Cons of needle exchange programs




















And if you do end up sharing needles, check out this blog to learn what you should do afterwards. Claim Your Recovery Today! May 16, Addiction. Major Pros and Cons Pros: Needle exchange programs reduce the risk of sharing contaminated needles by offering clean needles and disposing of used needles.

Most programs offer free HIV testing and counseling services for individuals who have participated in harmful activities. Cons: Needle exchange programs may increase rates of drug use by giving injection drug users more needle options. Needle exchange programs only attempt to lessen the risk of harm during drug use rather than stopping drug use completely. Facebook Twitter Share. In sum, from the earliest studies of needle exchanges, there has been a dominant trend in the data showing significant and meaningful associations between participation in needle exchange programs and lower levels of drug-use risk behaviors, and small or no change in sexual risk behaviors.

The most recent data continue to reflect this trend. Moreover, this pattern of findings has also been observed in foreign cities Davoli et al. Both reported a stabilization of HIV seroprevalence rates that coincided with reductions in high-risk behaviors and the implementation of various prevention programs including outreach, education, testing and counseling, bleach and condom distribution, and needle exchange programs.

Although these ecological studies do not provide direct causal evidence of the effect of such programs, they nonetheless document a pattern in behavioral risk reduction that corresponds with stabilization of seroprevalence rates in distinct populations of injection drug users.

Hagan and colleagues b reported seroprevalence rates of needle exchange participants and nonparticipants. Because the outcome measured in this study was prevalent infection, temporal associations cannot be established with certainty, and the possibility that the results might reflect that the needle exchange program attracts lower-risk injection drug users cannot be dismissed out of hand. However, the results are consistent with the inference that needle exchange programs are associated with a lower risk of infection.

On the basis of recent updates from the International Conference on AIDS, Des Jarlais ; in press provided descriptive information on HIV incidence among injection drug users who participate in needle exchange programs across 14 different cities Table 7. Some of these incidence rates were measured directly by testing cohorts of needle exchange participants; others were based on self-reports of prior serological tests; still others were derived from statistical modeling techniques e.

These findings are consistent with the premise that an AIDS prevention program e. Although the prevalence is moderate and has remained stable, the observed incidence is high among the needle exchange cohort being studied. The program is located in an area of the city noted for prostitution, and the program operates in the middle of the night, which makes it prone to recruiting high-risk users.

That is, although the risk of seroconversion was found to be higher among needle exchange participants when compared to nonparticipants, injection drug users who used the needle exchange program as their exclusive source of sterile needles were found to be at substantially lower risk than those who used diverse sources of sterile needles.

Furthermore, the needle exchange program limit of 15 needles per visit may not be sufficient to properly address drug-use risk behaviors of individuals who inject large amounts of cocaine. There is also a high level of male prostitution among the needle exchange participants.

Specific ethnographic studies are needed to better understand the primary routes of transmission implicated and their dynamics e. This would allow the program to better tailor its services e. The potential ability of needle exchanges to attract injection drug users that are at high risk of seroconversion was also recently reported in the United States by a San Francisco research team Hahn et al. Although the disparities in observed seroincidence rates between needle exchange participants and nonparticipants could not be attributed to having been exposed to the needle exchange program, the program appeared to serve a relatively high-risk subset of injection drug users.

The authors concluded that the San Francisco program provides a unique setting for intervention because it provides direct access to a population that is at high risk. Other cities with needle exchange programs that have high seroprevalence data e. These data are consistent with the premise that AIDS prevention programs e. Obviously, these results are descriptive in nature there are no comparison groups and, as a consequence, cannot in themselves provide evidence of the direct causal effect of needle exchange programs on HIV incidence rates.

Nonetheless, they do provide valuable insight into HIV incidence rates among needle exchange participants in cities with varying levels of HIV seroprevalence among the local populations of injection drug users. The HIV seroconversion rate among high-frequency drug injectors not using the needle exchange programs ranged from 4 to 7 per person years at risk, compared with needle exchange participant groups with seroconversion rates ranging from 1 to 2 per person years at risk.

