Needle and syringe programmes

Contents of a needle exchange kit

A needle & syringe program (NSP) or syringe exchange program (SEP) is a social policy based on the philosophy of harm reduction where injecting drug users can obtain hypodermic needles and associated injection equipment at little or no cost. Many programs are called "exchanges" because some require exchanging used needles for an equal number of new needles. Other programs do not have this requirement . The aim of these services is to reduce the damage associated with using unsterile or contaminated injecting equipment.

History and Development

"Sharps" container (for safe disposal of hypodermic needles)

Needle-exchange programs can be traced back to informal activities undertaken during the 1970s, however the idea is likely to have been discovered a number of times in different locations. The first government-approved initiative was undertaken in the early to mid 1980s, with other initiatives following closely. While the initial Dutch program was motivated by concerns regarding an outbreak of hepatitis B, the AIDS pandemic motivated the rapid adoption of these programs around the world. This reflects the pragmatic response to the pandemic undertaken by some governments, and encapsulated in the harm reduction / minimization philosophy.

Operation and Outcomes

In addition to sterile needles, syringe exchange programs typically offer other services such as: HIV and Hepatitis C testing; alcohol swabs; bleach and sterile water; aluminum "cookers"; citric acid powder (an imperative agent: enables heroin to dissolve in water); containers for needles and many other items. There was a survey conducted by Beth Israel Medical Center in New York city and the North American Syringe Exchange Network, which showed among the 126 SEPs surveyed, 77% provided to material abuse therapy, 72% provided voluntary counseling and HIV testing, and more than two-thirds provided supplies such as bleach, alcohol pads, and male and female condoms.

According to the Center for Disease Control (CDC), in the United States around 1/5 of all new HIV infections and the vast majority of Hepatitis C infections are the result of injection drug use. Dozens of peer-reviewed articles in prestigious medical journals such as The Lancet and The Journal of the American Medical Association have shown that needle exchanges reduce the transmission of HIV and Hepatitis C without increasing drug use. Critics of SEPs claim that the studies lack scientific rigor, but there have been no articles published in peer-reviewed journals that have found an increase in high-risk behavior, disease transmission or drug use because of SEP usage.

Supporters of SEPs have estimated that with the aid of SEPs, the number of HIV infections could be prevented from 4000-10000 between 1987–2000. According to their analysis of New York State-approved SEPs, during a one year period, SEPs contributed directly to the aversion of 87 HIV transmissions who.

Needle exchange programs are supported by the CDC and the National Institute of Health. The National Institute of Health 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. The presence of needle exchange programs has been attributed to a reduction of high-risk injection behavior by up to 74%, however these estimates have not been cognizant of the following issues.

Proponents of harm reduction argue that the provision of a needle exchange therefore provides a social benefit in reducing health costs and also provides a means to dispose of used needles in a safe manner. For example, in the United Kingdom, as the keystone prevention method, proponents of SEPs assert that the spread of HIV among intravenous drug users has been dramatically avoided. As a developed country, especially for medical care, the UK has been seen as a pioneer in establishing SEPs. In Australia, these programs have been credited with maintaining a very low rate of HIV infections among injecting drug users. These supposed benefits have led to an expansion of these programs in most jurisdictions that have introduced them, aiming to increase geographical coverage, but also the availability of these services out of hours. Vending machines which automatically dispense injecting equipment "pack" have been successfully introduced in a number of locations.

Another advantage cited by supporters of these programs are that SEPs can not only protect attenders themselves, but also provide a safe environment for their social network such as sexual partners, children or neighbors. If people among IDU did not attend SEP or share injection equipment with program attenders, SEPs can also have an indirect influence to control transmission risks. In fact, in those SEPs, nurses are very important in terms of spreading the knowledge about HIV among IDUs. Under this situation, people not only get physical protection from HIV, they also can learn a lot more information about HIV which can help them know well about this disease, and then learn how to protect by themselves and other people.

Other promoted benefits of these programs include being a first point of contact for drug treatment,access to health and counseling service referrals, the provision of up-to-date information about safe injecting practices, access to condoms, and as a means for data collection from injecting drug users about their behavior and/or drug use patterns.

These services can take on a wide range of configurations:

• Primary needle and syringe program ("stand alone" service)
• Secondary needle and syringe program (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

Countries where these programs exist include: Australia, Brazil, Canada, Netherlands, New Zealand, Portugal, Spain,Switzerland, United Kingdom, Ireland, [[Iran and the United States; however in the United States such programs may not receive federal funding.

American Programs

In the United States, Federally funded reports conducted by the National Commission on AIDS in 1991, the General Accounting Office in 1993, the Centers for Disease Control and Prevention (CDC) in 1993, the National Institute of Medicine's National Research Council, and the Office of Technology Assessment in 1995 all concluded that needle exchanges reduce the transmission of HIV while not increasing drug use.

Regardless of this evidence, the use of federal funds for needle-exchange programs was banned in the United States of America in 1988. Most U.S. states criminalize the possession of needles without a prescription, even going so far as to arrest people as they leave private needle-exchange facilities. Nonetheless, every state in the United States has a program that supports needle exchange in some form or the purchase of new needles without a prescription at pharmacies.

These programs were introduced during the Clinton Administration but were disbanded following negative public reactions to the initiatives. Covert programs still exist within the United States.

One such state operating with covert needle operations is Colorado. Current laws in Colorado leave room for interpretation on the requirement of a prescription to purchase syringes. Because of this law the majority of pharmacies will not sell needles without prescription, and police will arrest people in possession needles without prescription. Groups including The Works (Boulder), and The Underground Syringe Exchange of Denver (the USED), attempt to ease to burden this legislation places on IDUs in Colorado. Both exchanges operate covertly to avoid legal prosecution and are entirely funded by donations and operated by volunteers. Because of the illegal nature of the organization, the USED website specifies that new clients must be referred in order exchange needles. Both organizations have been highly successful in supplying IDUs with an alternative to using dirty needles. According to The Works website this year they have received over 45,000 dirty needles, and distributed around 45,200. Unfortunately no studies on the effectiveness of these specific exchange programs at reducing HIV and Hepatitis rates have been conducted.

