A single type of prevention or intervention strategy with regards to substance misuse. The needle exchange
The UK currently has an ambiguous and sometimes conflicting set of policies with regards to some issues surrounding drug use. In the words of Rice, the UK has:
an uneasy consensus of conflicting forces, opinions and positions that have shaped the whole legislative framework and surrounding issues that govern the way that we, as a society, deal not only with controlled drugs, but the problems that they cause directly and that are associated with their use. (Rice et al 1991)
If one considers the various ways in which this “consensus” has evolved over the last few decades, one could suggest that there is a clear dichotomy between those who feel that the way forward is through dual mechanisms of enforcement and prohibition (sometimes referred to as the illegalisation movement), and those who believe that systems employing legislation, harm reduction, empowerment and education comprise the rational way forward. Both parties appear to believe that their mechanism is the only way to protect society. (Holmberg SD 2006)
Holmberg’s view is further strengthened with an examination of recent events. The illegalisation movement has been demonstrated to be largely ineffective in countries where it has been employed on a large scale (viz. USA) (NSDU 2004). The harm reduction movement, considered by some to have a defeatist doctrine, accepts that drug use will still occur despite the imposition of the most draconian measures and therefore aims to reduce the potential levels of damage associated with drug use. (Reinaman & Levine 2004)
To summarise the thrust of Fordham’s work, it is often the case that when there is multi-agency involvement in decision making and government by committee, we arrive at a collective consensus of varying opinions that get amalgamated into some form of legislative framework that allows both the opposing factions to equally claim both victory and also to point to deficiencies in the scheme where they can manage to abdicate responsibility when it does not work effectively. (Fordham, F et al. 2007)
If one considers the specific concept of the needle exchange, then this can be assessed on a variety of levels of differing complexity. At the most simplistic level, it is a mechanism of harm reduction. Bulmenthal documents the fact that IV drug abusers can go to extraordinary lengths to continue their habit if their equipment is confiscated thereby exposing themselves to illness transmission risks by sharing needles. (Bluthenthal R N et al. 2005). The Des Jarlais paper putting forward the premise that if they are going to persist in injecting then it should be in the safest manner possible. (Des Jarlais et al 1995)
On a more complex level there are some that suggest that providing a needle exchange increases IV drug use. Such views are not based on available evidence. The Aggleton paper demonstrating clearly that syringe exchange centres, with access to clean and sterile equipment, neither increases the incidence of drug use, nor does it increase the frequency of injection of confirmed users (such factors are demonstrably far more dependent on the local availability of the drugs (CDCP 2002)) . More importantly, neither do they increase the number of new converts to drug injection (UNAIDS 2003)
(Aggleton. P 2000)
Arguably a more important consideration of a needle exchange is the potential benefit for improvement in the general health of the user (and some would argue in the Public Health). The Gostin study shows that use of a needle exchange implies contact between user and healthcare services who have the ability to place the user in contact with those services best suited to reduce high risk activities. (Gostin et al . 1997). This is also relevant in consideration of the fact that the majority of drug abusers have at least one associated pathology (viz. mental illness, physical illness or other social pathologies). Because they will typically be a highly mobile and itinerant population, these individuals are easily lost to any type of organised healthcare follow up or intervention. The needle exchange can act as an opportunity to intervene to try to assist the user deal with their problems. The simple provision of needles represents a lost opportunity in this respect.
There are two other important elements relating to the needle exchange. By protecting an addict form HIV/AIDS one is also protecting their sexual partners from exposure. The second (often cited) element is one of cost. Needle exchanges are comparatively cheap to run and this must be compared to the social and financial costs of not running them. Aggleton concluded that each syringe exchanged cost 18p. This equates to ?13 per case of HIV/AIDS prevented. Compared to a lifetime of healthcare costs for a single HIV/AIDS case, the savings to society are incalculable. (Aggleton P 2000)
Aggleton. P. (2000) UNAIDS, Report on the Global HIV/AIDS epidemic, June 2000; quoted in “Success in HIV Prevention”,. UNAIDS Best Practice Collection. Geneva, UNAIDS. 2000
Bluthenthal RN, Kral AH, Erringer EA, et al. 2005, Drug paraphernalia laws and injection-related infectious disease risk among drug injectors. Journal of Drug Issues. 2005 Vol.6
CDCP (2002) Centers for Disease Control and Prevention: HIV/AIDS Surveillance report 2002 : 14
Des Jarlais DC, Hagan H, Friedman SR, et al. (1995) Maintaining low HIV seroprevalence in populations of injecting drug users. Journal of the American Medical Association. 1995; 274 : 1226 – 1231.
Fordham, F Jones L , Sumnall, H McVeigh J Bellis M (2007) The economics of preventing drug use An introduction to the issues National collaborating centre for drug Prevention for the National Institute of Health and Clinical Excellence HMSO: London 2007
Gostin L O, Lazzarini Z, Jones T S, et al. (1997) Prevention of HIV/AIDS and other blood-borne diseases among injection drug users: a national survey on the regulation of syringes and needles. Journal of the American Medical Association. 1997; 277 : 53 – 62.
Holmberg SD. (2006) The estimated prevalence and incidence of HIV in 96 large US metropolitan areas. American Journal of Public Health. 2006; 86: 642 – 654.
NSDU (2004) National Survey on Drug Use and Health: 2003 Substance Abuse and Mental Health Service Administration. HMSO: Sept 2004:
Reinarman, C., Levine H G. (2004) “Crack in the Rearview Mirror: Deconstructing Drug War Mythology.” Social Justice 31 (2): 182 – 199
Rice D P, Kelman S, Miller L S. (1991) Estimates of economic costs of alcohol and drug abuse and mental illness, 1985 and 1988. Public Health Reports. 1991; 106: 280 – 92.
UNAIDS (2003) Fact sheet ‘High-income countries’. WHO Publication 2003