These findings suggest that the use of needle exchange programs has a substantial protective effect for preventing new HIV infections.

However, the results need to be interpreted with care. That is, nonequivalence across groups being compared needle exchange users versus nonusers precludes making strong causal inferences about the direct effect of the needle exchange on HIV incidence rates. Nonetheless, these data do reflect a significant association between needle exchange participation and HIV infection Des Jarlais et al. The most recent studies that have examined drug-use behaviors among needle exchange participants show either stable levels of reported drug injection frequency or even slight declines over time among injection drug users who continue to participate in needle exchange programs Watters et al.

In the recent New York City study, Paone et al. The only exception to this reported trend comes from an unpublished research manuscript from Chicago researchers O'Brien et al. As noted in the Preface, as the panel was concluding its deliberations, the Assistant Secretary for Health made public statements that a number of unpublished needle exchange evaluation reports had raised doubts in his mind about the effectiveness of these programs.

The panel deemed these statements to be significant in the public debate, therefore necessitating appropriate consideration in order for the panel to be fully responsive to its charge.

The panel therefore reviewed the unpublished studies, one of which was the aforementioned O'Brien et al. As unpublished findings, this research lacks the authority provided by the peer review and publication process. For this reason, the panel gave special attention to scrutinizing and describing in detail results reported by the researchers, as well as appraising their probative value see Appendix A.

The investigators infer from their findings that those who participate in needle exchange programs spend more money and inject more frequently than nonparticipants as a result of their participation in the program. Their assertion is based on data that, according to these authors, support the contention that program participation is economically driven i. The panel's review raised serious concerns about the tenability of their inferences.

For instance, a clearly insufficient theoretical and empirical development of the underlying models is used. That is, there are numerous other plausible models that could explain their data. From an economic standpoint, it would seem that individual socioeconomic status may be causally related to both drug abuse and use of the needle exchange program, rather than to the explanation that needle exchange programs cause drug use.

Nonetheless, the authors do not test any alternative plausible models to assess the relative fit of their models compared with other viable competing models.

Moreover, a weak theoretical justification is provided of their postulated model e. The empirical information provided on key variables is inadequate. Properties of the distributions of key variables are absent and aggregate summary statistics are used in various models without attention to the possible adverse effect of outliers.

The presence of such outliers can severely distort the results and challenges the viability of the inferences drawn by these investigators. Substantial inconsistencies between data on key variables self-report presented in the manuscript and information extracted from the needle exchange program records raised serious concerns among panel members.

Moreover, as discussed in some detail in Appendix A , the panel had serious reservations about the appropriateness of the modeling techniques as implemented by these researchers. Although this particular study suffers from serious limitations, the conclusions reached by the authors raise interesting questions and hypotheses that should be subjected to sound empirical testing.

These issues should be further studied with adequate designs, measures, and analytical methods. In the meantime, in the panel's opinion, these difficulties are serious enough to preclude making causal inferences about the effect of needle exchange programs. The concern that having the opportunity to use a needle exchange may lead persons who are not currently injecting to begin injecting demands attention, and some information about this is available.

If the opportunity to participate in needle exchange programs were to lead to an increase in the number of new injection drug users, one would expect to see relatively large numbers of young newer injectors at the needle exchange programs.

This has not been observed in any of the earlier studies e. Investigators in Amsterdam have recently published data that permit examination of the hypothesis that "mixing" of injecting and noninjecting drug users at needle exchanges will lead noninjectors to begin injecting behavior van Ameijden et al. Many of the Amsterdam needle exchanges are operated out of the "low-threshold" methadone programs.

These programs provide services to both heroin injectors and heroin smokers and do not require abstinence from illicit drug use as a condition for remaining in the program. Thus, these combined methadone treatment and needle exchange sites do provide frequent opportunities for social interactions between heroin injectors and heroin smokers. Despite this, the proportions of heroin users who smoke and those who inject have remained constant since the exchanges were implemented.

