THE JAMES A. BAKER III

INSTITUTE FOR PUBLIC POLICY 

RICE UNIVERSITY

A Response to Calvina Fay Regarding Needle Exchange Programs

January 25, 2009

Dear Senator/Representative:

I write in response to a fax and related materials sent to members of the Legislature on January 21, 2009, by Ms. Calvina Fay, voicing opposing to SB 188, HB 142 and HB 272, bills that would authorize the establishment of syringe/needle exchange programs (NEPs) in Texas.

As you may know, Ms. Fay is one of the nation's most ardent and controversial opponents of all forms of drug use. She is Executive Director of both Save Our Society From Drugs and the Drug Free America Foundation, and has been prominently involved in other anti-drug organizations and activities for many years. (The Drug Free America Foundation is a lineal descendant of Straight, Inc., which was repeatedly criticized and sued for abusive treatment of clients, as a Google search for "Straight, Inc." will show.) As a strict prohibitionist, Ms. Fay opposes measures such as needle exchange programs (NEPs), which have a proven record of reducing the harms associated with drug abuse.

As an advocate for NEPs, I am not surprised that Ms. Fay could not martial better arguments to support her opposition to these programs, since the evidence against her position is simply too strong. I am, however, somewhat surprised that she apparently assumed no one would examine her assertions and claims.

Because I know your time is limited, I will try to be as brief as I can in responding to Ms. Fay's many assertions. For your convenience, I am including a copy of her letter following this one.

1.   Ms. Fay mentions the shortcomings of the Swiss and Vancouver needle exchange programs. She refers to Vancouver again in her final argument and, in materials she sent, David Evans also refers to the Vancouver study, as well as to a similar study of a Montreal NEP.

Though she does not provide a reference for the Illinois study, I presume she is referring to the program launched in Zurich in 1986 in Platzpitz Park (AKA Needle Park), a designated area where drug users could gather without harassment from police. Swiss officials readily acknowledge that the experiment was a failure, leading to increased violence and crime. Their reaction, however, was not to abandon NEPs, but to establish heroin maintenance clinics, at which addicts are given pharmaceutical grade heroin, which they inject with sterile syringes under the care of medical personnel. The result has been dramatically positive, leading to a lowering of disease, a dramatic dropin drug-related crime, increased employment among addicts, and increased entry into treatment. Other European countries are emulating this model. (1) Needle exchange is a key component of Swiss efforts to control HIV/AIDS and hepatitis and includes NEPs in prisons. (2) (It is less effective with hepatitis than with HIV.)

Opponents of NEPs regularly cite the studies of the Vancouver and Montreal programs, a circumstance that led the authors of the 1997 Vancouver study, Stephanie Strathdee and Martin Schecter, to write a letter to Elias Zerhouni, Director of the National Institutes of Health, explicitly repudiating this interpretation of their research. Briefly put, injecting drug users in Vancouver had many legal ways to obtain sterile syringes. Those who frequented NEPs tended to be the most marginal in the addict population and therefore more likely to ignore instructions about not sharing needles. More importantly, the study occurred at the time of a dramatic increase in the use of cocaine, whose users inject much more frequently than do heroin users and who are often in a more disoriented frame of mind when intoxicated with cocaine. The researchers characterized the kind of use Ms. Fay makes of their work as "selective and self-serving," adding "One shudders to think what might have occurred in this setting in the absence of harm reduction programs."(3) 

The 1998 Montreal study, by Dr. Julie Bruneau et al., was similar in its findings and implications. Instead of declaring NEPs a failure, Bruneau and the editors of the American Journal of Epidemiology, where the study was published, both asserted that the study showed the need for more NEPs.(4) When the Washington Post contacted Dr. Bruneau, a professor at the University of Montreal, she said, "in the vast majority of cases needle exchange programs drive HIV incidence lower." When asked if she favored needle exchanges in countries such as Russia or Thailand, her answer was brief and unequivocal:  "Yes, sure."(5)

     2.   Ms. Fay asserts that NEPs do not lead people to treatment and that treatment, not NEPs, is the best way to get people off drugs.

The first assertion is simply wrong. Most NEPs of any consequence view directing addicts to treatment as a significant part of their task. A common estimate is that approximately 20 percent of NEP clients eventually seek treatment. Established programs complain that many more of their clients would seek treatment if treatment programs were available. NEPs typically function as an important bridge to treatment. I have no quarrel with Ms. Fay's support of treatment programs. A RAND study concludes that every dollar spent on treatment saves seven dollars in criminal justice, medical, and other costs.

3.   Four different studies do not support the efficacy of NEPs.

This assertion is difficult to check, since Ms. Fay does not provide references. I have done my best to find the studies she mentions, with the following results:

Pulse Check, January 2004 (6)

This is a long report and I may have missed something, but a search for "needle" found the following:

      Needle exchange programs have made shooting galleries irrelevant in Chicago. (p. 29)

      Mexican methamphetamine users are increasingly using a Manhattan needle exchange program. (p. 189)

      Needle sharing continues as a common cause of drug related illnesses. (p. 210)

I found nothing critical of NEPs in this report, but the Office of National Drug Control Policy, which publishes Pulse Check, has opposed needle exchange programs. This stance may change, since the White House website, in the section on civil rights, states that President Obama favors lifting the ban on the use of federal funds for needle exchange programs.(7)

Dr. Fred Payne's Review (8)

This is a reputable study that points out real or potential weaknesses in some studies of NEPs. For example, Payne notes the lack of closely monitored randomized trials and discounts the validity of many studies because they are typically based on the self-reports of addicts. These are reasonable criticisms and are recognized by most researchers and supporters of NEPs. It is not easy to conduct rigid scientific experiments in a population of drug addicts.

