Monday, January 12, 2004

Needle Exchange vs. Needle Legalization

New Jersey and California are considering proposals to allow IV drug users access to clean needles. These proposals come in two basic forms: setting up needle exchanges at which users can turn in dirty needles and receive clean ones, or allowing the purchase of clean syringes at drugstores, without a prescription.

Policy discussions seem to treat these options as essentially equivalent in their public health value, in that they both provide drug users with access to clean needles. Needle exchanges are backed up by a significant body of research literature demonstrating that they reduce transmission of blood-borne diseases without increasing drug use, and similar benefits are ascribed to the legalization of needle purchase. But there's no reason to believe that the benefits actually are similar.

Needle exchanges require a one-to-one trade: you get a clean needle for every dirty needle you turn in. The effect is not only to increase access to clean needles, but to decrease access to dirty needles. That's important because, if dirty needles are available, people who need a fix will use them - even if they could theoretically obtain a clean needle with a little more time, money, and effort. Dirty needles need to be taken off the streets. Legal needle purchase doesn't do that - it just increases the overall number of needles in circulation.

There are two other enormously important advantages of needle exchanges: they're free to the user, which makes them more likely to be used, and they offer a point of contact through which addicts can receive counseling and referrals for treatment. Drug users who use needle exchanges are more likely to enter rehab and more likely to get HIV tests, as well as other medical care. Legal needle purchase, on the other hand, doesn't provide the opportunity for counseling, and it assumes that people will spend money they might otherwise spend on drugs on clean needles instead. There are middle-class injection drug users for whom that might be true, but most street addicts - the ones at greatest risk for HIV and hepatitis - don't have that kind of discretionary spending capacity.

That's not to say that needle legalization has no benefits. It does increase the clean needle supply. It also increases the likelihood that users will carry their own needles. Right now, in most localities you can get busted for possessing an injection rig even if you don't have drugs on you - which makes people less likely to carry their own needles and thus more likely to share. If needle possession is legal, there will no longer be a disincentive to carry personal injection equipment.

But my cynical side says that the primary advantage governments see to legalizing the sale of needles is that it allows them to keep their hands clean. No one has to get personally involved in meeting the individual or public health needs of drug users - they can put the solutions out there and leave it to individual drug users to have the personal responsibility to access them. That's a nice ideal, but it's not what you do when you're really serious about fighting a public health threat.