Needle exchange programme
|Parts of this article (those related to Legal Aspects) are outdated. (July 2013)|
A needle and syringe programme (NSP) or syringe-exchange programme (SEP) is a social service that allows injecting drug users (IDUs) to obtain hypodermic needles and associated paraphernalia at little or no cost. It is based on the philosophy of harm reduction that attempts to reduce the risk factors for diseases such as HIV/AIDS and hepatitis. While NSPs provide most or all equipment free of charge, exchange programmes require service users to return used syringes to receive an equal number of new syringes.
A comprehensive 2004 study by the World Health Organization (WHO) found a "compelling case that NSPs substantially and cost effectively reduce the spread of HIV among IDUs and do so without evidence of exacerbating injecting drug use at either the individual or societal level." WHO's findings have also been supported by the American Medical Association (AMA), which in 2000 adopted a position strongly supporting NSPs when combined with addiction counseling.
- 1 History and development
- 2 Operation
- 3 Research
- 4 International experience
- 5 Law enforcement
- 6 Arguments for and against
- 7 See also
- 8 References
- 9 Further reading
History and development
Needle-exchange programmes can be traced back to informal activities undertaken during the 1970s. The idea is likely to have been rediscovered in multiple locations. The first government-approved initiative (Netherlands) was undertaken in the early to mid-1980s, followed closely by other initiatives. While the initial programme was motivated by an outbreak of hepatitis B, the AIDS pandemic motivated the rapid adoption of these programmes around the world.
In addition to sterile needles, syringe-exchange programmes typically offer services such as HIV and Hepatitis C testing; alcohol swabs; bleach water and normal saline (often as eye drops); aluminium "cookers"; citric acid powder (an imperative agent that enables heroin to dissolve in water); containers for needles and many other items. A survey conducted by Beth Israel Medical Center in New York city and the North American Syringe Exchange Network, among 126 surveyed SEPs that 77% provided material abuse therapy, 72% provided voluntary counselling and HIV testing, and more than two-thirds provided supplies such as bleach, alcohol pads and male and female condoms.
Needle-exchange programmes are supported by the CDC and the National Institute of Health. The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C.
Proponents of harm reduction argue that the provision of a needle exchange provides a social benefit in reducing health costs and also provides a safe means to dispose of used syringes. For example, in the United Kingdom, proponents of SEPs assert that, along with other programs, they have reduced the spread of HIV among intravenous drug users. These supposed benefits have led to an expansion of these programmes in most jurisdictions that have introduced them, increasing geographical coverage and operating hours. Vending machines that automatically dispense injecting equipment "packs" have been successfully introduced.
Another advantage cited by program supporters is that SEPs protect both users and their support network such as attenders, sexual partners, children or neighbours. SEPs can also have an indirect influence to control transmission risks. Nurses are important for spreading knowledge about HIV among users. These programmes provide physical protection from HIV and facilitate education by teaching users about blood-borne pathogens as well as how to protect themselves and others.
Other promoted benefits of these programmes include providing a first point of contact for formal drug treatment, access to health and counselling service referrals, the provision of up-to-date information about safe injecting practices, access to contraception and sexual health services and providing a means for data collection from users about their behaviour and/or drug use patterns. SEP outlets in some settings offer basic primary health care. These are known as 'targeted primary health care outlets', because they primarily target people who inject drugs and/or 'low-threshold health care outlets', because they reduce common barriers to health care from the conventional health care outlets,. Clients frequently visit SEP outlets for help accessing sterile injecting equipment. These visits are used opportunistically to offer other health care services.
A clinical trial of needle exchange found that needle exchange did not cause an increase in drug injection  These findings were endorsed by then United States Surgeon General Davis Satcher, then Director of the National Institutes of Health Harold Varmus and then Secretary of the Department of Health and Human Services, Donna Shalala.