Recent U. The recent San Francisco study Watters, found an increase in the mean age of injection drug users in the city during the years of operation of the needle exchange programs i. Moreover, the author reported that during that 5. In Portland Oliver et al. The average duration of injection drug use was 14 years, and more than 75 percent had been injecting for 5 years or more.

The presence of a needle exchange program does not appear to cause any increase in the number of new initiates to drug injection. Identifying what factors lead individuals to initiate injection drug use, despite knowing about AIDS, remains an important question for future research.

Since the University of California report was issued, only one study has dealt with needle exchange programs and improperly discarded needles. Doherty et al.. After extended legislative debate, Public Act allowed the City of New Haven, Connecticut, to implement—on an experimental basis—a legal needle exchange for injection drug users. This program operated from a van, typically 6 hours a day, 4 days a week, and traveled to specific sites known to involve high levels of drug activity.

The needle exchange program operated on an anonymous basis. Specifically, participants were assigned a fictitious name as a means of identification and tracking. New enrollees who did not have a needle and syringe to exchange at their first encounter with the needle exchange program were provided with a single ''rig.

Syringes that were distributed were coded to enable tracking and evaluation. The program accepted syringes that had not originated from the program.

All returned equipment was placed in a metal canister, and all returned equipment was turned over to an evaluation team at Yale University for assessment. In particular, a sample of returned syringes were assessed for the prevalence of HIV. In addition to exchanging used sterile equipment, program staff provided AIDS education and information on risk reduction. Condoms and bleach packets were provided to all participants at each encounter. All participants were also provided information on drug treatment and a broad range of other relevant services e.

In July , syringe possession without a prescription was decriminalized. This was followed by a reduction in the monthly volume of exchanges at the program from about 4, to a little more than half that number. The importance of the evidence from the New Haven studies is twofold. They provide: 1 direct evidence of lower levels of HIV infection among needles in use and 2 indirect, model-based estimates of changes in the incidence of new HIV infections among needle exchange program participants.

The direct evidence involves the impact of the needle exchange program on the critical features of program process. Specifically, the evaluation reveals significant and substantial reductions in the infectivity of the syringes exchanged through the needle exchange program. The data also reveal increases in referral to drug treatment and no change in the number of injection drug users. Prior to the distribution of sterile injection equipment, extremely sensitive DNA analyses using the polymerase chain reaction PCR to detect the presence of HIV-infected peripheral blood cells in the returned syringes of existing "street" syringes showed an HIV-positive rate of 0.

During the first month of the exchange, HIV-positive rate for needles turned into the exchange was 0. That is, the prevalence of HIV in needles decreased by one-third. Measures of syringe infectivity gradually declined over time, with the sharpest decline occurring in the first 3 months after the implementation of the needle exchange program.

If the reduction in the infectivity of needles is due to the activities of the program, it is reasonable to expect changes in program operations that parallel the pattern of reductions in needle infectivity. Data about program operations tend to support the plausibility that reductions in infectivity are connected to the activities of the clients of the needle exchange program and the program itself. In particular, the number of visits increased more rapidly than the number of clients, suggesting that the same clients were exchanging needles more frequently.

Specifically, in December there were about clients and visits. By June there were clients and visits. Program data are also consistent with a fundamental concept of the circulation theory advanced by Kaplan—namely, the law of conservation of needles. Specifically, there was a close match between the number of inbound and outbound needles, and there was a substantial increase in the volume of exchanges between December and June That is, the volume of exchanges increased from less than to over 4, in June After decriminalization in , the volume of exchanges decreased to between 2, and 2, Over the entire study period November through June , a total of 80, needles were distributed; for the same period, the total number of needles that were returned was 78, That is, It appears that these figures include the "return" of nonprogram needles.

In other papers e. Using estimates of the size of the population of injection drug users in New Haven derived by Kaplan and Soloshatz , it appears that about half of the injection drug users have had contact with the needle exchange program Lurie et al.

Central to the circulation theory advanced by Kaplan is the notion that "more frequent exchanging should lead to a reduction in mean needle circulation times" b Data obtained from the syringe tracking system confirm this expectation. In December , the mean circulation time for syringes was about 7 days.