Payne acknowledges that “NEPs should confer some measurable protective effect, at least if the participants use them regularly and avoid risky injection practices," but argues that the energy and resources used for NEPs would be better spent for more treatment and rehabilitation services. That is a plausible preference, but I regard these programs as complimentary, not competitive. And, as noted above, NEPs can serve as a bridge to treatment. In the absence of such programs, addicts have a reduced chance of regular contact with concerned people who will direct them to treatment. Like most people who favor NEPs, I fully support a significant increase in treatment programs.

DAWN study

I don't know what study this refers to. I have checked the website of the Drug Awareness Network, but find no clear reference to such a study.

Study of the New York Academy of Medicine

Again, no reference. I did find the following studies involving the New York Academy of Medicine.

1. •     Injection drug users share few syringes, and those who do, share them with friends. (9)
   

2. •     Another article discussed the optimal placement of NEPs in New York City. (10)
   

3. •     Another noted that needle sharing in a studied population had decreased from 70 percent in 1990 to 25 percent in 2000 and recommended against needle sharing.  (11)
   

It is striking, though understandable, that Ms. Fay did not mention that key governmental and professional bodies, including the National Academy of Science, the Centers for Disease Control, the American Medical Association, the Institute of Medicine, the National Institutes of Health, the American Public Health Association, and the American Bar Association have conducted studies and issued reports on the topic of access to clean needles. Without exception, these studies and organizations have endorsed access to clean needles as an effective measure for reducing the incidence of blood-borne diseases and increasing access to treatment for drug users. In addition, they have persuasively documented the important finding that access to sterile needles neither encourages people to start injecting drugs nor increases drug use by those who are already users. 

     4. Studies of NEPs lack scientific rigor.

Whatever validity this contention has is weakened by the hundreds of studies that provide overwhelming agreement as to the efficacy of NEPs.

      5. NEPs increase the number of discarded needles.

Advocates for NEPs often make the opposite argument, contending that their programs reduce the number of used syringes, protecting not only addicts, but children, police, health and sanitation workers, and others who might accidentally come in contact with the needles. Some studies have addressed this issue, with mixed results. A 2004 study of needle return rates found that the average return is approximately 90 percent, but that some NEPs get fewer needles back than they distribute and, oddly, some get back more than they distribute. It appears that, as addicts become familiar with and more trusting of NEPs, the number of needles returned increases. Attention to this issue on the part of NEP personnel should result, as it has in some cities, in fewer discarded needles than before the NEP existed.

      6. Addicts are not models of responsibility and self-discipline.

True, but extensive experience worldwide makes clear that addicts do understand the risk of needle-borne disease and will use the programs.

      7. NEPs send the wrong message.

Opponents make this argument when faced with the mountain of evidence that strongly

supports NEPs. I understand its appeal, but I ask you to consider the message we send when we refuse to provide injecting drug users with sterile syringes: “We know a way to dramatically cut your chances of contracting a deadly disease, then spreading it to others, including your unborn children. It would also dramatically cut the amount of money society is going to have to spend on you and those you infect. But because we believe what you are doing is illegal, immoral, and sinful, we are not going to do what we know works. You are social lepers and, as upright, moral, sincerely religious people, we prefer that you and others in your social orbit die.” This, I think, is not the message the people of Texas want to send.

I am attaching a paper I have written for the James A. Baker III Institute for Public Policy at Rice, where I am the Senior Fellow for Drug Policy. Entitled "Needle Exchange Programs: Sending the Right Message." It is available on the Baker Institute website. Thank you for your patience in reading this letter. If I can be of any help to you as you consider this important issue, please feel free to call on me.

Sincerely,

William Martin,

Senior Fellow for Drug Policy

Rice University ● Baker Institute – MS 40 ● P.O. Box 1892 ● Houston, Texas 77251-1892

Phone: 713-348-4683 ● Fax: 713-348-5993 ● E-mail: bipp@rice.edu

(1) For a description of this program by Francois Van Der Linde, Chairman of the Swiss Federal Commission for Drug Issues, see

  "http://www.bakerinstitute.org/publications/wp_dp_vanderlinde.pdf"

(2) "http://www.ncbi.nlm.nih.gov/pubmed/16809115" http://www.ncbi.nlm.nih.gov/pubmed/16809115

(3)  "http://www.drugpolicy.org/library/05_08_04strathdee.cfm"

(4) Julie Bruneau, et al., "High Rates of HIV Infection Among Injection Drug Users Participating in Needle Exchange Programs in Montreal: Results             of a Cohort Study," American Journal of Epidemiology, December 15, 1997, Vol. 146, No. 12, pp. 994-1002.  "http://ndsn.org/jan98/harmred1.html" http://ndsn.org/jan98/harmred1.html

(5) "http://www.washingtonpost.com/ac2/wp-dyn/A56611-2005Feb26?

(6) "http://www.whitehousedrugpolicy.gov/publications/drugfact/pulsechk/january04/index.html"

        (7) http://www.whitehouse.gov/agenda/civil_rights/

(8) "http://www.drugwatch.org/research/An%20evidence%20based%20review%20of%20NEP.htm"

(9) "http://www.aegis.com/news/ads/2001/AD010328.html" 

(10) "http://www.nyam.org/news/1994.html" 

(11) "http://www.scienceblog.com/community/older/2001/E/200115619.html"

(12) "http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=419716"  

13. (13)"http://www.bakerinstitute.org/programs/drug-policy"