflammation disease), gonorrhoea, syphilis, HIV, Hep B & C. Some of these don’t have obvious symptoms so make sure you’re well informed of the signs, symptoms and risks, or how to protect yourself. Your local prostitution project or GUM clinic should be able to give you good information
  • If you’re doing street work, try to arrange price, location and service outside of the car to avoid getting into conflict when in the client’s car
  • Check numbers of passengers and license plate before getting in. READ UGLY MUGS LISTS if there are any in your area
  • Let someone know where you’re going if possible
  • Familiarise yourself with car locking mechanisms as soon as you get in
  • Get the money first and stash it away from your other money so that if your punter does try to rob you it’s less likely he’ll get it all
  • Keep an eye on your client’s hands all the time.
  • Avoid getting spiked by not accepting drinks from punters
  • Don’t wear clothing that can be used to harm you (e.g., scarves, heavy necklaces and across the shoulder bags)
  • Wear shoes you can run in easily
  • Don’t wear clothing that has to be removed to have sex and avoid floaty clothes that can get trapped in car doors
  • Don’t carry weapons that can be used against you. Try keys, hairspray, pin tail combs etc for self defence
  • If you are raped or assaulted in a car, try to leave an earring or small personal item down the back of a seat so that the police can identify you having been there later
  • If you have to defend yourself attack soft areas such as throat, eyes, Adams apple, underside of the nose, balls, stamp on instep or kick shins

ABOVE ALL, BE SENSIBLE AND TRUST YOUR INTUITION.

And for those of you who do want help getting out of prostitution, ask your local prostitution project or harm reduction service where you can go to get it.

Snapping Needles

This isn’t an article about needles accidentally snapping, but instead the idea of deliberately snapping a pin after use to prevent it from ever being usable as a form of harm reduction.

Like all good needle programmes we supply people with secure sharps bins (cin bins) for people to return used equipment in. But studies have shown (Taylor et al 2004) that sometimes desperate times call for desperate measures. In desperate times people don’t always make the best or safest decisions.

Let’s think about this though. Most injectors know the risks of reuse, and most of the time would choose not to reuse. The decision to reuse is often directly as a result of an impulse, and an imbalance of availability (ie not enough sterile, but plenty of used needles). Pin snapping is another strategy to remove temptation to reuse in times of desperation, after all if someone can make sure a needle isn’t reusable at all while there is sterile kit around then there will be no temptation to reuse when sources are low. (In a previous article I talked about people having spare needles put aside for ’emergencies’.)

How to do it

It’s possible to buy needle clippers (as seen in the image above) which will cut the needle itself, I’ve kept a small stock of these before to give out to people. These normally store the needle as well and can hold plenty of them safely and securely.

snapping needlesIf your needle programme supplies 1ml BD insulin fixed units another option is available. Once one of these needle has been used you can to recap it, then, holding it firmly just below the cap you tap the cap on a table edge (as shown). The end will go flying, but once you find it you’ll see that the entire end of the syringe and needle has snapped off and is now safely contained in the cap itself.

Of course this advice isn’t going to be used by everyone; for a lot of people a used pin is kept as a safety net just in case they can not access a new one. For others reuse is not something they would ever do.

Snapping pins might be a good option for folks in relationships, who wanted to make sure their partner or friends don’t accidentally reuse equipment that may contain HepC or something else they don’t want to risk sharing. This also might be a good option for folks who would prefer not to reuse but due to desperation have reused in the past.

I’ve given pin clippers out before with some success, and I’ve also shown plenty of injectors how to tap off the end of a BD, which I have to say, normally gets the reaction “Cool!”

Stop And Search

I spoke to someone recently who had had his freshly collected new injecting equipment taken off him during a stop and search by police, he wasn’t charged with anything, and he wasn’t given any paperwork. This isn’t the first time I’ve heard of this happening and it’s not what’s supposed to happen.

For most people who inject, especially if they commit acquisitive crime, a police stop and search is a normal part of the daily routine. Totally understandable really, some of the folk we work with are likely to have stolen goods on them and if they have committed theft they risk arrest. But in no way is this a reason for the removal of sterile injecting equipment if there is no other evidence of a crime.

There is no UK law (that I’m aware of) preventing possession of unused kit…. well ok technically you could cite the Knives Act but that would be really pushing it to the limit. It’s just not in the public interest to prevent drug users from accessing sterile needles.

What if the needles are used?