It should be noted that Kaplan's linear regression results project an estimated preprogram circulation time of Over the course of the intervention, circulation time declined steadily, to about 3 days in September Circulation time stabilized between 2 and 3 days thereafter through June This appears to be consistent with the linear regression estimates provided in Figure 4 of Kaplan b Kaplan concluded that the needle exchange program "appears to be interrupting the needle circulation process in the manner intended" b To summarize the empirical results so far, evaluation data reveal: 1 increased exchange rates per injection drug user and 2 increased return of program syringes, resulting in a decrease in mean circulation time for each syringe.

Because needles are in circulation for shorter periods, there is a decline in the probability of infection. Taken together, these data indicate that the New Haven needle exchange program, a substantial intervention effort, was a plausible contributor to reductions in the infectivity level of needles. Kaplan and colleagues Kaplan and Heimer, ; Kaplan and O'Keefe, could not directly observe HIV infection in needle exchange program clients as they could in needles and, as a consequence, turned to a mathematical modeling approach.

They estimated the relative effects the proportionate reduction of incidence per year and the absolute impact number of infections prevented per client year of the New Haven needle exchange program.

It was estimated from these models that the project was associated with a relative reduction in HIV incidence of 33 percent. It was further estimated that between 1 and 3 infections per participant years were prevented annually. An update of this rate of new HIV infections among participants yielded a revised maximum likelihood incidence estimate of 1. Moreover, a test of the null hypothesis that no new infections had occurred could not be rejected, providing further support for the efficacy of New Haven's needle exchange program.

Because these assessments are based on mathematical models that, of necessity, must rely on various assumptions, the validity of the resulting estimates hinges critically on the validity of the assumptions that had to be made. Two scientific reviews of the procedures and assumptions embodied in Kaplan's models issued in recent years U.

General Accounting Office, ; Lurie et al. GAO summarized Kaplan's work as follows p. Both our experts found that the mathematical specifications used in both equations appropriately express the dynamic process of HIV transmission among injection drug users via infected needles. They agree in their assessment that the model is technically sound and incorporates all key parameters. The circulation model is a very significant contribution to NEP [needle exchange program] evaluation efforts.

By focusing on how NEP needles alter the characteristics of needles in circulation, the model circumvents reliance on injection drug user self-reports of behavior change. Rather, the model uses syringe tracking and testing data to demonstrate that even if injection drug users made no effort to change behavior aside from obtaining needles at the NEP , HIV incidence would drop as a result of lower HIV prevalence in the needles.

Any additional reduction in risk behavior such as cessation of sharing or increased bleaching would reduce HIV incidence even further. Concerning the numerical estimates, from applying the model to the study data in New Haven, the GAO review concludes pp.

Our experts agreed that Dr. Kaplan's assumptions serve to underestimate the impact of the New Haven program on the rate of new HIV infections. The expert reviewers strongly believe that 33 percent understates the true percentage reduction in new infections attributable to the program.

The data used in the model were primarily obtained from three sources: 1 data developed from the program's syringe tracking and testing system, 2 self-reports from injection drug users participating in the program, and 3 data developed from other AIDS research studies. Our experts noted that the data values used from these sources are reasonable and produce a conservative estimate of the program's impact on the rate of new HIV transmissions.

The model's estimate that the New Haven needle exchange program results in a reduction of new HIV infections among participants over 1 year is defensible as a minimal estimate of the program's impact. The 33 percent difference is strictly attributable to the reduction in levels of infection in needles due to the shorter length of time that needles are in use or needle circulation time.

Relative impact would decrease modestly if different values were used for certain model parameters. Absolute impact would probably decrease below the published value of 0.

The panel's view is that these models provide important qualitative insight into why needle exchange programs should work. However, conclusions from modeling a complex process can rarely have the force of absolute proof. Kaplan and his colleagues recognize this, offering a range of calculations based on competing assumptions, parameter values, and models. Despite these admirable efforts, it is true that unmodeled features of the needle exchange program process might make the efficacy estimates either too high or too low.

