Analytical Essay: Needle and Syringe Programs

Lee Cheadle

************** University

Alcohol and Other Drugs Studies

Dr. *****************

24 April 2023

 

 

Needle and syringe programs (NSPs) have been widely implemented worldwide to reduce the harms associated with injection drug use, primarily the spread of blood-borne infections such as HIV and HCV. NSPs achieve this by providing sterile injecting equipment, educational services, and referrals to other health and wellbeing services to people who inject drugs (PWID). NSPs have been the topic of many debates and controversies since their introduction in the 1980s in response to HIV outbreaks, with some arguing that they promote drug use and increase injection rates and others arguing that they have been a cornerstone in improving public health. This paper aims to analyse the findings produced by studies, identify some of the core strengths and weaknesses of NSPs, and reach an evidence-based conclusion on their effectiveness, followed by a statement that outlines what can be done to aid their efforts in promoting public health.

Many studies have concluded that NSPs are an effective means of harm minimisation and have many strengths. One of the key and most important strengths of NSPs is their ability and effectiveness in reducing the transmission of blood-borne infections among those who inject drugs, most notably HIV and HCV. NSPs achieve this by providing clean and sterile injecting equipment and, by doing so, significantly decrease the odds of needle sharing among PWID. A study noted that as of 2019, an estimated 11.2 million people worldwide injected drugs. Among those people, 1.4 million were infected with HIV, and 5.6 million were infected with HCV (Santen et al., 2023). Another study shows that due to NSPs, there has been a 46-56% decreased odds of needle sharing among PWID, with a 50% reduction in the odds of those infected with HIV (Levitt et al., 2020). This clearly shows a correlation between PWID having access to sterile equipment for injecting and a significant decrease in needle sharing and, therefore, less spread of infection. Another strength of NSPs is their ability to connect people who use drugs to other services that provide education, counselling and other treatment services that most drug users otherwise would not seek without NSPs. Burrows (2000) emphasises that any NSP will significantly reduce harm when incorporating counselling and educational services. In support of this, Broz et al. (2021) state that NSPs are known to significantly increase the chance that PWID access these services, as there are fewer structural and individual barriers such as the stigma of drug use, upfront costs, transportation problems and issues with living situations. While the primary function of NSPs is to reduce the spread of blood-borne infections, they have also implemented strategies to reduce other harms of injection drug use, such as overdose prevention. Geddes et al. (2021) discuss how some NSPs actively distribute naloxone. This medication temporarily reverses opioid overdoses by stopping opioid drugs from attaching to opioid receptors in the brain. For NSPs to be a practical means of harm minimisation, they must be cost-effective. A study published in 2012 (Kwon et al., 2012) identifies that the cost of funding NSPs is considerably less than that of treating people infected with HIV. In Australia, NSPs were found to have prevented 25,000 HIV and 21,000 HCV infections, creating a cost saving of 20 million AUD. This is clear evidence that NSPs are a cost-effective means of harm reduction in the long term. These strengths give a clear emphasis on how effective NSPs are in improving public health around the world.

Despite these strengths, NSPs have faced criticism for concerns that question whether the good outweighs the bad and if their ability to reduce harm is worth the perceived risk. One of the biggest criticisms of NSPs is that they promote drug use. Ritter et al. (2017) discuss that when NSPs were first introduced, debates argued that the programs would cause more harm by promoting drug use than good by preventing the spread of HIV. This debate continues even though there is not enough evidence to conclude that NSPs cause increased injection rates. Another concern with these programs is the fear that there will be a drastic increase in the number of syringes that are incorrectly discarded, posing a threat to public health and increasing environmental hazards. Bluthenthal et al. (2007) find that despite safe syringe disposal being critical, there is little evidence that higher syringe coverage is associated with increased unsafe syringe disposal by PWID. Additionally, many programs have policies such as the ‘1 for 1’ approach, requiring drug users to trade one used syringe for one sterile syringe to prevent unsafely discarded syringes. Since the launch of NSPs in the 1980s, there has been a continuous debate regarding the ethical implications and concerns of the programs. Kleinig (2006) discusses this in detail, noting the fears that NSPs could send the message that drug use is not as severe as it actually is or that laws against drug use become less enforceable. Additionally, it could be believed that taking drugs is not as severe as preventing the consequences of taking them. NSPs can have difficulty reaching all those needing support, including PWID living in poverty, rural areas, homeless, and some in prison. These populations must be reached for effective results, as evident by studies that, for example, found that 22.1% of PWID had been to prison or in custody within the previous year and 71.2% had experienced being in custody or prison sometime in their life (Kaberg et al., 2020). According to studies, prison authorities do not allow NSPs inside their prisons due to fears that syringes could be used as weapons and NSPs may increase drug use and admit a security failure on part of the prisons. However, EU countries that allow NSPs have not reported instances where drug use increased or needles were used as weapons (Moazen et al., 2020). Sufficient funding is vital for NSPs to succeed, but many programs do not receive the required funding to run effectively. Broz et al. (2021) discuss that while funding has partially improved in the US for NSPs, they are still faced with the challenge of bans on federal funds being used to purchase syringes for NSPs, and they do not have enough federal funding to run large-scale programs required for effective results. This evidence shows that there are weaknesses that challenge NSPs in their ability to minimise harm and promote public health. However, some of these concerns have little evidence to support themselves, and some problems would have less of an effect on NSPs with more support on a political and community level.

