Opposition to clean needles for addicts: Symbolism over science?

In the midst of a debate over a controversial law calling for drug tests for any welfare recipients, public health researchers and activists in Georgia are calling for a more scientifically backed means of reaching out to and helping drug users — one that has, save for one brief period, been restricted from receiving federal funds for more than 25 years.

Georgia, along with Florida and Utah, has sought to test welfare recipients for drugs with the stated aim of saving tax dollars and getting people off drugs, but at the same time those three states combined have just one center that has scientific backing for accomplishing those goals — neither of which has been shown to be accomplished by drug testing.

Advocates say that distributing the equivalent of a few dimes a day to try and prevent a disease that may cost hundreds of thousands of dollars over a lifetime may seem a simple and smart policy, particularly when those few dimes connect recipients with health care workers they are more likely to trust and when the program is endorsed by leading health organizations. But when the few dimes represent the cost of a few syringes and the recipients are IV drug users, symbolism seems to overwhelm the scientific evidence.

Syringe exchange, in which intravenous drug users can obtain fresh syringes, has been a controversial program in large part because it is perceived as promoting drug use among clients who receive clean syringes. Opposition to it led to a ban on exchanges run by programs receiving federal funding beginning in 1988. But decades of research have told a different story, and needle-exchange programs have been credited for helping to dramatically reduce the transmission of HIV among IV drug users. The programs have also been endorsed by numerous medical and public health organizations, including the Centers for Disease Control and Prevention, the Institute of Medicine, the Substance Abuse and Mental Health Services Administration and the World Health Organization.

Needle-exchange programs gained attention with the discovery of HIV, which can be spread by reusing syringes. Although there is documentation of the intent to provide clean needles to IV drug users in the 1970s because of concerns about hepatitis, “HIV was really the factor that drove creation and expansion of syringe-exchange programs,” said Don Des Jarlais, director of research for the Baron Edmond de Rothschild Chemical Dependency Institute at Beth Israel Medical Center in New York and a leading researcher into the use of needle-exchange programs, who calls the programs “one of the most effective interventions of reducing HIV transmission that we have.”

Des Jarlais and other researchers in the area point out that in order to be effective, needle exchange has to be part of a more comprehensive set of services for the people who make use of it — a way to get people in the door for more essential help. The other services provided, and relationships and trust between IV drug users and people running the program, are important as well, and so counseling, testing, condom distribution and referrals to drug treatment programs are part of the package that programs provide, depending on funding.

“From the beginning there was a realization you needed to provide as many other services as you had money for,” Des Jarlais said.

But funding has been a major obstacle, as many programs face federal and sometimes state or local bans, limiting not only the needles but a method of outreach. 

Needle-exchange programs have also been utilized in many other countries, often with fewer obstacles.

Umedjon Ibragimov, a doctoral student in the behavioral sciences and health education program at Emory University researching HIV prevention strategies, said he first became aware of the issue in his native Tajikistan in the late 1990s as heroin came into the country from neighboring Afghanistan — and with it came transmission of hepatitis and HIV. Meanwhile, he said, the Open Society Foundations had come in and brought programs to combat the problem, including needle exchange.

Ibragimov said that in order to start a needle-exchange program, there needs to be some recognition of the problem as well as a lessening of the stigma against drug users that exists in many parts of the world. Even in Tajikistan, where needles could be purchased over the counter, many people were reluctant to do so and ended up reusing. Syringe-exchange programs have been used to varying extents in countries as diverse as Canada, the Netherlands, Iran and Ukraine, among many others.

Despite the federal funding ban, a number of needle-exchange programs exist in the U.S., but their presence at 216 sites in 31 states, Washington, D.C., and Puerto Rico, according to figures provided by the Foundation for AIDS Research (amfAR), is far from uniform.

That leads to some programs servicing a wide area. The Atlanta Harm Reduction Coalition operates the only program in Georgia, and ends up having clients come from all around the metro Atlanta area and places as far away as Macon and Augusta, as well as Chattanooga, Tenn., according to interim Executive Director Mona Bennett. North Carolina is the only neighboring state with any needle-exchange programs.