For example, the Kaplan model does not take account of changes in the percentage of infected participants that result if disproportionately many dropouts from the program population were infected or were not infected. Likewise, if new entrants to the needle exchange program population were less infected or more that would artificially raise or lower the apparent effectiveness of the needle exchange program.

Therefore, we must regard numerical estimates from these models with some caution. In summary, the model-based evaluation of the New Haven needle exchange program provides important insights into the dynamics of such programs and useful preliminary estimates of their efficacy. We cannot attach the same level of confidence to these model-based estimates as we could to evaluation programs that included a suitable control group in which individuals were tested directly for HIV infection.

Unfortunately, such an evaluation program would face formidable obstacles because of concerns about privacy and confidentiality, difficulties ingeniously and conscientiously sidestepped by Kaplan's study methods. Several other outcome variables were also studied at the New Haven needle exchange program, and these are described below. If needle exchange programs attracted new initiates to injection drug use, a drop in the average age of program participants who enroll over time would be expected to be observed, coupled with a downward shift in the average number of years of injection drug use.

Using demographic data obtained from needle exchange program enrollees over the course of the program operation November to December , Heimer and colleagues Heimer et al. Throughout the study period, male and female enrollees were, on average, approximately 33 to 34 years old.

Male enrollees reported using injection drugs for about 10 years; female self-reports on duration showed more month-to-month variability averaging about 5 to 10 years.

From this set of indicators, it would appear that the needle exchange program did not increase the number of new initiates. The authors also provided an additional observation that counters the argument that needle exchange programs encourage the initiation of injection drug use. They argued that, if the presence of a needle exchange program did enhance use, an increase in the number of new initiates to injection drug use would be most prominent following public disclosure of the first report on the effects of the program.

But, at the time of the report's release and publicity , there was "no increase in the percentage of enrolling clients with very short durations of intravenous drug use" p. Participants requested drug treatment at a nearly constant rate 25 percent throughout the study period.

The percentage entering treatment increased from 15 percent first 7 months to 18 percent end of Another noteworthy observation is that a substantial proportion of people who visit the program's van are not needle exchange participants but are visiting the van because they are seeking treatment for drug abuse Heimer, As we have noted in our critique of the model-based estimates of HIV incidence, the change in outcomes especially the infectivity of needles might possibly be due to changes in the population served.

It is possible that the reduction in the infectivity of needles and syringes could be due to changes in the risk characteristics of participants.

But little of the available evidence indicates such client population shifts Kaplan and Heimer, a. The mean age of enrollees and the mean duration of drug use did not change over the course of the program. The percentage of women remained constant at 20 percent over the course of the study November to June Self-reported drug behaviors were not associated with enrollment date. Analyses of changes over time in frequency of injection, use of shooting galleries, injections shared, using cocaine, and risky injection frequency failed to show any statistically significant trends.

More sophisticated, multivariate models were also used, with similar results. Although drug behaviors and gender remained statistically constant over time, Kaplan and colleagues Heimer et al. Because white participants are less at risk, the change in HIV prevalence might be due to the change in the composition of the population served, but, as the authors note, this does not appear to be a viable plausible explanation for the decline in the infectivity of needles.

The decline occurred in the first days and then stabilized. The number of white participants steadily increased throughout the duration of the project. The magnitude of the change in composition is also not great enough to explain the reduction in HIV seropositivity. Specifically, the authors state Heimer et al. If needle exchange were without effect, then However, Also, Heimer et al.

As noted by the authors, because of the manner in which the exchange operated, it is not possible to know with certainty whether discordant needles i. Finally, Kaplan and others Kaplan, a; O'Keefe et al. Although the status of those who dropped out was not always clear, as noted above, a small fraction of these participants were known to have entered drug treatment.

