Needle-exchange programme

Contents of a needle-exchange kit

A Needle & syringe programme (NSP) or syringe-exchange programme (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 programmes are called "exchanges" because some require exchanging used needles for an equal number of new needles. Other programmes do not have this requirement.^[1] The aim of these services is to reduce the damage associated with using unsterile or contaminated injecting equipment.

A 2010 review of reviews led by Norah Palmateer which examined systematic reviews and meta-analyses on the topic concluded that there is 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 injecting risk behaviour.^[2] In a comment Palmateer warned politicians not to use her team's review of review as a justification to close existing programs or to hinder the introduction of new needle-exchange schemes. The weak evidence on the programs' effectiveness at preventing disease, is rather due to inherent limitations in the designs of the reviewed primary studies and should not be interpreted as that the programs lack preventative effects.^[3]

History and development

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

Needle-exchange programmes 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 programme was motivated by concerns regarding an outbreak of hepatitis B, the AIDS pandemic motivated the rapid adoption of these programmes around the world.^[4] This reflects the pragmatic response to the pandemic undertaken by some governments, and encapsulated in the harm reduction / minimization philosophy.

Operation

In addition to sterile needles, syringe-exchange programmes typically offer other services such as: HIV and Hepatitis C testing; alcohol swabs; bleach water and normal saline (often as rinse eye drops); aluminium "cookers"; citric acid powder (an imperative agent: enables heroin to dissolve in water); containers for needles and many other items.^[5] 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 counselling 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.^[6]

Needle-exchange programmes are supported by the CDC and the National Institute of Health.^[6][7] 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.^[7]

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, along with other programs, they have reduced the spread of HIV among intravenous drug users. The most extensive review of research into their effectiveness backs this claim.^[8] As a developed country, especially for medical care, the UK has been seen as a pioneer in establishing SEPs. These supposed benefits have led to an expansion of these programmes 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.^[9][10][11]

Another advantage cited by supporters of these programmes 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 neighbours. If people among injecting drug users (IDU) did not attend SEP or share injection equipment with programme 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 programmes include being a first point of contact for drug treatment,^[12] access to health and counselling 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 behaviour and/or drug use patterns.

A clinical trial of needle exchange found that needle exchange did not cause an increase in drug injection ^[13] 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.^[14][15]

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

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

U.S. programmes

The use of federal funds for needle-exchange programmes was banned in the United States of America in 1988, but this ban was overturned in 2009.^[16] In the past, many U.S. states criminalized the possession of needles without a prescription, even going so far as to arrest people as they leave private needle-exchange facilities.^[17] Nonetheless, as of 2006, 48 states in the United States had a programme that supported needle exchange in some form or the purchase of new needles without a prescription at pharmacies.^[18]

These programmes were introduced during the Clinton Administration but were disbanded following negative public reactions to the initiatives. Covert programmes still exist within the United States.^[19]

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.^[20] Groups including The Works (Boulder) and The Underground Syringe Exchange of Denver (the USED) attempt to ease the 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 to 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.^[21]

Research

The two 2010 Palmateer et al. 'review of reviews' scrutinised previous formal reviews of needle exchange studies and after critical appraisal four reviews met the inclution criteria, where three where deemed to be of good quality (Gibson et al., 2001; Tilson et al., 2007; Wodak and Cooney, 2004) while one was of poor quality (Käll et al., 2007). Tilson et al. was judged to be the most rigorous of these studies, with its review determining that the evidence was modest concerning the effectiveness of needle exchange programmes in keeping back HIV prevalence, modest the strength of the evidence is limited by study designs. For Gibson et al., "as for Wodak and Cooney, their conclusions seemed inconsistent with the HIV studies reviewed". The Käll et al. review was reported to have noted that "errors in categorising studies in favour of NEPs have been made (Wodak and Cooney, 2004; Wodak and Cooney, 2006) and studies claiming positive results have not been adequately scrutinized." The Palmateer review also considered the evidence from the relevant reviews on the effectiveness of NEPs in preventing Hepatitis C (HCV) transmission and self-reported injecting risk behaviours. They concluded that "there is 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 injecting risk behaviour."^[2][22]

The Palmateer reviews have been criticized by drug prevention organization, Drug Free Australia, as themselves reaching conclusions at odds with two of the four 'core' reviews scrutinised. They noted that Palmateer et al. had relied for its conclusion of 'tentative' support for HIV prevention on an unscrutinized acceptance of positive findings from the Wodak/Cooney World Health Organization (WHO) review, which had been found by Käll et al. to have been based on "significant errors which, when corrected, would alter the WHO finding from positive to inconclusive."^[23][24][25]

Opposition

Discarded needles dangerous to the community

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.^[26] Community concern about discarded needles^[27] 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.

