...Counter Point

Needle Exchange ProgramsDo Not Solve the Problem

of HIV Transmission

By Beny Primm, M.D.

W' hen we talk about using drugs,we are talking about not onlythe needles and syringes but

other drug paraphernalia. There are cook-ers and the cotton that's often used rolledup in a little ball and placed in the cooker.Once the heroin and water are mixed andheated into solution, they draw up the so-

lution and filter it through the cotton ballor whatever else the user might choose. InNew York, if they don't have the cotton,they use a cigarette filter. In Holland, forexample, they use tissue paper. On x-rayof the lungs, you often see cotton fibersseeding the lungs of addicts as they drawup the mixture of drug and water throughthe strainer. Not only are the syringe andneedle a problem, but the cooker and thesharing of other narcotic implements isalso a problem.There also is a common source of water

that's used to rinse out the syringes. Wehave found that there is a considerableamount of virions in these kinds of recep-tacles and certainly in the blood-contami-nated water that is used as a source ofwater in the shooting gallery. In many in-stances, this water is captured from rooftops or from any other place where it also

Presented at the 4th National Forum on AIDSand Chemical Dependency, February 22-24,1990, Miami, FL and sponsored by the Ameri-can Society of Addiction Medicine (ASAM).

could be contaminated and a possiblesource of infection. We also don't knowwhat's in the drug itself. It is generallybought from a pusher. It is not a USP certi-fied substance and that creates a problemalso. The drug is also cut with substancesthat include unsterile quinine and milksugar.Sharing is very common among addicts,

the sharing not only of helping one an-

other, which is part of the ritual of drugtaking, but also of helping one anothershoot up. If one person can't get his or hervein, somebody else will get it for him or

her. If they have a small amount of thedrug left in the syringe, theywill just drawup some water in the used syringe and theother fellow will shoot what is commonlycalled a rinse, or geezer. That's a very com-

mon phenomenon. A home-made syringecan be made out of a medicine dropper us-ing the nipple of a baby's pacifier becausethe tensile strength of that rubber is fargreater than one that you find on a normalmedicine dropper. This is used for bootingthe drug back and forth. Many addicts,even when they can have disposablesyringes and needles, still resort tothis needle and syringe because it's mucheasier to use and to manipulate for per-forming the booting.One of the things that I'm greatly con-

cerned about is not only the needle and sy-ringe as being a culprit, but also what iscontained in the drug itself. Since WWII,quinine has been used to cut the drug be-cause malaria was being passed back andforth among intravenous drug users andthe pushers were losing money. They

knew that quinine was a medicine the Ar-my used in the South Pacific to stop thepassing back and forth of malaria. So, thepushers added quinine to the drugs and itincreased their sales; to this day quinine isstill used. But the quinine causes necrosisof the subcutaneous tissue and skin, withsubsequent infection from the bacteria on

the skin, which is often contaminatedwith staphylococcus, streptococcus, andcoli bacillus. Anybody working in drugtreatment programs s»'es this. Not onlycould the needle be contaminated but theskin is contaminated also. Unless we teachpeople to use antiseptics and other kindsof skin cleansing methods, giving themclean needles and syringes to put in dirtydrugs to shoot up on dirty skin is not theright way to go.

Addicts Can Be EducatedThere are, of course, a number of ap-

proaches to reduced needle- and syringe-related HIV transmission, and some ofthese have been very effective in my own

treatment program. Even in programs inwhich needles and syringes are ex-

changed, education and information are

provided. Drug users are educable and forus to think that they are not is pure folly.Nobody wants to die. Nobody wants a

disease. They are quick to learn if they are

taught, if you hold sessions, and if you are

patient with them. They are no differentfrom the gay community, among whosemembers education to reduce HIV trans-mission in sexual practices has worked.Addicts certainly can be educated and

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AIDS PATIENT CARE/AUGUST 1990 19

Addicts are educable.

have been educated. Proof of this is thatwe're seeing in New York a stabilization ofthe numbers. I feel that there's a satura-tion of the community in New York. Pro-viding sterilization materials is anotherway to do it.Drug abuse treatment is probably the

best possible way to do it. We have never

really been serious about drug treatmentprograms in our country. We have never

supported them. It is no different thanwhen you hear the previous people talkabout AIDS control being more importantthan drug control from a public health per-spective. We have never been seriousabout it. Until we begin to have people ingovernment who are serious about it,we're not going to end these simplistic so-lutions for major problems. We ought tobe looking at doing something about theproblem that has been plaguing thesecountries for centuries.Needle-associated HIV transmission ed-

ucation and information should be cultur-ally sensitive, logistically sound, anddesigned to increase the addicit's knowl-edge base. Although education is sup-posed to be very good, there is an unclearrelationship to behavior change. Peoplecan be educated just like we are educatedabout smoking cigarettes. Despite educa-tion about cigarettes, the number of peo-ple smoking them hasn't changed toomuch over the last 20 years; 27 percent ofthe people still smoke. Twenty years ago50 percent of the people in the nation were,

smoking cigarettes. There is an unclear re-lationship between education and behav-ior change. We just have to keep at it and

have to be patient about it and not use sim-plistic and possibly dangerous solutions.

