[Scheduled for
Publication in Subject to Debate, Police Executive Research Forum, October 2000
Vol. 14, No. 10]
Needle exchange programs (NEPs) are one part
of a comprehensive public health strategy to address the spread of blood-borne diseases in
intravenous drug users (IDUs). NEPs exchange dirty, used needles for clean ones, and
provide IDUs with a gateway to treatment and other services.
During a panel on needle exchange programs at
the PERF Annual Meeting in May, a police chief asked, "Why should I give a
darn?" about needle exchange programs.
The chief’s question was very
reasonable. Many police chiefs are grappling now, or will grapple in the future, with
needle exchange programs as part of a harm reduction strategy for their communities.
Science clearly documents that such programs prevent fatal blood-borne diseases.1 The
dilemma for police is that the NEPs also provide the means for intravenous drug users to
inject illegal drugs. Some feel that the "science" behind NEPs has been lost in
the controversy. Among the questions being asked are:
- Do NEPs increase drug use and encourage an immigration of drug
users from adjacent communities?
- Does crime increase in areas where NEPs operate?
- Will the number of dirty needles increase in areas where NEPs
operate?
- Will government support of NEPs send the wrong message to kids
about using drugs?
Background
In 1998, the estimated number of syringes
exchanged in the United States as part of NEPs was 19.4 million, an increase of
almost 11% from the previous year. One hundred and thirteen NEPs are operating in at least
30 states, some legal, some not. The most recent survey of NEPs found that 25 percent of
the programs responding were "illegal-underground," meaning that they operate in
a state with a prescription law and do not have formal support of local elected officials.
Twenty-two percent of programs reported that they were "illegal-tolerated,"
meaning that they operate in a state with a prescription law and received a formal vote of
support of approval of a local elected body. Fifty-three percent of program considered
themselves to be "legal" meaning they operate in a state that has no law
requiring a prescription to purchase a hypodermic syringe or has an exception to the law
allowing the NEP to operate. Furthermore, the survey reported that the number of
"legal" programs has grown from 33 in 1995 to 59 in 1998.2
Yet, until recently, police have mostly heard
anecdotal evidence in favor of or against NEPs, despite the long history of scientific
research supporting NEPs as one part of HIV/AIDS prevention. For example, during the last
five years, Johns Hopkins University’s School of Public Health conducted several
studies based on Baltimore’s NEPs. The results of these studies offer some answers.
Baltimore’s Bottom Line
The City of Baltimore is often cited by those
who wish to make a case for, or against the efficacy of needle exchange programs. To
explore this "Baltimore Connection" further, a panel at PERF’s Annual
Meeting, May 2000, heard the facts about Baltimore’s experience with their needle
exchange program.
The City of Baltimore operates its NEPs from
two vans at seven sites, including one pharmacy. The results of their program are as
follows:
- A Bridge to Treatment: Approximately 1,500 IDUs have entered
drug treatment programs.3
- AIDS and HIV Decline: Based on more than eight years of
follow-up in Baltimore’s ALIVE study of IDUs, HIV incidence decreased 35% after the
opening of the NEP in Baltimore City.4
- Arrest patterns found not to be significantly different in
areas served by the NEP program than in other areas of the city. This held true for
cocaine and heroin possession, as well as burglaries, prostitution and other crimes linked
to drug activities.5
- Fewer Incidents of Dirty Needles: There was a significant drop
in the number of dirty needles in the areas around the NEPs compared to other areas with
heavy drug users because the IDUs exchange their dirty needles for clean ones.6
- No Adverse Impact on Kids: Johns Hopkins University
researchers interviewed 1000 high school students about what influences them to use drugs.
Their answer as reported in this major study? Peers, family and friends are the biggest
influences. The students surveyed said NEPs were as likely to encourage them to use drugs
as anti-drug ads were to discourage them from using.7
- No Magnet Effect: Eighty-five percent of the clients served by
the NEPs resided in the same zip code. NEPs did not attract IDUs from other communities.8
The bottom line in Baltimore? Where NEPs
operate, the rate of HIV infection is down and crime has not gone up. The presence of
dirty needles is down, and 1,500 IDUs used NEPs as a bridge to treatment.
Is Baltimore a fluke? The Hawaii Department
of Health also funds an NEP and reports similar success rates. Rates of HIV infection
among IDUs in the areas served by these NEPs dropped from 5 percent in 1989 to 1.1 percent
in 1994. That rate held steady from 1994 to 1996. From 1993 until 1996, 74 percent of
Hawaii’s NEP clients reported they did not share needles. Additionally, only 18% of
the AIDS cases reported in Hawaii during 1997 were related to drug injectors, as compared
to one-third of reported new cases throughout the rest of the United States.9
The Cost of Not Giving a Darn
According to Peter Beilenson, MD, M.P.H,
Director, Public Health Department, City of Baltimore during his presentation at the PERF
2000 Annual Meeting, there are 650,000 residents in Baltimore. Every year, police make
90,000 arrests of 60,000 individuals. Of these arrests, 85 to 90 percent are drug related
and 90 percent of the drug-related arrests are for non-violent offenses -- property crimes
committed to feed drug addiction.
