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Needle and syringe programmes

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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 . 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.

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. 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 and sterile water; aluminium "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 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.

Needle-exchange programmes 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.

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. 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..


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, 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 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.

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. 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 programme that supports needle exchange in some form or the purchase of new needles without a prescription at pharmacies.

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.

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 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.

Opposition

Critics of needle exchange programmes question any literature review finding that gives positive or tentative support for the effectiveness of needle exchange programmes in reducing the transmission of HIV. The Palmateer review of reviews which evaluated three previous major reviews of needle exchange programmes, concluded that the 2004 World Health Organisation study had cited five studies with positive findings, but that "(f)our of the five positive findings were generated by studies with weaker designs" and that "on the basis of a tentative statement from one core review, supported by consistent evidence from the less robust primary studies" they concluded that "there is tentative evidence to support the effectiveness of NSP in reducing HIV transmission."

A review by Kall et al. criticised a number of studies that were cited by the 2004 WHO review as positive. The 1993 Heimer et al study did not measure HIV prevalence among IDUs but only in returned needles, which, they stated, cannot 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 they maintained that this study should have been moved to the inconclusive table.

Critics further contend that proponents' claims that the implementation of needle exchange programmes in Australia was responsible for continuing low rates of HIV, while the lack thereof in the United States explains its ongoing epidemic, has no validity. Australia's high rates of Hepatitis C, which are the same as for the United States, are excused by the 'runaway train' explanation which asserts that there were already epidemic numbers of HCV infections before the introduction of needle exchanges. The same runaway train explanation well describes the situation in the United States before HIV prevention strategies were implemented and it can also be demonstrated that Australia’s HIV rates were very low when needle exchanges and other prevention strategies were introduced.

Rises in drug use

Drug Free Australia has questioned whether the introduction of harm minimization and needle exchanges in Australia, with its lesser emphasis on prevention, was responsible for the escalating heroin user numbers and associated heroin deaths which correlated with the increasing numbers of needles dispensed throughout the country. They further contend from 12 month illicit drug prevalence data from Sweden, Australia and the United States that concerted prevention efforts yield significantly lower levels of illicit drug use.

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. 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.

See also

References

Notes

  1. Safer Ottawa
  2. ^ Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D (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. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  3. 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.
  4. North American Syringe Exchange Network. 2000. “2000 National Syringe Exchange Survey.” Harm Reduction Coalition. (http://www.harmreduction.org/research/dbase/survey2000/dataMain.html)
  5. ^ United States. Center for Disease Control and Prevention. December 2005. “Syringe Exchange Programs”.
  6. ^ United States. National Institute of Health. 2002. Consensus development conference statement on the management of Hepatitis C. Conference held June 10–12, 2002.
  7. McDonald, D (2006), ACT Syringe Vending Machines Trial 2004–2006, Progress Report No. 3, August to December 2005, and preliminary evaluation findings Siggins Miller in association with Social Research & Evaluation Pty Ltd, Canberra
  8. 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 - 212.
  9. Islam MM, Stern T, Conigrave KM, Wodak A (2008). Client satisfaction and risk behaviours of the users of syringe dispensing machines: a pilot study. Drug Alcohol Rev. 2008 Jan;27(1):13-9
  10. Brooner R, Kidorf M, King V, Beilenson P, Svikis D, Vlahov D (1998). "Drug abuse treatment success among needle exchange participants". Public Health Rep. 113 Suppl 1: 129–39. PMC 1307735. PMID 9722818. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  11. Fisher DG, Fenaughty AM, Cagle HH, Wells RS (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. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  12. http://proxy.baremetal.com/csdp.org/research/surgeongennex.pdf Surgeon General's Needle Exchange Review
  13. http://drugwarfacts.org/cms/?q=node/66 Syringe/Needle Exchange Programs, DrugWarFacts, Accessed 06-02-2010
  14. 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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. 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 2006-06-18. Retrieved 2006-06-10. Note: this article contains a picture of the interior of a "shooting gallery"
  16. Lune, H (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. {{cite journal}}: Unknown parameter |month= ignored (help)
  17. http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102187404.html
  18. http://www.bouldercounty.org/health/hpe/STI/exchange.htm
  19. Kall K, Hermansson U, Amundsen E, Ronnback K, Ronnberg S "The Effectiveness of Needle Exchange Programmes for HIV Prevention - A Critical Review". Retrieved 2010-09-27. Journal of Global Drug Policy and Practice VOLUME 1, ISSUE 3 - FALL 2007
  20. N. Crofts, C.K. Aitken, J. Kaldor "The force of numbers: why hepatitis C is spreading among Australian injecting drug users while HIV is not". Retrieved 2010-01-09. MJA 1999; 170: 220-221
  21. National Institutes of Health "Management of Hepatitis C: 2002". Retrieved 2010-09-27.
  22. Drug Free Australia "The Reality on Government Needle Programs - Exposing the False Claims Made for Needle Programs in Australia" (PDF). Retrieved 2010-04-20. p 4
  23. UNODC "Sweden's successful drug policy: A review of the evidence" (PDF). Retrieved 2010-05-01. pp 26,7; UNODC "2000 World Drug Report". Retrieved 2010-05-01. p 89
  24. See graph of OECD drug use for 2000 UN Drug Report, Drug Free Australia "The Case for Closure" (PDF). Retrieved 2010-04-20. p 11
  25. Australian House of Representatives Standing Committee on Family and Community Affairs "Road to Recovery". Retrieved 2010-01-09. 2003 p 187
  26. See for example "Drug-injecting hotspot near Collingwood childcare center". Retrieved 2010-05-01. Melbourne Leader 8 March 2010
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