These services can take on a wide range of configurations:
- Primary needle and syringe programme ("stand alone" service)
- Secondary needle and syringe programme (such as incorporated within a pharmacy or health service)
- Mobile or on-call Service
- Dispensing machine distribution ("vending machine")
- Peer service: distribution networks
- Peer service: "flooding" or mass distribution
- Peer service: underground
- Prison-based facilities
- Distribution of bleach or other cleaning equipment (rather than needles and syringes)
- Ad hoc or informal distribution
|This section requires expansion. (May 2013)|
Two 2010 ‘reviews of reviews’ by a team originally led by Norah Palmateer that examined systematic reviews and meta-analyses on the topic found insufficient evidence that NSP prevents transmission of the Hepatitis C virus, tentative evidence that it prevents transmission of HIV and sufficient evidence that it reduces self-reported risky injecting behaviour. In a comment Palmateer warned politicians not to use her team's review of reviews as a justification to close existing programs or to hinder the introduction of new needle-exchange schemes. The weak evidence on the programs' disease prevention effectiveness is due to inherent design limitations of the reviewed primary studies and should not be interpreted as the programs lacking preventive effects.
The second of the Palmateer team 'review of reviews' scrutinised 10 previous formal reviews of needle exchange studies, and after critical appraisal only four reviews were considered rigorous enough to meet the inclusion criteria. Those were done by the teams of Gibson (2001), Wodak and Cooney (2004), Tilson (2007) and Käll (2007). The Palmateer team judged that their conclusion in favour of NSP effectiveness was not consistent with the results from the HIV studies they reviewed.
The Wodak and Cooney review had, from 11 studies of what they determined as demonstrating acceptable rigour, found 6 that were positive regarding the effectiveness of NSPs in preventing HIV, 3 that were negative and 2 inconclusive. However a review by Käll et al. disagreed with the Wodak and Cooney review, reclassifying the studies on NSP effectiveness to 3 positive, 3 negative and 5 inconclusive. The US Institute of Medicine evaluated the conflicting evidence of both Drs Wodak and Käll in their Geneva session and concluded that although multicomponent HIV prevention programs that include needle and syringe exchange reduced intermediate HIV risk behavior, evidence regarding the effect of needle and syringe exchange alone on HIV incidence was limited and inconclusive, given "myriad design and methodological issues noted in the majority of studies." Four studies that associated needle exchange with reduced HIV prevalence failed to establish a causal link, because they were designed as population studies rather than assessing individuals.
Lemon and Shah presented a 2013 paper at the International Congress of Psychiatrists that highlighted lack of training for needle exchange workers and also showed the workers performing a range of tasks beyond contractual obligations, for which they had little support or training. It also showed how needle exchange workers were a common first contact for distressed drug users. Perhaps the most concerning finding was that workers were not legally allowed to provide Naloxone should it be needed.
Countries where these programmes exist include: Australia, Brazil, Canada, the Czech Republic, Netherlands, New Zealand, Norway, Portugal, Spain, Switzerland, United Kingdom, Ireland, Iran and the United States. In the United States such programmes may not receive federal funding, but this ban was briefly lifted in 2009 before being re-instated in 2010.
The Melbourne, Australia inner-city suburbs of Richmond and Abbotsford are locations in which the use and dealing of heroin has been concentrated. The Burnet Institute research organisation completed the 2013 'North Richmond Public Injecting Impact Study' in collaboration with the Yarra Drug and Health Forum and North Richmond Community Health Centre and recommended 24-hour access to sterile injecting equipment due to the ongoing "widespread, frequent and highly visible" nature of illicit drug use in the areas. Between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. In the surrounding City of Yarra, an average of 1,550 syringes per month were collected from public syringe disposal bins in 2012. Paul Dietze stated, "We have tried different measures and the problem persists, so it's time to change our approach".
On 28 May 2013, the Burnet Institute stated that it recommended 24-hour access to sterile injecting equipment in the Melbourne suburb of Footscray after the area's drug culture continued to grow after more than ten years of intense law enforcement efforts. The Institute's research concluded that public injecting behaviour is frequent in the area and injecting paraphernalia has been found in carparks, parks, footpaths and drives. Furthermore, people who inject drugs have broken into syringe disposal bins to reuse discarded equipment.
|This section requires expansion. (April 2014)|
The British public body, the National Institute for Health and Care Excellence (NICE), introduced a recommendation in April 2014 due to an increase in the number of young people who inject steroids at UK needle exchanges. NICE previously published needle exchange guidelines in 2009, in which needle and syringe services were not advised for people under 18, but the organisation's director Professor Mike Kelly explained that a "completely different group" of people were presenting at programs. In the updated guidance, NICE recommended the provision of specialist services for “rapidly increasing numbers of steroid users”, and that needles should be provided to people under the age of 18—a first for NICE—following reports of 15-year-old steroid injectors seeking to develop their muscles.