If the needles are used they can of course be counted as evidence, although this would be extremely unlikely unless there is other supporting evidence of an offence, again this is because it would not be in the public interest to stop someone who injects returning used needles to an syringe programme. In fact the Crown Prosecution Service (CPS) has specific guidance around this:

It is well known that blood borne viruses including HIV and hepatitis C can be transmitted between drug users who use the same injecting equipment. A number of schemes have been established to provide counselling and exchange facilities where sterile equipment can be obtained…

These schemes need police and CPS co-operation because those who run and use them will necessarily commit offences under the Act. It is therefore not normally in the public interest to prosecute:

  • a drug user retaining used needles
  • a drug user possessing sterile needles
  • bona fide operators of schemes

What should someone do if this happens?

Any Stop and Search has to be for a good legal reason and the person being searched should be given the reason. The police are also supposed to give you a form detailing the reason for the search, this would also include outcomes – in this case that needles have been confiscated (this didn’t happen to the person I spoke to). Make sure you ask for this and make sure that you get the officer’s ID number. This can form the basis of any legal action you may wish to take if you think you are being harassed or illegally searched. You should let the needle programme you pick up equipment from know the details so they can follow it up.

What should the NSP do?

As DEFRA say in the Tackling Drug Related Litter guidance it’s important to:

…establish an agreement or protocol between the Police and local agencies regarding the possession of used needles and drug paraphernalia.

Tackling Drug Related Litter – DEFRA

Part of this should be the relationship with the programme manager and the local police. I’ve been involved in previous services that invite all new police recruits to visit the service and learn why we do the work we do. This can help police see the wider picture of harm reduction and greatly improve partnership working.

However if your NSP visitors are reporting sterile needles being removed this should be taken higher up the police management structure as the police involved may not be aware of the wide community harm reduction issues.

Further action

If you (as a person who uses drugs OR as any other member of the public) feel that you are being subjected to Stop and Search maliciously or for unlawful reasons I would encourage you to use the Bust Card from Release, or the Stop and Search card made by Mark Thomas.

Emergency Needles

I’ve got a bit of a bee in my bonnet at the moment (for any of you that have met me, I’m sure that mental image is a great one). This happens a lot, I get very focused on one area of advice and hammer it home in everyone I see. This week it’s convincing people to take enough needles, and making sure they have spare.

Anyone who has worked in a good NSP (needle and syringe programme) knows the score, its Friday afternoon and people are coming in and only asking for 5 or 10 needles:

“Are you sure that’s enough? Tomorrows the weekend.”
“Ohh yeah… give us another twenty then.”

I’ve always been of the opinion that every NSP worker should take the time to work out with people how much kit they need, as most people who inject tend to underestimate their needs. This should include discussing how many times the person injects and how many times they miss or get a blocked pin. But working out minimum need alone isn’t enough.

Problems of reuse

Once a needle has been used for injecting it will have bacteria growing, and as I’m very fond of mentioning to people this kind of bacteria could double about every 20 minutes at room temperature (and how many people keep their used kit in the fridge).

So even injecting with your own used needle will greatly increase the chances of developing an abscess.

Emergency needles

What we need is for people to ALWAYS have a sterile needle. That means allowing for:

  • Giving needles to friends
  • Bent needles
  • Blocked needles
  • Dropped needles (which shouldn’t be used)
  • The NSP being unexpectedly shut
  • Illness preventing you getting out to the NSP

One solution, and this is the one I’m currently pushing at work, is for people to take a number of ‘emergency kits’. These should contain everything someone needs for at least 2 days injecting. Spoons, needles, barrels, acids, filters, swabs and if you have it water.

I’m currently getting everyone to take spare kit and stow it away on a cupboard or somewhere else safe and out of the way. I think it’s important that this is kept away from their normal needle stores to prevent it being just used as standard, emphasis should be put on the emergency aspect of this ‘pack’. I’m even considering the idea of printing small bags or stickers with ‘To be used in emergency’.

LabelThere’s a great website for generating your own warning labels, and I’ve used it to make the label shown here which you are of course free to download and use on any pack you might put together.

I think this is an important aspect of work and that all NSP workers should do their best to encourage injectors to take spare kit, and for any injectors reading this ask yourself. “If I’m too ill to get to the NSP this week have I got enough kit to get me though?”

Coping Toolbox

How things are explained will, of course, have a huge impact on how they are remembered. I’m a fan of explaining things with analogy. So I thought I’d share the one I use with people when I’m explaining the need to develop more coping strategies.

Heroin as a strategy

A few years ago I had a young client about the age of 19 who had been dragged in by his mother because she was “sick of his heroin use”. At one stage she said:

I’ve told him this is his last chance, I don’t know why he keeps using this heroin, he has to just stop for good this time.

The kid looked totally brow beaten, depressed and had obviously been having this conversation again and again so I decided to explain, at least from my point of view, one of the possible reasons for him repeatedly returning to heroin.