Opposition

The provision of needle-exchange programs is opposed by different groups on a wide range of grounds. These can include:

• That the programs represents a weakening of the "War on Drugs" (or equivalent) policy;
• That the programs encourage drug use;
• The services attract crime to an area;
• That the permanent location of such services may lower surrounding property values;
• There will be an increase in discarded injecting equipment around the service; and/or
• The services build and/or strengthen social networks of injectors and undermine treatment or diversion.
• Health centres for those who are drug dependent, without distribution of needles, can offer condoms, dental service, HIV-test, medical services, contact with drug treatment etc without the risks connected to needle distribution.

Regarding the fifth concern described above, 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.

Each of these concerns have varying degrees of validity, though a number of meta-analysis of studies from around the world give mixed results. The methodology of such studies is under debate. European studies have found the provision of needles does not cause a rise in drug use. A clinical trial of needle exchange found that needle exchange did not cause an increase in drug injection These findings have been endorsed by, among others, former United States Surgeon General Dr. Davis Satcher, former Director of the National Institutes of Health Dr. Harold Varmus, and former Secretary of the Department of Health and Human Services, Donna Shalala.

Critics point out that needle exchanges were responsible for low rates of HIV in Australia, while a lack of needle exchanges comparably explains the ongoing epidemic of HIV in the United States - rests on a very apparent contradiction. If the failure of needle exchanges in Australia to control Hepatitis C transmission is excused by the ‘runaway train’ explanation, i.e. there were already epidemic numbers of HCV infections before the introduction of needle exchanges, then the failure of the United States to control high HIV transmission rates can similarly be excused on the grounds that HIV was already at epidemic proportions when their alternate prevention strategies were introduced, while Australia’s HIV rates were never at epidemic proportions when needle exchanges were introduced.

The 2004 review by the World Health Organisation (WHO) on the effectiveness of needle exchanges in the prevention of HIV transmission has been considered by supporters of needle exchange to be the most definitive review up until that date . However the WHO review contains serious errors which when corrected nullify its claims of demonstrated effectiveness. The WHO review had found 11 journal studies on needle exchanges which demonstrated sufficient scientific rigor to judge effectiveness or otherwise, and had judged 6 of the studies to show a positive result for needle exchanges regarding reduced HIV transmission. Three returned a negative result (i.e. increases in HIV in needle exchange populations), and 2 were inconclusive.

Of the 6 studies judged positive, the 1993 Heimer et al. study did not measure HIV prevalence among IDUs but only in returned needles, which can not be directly translated into a population and therefore should not have been included. The 2000 study by Monterosso and co-workers was misclassified as positive for NEP, whereas in fact the result was statistically non-significant and should have been labelled inconclusive. The purportedly positive 1991 Ljungberg et al. study had found HIV seroprevalence in Sweden’s Lund, a city with needle exchange, to be maintained at -1% in contrast to 60% in Stockholm, but ignored the authors’ own comment that incidence in Stockholm had been reduced to 1% by the time of the study without the implementation of needle exchanges, therefore this study should have been moved to the inconclusive table.

Two of the remaining positively labelled three were ecological studies. The most extensive review of the effectiveness of needle exchanges in 2006 by the US Institute of Medicine, with its extensive panel of scientists, medical practitioners and reviewers, noted that ecological studies monitor populations rather than individuals, and therefore cannot establish causal links. It also noted that ecological studies cannot separate the effect of needle exchanges from the effect of other preventative measures which customarily accompany them. For instance, comparisons of HIV transmission amongst intravenous drug users (IDUs) in Norway, Denmark and Sweden found that Sweden and Norway, with higher levels of HIV counselling and testing, had significantly lower incidence rates of HIV amongst IDUs than Denmark where there was legal access to needles and syringes and a lower level of HIV counselling and testing. This suggests that needle exchanges’ accompanying interventions may be more effective than the needle exchanges themselves.

The effectiveness of needle exchanges in preventing Hepatitis C (HCV) has likewise not been demonstrated. A 1997 epidemiological review of needle exchange effectiveness in Australia, which has one of the most comprehensive programs of any country worldwide, found no demonstrated effectiveness in reducing HCV rates in the country. The aforementioned 2006 Institute of Medicine review likewise concluded that “multiple studies show that NSEs do not reduce transmission of HCV.” At the population level, between 60% and 70% of Australian IDUs are estimated to have Hepatitis C, despite the comprehensiveness of the Australian needle exchange interventions nationally since 1991. These rates are no different to rates in other countries, whether they have needle exchanges or not.

See also

• Arguments for and against drug prohibition
• Drug abuse
• Drug addiction
• Drug possession
• Demand reduction
• Hard and soft drugs
• Moral panic
• Recreational drug use
• Safe injection site
• Taboo
• War on drugs

References

• "Syringe Exchange". "Common Sense for Drug Policy Presents the Facts: Syringe Exchange & Safe Injection Facilities". Retrieved May 1, 2005.
• Barkham, Patrick. "Australia opens first heroin injecting room." Guardian. 8 May 2001.[1]
• Day, Carolyn (2004). "Effects of reduction in heroin supply on injecting drug use: analysis of data from needle and syringe programs". BMJ (British Medical Journal). 329 (7463): 428–429. doi:10.1136/bmj.38201.410255.55. PMID 15292056. Retrieved 2006-06-10. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)