As of 2011, at least 221 programs operated in the US. Most (91%) were legally authorized to operate; 38.2% were managed by their local health authorities. More than 36 million syringes were distributed annually, mostly through large urban programs operating a stationary site. More generally, US NEPs distribute syringes through a variety of methods including mobile vans, delivery services and backpack/pedestrian routes that include secondary (peer-to-peer) exchange.
The use of federal funds for needle-exchange programs was banned in 1988, but this ban was overturned in 2009. In the time before the federal funding ban was re-instated in 2011, at least three programs were able to obtain federal funds and two thirds reported planning to pursue such funding. US NEPs continue to be funded through a mixture of state and local government funds, supplemented by private donations.
Many states criminalized needle possession without a prescription, arresting people as they left private needle exchange facilities. In jurisdictions where syringe-prescription status presented a legal barrier, physician-based prescription programs showed promise. Epidemiological research demonstrating that syringe access programs are both effective and cost-effective helped to change state and local NEP-operation laws, as well as the status of syringe possession more broadly. As of 2006, 48 states authorized needle exchange in some form or allowed the purchase of sterile syringes without a prescription at pharmacies.
By 2012, legal syringe exchange programs existed in at least 35 states. In some settings, syringe possession and purchase is decriminalized, while in others, authorized NEP clients are exempt from certain drug paraphernalia laws. However, despite the legal changes, gaps between the formal law and environment mean that many programs continue to face law enforcement interference and covert programs continue to exist within the U.S.
Colorado allows covert syringe exchange programs to operate. Current Colorado laws leave room for interpretation over the requirement of a prescription to purchase syringes. Based on such laws, the majority of pharmacies do not sell syringes without a prescription and police arrest people who possess syringes without a prescription. Volunteer-run groups such as The Works (Boulder) and The Underground Syringe Exchange of Denver (the USED) operate covertly to avoid prosecution and are entirely funded by donations. Due to the illegal nature of the organization, the USED website specifies that new clients must be referred in order to exchange syringes. According to The Works website, between January 2012 and March 2012, the group received over 45,000 dirty needles and distributed around 45,200 sterile syringes.
Interference with NEP, regardless of the law
Removal of legal barriers to the operation of NEPs and other syringe access initiatives has been identified as an important part of a comprehensive approach to reducing HIV transmission among IDUs. Legal barriers include both "law on the books" and "law on the streets," i.e., the actual practices of law enforcement officers, which may or may not reflect the formal law. Changes in syringe and drug control policy can be ineffective in reducing such barriers if police continue to treat syringe possession as a crime or participation in NEP as evidence of criminal activity. 
Although most NEPs in the US are now operating legally, many report some form of police interference. In a 2009 national survey of 111 US NEP managers, 43% reported at least monthly client harassment, 31% at least monthly unauthorized confiscation of clients’ syringes, 12% at least monthly client arrest en route to or from NEP and 26% uninvited police appearances at program sites at least every 6 months. In multivariate modeling, legal status of the program (operating legally vs illegally) and jurisdiction’s syringe regulation environment were not associated with frequency of police interference. This finding confirms a substantial gap between the formal law and its enforcement by police.
A detailed 2011 analysis of NEP client experiences in Los Angeles suggested that as many as 7% of clients report negative encounters with security officers in any given month. Given that syringes are not prohibited in the jurisdiction and their confiscation can only occur as part of an otherwise authorized arrest, almost 40% of those who reported syringe confiscation were not arrested. This raises concerns about extrajudicial confiscation of personal property. Approximately 25% of the encounters detailed by respondents involved private security personnel, rather than local police.
Similar findings have been researched internationally. For example, despite instituting laws protecting syringe access and possession and adopting NEPs, IDUs and sex workers in Mexico’s Northern Border regions report frequent syringe confiscation by law enforcement personnel. In this region, as well as elsewhere, reports of syringe confiscation are correlated with increases in risky behaviors, such as groin injecting, public injection, and utilization of pharmacies. These practices translate to risk for HIV and other blood-borne diseases.