Sharing Still Goes On

Providing sterilizing materials, ofcourse, is inexpensive and it's beenproven to be fairly effective. Yet, the con-

sistent use of these materials is unclear. Ihave addicts who report to me that theyshare their needle and syringe with theirsignificant other even if the significantother has a needle and syringe. That's partof the bonding that takes place betweenlovers and addicts. They still share theircooker; they still share their cotton at alltimes. Needle and syringe exchange pro-grams focus only upon the needle and sy-ringe as the culprit. I think that's a

mistake.There are some theoretical benefits, of

course, in providing sterile needles. It's in-expensive, relative to drug treatment. Thisis perhaps why so many people are em-

bracing it and why public health officialsare talking about the potential control ofHIV transmission as being more impor-tant than drug treatment. It raises the is-sue of liability. Suppose we give our cleanneedles and syringes to people, some-

body uses them, and injects themselveswith an overdose. Are we subject to suit?Arewe liable, legitimately liable? What arethe public policy implications? Needles,syringes, and drugs have been destructiveforces. It is very difficult to convince com-

munities to accept needle exchange pro-grams as a way to make things better. Itmay encourage sexual transmission of

HIV. In other words, we might focus on

needle exchange so much and not talkabout what might happen if you have un-

protected sexual activity, which a lot ofpeople do.

Treatment Program Quality Issues

If you look at drug abuse treatment inthis country, it has a variable quality to itdepending on the program. There is eventalk now of no frills methadone mainte-nance programs. Called interim metha-done maintenance or treatment programs,they deliver no counseling or other sup-portive therapy except substitution ther-apy. There also are indirect benefits thataccrue from drug abuse treatment pro-grams. The comprehensive programs, ac-

cording to another argument, are veryexpensive and there is an inadequate andmaldistributed supply of these programsthroughout the nation. We should notspare dollars when it comes to correcting a

problem or disease entity we're facing. Weneed to give the money no differently thanwe have done in AIDS education, preven-tion, and development of drugs to treat it.We need to do the same thing in drugabuse.

An Irrational Drug PolicyAnother thing that is a disincentive to ef-

fective drug treatment in this nation is anirrational national drug policy—licit vs. il-licit drugs. For example, we looked at alco-hol and cigarettes. Alcohol causes 350deaths a day. Alcohol-related problems

Beny Primm, M.D. (Courtesy World HealthCommunications, New York, NY)

and cigarettes cause 1,000 deaths a day. Ofcourse, drug abuse from illicit drugscauses maybe 20 deaths a day. We need tocorrect our drug policy, pay more atten-tion, and not have a hypocritical approachto it but one that is equal across the board.There's a societal stigma attached to drugabuse itself that makes it very difficult toopen up drug treatment programs.There's an irrational relationship betweenpublic health and drug abuse. When I hearpublic health officials talking about it be-ing more important to concentrate on HIVtransmission than it is to concentrate on

They still share the cooker.

drug treatment, it sickens me with thenumber of peoplewho are affected by HIVdisease and HIV infection secondary to

drug abuse.

Ineffective MarketingThere is inadequate marketing of the

benefits of drug abuse treatment. We'venever really marketed the concept thatdrug abuse treatment is effective. Many ofus are not proud enough to say that wework in drug abuse treatment. I rememberup until about 8 years ago, when some-

body asked me what I did, I said I workedin rehabilitation. And they'd say, well,what kind of rehabilitation. And then I'dsay, I work with people. I went all aroundthe barn before I would say that I workedwith addicts because of the stigma associ-ated with working with addicts. Also,there is inadequate reimbursement fortreatment, both public and private.

Poor Training and EvaluationThere's inadequate drug-abuse-related

training of health professionals. Inade-quate staff training will continue in educa-tion for drug abuse personnel. We allknow that these are major problems. In-adequate funding of evaluation and treat-ment research is another. It has been saidthat there is federal opposition to fundingthe evaluation of needle exhange pro-grams. Dr. Mason held a conference about4 or 5 months ago and brought in a num-

ber of experts from throughout the coun-

try. It was decided that perhaps we wouldfund evaluation but not necessarily in thiscountry. We might fund it in Holland be-cause the evaluation of the progams theredid not fit our peer review standards. Nee-

dle and syringe exchange schemes havenot demonstrated a reduction in transmis-sion of HIV when we looked closely atseroprevalence rates among drug usersbefore and after their participation inthese programs. Should we take some-

thing that has not been adequately evalu-ated in another country and copy it in thiscountry?

Giving the Wrong MessageIf we corrected some of these problems,

we would have a more beneficial and ef-fective response to AIDS and IV drugabuse along with significantly reducing a

considerable portion of HIV-associatedmedical, social, and economic conse-

quences. We would also see the develop-ment of a more effective, rational responseto drug abuse by both public officials andother citizens in our nation. Treatmentworks, and addicts are educable. We mustget the rightmessage out there that we cando this without necessarily supplying ad-dicts with needles and syringes. Supply-ing addicts with needles and syringesgives the wrong message and muddies thewhole effort of stopping people from us-

ing drugs. D

Dr. Primm is director, Office for TreatmentImprovement and associate administrator,Alcohol, Drug Abuse, and Mental Health Ad-ministration (ADAMHA), Rockville, MD, andexecutive director, Addiction Research andTreatment Corporation, Brooklyn, NY.

Reprints of this article are available in bulkquantity. For information and prices, write toor call: Karen Ballen, AIDS PATIENT CARE,1651 Third Avenue, New York, NY 10128,(212) 289-2300.

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