Well, think about how you cope with stress or things upsetting you, you probably have loads of things you do to get though a day. Buy some clothes, have a coffee with friends, maybe a glass of wine, hot bath, go for a walk or just sit reading a book. For most things you’ll have a strategy that works.

OK, now imagine instead of developing these over the years, you had found one thing that did the lot, physical, emotional and psychological pain or stress all dealt with. Do you think yo’d have come up with any of them? Well your son has been using heroin for a good chunk of the time of life that most people develop core coping skills. And heroin has worked every time he needs it to. The problem is though that as well as helping him cope, it’s also now one of the problems. What I’m going to try and do with him is help him develop more appropriate skills and the ability to come up with more as he needs them.

The mother now appeared to have some idea what her kid was going through, and he looked like he could jump over the moon.

Unlocking a Toolbox

This is how I explain developing coping to people when I start working with people. Imagine you’ve moved into your first house, your parents might if you’re lucky give you a hammer and a screwdriver. And they work really well, those are your core ‘coping tools’ and they’ll serve you well. But after a few months your partner wants shelves putting up, you give the hammer & screwdriver combo a try but realise you’ll need to go buy a drill. Over the years you’ll have many trips to the hardware store to get more tools for specialised jobs and you’ll end up with a shed full of them. But when a new job comes up that can’t be done by a tool you have you’ll normally give the hammer a try.

Well the hammer in this case is heroin, it’s a strategy that’s worked for you in the past, what we need to do is give you more tools, and to unlock the ability to develop more over time to stop you having to just whack things with a hammer.

The more approaches we have in our toolboxes the better we can cope ourselves.

Hand Washing

I’ve been doing a lot of training work lately and one of the main things I always focus on is the fact that people forget the basics. Its all well and good explaining to people the risks of endocarditis or going though something like vein structure. But at the end of the day the basic advice needs to be given, I’ve already spoken in a previous article about the advantages of giving swabbing advice, so today is the turn of hand washing.

In Avril Taylor’s study of Injecting Drug Use in Scotland the point was raised that most of the people they observed injecting didn’t take the opportunity to wash their hands even when they had ready access to a clean water supply. As anyone who has watched the footage from this study knows this means that there are lots of hands out there with blood on them from touching fresh injecting sites.

Add into this the amount of bacteria and dirt on even the average persons hands and you have a great route of not only blood borne viruses but also abscesses and other related infections. Washing hand protects These risks can be reduced by simple hand washing, and it only takes 30 seconds. But how well do people really wash their hands?

The NTA’s campaign Harm Reduction Works has DVDs available free of charge in England (UPDATE: Now that the NTA no longer exists this campaign has ended as a ‘free’ campaign, however all the materials are available from Exchange Supplies for a small cost… this set of materials are some of the best produced) and it includes two great short films on how to wash your hands. If you have a DVD player, computer or laptop that can be taken into your NSP I’d really recommend using this resource with injectors.

Hand washing video

People who are Homeless and inject

Of course not everyone has access to clean water, so how do you follow the advice in this film if you have to use public toilets or unclean washing facilities? One option is to wash the taps before washing your hands, but that’s only useful if you have access to water.

If your NSP provides alcohol gels or hand wipes these are great for people who are homeless and people who inject outdoors, but you should still give advice to still hand wash when the opportunity is there. The main reason for this is that using alcohol gel is not a replacement for washing, they won’t remove all the dirt so hands can still carry a level of risk. The other thing to bear in mind is that having wet hands or greasy food residue will also reduce the gels effectiveness.

Using Real Names

I’m going to talk today about the idea of using a full name and date of birth for needle programme clients. You see, I think we should use peoples real names. I think there are some very good reasons why we should, and they are mostly for the benefit of the client.

So, as anyone working in needle programmes probably knows it has been traditional to have a fully anonymous service. Different services manage this in different ways, some giving out colour coded key-rings, some assigning a number and others working from initials.

The reasons for this have always been to protect client identity, and a perception that nobody would attend for sterile equipment if they thought they’d have to give a real name.

In most places I’ve worked when an attempt is made to increase the amount of information collected from clients there has been great resistance, but this has never been from the clients. It’s usually staff resistance with comments like “If we start asking those questions no clients will come in.”

