Needle Exchange Programs: Overview

Introduction

Needle exchange programs (NEPs), also known as syringe services programs (SSPs), are public health programs in which clean, sterile hypodermic needles and other injection equipment are made freely available to intravenous drug users and used needles are safely disposed. The purpose of such programs is to reduce the spread of blood-borne diseases, particularly HIV/AIDS but also diseases such as hepatitis, which can be transmitted from person to person when needles are shared among users. Needle exchange programs also typically provide users with opportunities to access health and social services, including education, referrals to substance abuse programs, STD screening, and primary medical care.

According to the US Centers for Disease Control and Prevention (CDC), the majority of new hepatitis C virus (HCV) infections in the United States are related to intravenous drug use. Thousands of new HIV/AIDS cases each year are also linked to drug injection. The CDC and many other public health organizations have endorsed needle exchange programs as a tool to reduce the spread of these and other infectious diseases. Numerous studies have found that such programs are effective, safe, and cost beneficial. Despite this evidence, however, needle exchange programs have proven quite controversial in the US. Critics often raise fears that the programs encourage illicit drug use and may increase crime, and challenge the validity of research indicating otherwise. These critics tend to prefer a zero-tolerance approach to drug use, which they believe sends a stronger message.

The debate over needle exchange programs in the US often centers on whether the federal government should provide funding for such programs. For decades, a ban on federal funding of needle exchanges meant that all needle exchange programs in the country were run and paid for by private organizations. In the twenty-first century there were several motions to overturn this ban. In the mid- to late-2010s, as the opioid epidemic drove up rates of drug injection nationwide, Congress approved measures that allowed federal funding of needle exchanges in specific circumstances. However, use of federal funds to directly purchase syringes or needles themselves was still not allowed in most cases. Needle exchange programs remain controversial, and state and local regulation and implementation varies widely.

Understanding the Discussion

Blood-borne disease: A disease spread by contact with contaminated blood or other bodily fluids.

Harm reduction: A strategy or social policy based on the belief that certain human actions, such as drug or alcohol abuse, are likely to occur despite attempts to reduce or stop them entirely, and therefore it is important to take steps to minimize the negative impact caused by these actions.

HIV/AIDS: The human immunodeficiency virus (HIV) is spread via contact with bodily fluids (e.g., blood from contaminated needles). HIV causes acquired immune deficiency syndrome (AIDS), an incurable and often deadly infection in which the cells of the human immune system are attacked and eliminated.

Hypodermic needle: A very thin, hollow needle used with a syringe to administer an injection, often intravenously. Hypodermics are single-use needles and should not be reused.

Intravenous drug use: The injection of a drug, such as heroin or cocaine, directly into the bloodstream.

Zero-tolerance policy: A very strict enforcement of a rule or law that allows no compromises and usually involves harsh punishment if the law is broken.

History

The nonmedical, or recreational, use of medicinal drugs has a long history in the United States. During and after the Civil War, morphine and opium use was common among army veterans, partly because narcotics were widely prescribed as painkillers for wounded soldiers and used as treatments for diseases such as dysentery and malaria. However, addiction was not just a military problem. Housewives and others routinely used opiates for various minor ailments. In addition, the hypodermic syringe was invented in the nineteenth century, making it possible to inject morphine directly into the bloodstream for a quicker, more powerful effect.

Many drugs considered dangerous today were once perfectly legal, including heroin (introduced by the Bayer drug company in 1898 as a "safe" substitute for morphine) and cocaine (endorsed by psychotherapist Sigmund Freud and rumored to have once been found in small amounts in Coca-Cola, which was then marketed as a health drink). Doctors and government officials did not understand the negative health and social impacts and the potentially addictive power of such substances.

Soon, people began to worry about the growing number of Americans who were addicted to drugs. At the beginning of the twentieth century, two important pieces of federal legislation were passed. In 1906, the Food and Drug Act called for any food or drug intended for human consumption to receive government approval. The act also stated that some drugs could not be sold without a doctor's prescription and made it necessary for any potentially addictive drug to be labeled with a warning. In 1914, the Harrison Narcotics Tax Act made it a criminal offense for anyone other than a doctor to dispense opiates and prohibited even doctors from prescribing drugs to addicts.

From the 1920s onward, legislation against the nonmedical use of drugs grew stronger, and enforcement became more effective. The Supreme Court ruled that it was illegal for doctors to prescribe drugs to addicts, and the drug trade went underground, creating new criminal enterprises and making it so that addicts were engaging in criminal acts each time they obtained drugs.