See also

• Arguments for and against drug prohibition
• Drug abuse
• Drug addiction
• Drug policy of the Soviet Union
• 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". http://www.drugwarfacts.org/syringee.htm. Retrieved May 1, 2005. 
• Barkham, Patrick. "Australia opens first heroin injecting room." Guardian. 8 May 2001.[1]
• Day, Carolyn; Louisa Degenhardt, Stuart Gilmour, Wayne Hall (August 2004). "Effects of reduction in heroin supply on injecting drug use: analysis of data from needle and syringe programmes". BMJ (British Medical Journal) 329 (7463): 428–429. doi:10.1136/bmj.38201.410255.55. PMC 514203. PMID 15292056. http://bmj.bmjjournals.com/cgi/content/full/329/7463/428. 

Notes

1. ^ Safer Ottawa
2. ^ ^{a b} Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D (May 2010). "Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews". Addiction 105 (5): 844–59. doi:10.1111/j.1360-0443.2009.02888.x. PMID 20219055. 
3. ^ Amy Norton (March 11, 2010). "Do needle-exchange programs really work?". Reuters Health. http://www.reuters.com/article/2010/03/11/us-needle-exchange-idUSTRE62A4EC20100311. Retrieved October 18, 2011. 
4. ^ Ritter, A and Cameron, J (2006) A Systematic Review of Harm Reduction, Drug Policy Modeling Project, Monograph 06, Turning Point Alcohol and Drug Center, University of Melbourne, December.
5. ^ North American Syringe Exchange Network (2000). "2000 National Syringe Exchange Survey". Harm Reduction Coalition. http://www.harmreduction.org/research/dbase/survey2000/dataMain.html. 
6. ^ ^{a b} Centers for Disease Control and Prevention (CDC) (15 July 2005). "Update:Syringe Exchange Programs". MMWR Morb Mortal Wkly Rep (United States Center for Disease Control and Prevention) 54 (27): 673–6. PMID 16015218. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5427a1.htm. 
7. ^ ^{a b} National Institutes Of, Health (2002 Nov). "National Institutes of Health Consensus Development Conference Statement: Management of hepatitis C: 2002--June 10–12, 2002". Hepatology 36 (5 Suppl 1): S3–20. doi:10.1002/hep.1840360703. PMID 12407572. 
8. ^ United States Institute of Medicine [http:http://www.iom.edu/Reports/2006/Preventing-HIV-Infection-among-Injecting-Drug-Users-in-High-Risk-Countries-An-Assessment-of-the-Evidence.aspx "Preventing HIV Infection Among Injecting Drug Users in High-Risk Countries"]. http:http://www.iom.edu/Reports/2006/Preventing-HIV-Infection-among-Injecting-Drug-Users-in-High-Risk-Countries-An-Assessment-of-the-Evidence.aspx. Retrieved 2010-01-09. 
9. ^ McDonald D (2006). "ACT Syringe Vending Machines Trial 2004–2006, Progress Report No. 3, August to December 2005, and preliminary evaluation findings". Siggins Miller Consultants and Social Research & Evaluation Pty Ltd, Brisbane; Canberra. http://www.health.act.gov.au/c/health?a=sendfile&ft=p&fid=1157424055. 
10. ^ Islam MM, Conigrave KM (2007). "Syringe vending machines as a form of needle syringe program: Advantages and Disadvantages". Journal of Substance Use 12 (3): 203–12. doi:10.1080/14659890701249640. 
11. ^ Islam MM, Stern T, Conigrave KM, Wodak A (2008 Jan). "Client satisfaction and risk behaviours of the users of syringe dispensing machines: a pilot study". Drug Alcohol Rev 27 (1): 13–9. doi:10.1080/09595230701711199. PMID 18034377. 