Reasons for using names

  • Improved treatment journeys: While I’m all for allowing anyone to be given a service under the name Mortimer Mouse, it’s really difficult to arrange a hepatology referral for Mr. Mouse. Needle programmes as I’ve said many times, are gateway services that attract people at earlier stages and refer into appropriate treatments, that’s one of the main arguments we have for continued funding. Using full names and dates of birth means we have the evidence of the work we do for each client.
  • Better services: If you assess people properly for their needs you can provide better more targeted services. Not something that is fully possible when they are identifying themselves through a number (every service I’ve worked in using ‘number IDs’ has had issues with people just giving a random number when they attend). Also if you keep a regular record of the work done during an exchange then you can follow up on previous advice as well as minimising repetition. (This is also a way of evidencing the work we do to commissioners).
  • The most important reason: What is the message given to the client when the first thing we say is don’t worry you can use any initials you want, no one will know you are coming etc etc. Personally I feel we are at risk of it seeming like “don’t worry about your dirty guilty secret, you should be ashamed, no one will find out.”. It’s just not normal to use initials when talking to people, I use names when I talk to clients or anyone else, not using names separates the process out as different, unusual, clandestine. Our clients are stigmatised enough by the rest of society, we shouldn’t be adding to this. Treat your clients with respect and use their names.

Confidentiality

Of course we need to get clients to understand that services are still confidential, but that can be done by having robust confidentiality systems. At first presentation you should be explaining to people in what way information is kept, why it’s kept and the limits on how confidential we can be within current UK law (or whatever the local law is to you). You should be doing this for EVERY client you work with anyway.

Staff ‘buy in’

It’s no good just asking people to start doing robust assessments for needle exchange visitors if they don’t understand the advantages to the service and the clients. Because of this it is important that you get all staff on board with any changes you make before letting them loose on your clients.

Important

If someone doesn’t want to give a name this shouldn’t be a barrier to receiving a service, I’d in no way condone forcing people to give names. My point is more that we shouldn’t avoid using names as this could be even more stigmatising to a group that already gets enough stigma in their lives.

Increasing Returns

OK let’s get one thing straight before we start. I’m not obsessive about returns and I don’t think needle programmes should be as focused on them as most seem to be, but we live in the real world. A world where people become really angry when someone dumps used works near their home/school/shop/park. Because of this exchanges come under pressure to limit the equipment they give out.

So there’s pressure for the local needle programme to put limits on the equipment it gives out, although this may seem a logical approach there is plenty of evidence based guidance not to do this as it actually increases hoarding behaviour etc. Besides we have a problem with not enough sterile equipment getting out already, putting limits on further supply isn’t going to do anything but increase sharing behaviours. So here are some alternative approaches:

Advertise needle drops
Next time your local paper has that dreaded front page story about needles found near a school field (or any other place guaranteed to cause dread and fear in their readers), get the article copied and blown up to A3 size at your local printers.

Put the article up in your exchange and make sure you point it out to visitors, talk to them about how things like this put the exchange under pressure. You’ll find that the majority of visitors will get as angry as everyone else, the difference is in a lot of cases they may have some idea of who is likely to drop equipment.

I’ve used this one a couple of times myself and returns increased due to peer pressure.

Incentives for returns
By now we are all familiar with loyalty schemes like the ones the local coffee shop use. Why not do the same for your clients?

Get a few books of raffle tickets and use petty cash to get some kind of prize, make it something people will actually want (or even negotiate with local businesses like gyms for a free weeks trial or a months cinema pass from the nearest Showcase). Every time a client brings back equipment they get a ticket for the weekly/monthly draw.

Your manager might take a bit of convincing at first but if you can improve the percentage of returns to the point the commissioners stop shouting, then they will get used to the idea.

Outreach
The Drug Action Team (or equivalent if you live outside the UK) should have details of hotspots for needle drops. It may be time to pay these places a visit; if people are there talk to them, ask them if they have seen people leaving pins about (much less likely to get you a smack in the mouth than saying “stop leaving your pins here”). If no one is around leave some info on your service and the pressures it faces, maybe even with some fresh cin bins.
External drop bins
Depending on your building it may be possible to attach a wall mounted bin to the outside. The advantage of this is clients have somewhere to drop off when your service is closed. When services I’ve worked in have had these they’ve always been well used.
Needle Amnesty
Have a needle amnesty for your service. This would involve every staff member pushing the returns agenda on each exchange. You could also offer to collect pins from users homes (assuming you can convince your manager). This works best when you get every service in the city or town to work together, but be careful not to do them too often as they loose their impact. Nothing goes as unnoticed as a message you see every day.
Talk to your clients
I didn’t do this one first because if you are taking the time to read this you probably already do this. But talking to clients about why you need to have returns and why dropped pins cause both you and them problems is one of the best ways to get a culture of returns.
Run a quality service
Like the point above, this one is a no-brainer. The better quality the service, the more likely that people will listen to what you say.

Summary

Although returns are more an issue of public perception, they are something we do need to keep on top of. If only for the survival of the services we deliver.