The one exception to this law came in the form of "narcotic clinics," which between 1912 and 1925 offered decreasing amounts of heroin, cocaine, and morphine to addicts over time in an effort to avoid the devastating withdrawal symptoms associated with quitting "cold turkey." These clinics, often state sanctioned, were intended to help addicts quit gradually, without resorting to illegal activities. Though the clinics were few and did not last long, as some were poorly run and many addicts failed to successfully quit, they represented an early harm-reduction approach to the problem of drug addiction.

Harm-reduction strategies have been used throughout the history of drug policy in the United States. In the 1970s, there was a brief period in which "responsible use" approaches were employed, which involved the distribution of educational materials that explained how to obtain a high in less dangerous ways. However, zero-tolerance approaches have generally been more effective.

During the twentieth century, the picture of drug abuse in the United States grew steadily more complicated, with new and newly restricted drugs—both organic, such as marijuana (commonly used throughout history but classified as a poison and restricted in various parts of the United States starting in 1906), and synthetic, such as barbiturates (first sold in the United States in 1904) and amphetamines (first sold in the 1920s)—entering the country and enduring periods of greater or less popularity. In 1970, rather than dealing with each new addictive substance with a new law, the federal government passed the Controlled Substances Act as part of the Comprehensive Drug Abuse Prevention and Control Act.

At the same time, the federal agency known as the Drug Enforcement Administration (DEA) was formed to enforce the new legislation. The head of the DEA has come to be known as the "drug czar" and serves as the leader of the "war on drugs." This military metaphor highlights the attitude of most zero-tolerance advocates, who view drug abuse as a criminal problem. This attitude was partly a response to the crack cocaine epidemic of the late 1980s, which led to increased street violence and a strong opposition to drugs and, eventually, to needle exchange programs. In contrast, harm-reduction supporters view drug abuse as a public health problem that should be dealt with in the same manner as other social ills.

Needle exchange programs are just one type of harm-reduction strategy, and they have a relatively short history. In the 1970s, some doctors and nurses distributed clean needles to intravenous drug users on an individual basis in order to prevent the spread of diseases such as jaundice and to ensure that the injection sites did not become infected. These quiet transactions were sometimes not even openly acknowledged by doctor or patient.

When AIDS appeared in the 1980s and the spread of HIV became a major national concern, needle exchange programs entered the public conversation as one way of reducing the transmission of the virus among drug users. The first such programs started in late 1980s in Tacoma, Washington; New York City; San Francisco; and Portland, Oregon. In 1988, a handful of programs were developed in various states, including the Point Defiance AIDS Project in Washington and a program run by the New York State Department of Health. That same year, however, Congress enacted a ban on any federal funding for needle exchange programs. State or local funding remained available in some places, but other states and municipalities established their own bans or limitations on such programs.

Nevertheless, over the following decades needle exchange programs slowly became more widespread, as many studies indicated that they were effective. For example, HIV transmission via injection decreased by 10 percent per year from 2001 to 2005, at least in states that reported this type of transmission. According to a report published in the CDC's Morbidity and Mortality Weekly Report in November 2010, 123 of the 184 needle exchange programs known to exist in the United States at the time had exchanged approximately 29.1 million syringes in a single year.

Needle Exchange Programs Today

Needle exchange programs have remained a controversial subject in the United States in the twenty-first century. With support from the administration of President Barack Obama, the ban on federal funding was briefly lifted between 2009 and 2011. By 2012, there were at least 221 programs in thirty-five states, with half receiving state or local funding. In contrast, the distribution of clean hypodermic needles without a prescription remained illegal in several states, though in a few cases state legislators chose to tolerate needle exchange programs without prosecution. In other areas, stigmatization of drug use and zero-tolerance policies drove exchange programs underground. Many opponents expressed a NIMBY (not in my backyard) perspective, citing worries about loss of property value and fear of accidental exposure to dirty needles as reasons for not wanting a needle exchange program in their neighborhood.

