In the past few weeks, there has been considerable press surrounding needle exchanges and the recently declared HIV epidemic in Indiana.
The first time I talked with my friends about needle exchanges, I had a visceral reaction. “Why would you give people new needles?” I asked, completely outraged. “Isn’t that enabling and therefore doing a disservice to the very people you’re trying to help?”
I took my confusion to one of my favorite professors who explained to me the key goal of a needle exchange: harm reduction. I always relish a challenge — hence why I still haven’t dropped out of medical school — so I spent a lot of time dissecting the public health implications of needle exchanges.
In an effort to better understand our patients’ needs, I thought we could do some myth busting on needle exchanges and needle exchange policy.
MYTH ONE: Needle exchanges enable people using intravenous drugs.
Now, I can’t change personal opinions on addiction, but I can explain the underlying processes at work in a needle exchange program. The primary notion is that by providing clean syringes, the exchange functions to prevent some of the serious consequences associated with IV drug use, particularly HIV and hepatitis C virus transmission. In addition, participating in a regular needle exchange provides a point of contact between a person using intravenous drugs and the health care system. Many exchanges are staffed with addiction counselors and other health care providers. Over time, as people build their trust in the needle exchange, clinicians or people working in the exchange can engage in a conversation about seeking treatment. With the integration of other clinicians, many needle exchanges are not stand-alone efforts. Rather they are a part of a broader substance use treatment plan, such as providing methadone or the aforementioned counseling. In addition, prophylactic and post-exposure HIV treatment can be provided and testing can be done for early diagnosis.
MYTH TWO: Needle exchanges increase the rate of drug use in the population.
The City of San Francisco implemented a needle exchanges and engaged in a five year review of their program. The per-day injection rate declined among needle exchange participants from 1.9 injections per day to 0.7 injections per day. Similarly, the rate of IV drug use initiation fell from 3 percent to 1 percent. More recently, a study by Kidorf et al. found reductions in drug use with the use of a needle exchange. Many research studies have investigated whether needle exchanges increase the rate of drug use in the population, but the overwhelming response is that they do not.
MYTH THREE: Needle exchanges are not cost effective.
Like any health care program, running a needle exchange is expensive; however, over the years a sizable body of research has found that needle exchanges are in fact cost-effective programs. Part of this stems from the reality that intravenous drug users are more likely to be unemployed and therefore may have less stable access to health insurance. This would make treating any HIV or hepatitis C cases particularly expensive. With the ongoing implementation of the ACA and the conversation about parity for behavioral health conditions being expanded, we likely will see changes in access to treatment for any incidental HIV or hepatitis C cases. Additionally improved access to addiction treatment services such as counseling and rehabilitation will likely be implemented.
As the spread of HIV becomes a major concern in Indiana, Governor Pence has elected to expand the needle exchange program for an additional thirty days. In this time, he hopes to better identify and understand long-term solutions for his constituents. There is no wrong or right answer to the problem at the moment, and opening a dialogue about addiction and drug use is making progress.
Doctor of Policy is a column dedicated to exploring and challenging contemporary health policy issues, especially in the fields of behavioral health, health care access, and inclusion, all from the eyes of a public health girl in a basic sciences world.