HARM REDUCTION AND NEEDLE EXCHANGE PROGRAMMES

Sir--It is profoundly troubling that Sandra Bennett (March 14, p 839)1
cites as "telling indications of the failure of needle exchange programmes"
(NEPs) the deaths of two proponents of NEPs from an alleged drug overdose.
One of the two individuals she names was John Watters, Director of the
Urban Health Study. Personally and professionally, Watters was a committed
and tireless researcher whose life's work reflected his passionate belief
that public-health interventions and the search for knowledge had to be
extended to those from whom society and the medical community often turned
away. His contributions to HIV prevention and drug abuse research included
not only evaluation of different harm reduction strategies such as
street-based education,2 but also the development of innovative methods for
community-based sampling of a difficult to access and often hidden
population. These studies included the finding that users of NEPs were less
likely to engage in syringe sharing,3 a risk factor for HIV infection among
injection drug users.

Many publications and several major reports support the belief that NEPs do
not promote drug abuse in a community, are associated with a reduction in
high-risk drug practices, and are likely to reduce the risk of HIV
infection. Contrary to Bennett's speculations, studies indicate that NEPs
are not associated with an increased risk of hepatitis C4 or with an
increase in the number of discarded needles.5 The contention that
Baltimore, MD (one of many metropolitan areas throughout the world with an
NEP), has a high mortality rate hardly proves that one factor is causally
related to the other.

Identifying the most effective ways to reduce HIV transmission among
injection drug users throughout the world is a critical public health
priority. Evidence concerning the potential harm as well as the benefit of
NEPs needs to be rigorously examined and openly debated. However, lowering
the level of this debate to personal innuendo and insinuation is not the
way to go. The preventable death of any individual, whether well known or
forgotten, is a tragedy. Exploiting these tragedies to score debating
points cheapens us all.

Alan R Lifson

Division of Epidemiology, School of Public Health, University of Minnesota,
Minneapolis, MN 55454, USA

1 Bennett SS. Needle-exchange programmes in the USA. Lancet 1998; 351: 839.
2 Watters JK, Downing M, Case P, Lorvick J, Cheng YT, Fergusson B. AIDS
prevention for intravenous drug users in the community: street-based
education and risk behaviour. Am J Comm Psych 1990; 18: 587-96.

3 Watters JK, Estilo MJ, Clark GL, Lorvick J. Syringe and needle exchange
as HIV/AIDS prevention for injection drug users. JAMA 1994; 271: 115-20.

4 Hagan H, Des Jarlais DC, Friedman SR, Purchase D, Alter MJ. Reduced risk
of hepatitis B and hepatitis C among injection drug users in the Tacoma
syringe exchange program. Am J Publ Health 1995; 85: 1531-37.

5 Oliver KJ, Friedman SR, Maynard H, Magnuson L, Des Jarlais DC. Impact of
a needle exchange program on potentially infectious syringes in public
places. J Acquir Immune Defic Syndr 1992; 5: 534-35.

Author's reply

Sir--It is tragic enough when someone decides to try an illicit substance
and becomes addicted, but it is even more distressing when the user is a
physician, a person whom the population relies on to be wise, honest,
compassionate, and law abiding. Although Alan Lifson recites a number of
Watters' contributions, the fact remains that Watters died of a heroin
overdose.

Like Watters, many of the leaders of the movement to legalise psychoactive
and addictive drugs for personal reacreational use are professionals, who
perhaps seek to justify, sanctify, and exonerate their own illegal and
dangerous involvement with illicit drugs.

Several studies have shown that even a small amount of cocaine can cause a
fatal cardiac episode.1,2 In 1980, Lester Grinspoon of Harvard, an
outspoken supporter of legalisation, wrote that "used no more than two or
three times a week, cocaine creates no serious problems",3 and in 1988 that
cocaine is "a relatively safe, nonaddicting euphoriant agent", and
dismissed the idea of cocaine dependence as "moralistic exaggerations".4
There is no doubt that such misleading and unscientific rhetoric, published
in prestigious medical journals and repeated on university campuses across
the USA, played an important part in the explosion of cocaine use and
related deaths. Government-endorsed needle-exchange programmes will give
the same message--ie, that it is okay to do it if you do it carefully. The
proliferation of needle exchanges as a factor in the death rate in
Baltimore was only postulated, but it certainly cannot be disregarded.
However, a flyer from the Baltimore City needle exchange states "This
program is free and confidential. No identification is needed. There is no
minimum age requirement. All that is needed is a desire to live
healthier".5 If health and safety were truly a concern of those using
injection drugs, then their own personal vial of bleach would be a cheap,
easy, and confidential way to avoid HIV contaminated needles, and the use
of condoms could prevent sexual transmission of the disease. But many of
those using NEPs use them mainly as a resource for finding a supply of
drugs, and share needles anyway.