NEPs serving predominantly IDUs of color may be almost 4 times more likely to report frequent client arrest en route to or from the program and almost 4 times more likely to report unauthorized syringe confiscation from clients. A 2005 study in Philadelphia found that Black individuals accessing the city's legally operated exchange decreased at more than twice the rate of white individuals after the initiation of a police anti-drug operation. These and other findings illustrate a possible mechanism by which racial disparities in the criminal justice enforcement can translate into disparities in HIV transmission. Notably, the majority (56%) of respondents reported not documenting adverse police events; those who did were 2.92 times more likely to report unauthorized syringe confiscation from clients. These findings suggest that systematic surveillance and interventions are needed to address police interference.
Police interference with legal NEP operations may be partially explained by poor knowledge and the lack of targeted education of police about the law and public health rationale relating to the operation of such programs. A study of police officers in an urban police department four years after the decriminalization of syringe purchase and possession in the US state of Rhode Island suggested that up to a third of police officers were not aware that the law had changed. This knowledge gap parallels other areas of public health law, underscoring pervasive gaps in dissemination.
Even police officers with accurate knowledge of the law, however, reported intention to confiscate syringes from drug users as a way to address problematic substance abuse. Police also reported being anxious about accidental needle sticks and acquiring communicable diseases from IDUs, but were not trained or equipped to deal with this occupational risk; this anxiety was intertwined with negative attitudes towards syringe access initiatives.
Training and interventions to address law enforcement barriers
Police trainings by US NEPs have been shown to be feasible, especially when framed from the standpoint of addressing police occupational safety and human resources concerns. Preliminary evidence also suggests that such trainings can shift police knowledge and attitudes regarding NEPs specifically and public health-based approaches towards problematic drug use in general.
According to a 2011 survey, 20% of US NEPs reported participating in police trainings during the previous year. Covered topics included the public health rationale behind NEPs (71%), police occupational health (67%), needle stick injury (62%), NEPs’ legal status (57%), and harm reduction philosophy (67%). On average, trainings were seen as moderately effective, but only four programs reported conducting any formal evaluation. Assistance with police trainings was identified by 72% of respondents as the key to improving police relations.
Arguments for and against
Pro-Needle Exchange Arguments
Organizations ranging from the National Institutes of Health, the Centers for Disease Control, the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organization, and many others have endorsed low-threshold programs including needle exchange.
Needle exchanges help fight HIV/AIDS
- Sterile needle and syringe access stand as one component of a wide range of HIV prevention strategies that include drug dependence treatment (pharmacotherapies and psychosocial interventions), outreach and education programs, counseling and testing, antiretroviral therapy, and treatment of sexually transmitted infections.
- Many studies and review papers have shown that participation in multi-component HIV prevention programs that include NSE is associated with a reduction in drug-related HIV risk behaviors. Evidence points towards the enhanced impact of harm reduction services when they work in combination.
Needle exchanges place harm reduction over punitive actions
- The ethos of NEPs typically consists of support for the health and well-being of people who use drugs through awareness, education, and empowerment; for example, programs in Australia use the community development (CD) discipline as a basis for their work.
- In accordance with the philosophy of harm reduction, NEPs treat illicit drug use as a health issue and neither condemn nor condone the practice.
- Some U.S. states require a prescription to buy needles and syringes, as they are considered drug paraphernalia rather than medical equipment, and NEPs provide access in such areas.
No evidence of unintended consequences
- "Few studies have specifically evaluated whether HIV prevention programs that include needle and syringe exchange lead to unintended consequences, such as increases in new drug users, more frequent injection among established users, expanded networks of high-risk users, more discarded needles in the community, and changes in crime trends. Modest evidence shows that NSE does not increase the number of discarded needles in the community, and that injection frequency does not increase among NSE participants. Weak evidence and limited data suggest that programs that include NSEs do not lead to new users, expanded drug networks, or increases in crime."
Needle exchanges benefit their areas of implementation
- Most NSPs operate on a one-for-one basis, and in so doing reduce the presence of discarded needles in the area; they provide safe disposal for discarded needles.
