STATS ARTICLES 2008
Needle exchange and the new drug czar
By Maia Szalavitz, Dec 3, 2008
Is the Obama administration choosing ideology over scientific consensus in its pick for the new drug czar?
President-elect Obama’s staff recently floated the name of Rep. Jim Ramstad, a Republican from Minnesota who is a recovering alcoholic, as the possible “drug czar.”
While the nomination of someone with personal experience of addiction to this post is, in principle, something worthy of applause, Ramstad appears to see addiction and recovery through too personal a lens, putting, in the process, ideology ahead of science.
Crucially, he opposes needle exchange programs to prevent the spread of HIV among addicts, which is one of the best-studied interventions in public health. He even voted against allowing Washington, DC to use its own money to fund these programs.
And yet, every single medical, scientific and legal body ever to look at the data has come down in favor of it and other programs to expand access to syringes.
The evidence for
These include (and the links take you to the research): The Institute of Medicine, the National Institutes on Health, the Centers for Disease Control and Prevention, the American Bar Association, the American Medical Association, the American Psychological Association, the American Society on Addiction Medicine the American Public Health Association, the World Health Organization, Britain’s Advisory Council on the Misuse of Drugs, the United Nations Office of Drug Control, the Joint United Nations Programme on HIV/AIDS the Office of Technology Assessment of the U.S. Congress and both President Bush's and President Clinton's AIDS Advisory Commissions, the Surgeon General and many others.
Here is just a small sampling of the research which shows that not only does needle exchange reduce HIV infections, it also does not increase injection drug use or crime and steers addicts towards treatment, not away from it:
The first international review of the data, conducted in 2006, concluded: “There is compelling evidence of effectiveness, safety, and cost-effectiveness,” of needle exchange programs.
A 2003 study of 99 cities around the world compared HIV rates in addicts in cities with and without needle exchange programs. In cities which started needle exchanges, HIV prevalence in addicts fell by 18.6 percent, while those which failed to do so saw an 8.1 percent increase. [MacDonald M, Law M, Kaldor J, Hales J, Dore GJ. 2003. Effectiveness of needle and syringe programmes for preventing HIV transmission. International Journal of Drug Policy Sterile Syringe Access for Injection Drug Users in the 21st Century: Progress and Prospects. 14(5-6):353–357]
A 1999 study found that needle exchange users were three times more likely than non-users to seek detoxification treatment to try to end their drug use.
A 2005 study found that when needle exchange expanded from 250,000 needles per year to 3 million annually between 1990 and 2001 in New York, the HIV prevalence rate amongst IV drug users entering addiction treatment fell from 54 percent to 13 percent and Hepatitis C prevalence fell from 90 percent to 63 percent.
Over a five and a half year period, a study in San Francisco found that the percentage of needle exchange users reporting having started injecting in the last year went from 3 percent to 1 percent, suggesting a decline in the number of new injectors.
A Baltimore study found that the introduction of needle exchange was not accompanied by an increase in crime – and a study in New York found no association between nearness to a needle exchange and violence or robberies by drug users.
The Institute of Medicine’s Board of Global Health most recently reviewed the needle exchange data in 2006. It found 26 prospective cohort studies and six ecological studies of the programs. The Board critiqued the data for lack of randomization (and as a result, called it “moderate” rather than strong data), but for some reason failed to note that ethical issues preclude randomizing people when denying access to an intervention could be deadly. It concluded:
Moderate evidence from developed countries points to a beneficial effect of multi-component HIV prevention programs that include needle and syringe exchange on injection-related HIV risk behavior, such as self-reported needle sharing and frequency of injection. Modest evidence also points to decreasing trends in HIV prevalence in selected cities studied over time. Although many of the studies have design limitations, the consistency of these results across a large number of studies supports these conclusions.
The only studies that have ever suggested negative effects of needle exchange were cohort studies in Vancouver and Montreal, both of which, early on, found that use of needle exchange programs was associated with substantially increased risk of HIV infection.