Kaplan a argues that even short-term exposure to the needle exchange program could contribute to its aggregate impact. The pattern of evidence surrounding the New Haven needle exchange program involves a set of models, driven in large measure by empirical data gathered from participants and the needles they exchanged. Although the estimates of relative and absolute reduction in HIV incidence are based on mathematical models, Kaplan and his colleagues have explored the computational implications of a range of parameter values.

These varied models provide estimates that are not dramatically different, lending credibility to the methods. Nevertheless, the models are not infallible. The most compelling evidence from this set of evaluation studies is the direct evidence from the actual testing of syringes for the presence of HIV positivity.

Here the empirical results of monthly assessments show about a one-third reduction in the rates of infected needles. These empirical results are consistent with those produced by the models underlying Kaplan's circulation theory. Furthermore, evidence about the actual operation of the needle exchange program reveals that the mechanisms necessary for change were in place. A substantial number of needles were exchanged removed from circulation , the frequency of exchanging increased, and the mean circulation time of needles declined.

Had these changes not occurred or had there been observed changes in the composition of the study population, the plausibility of the observed effect i.

Evidence about the program processes strongly suggests that the reduction in the rate of infected needles is plausibly due to the program. Similarly, reduction in the rate of infected needles strongly suggests but does not directly test that there should be a reduction in HIV incidence on the order of magnitude projected by Kaplan's models.

In the panel's view, the empirical data clearly indicate that needles used by program participants have a lower probability of being infected and, consequently, program participants are less likely to become infected. The first legally authorized needle exchange program in the United States was implemented in Tacoma, Washington, in There are several reasons for examining the research on the Tacoma needle exchange in some detail.

The needle exchange was the dominant HIV prevention effort in the local area, so there is less confounding with other simultaneous HIV prevention efforts than in other geographic areas. Also, several studies have been conducted on the Tacoma needle exchange program, making it possible to assess consistency across different outcome measures and study designs.

The importance of the Tacoma studies on needle exchange programs is the fact that they provide direct evidence of the incidence of a blood-borne viral disease, spread by needles and sexual contact, among individuals who attended and those who did not attend a needle exchange program. In Tacoma, the prevalence of HIV infection among injection drug users was low, indicative that incident HIV infections would be expected to be rare. The Tacoma needle exchange program began operating "unofficially" in August After informing city officials that a needle exchange would be opening, a community-based organization set up a folding table on a sidewalk in an area of downtown Tacoma where there was a visible concentration of drug users and began exchanging syringes.

The unofficial program was officially sanctioned and funded by the local health department beginning in January A few months later, the health department filed a lawsuit to settle the issue of the legality of the program in view of existing drug paraphernalia laws.

In early , a Pierce County Superior Court judge declared that needle exchange was legal in the county. During the past 6 years, the needle exchange has developed into a broad public health program of prevention and education for injection drug users. At present, the Tacoma needle exchange program consists of two fixed outdoor exchange sites, one located two blocks from the original location and another in a Tacoma neighborhood. Both fixed sites are located near shelters or food kitchens that provide services to homeless persons and operate in areas of the city where there are many injecting drug users.

In the Blue Grass state, approval is needed from the county and city. Exchange students listen to instructions before planting vegetation in Santa Clara County, Calif. Photo courtesy of the American Exchange Project. The Graves County, Ky. Emergency Management Agency.

Photo by Hugh Clarke. Boone County, Ky. Judge-Executive Gary Moore looks on. Skip to main content. County News. By Charles Taylor Feb. Error message In order to filter by the "in queue" property, you need to add the Entityqueue: Queue relationship. The CDC shows participants in syringe exchange programs are more likely to enter drug treatment programs and more likely to stop injecting drugs, but the programs don't increase drug consumption.

More from Charles Taylor The benefits and challenges of needle exchange programs Substance abuse hits home for county officials. Alameda County created a program to put fresh produce in the hands of the residents who need it most and taught them how to live a healthy lifestyle and foster a healthy community.

The American Exchange Project is introducing U. Commissioner Mike McGinley has put his county on the list of participants. A series of tornadoes killed dozens and caused massive damage in Kentucky, Illinois, Tennessee, Arkansas, Mississippi and Missouri.



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