Needle exchanges help bring addicts into treatment programs
- Injection drug users (IDUs) are at risk of a wide range of health problems arising from non-sterile injecting practices, complications of the drug itself or of the lifestyle associated with drug use and dependence. Furthermore, unrelated health problems, such as diabetes, may be neglected because of drug dependence. However, despite their increased health care needs, IDUs do not have the required access to care or may be reluctant to use conventional services. Consequently, their health may deteriorate to a point at which emergency treatment is required, with considerable costs to both the IDUs and the health system. Accordingly harm reduction based health care centers, also known as targeted health care outlet or low-threshold health care outlet for IDUs have been established across a range of settings utilising a variety of models.
- NSP staff facilitate a connection between people who use drugs and medical facilities, thereby exposing them to voluntary physical, psychological, and emotional treatment programs.
- Social services for addicts can be centered around needle exchanges.
Needle exchanges are cost effective
- As of 2011, the Centers for Disease Control and Prevention estimate that every HIV infection prevented through a needle exchange program saves an estimated US$178,000+, as well as an overall estimate whereby a reduction of 30 percent or more HIV cases is reported among people who inject drugs. As of March 2012, an estimated 1.2 million people were living with HIV in the United States, with one in five people unaware of their HIV-positive status—of those 1.2 million people infected, 25 percent resulted from injecting drug use, which is the fastest growing population of HIV. For the same time period, over 50,000 new cases of HIV are estimated to occur each year.
- NEPs represent a significant saving in public healthcare costs. For example, it is estimated that the average annual cost of HIV care per person in the United States is US$15,745. Those with advanced HIV had an annual estimated cost of US$40,678. Depending on when infection is detected and when the treatment process begins, it is estimated that, as of November 2006, the total lifetime healthcare costs of HIV care are between US$303,000 and $619,000.
- In the U.S., the cost per needle at a NEP is approximately US$0.97, whereas the estimated cost of one day’s worth of the HIV treatment medication Truvada is US$36.
Needle exchanges have reached a certain degree of public acceptance
- Although needle exchange is a controversial subject in the United States, needle exchange programs—supported by private, state, and local funding—have proliferated. Internationally, there is much broader acceptance of the needle exchange model and its well-documented efficacy.
- Needle exchanges have achieved varying degrees of acceptance by churches and other religious groups as expressed in official resolutions from organizations such as the House of Bishops of the Episcopal Church, the Central Conference of American Rabbis, the Presbyterian Church, and the Society of Christian Ethics.
Anti-Needle Exchange Arguments
Needle exchange programs have faced much opposition on political and moral grounds. Advocacy groups ranging from the National District Attorneys Association, Drug Watch International, the Heritage Foundation, Drug Free Australia, and so forth, religious organizations such as the Catholic Church, and many individuals in important policy-making positions have united to oppose these programs.
- Harm reduction begins with the assumption that it is not possible to assume that individuals will make healthy decisions. Advocates of harm reduction hold that those trapped in dangerous behaviors are often unable and/or unwilling to break free of them, and should at least be enabled to continue these behaviors in a less harmful manner. A strong current tendency in the medical profession has been to consider drug dependency as a chronic illness like other chronic illnesses such as diabetes, hypertension and asthma, arguing for their treatment, evaluation, and even insurance in like manner. By treating drug dependency as an illness, the effect appears to be largely to absolve drug users of responsibility for their behavior.
- In the view of the NDAA, such a position strikes at a basic tenet of the criminal law and common sense, namely that people are responsible for their actions. Where criminal decisions are made that impact public health and the welfare of society, sanctions are appropriate and necessary.
- Such a position is also directly against Catholic Church doctrine, because it treats persons as objects not in control of their own actions and gives the impression that certain types of irresponsible behavior are somehow morally acceptable.
- Concerning the personal accountability issue, former President George W. Bush wrote: "Drug use in America, especially among children, increased dramatically under the Clinton-Gore Administration, and needle exchange programs signal nothing but abdication, that these dangers are here to stay. Children deserve a clear, unmixed message that there are right choices in life and wrong choices in life, that we are responsible for our actions, and that using drugs will destroy your life."