Opponents of needle exchange – including the U.S. Office of National Drug Control Policy – seized on these results, claiming that they overshadowed all the other data and proved that needle exchange was dangerous.
They went so far as to suggest that the Washington Post, which had been critical of the ban, contact the authors of the studies to confirm this. But when a reporter actually did so, all of the researchers said that their work did not show anything of the sort. In fact, these researchers had been so upset about the misuse of their data by politicians that, earlier, they had sent a letter of complaint to Congress.
It turned out that both cities were in the grips of a cocaine epidemic – and cocaine is injected at least three to five times more frequently than heroin, which radically increases the chances of getting infected, for obvious reasons.
Worse, both needle exchange programs set strict limits on the number of needles they would provide, leading to increased pressure to share. After these restrictions were eased in Montreal, HIV incidence amongst needle exchange users fell from 6.1 per 100 person-years in 1995 to 4.7 by 2004. In Vancouver, after similar policy changes were made, HIV incidence fell by 30 percent.
This is why these studies did not persuade the organizations that support needle exchange programs to change their positions.
An unheralded success
While the “AIDS cocktail” has received massive attention for turning HIV infection into a severe, chronic illness as opposed to a nearly certain death sentence, the prevention success of needle exchange and other programs to expand access to clean syringes (like making them available without a prescription), has gone largely unnoticed.
In New York City – the epicenter of the epidemic amongst IV drug users, with the largest population of addicts in the U.S. – infection rates went from over 50 percent in the early 90’s to 13 percent as of 2005. New York was, for the U.S., a relatively early adopter of needle exchange and in 2000, it made syringe purchase without a prescription legal. Studies found that this further expanded access to clean needles and reduced sharing.
In the early 90’s, over 75 percent of pediatric cases in New York were babies born to infected IV drug-using parents – there were 320 such babies born in 1990, compared to just five in 2003. Much of this decrease is due to use of medications to reduce prenatal transmission, but since many IV drug users do not receive prenatal care, the falling rate of infections in addicts is also a cause.
In addition, at the peak of the epidemic, some 80 percent of heterosexually-acquired infections involved people whose partners were IV drug users. The dramatic decrease in infections amongst addicts reduced risk for both their children and their partners and their partner’s partners.
The tragedy is that virtually all of these infections were preventable. The UK, which instituted needle exchange as a national policy in 1986 under Margaret Thatcher, did not have a heterosexual or pediatric epidemic and the infection rate amongst IV drug users did not rise above 1 percent. In American IV drug users, rates climbed higher than 50 percent in some cities at the epidemic’s peak.
In the African American community, there are 68.7 HIV infections per 100,000 people – a rate nearly ten times that of whites. Many of these infections resulted either directly or indirectly from IV drug use, including infections contracted in prison. IV drug use is the second leading cause of infections amongst African-Americans and is the source of much of the heterosexual epidemic.
In 1988, Congress passed the first law banning federal funding for needle exchange – many revisions have been made over the years, but the legislation ultimately said that funding could not be allowed unless the President, through the Department of Health and Human Services, declared that it was effective and did not encourage drug use.
President Bill Clinton allowed his HHS secretary to make this declaration, but did not lift the ban for political reasons, an action he says he now regrets. As of 2005, there were 184 needle exchanges in 38 states, DC and other U.S. territories, but these rely on state and private funding.
A 1998 law added insult to injury in the nation’s capitol by banning Washington, DC from even spending its own money on the programs. That ban was recently lifted, but it was re-inserted into an appropriations bill by President Bush in early 2008.
Washington currently has the nation’s highest HIV infection rate and IV drug use is the source of nearly one-fifth of AIDS cases. Fortunately, the final version of the bill did not include the ban and now needle exchange is finally being publicly funded in the nation’s capitol.
Two decades of empirical research on needle exchange should provide the foundation for the nation’s drug policy, not a former addict’s personal experience. Sympathy is not a substitute for rigorous, dispassionate analysis. If the Obama administration is determined to nominate Rep. Jim Ramstad to the position of “drug czar,” it needs to explain why his personal experience and opinion disqualifies the weight of scientific evidence.