12. ^ Brooner R, Kidorf M, King V, Beilenson P, Svikis D, Vlahov D (June 1998). "Drug abuse treatment success among needle exchange participants". Public Health Rep 113 Suppl 1 (Suppl 1): 129–39. PMC 1307735. PMID 9722818. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1307735. 
13. ^ Fisher DG, Fenaughty AM, Cagle HH, Wells RS (June 2003). "Needle exchange and injection drug use frequency: a randomized clinical trial". J. Acquir. Immune Defic. Syndr. 33 (2): 199–205. doi:10.1097/00126334-200306010-00014. PMID 12794555. 
14. ^ http://proxy.baremetal.com/csdp.org/research/surgeongennex.pdf Surgeon General's Needle Exchange Review
15. ^ http://drugwarfacts.org/cms/?q=node/66 Syringe/Needle Exchange Programs, DrugWarFacts, Accessed 06-02-2010
16. ^ Sharon, Susan (2009-12-09). "Ban Lifted On Federal Funding For Needle Exchange". NPR. http://www.npr.org/templates/story/story.php?storyId=121511681. Retrieved 2011-03-25. 
17. ^ Case P, Meehan T, Jones TS (1998). "Arrests and incarceration of injection drug users for syringe possession in Massachusetts: implications for HIV prevention". J. Acquir. Immune Defic. Syndr. Hum. Retrovirol. 18 Suppl 1: S71–5. PMID 9663627. 
18. ^ Chris Barrish (10 June 2006). "To stop AIDS 'breeding ground' needle exchange a must, many say". The News Journal. pp. A1, A5. Archived from the original on 2 September 2006. http://web.archive.org/web/20060902012926/http://www.delawareonline.com/apps/pbcs.dll/article?AID=/20060610/NEWS/606100309. Retrieved 2006-06-10.  Note: this article contains a picture of the interior of a "shooting gallery"
19. ^ Lune, H (December 2002). "Weathering the Storm: Non-profit Organization Survival Strategies in a Hostile Climate". Non-profit and Voluntary Sector Quarterly 31 (4): 463–83. doi:10.1177/0899764002238096. 
20. ^ http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102187404.html
21. ^ http://www.bouldercounty.org/health/hpe/STI/exchange.htm
22. ^ EMCDDA "Monograph 10 - Harm Reduction". http://www.emcdda.europa.eu/attachements.cfm/att_101268_EN_emcdda-harm%20red-mon-ch5-web.pdf. Retrieved 2011-05-29.  pp 126,27
23. ^ Drug Free Australia [tt_news=72&no_cache=1 "LATEST NEEDLE EXCHANGE REVIEW FINDS NO PROVEN EFFECTIVENESS ON HEP C TRANMISSION"]. http://www.drugfree.org.au/index.php?id=81&tx_ttnews[tt_news]=72&no_cache=1. Retrieved 2011-05-29. 
24. ^ Kall K, Hermansson U, Amundsen E "The Effectiveness of Needle Exchange Programmes". http://www.health.gov.au/internet/drugstrategy/consult.nsf/080570BF7A9D2A03CA2577F900154B77/$FILE/Attachment%202_Kerstin%20Kall_The_effectiveness_of_needle_exchange_programmes%5B1%5D.pdf. Retrieved 2011-05-29. 
25. ^ Kall K, Hermansson U, Amundsen E, Ronnback K, Ronnberg S "The Effectiveness of Needle Exchange Programmes for HIV Prevention - A Critical Review". http://www.globaldrugpolicy.org/1/3/1.php. Retrieved 2010-09-27.  Journal of Global Drug Policy and Practice VOLUME 1, ISSUE 3 - FALL 2007
26. ^ "Road to Recovery". Australian House of Representatives Standing Committee on Family and Community Affairs. 2003. p. 187. http://www.aph.gov.au/House/committee/fca/subabuse/report.htm. Retrieved 2010-01-09. 
27. ^ "Drug-injecting hotspot near Collingwood childcare center". Melbourne Leader. 8 March 2010. http://melbourne-leader.whereilive.com.au/news/story/drug-injecting-hotspot-near-collingwood-childcare-centre/. Retrieved 2010-05-01.