Atlanta’s program is located in an area known as English Avenue or the Bluff, a “high-intensity drug trafficking area,” Bennett said. She said many of the objections to programs like hers — which is funded by private grants and is susceptible to swings in the availability of funds — are rooted in what she calls an “unnecessary split”: the idea that giving out needles and helping people ultimately get into treatment can’t coexist.

“Drug users are gonna use drugs, and they want to protect their health,” Bennett said. “When made easy for them, when put in the communities where drug users are, drug users will come. When staff and volunteers treat the people we serve with respect, people will come.”

With regard to opposition to the program, she said, “Some things are just data-proof.”

Despite widespread consensus from medical authorities on the effectiveness of needle exchanges, there has been plenty of opposition to their presence in the United States.

“Certainly it’s more acceptable if it’s being used as a means of getting people into treatment, but we don’t think the science really justifies it,” said David Evans, a New Jersey attorney and special adviser to the Drug Free America Foundation. “We’d much prefer that we emphasize abstinence and getting people into treatment rather than just giving them needles.”

In past testimony before the New Jersey state Assembly, Evans expressed a number of concerns about neighborhoods where exchanges would take place and said such programs send the wrong message to schoolchildren about drug use.

To be sure, there are some studies that have indicated significant failures by needle-exchange programs, but follow-up research has often supported the scientific consensus.

One study widely cited by opponents, published in 1997, was conducted in Montreal and showed that needle-exchange users doubled their risk of HIV infection. However, subsequent research showed that this was the result of a different profile for users of the exchange. While she was traveling overseas and could not be reached for comment before press time, Dr. Julie Bruneau, who authored that study, continues to work in needle exchange, according to information on her university’s Web page.

Des Jarlais said he sees many of the objections as being grounded less in the effectiveness of the programs than in a stigmatizing of drug users and disapproval of drug use to the point where the value of users’ lives is questioned.

“The symbolism of giving somebody a lifesaving medication is very different from the symbolism of giving them sterile needles and syringes, even though giving them sterile needles and syringes may also be lifesaving,” he said.

Those sentiments were echoed by Kirk Elifson, a professor of behavioral sciences and health education at the Rollins School of Public Health at Emory, who said that among conservative elements in the South, there appears to be a perception that the lives of drug users are “not worth saving.”

“These are the kinds of messages we’re up against,” he told an audience at Rollins during a recent panel discussion on the federal ban on needle exchange.

Also at the panel discussion was Kali Lindsey, deputy director of public policy for amfAR, which is lobbying Congress to have the ban rescinded — lobbying primarily aimed at Rep. Jack Kingston, R-Ga., chairman of the Labor, Health and Human Services, Education and Related Agencies Subcommittee, who could alter language in the next budget, and is currently running for a Senate seat from Georgia.

Kingston’s office did not reply to requests for comment.

Because of the federal ban and opposition in many communities, Lindsey said, it’s often important to work with three groups for support on the issue — health care workers, police officers and local parents — all of whom have varying concerns about needle exchanges that the programs have worked to address.

Congress lifted the ban on needle-exchange funding was lifted in 2009 in what was hailed as a victory by HIV-prevention advocates, but the ban was reinstated in 2011 by Republican leaders as part of a tense budget negotiation. During that brief window, however, a number of programs were able to secure funding for the first time.

Researchers for amfAR are now looking at the effect of this temporary lift in the ban, although they could not discuss findings before they are published. Lindsey pointed to some signs that the brief period may be enough to show a long-term benefit.

“Areas that had never had a syringe exchange had one for the first time,” Lindsey said, including programs in New Jersey and Long Island. “When the ban was reinstated, funding was found to continue these programs … In other words, federal funding allowed the programs to demonstrate their effectiveness and served as a gold seal of approval for such programs, opening doors to new funders.”