The average heroin addict has 225 days during
which they commit crimes each year to support a daily habit of between $50 and $75. That
means the illicit use of drugs cost the citizens of Baltimore $1 billion per year for the
city’s 60,000 addicts. Of that billion dollars, about half comes from illegally
obtained funds. Experts also suggest that the $1 billion figure represents one-third of
the real cost. The cost of not giving a darn? It’s about $3 billion per year.
What’s In It for Police?
Cambridge, Massachusetts operates a NEP.
Cambridge Police Commissioner Ronnie Watson reported during the panel on needle exchange
programs at the PERF Annual Meeting, that the existence of NEPs had no impact on crime in
Cambridge, no impact on his department’s ability to make drug arrests and no impact
on their ability to police. The arrest ratio is the same as it was before the NEP began
operating.
NEPs are but one small part of a larger
strategy to reduce rates of HIV infection in Cambridge. The program also frees up
resources for other endeavors.
What’s in it for police? NEPs decrease
the likelihood that a dirty needle will stick police officers. As noted above, the
existence of NEPs help drive down the presence of dirty needles because IDUs need a dirty
needle to exchange for a clean one. Likewise, IDUs feel safer telling officers when they
have a needle on their person if they are a NEP client.
The Last Word
NEPs have been a highly charged topic of
debate among policing professionals. Perhaps now is the time to examine this issue with
less passion and more focus on the existing strong body of scientific data as we attempt
to ascertain what course of action is ultimately in our communities’ best interest.
Meanwhile, the indisputable fact remains that
whether or not NEPs exist, addicts will continue to use drugs, and dirty needles will
continue to be a health hazard for the public and a safety concern for officers. The
question of NEPs appears no longer to be a question of science, but rather a question of
politics.
As one police chief said at the conclusion of
the PERF workshop, "I may agree or disagree philosophically with NEPs, but if it
keeps my officers safe, I may need to put my philosophy aside."
More information on needle exchange programs, contact cipporg@aol.com
1
Department
of Health and Human Services, Press Release, April 20, 1998, and National
Institutes of Health, Consensus
Development Statement on Interventions to Prevent HIV Risk Behaviors, March
1997.
Dr.
Denise Paone, Beth Israel Hospital, New York, New York, Presentation to the
North American Syringe Exchange Conference X, Portland, Oregon, April 27,
2000.Strathdee,
Steffanie, Ph.D., David D. Celetano, ScD, Nina Shah, MSc., Cynthia Lyles, PhD,
Veronica A. Stambolis, MA, Grace Mccalino, MPH, Kenrad Nelson, MD and David
Vlahov, PhD., Needle-Exchange Attendance
and Health Care Utilization Promote Entry into Detoxification, Journal of
Urban Health: Bulletin of the New
Your Academy of Medicine, Vol. 76, Number 4, December 1999.Strathdee,
Steffanie, Ph.D., Association Professor, Johns Hopkins University, School of
Public Health and Hygiene, Summary of
Research Findings in Support of Needle Exchange Programs, December 13,
1999 and Vertefeuille., M. Tun W., Huettner, S. Strathdee, S. Vlahov, D.,
Decline in self-reported high risk injection-related behaviors among HIV
seropositive participants in the Baltimore Needle Exchange Program, Presented
at the 127th Annual Meeting of the American Public Health
Association, Chicago, Ill., 1999. “Needle
Program No Spur to Crime”, The
Baltimore Sun, March 30, 1999. Doherty,
M., Garfein, R., Vlahov, D., Junge, B., Rathouz, Pr., Galai, N., Anthony, J.,
and Beilenson, P., Discarded Needles Do Not Increase Soon After the Opening of a Needle
Exchange Program. American Journal of Epidemiology 1997, 145 (3): 730 –
736. Marx,
MS, Beilenson, P., Alexander, CA, Safaeian, M., Vlahov, D. Attitudes of Adolescents about Illicit Drug Use and Needle Exchange
Programs: Final Program: 10th International Conference on Reduction of
Drug-Related Harm, Geneva, Switzerland.
Mary 21 – 25, 1999. Peter
Beilenson, MD, M.P.H., Remarks to Police Executive Research Forum Annual
Meeting, Washington, D. C., May 12, 2000.Report Says Hawaii’s Syringe
Exchange Program Works, Press Release, Hawaii Department
of Health, February 12, 1998.
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