Lifson would do well to look carefully at the Canadian studies on needle
exchange and the explosion of drug addiction in those cities in which
needle exchange programmes have been entrenched. If saving lives is the
goal, needle exchange is not the answer.

Sandra S Bennett

Northwest Center for Health and Safety, PO Box 5853, Portland, OR 97228,
USA 1 Liberthson RR. Sudden death from cardiac causes in children and young
adults. N Engl J Med 1996; 334: 1043.

2 Morris DC. Cocaine heart disease. Hospital Pract 1991; 26: 83-92.

3 Grinspoon L, Bakalar JB. Drug dependence: non-narcotic agents. In: Kaplan
HI, Freedman AM, Sidock BJ, eds. Comprehensive textbook of psychiatry, 3rd
edn. Maryland: Williams and Wilkins, 1980.

4 Gawin FH, Ellinwood EH Jr. Cocaine and other stimulants. N Engl J Med
1988; 318: 1173-82.

5 Baltimore City Needle Exchange (April 1-30), 1998.

Sir--In her response 1 to your Jan 10 editorial 2 urging the lifting of the
federal ban on funding for needle-exchange programmes (NEP) in the USA,
Sandra Bennett suggests that overdoses among injection-drug users (IDUs)
could result from NEP use. Although there is some debate about the causes
of fatal drug overdose,3 it is possible to explore whether there is an
association between NEP use and non-fatal overdoses. To do this, we
examined cross-sectional data collected by the Urban Health Study from 1114
street-recruited, active IDUs in six San Francisco Bay Area communities in
1997.

Study participants were asked to report if they had ever overdosed, how
many times they had overdosed, and the month and year when they last
overdosed. Of the 1114 respondents, 469 (42%) reported that they had
overdosed, 137 of whom overdosed in 1996 or 1997 (referred to hereafter as
recent overdose). IDUs who reported that the syringe exchange was their
usual source of syringes in the past 6 months and who also reported use of
the NEP in the 30 days before interview were classified as NEP users. In
our respondents, NEP users were less likely than non-users to report recent
overdose (10B79% vs 14B73%, p(0B709).

To assess whether the absence of an association between recent overdose and
NEP use was due to confounding by other factors, we used multiple logistic
regression. Included in the regression model were factors previously
associated with overdose (sex, years of injection, alcohol use in the past
week, frequency of injection, frequency of heroin injection, and the use of
various drugs in the past 30 days). In this model, NEP use was not
significantly associated with increased likelihood of recent overdose
(adjusted odds ratio 0B773 [95% CI 0B750-1B707]). Indeed, there was a
trend towards a protective effect against overdose.

No studies to date have found an association between NEP use and increased
drug use at the individual or community levels, nor have they been found to
foster the use of injection drugs.4 Drug overdose is a leading cause of
morbidity and mortality among IDUs and is worthy of prevention
interventions in its own right. In our sample, 12B73% of respondents
reported a recent overdose. We support the increased use of
overdose-prevention strategies, such as expansion of the capacity and
diversity of drug treatment, distribution of naloxone to heroin users, and
heroin prescription for long-term, treatment-adverse IDUs.

Funding was provided by the National Institute on Drug Abuse (grant
R01-DA09532) and AIDS Office of the San Francisco Department of Public Health.

*Ricky N Bluthenthal, Alex H Kral, Jennifer Lorvick, Elizabeth A Erringer,
Brian R Edlin

University of California, Urban Health Study, Institute for Health Policy
Studies, School of Medicine, Box 1304, San Francisco, CA 94143, USA

1 Bennett SS. Needle exchange programmes in the USA. Lancet 1998; 351: 839.
2 Editorial. Needle-exchange programmes in USA: time to act now. Lancet
1998; 351: 75.

3 Darke S, Zador D. Fatal heroin "overdose" a review. Addiction 1996; 91:
1765-72.

4 Normand J, Vlahov D, Moses L, eds. Preventing HIV transmission:" the role
of sterile needles and bleach. Washington, DC: National Academy Press, 1995.


Checked-by: Mike Gogulski