NSPs have been widely adopted worldwide to control and reduce the spread of blood-borne illness and minimise other harms associated with injection drug use. They achieve this by providing sterile injecting equipment to PWID and various other services, including educational materials or face-to-face sessions and referrals to other health and wellbeing services. Despite many controversies surrounding these programs, growing evidence suggests they have been primarily successful with many strengths. These strengths include but are not limited to; reducing the need for needle sharing between PWID, assisting drug users in seeking additional services to improve their well-being, and presenting governments with a cost-effective means of improving public health. However, NSPs are not free of weaknesses, as many of these controversies make it a slow process to implement these programs effectively due to the political and societal resistance and limited funding they are faced with. Finally, with everything taken into consideration, it is evident that for NSPs to reach their full potential in minimising harm, they need full support from society and their governments to break the stigma regarding injection drug use systematically (Wodak & Cooney., 2005), doing this will allow for NSPs to have the appropriate political support and funding to provide sterile equipment, educational services, and referrals to other health-promoting services, regardless of any location or situation someone may be in.

 

 

 

 

 

Bluthenthal, R. N., Anderson, R., Flynn, N. M., & Kral, A. H. (2007). Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among Syringe Exchange Program clients. Drug and Alcohol Dependence, 89(2-3), 214–222. https://doi.org/10.1016/j.drugalcdep.2006.12.035

Broz, D., Carnes, N., Chapin-Bardales, J., Des Jarlais, D. C., Handanagic, S., Jones, C. M., McClung, R. P., & Asher, A. K. (2021). Syringe Services Programs’ role in ending the HIV epidemic in the U.S.: Why we cannot do it without them. American Journal of Preventive Medicine, 61(5). https://doi.org/10.1016/j.amepre.2021.05.044  

Burrows, D. (2000). Starting and managing needle and Syringe Programs: A guide for central and Eastern Europe and the newly independent states of the former Soviet Union. International Harm Reduction Development.

Geddes, L., Iversen, J., Darke, S., Dietze, P., & Maher, L. (2021). Prevalence and correlates of multiple non-fatal opioid overdoses among people who inject drugs who utilise needle syringe programs in Australia. International Journal of Drug Policy, 96, 103245. https://doi.org/10.1016/j.drugpo.2021.103245  

Kleinig, J. (2006). Thinking ethically about needle and Syringe programs. Substance Use & Misuse, 41(6-7), 815–825. https://doi.org/10.1080/10826080600668670  

Kwon, J. A., Anderson, J., Kerr, C. C., Thein, H.-H., Zhang, L., Iversen, J., Dore, G. J., Kaldor, J. M., Law, M. G., Maher, L., & Wilson, D. P. (2012). Estimating the cost-effectiveness of needle-syringe programs in Australia. AIDS, 26(17), 2201–2210. https://doi.org/10.1097/qad.0b013e3283578b5d  

Kåberg, M., Karlsson, N., Discacciati, A., Widgren, K., Weiland, O., Ekström, A. M., & Hammarberg, A. (2020). Significant decrease in injection risk behaviours among participants in a needle exchange programme. Infectious Diseases, 52(5), 336–346. https://doi.org/10.1080/23744235.2020.1727002  

Levitt, A., Mermin, J., Jones, C. M., See, I., & Butler, J. C. (2020). Infectious diseases and injection drug use: Public health burden and response. The Journal of Infectious Diseases, 222(Supplement_5). https://doi.org/10.1093/infdis/jiaa432  

Moazen, B., Dolan, K., Saeedi Moghaddam, S., Lotfizadeh, M., Duke, K., Neuhann, F., Stöver, H., & Jahn, A. (2020). Availability, accessibility, and coverage of needle and syringe programs in prisons in the European Union. Epidemiologic Reviews, 42(1), 19–26. https://doi.org/10.1093/epirev/mxaa003  

Ritter, A., King, T., & Lee, N. (2017). Drug use in Australian society. Oxford University Press.

Van Santen, D. K., Lodi, S., Dietze, P., van den Boom, W., Hayashi, K., Dong, H., Cui, Z., Maher, L., Hickman, M., Boyd, A., & Prins, M. (2023). Comprehensive needle and syringe program and opioid agonist therapy reduce HIV and hepatitis C virus acquisition among people who inject drugs in different settings: A pooled analysis of emulated trials. Addiction. https://doi.org/10.1111/add.16147

Wodak, A., & Cooney, A. (2005). Effectiveness of sterile needle and syringe programmes. International Journal of Drug Policy, 16, 31–44. https://doi.org/10.1016/j.drugpo.2005.02.004