Most evaluations of needle exchange programs indicate that they successfully reduce the transmission of HIV among intravenous drug users and do not increase the overall amount of intravenous drug use. Proponents of needle exchange programs also argue that bans or strict limitations on federal funding effectively discriminate against minorities and the poor, who are at disproportionate risk for contracting HIV through contaminated needles. They suggest that arrests of injection users may ultimately increase the spread of disease by displacing drug markets to new neighborhoods and driving users away from harm reduction programs. In addition, supporters cite evidence that needle exchange programs are cost-effective, especially when compared to the cost of HIV treatment. In the 2010s, the cost of preventing a single HIV infection through a needle exchange program ranged from $4,000 to $12,000, while it could cost as much as $190,000 to treat a patient with HIV.

Opponents of needle exchange programs claim that needle distribution sends a negative message to the public, including children, about the nature of drug use. Furthermore, they often argue that harm-reduction strategies do, in fact, increase the overall amount of intravenous drug use. Some also suggest that it is irresponsible to rely on needle exchange programs to solve the larger problem of drug addiction in society, as such programs do not address the root causes of drug abuse.

Support for federal funding of needle exchange programs and similar harm reduction initiatives increased significantly as opioid abuse gained increasing recognition as a major public health crisis in the mid-2010s. In December 2015 Congress released the FY 2016 Omnibus bill, which President Obama signed, that partially lifted the ban on using federal funds for needle exchange programs (by then more often officially known as syringe services programs). Though federal funds still could not be used to purchase needles and syringes, they could be used for other services related to diseases such as HIV that stem from drug injection. These services include counseling, disease screening, and referral to drug treatment and medical care centers. According to the language of the Health and Human Services guidelines, facilities seeking to use federal funds for these services were required to "consult with CDC and provide evidence that their jurisdiction is (1) experiencing, or (2) at risk for significant increases in hepatitis infections or an HIV outbreak due to injection drug use." Later legislation, including the Consolidated Appropriations Act of 2018, continued this general policy. However, some state and local regulations continued to ban syringe services programs in effect, with some observers reporting an increase in such legislation in the 2020s.

These essays and any opinions, information, or representations contained therein are the creation of the particular author and do not necessarily reflect the opinion of EBSCO Information Services.

Bibliography

Anderson, Kenneth. "Why Needle Exchange Is Good for Your Community." Psychology Today, 19 July 2013, www.psychologytoday.com/blog/overcoming-addiction/201307/why-needle-exchange-is-good-your-community. Accessed 19 Oct. 2016.

"Directory of Syringe Exchange Programs." North American Syringe Exchange Network, nasen.org/directory.

Green, Traci C., et al. "Life after the Ban: An Assessment of US Syringe Exchange Programs' Attitudes about and Early Experiences with Federal Funding." American Journal of Public Health, vol. 102, no. 5, 2012, pp. E9–16, doi: 10.2105/AJPH.2011.300595.

Hankins, Catherine. "Needle Exchange: Panacea or Problem?" CMAJ, vol. 157, no. 3, 1997, pp. 275–77, citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.567.5036&rep=rep1&type=pdf.

MacNeil, Joan, and Bernadette Pauly. "Needle Exchange as a Safe Haven in an Unsafe World." Drug and Alcohol Review, vol. 30, no. 1, Jan. 2011, pp. 26–32, doi: 10.1111/j.1465-3362.2010.00188.x.

McLean, Katherine. "The Biopolitics of Needle Exchange in the United States." Critical Public Health, vol. 21, no. 1, 2011, pp. 71–79.

McLean, Katherine. "Reducing Risk, Producing Order: The Surprisingly Disciplinary World of Needle Exchange." Contemporary Drug Problems, vol. 40, no. 3, 2013, pp. 415–445.

"Syringe Services Programs." CDC, www.cdc.gov/syringe-services-programs/php/index.html. Accessed 24 May 2024.

"Syringe Services Programs." HIV.gov, www.hiv.gov/federal-response/policies-issues/syringe-services-programs. Accessed 24 May 2024.

"Syringe Services Programs: Summary of State Laws." Legislative Analysis and Public Policy Association, August 2023, legislativeanalysis.org/wp-content/uploads/2023/11/Syringe-Services-Programs-Summary-of-State-Laws.pdf. Accessed 24 May 2024.

Vlahov, David. "The Role of Epidemiology in Needle Exchange Programs." American Journal of Public Health, vol. 90, no. 9, 2000, pp. 1390–1392.

Wolitski, Rich. "HHS Releases Guidance for Syringe Services Programs." The White House, 29 Mar. 2016, www.whitehouse.gov/blog/2016/03/29/hhs-released-guidance-syringe-services-programs. Accessed 19 Oct. 2016.