Effectiveness of NSPs not proven
- As summarized in the Research section of this article, despite the existence of moderate evidence that multicomponent HIV prevention programs that include needle exchange reduce the incidence of high-risk behaviors, conclusive evidence is lacking that this translates into an actual reduction in HIV or hepatitis C incidence.
- The conclusion of reports such as that by Tilson (2007) is that only comprehensive packages of services in multi-component prevention programs can be effective in reducing drug-related HIV risks. In such packages, it is unclear what the relative contribution of needle exchange may be to reductions in risk behavior and HIV incidence.
- Multiple examples can be cited showing the relative ineffectiveness of needle exchange programs alone in stopping the spread of blood-borne disease.
- Despite the ineffectiveness of needle exchange alone to stop the spread of HIV, the fact remains that many needle exchange programs do not make any serious effort to treat drug addiction. For example, David Noffs of the Life Education Center wrote, "I have visited sites around Chicago where people who request info on quitting their habit are given a single sheet on how to go cold turkey -- hardly effective treatment or counseling."
Overemphasis on NSPs can take attention away from bigger drug problems
- Especially given the ambiguous data concerning the effectiveness of NSPs, it has been argued that in fighting HIV, needle exchanges take attention away from bigger drug problems, and that, contrary to saving lives, they actually contribute to drug-related deaths. Giving out clean needles does not discourage drug dependence, and although participants in a needle exchange program may possibly expect a reduced incidence of HIV, they can still die of overdose, collapsed veins, contaminated dope, street violence and so forth. Drug-addicted mothers will still deliver drug-addicted babies. Educating drug addicts to inject in a safer manner means that they will continue to support the violent and criminal drug trade. The fundamental issues that led an addict to drugs in the first place will continue to be untreated.
- This argument is highlighted by the results of a 1993 study of the causes of death among 415 injection drug users in the Philadelphia area. Over a four year period, 28 died. Only 5 died from causes associated with HIV disease; 7 died from drug overdoses, 5 died from homicide, 4 died from heart disease, 3 died from renal failure, 2 died from liver disease, 1 died from suicide, and 1 died from cancer.
- Studies on the effectiveness of NSPs have usually focused on the health effects for the addicts while neglecting community issues. The needs of the community cannot be neglected; rather, the needs of addicts and the needs of the community must be balanced. Concerns are often expressed that NSPs may encourage drug use, or may actually increase the number of dirty needles in the community. Another fear is that NSPs may draw drug activity into the communities in which they operate. Only a very small number of short-term scientific studies have focused on the question of whether NSPs may draw drug activity into the communities in which they operate.
- Regardless of the degree of truth in such fears, the fact is that the fears are very real, and a powerful Not In My Backyard (NIMBY) stigma is attached to NSPs. Concerns are expressed on such things as the negative impact on property values, the possible drawing in of the "wrong element" to the neighbourhood, "spoiling the identity" of the neighborhood and so forth.
- Critics of needle exchange often cite the case of Platzspitz Park. "...in 1987 the authorities chose to allow illegal drug use and sales at the park, in an effort to contain Zurich's growing drug problem. Police were not allowed to enter the park or make arrests. Clean needles were given out to addicts as part of the Zurich Intervention Pilot Project, or ZIPP-AIDS program. However, lack of control over what went on in the park caused a multitude of problems. Drug dealers and users arrived from all over Europe, and crime became rampant as dealers fought for control and addicts (who numbered up to 20,000) stole to support their habit."
- Even in Australia, which is considered a leading country in harm reduction, a survey showed that a third of the public believed that NSPs encouraged drug use, and 20% believed that NSPs dispensed drugs.
Discarded needles dangerous
- Many NSPs do not operate on a strict one-for-one basis.
- An Australian bi-partisan Federal Parliamentary inquiry which published recommendations in 2003 registered government concern about the lack of accountability of Australia’s needle exchanges, inadequate exchange and lack of a national register of resulting needle stick injuries. Community concern about discarded needles and needle stick injury led the Australian Federal Government to allocate $17.5 million in 2003/4 to investigating the provision of retractable technology for syringes.
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- Arguments for and against drug prohibition
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