![Sample our Health and Social Care journals, sign in here to start your FREE access for 14 days]({"type":"image" , "src" : "/sda/5938/TOC-Subject-Sample-2021-Health-Social-Care.jpg"})
Abstract
Accepting—for the sake of argument—our current legal policies concerning heroin use and its users, what ethical questions are raised for needle and syringe program (NSPs)? Do they weaken drug laws, send the wrong message or obscure the right message, do little to eliminate the harm of drugs, detract from alternatives, and/or constitute a counsel of despair? I suggest that in the absence of established better alternatives, NSPs constitute a morally acceptable and in some cases even desirable option despite the continued criminalization of injecting drug use. Yet they must be conceived and administered in ways that do not reinforce prevailing social prejudices.
Notes
2This hard saying also makes tendentious suggestions about responsibility for drug dependence. For discussion, see Tziporah Kasachkoff, “Drug Addiction and Responsibility for the Health Care of Drug Addicts,” Substance Use & Misuse, 39(3) (2004), 489–509.
3NSPs may also reduce hepatitis B virus (HBV) and bacterial infections.
4There are, unfortunately, those who see it either as God's punishment on certain kinds of behavior or, less personally, as some form of natural sanction (cosmic justice).
5In some jurisdictions injecting equipment is provided only on a one-to-one exchange basis; sometimes that is simply an aspiration; sometimes there is no exchange requirement or even expectation. The name used need not be tightly correlated with practice. In decisions about how a program is to be administered, trade-offs are involved. A strict exchange program may minimize the number of abandoned—and infected or otherwise dangerous—needles; on the other hand, a strictly administered exchange program may, for various reasons, increase the likelihood of using infected paraphernalia. In general, the less tolerant a jurisdiction, the more likely it is that exchange is “expected.” It is not unreasonable to believe that a program that dispenses according to need (rather than some form of exchange) diminishes the likelihood of reuse/sharing and thus of riskier behavior. Generally, programs—and communities—that distribute according to need also provide facilities (often also in public restrooms) for needle disposal. Strict one-for-one exchanges sometimes encourage needle reuse because injection drug users who carry paraphernalia all the time face an increased likelihood of apprehension by police. For some comparative discussion, see Alex H. Kral, Rachel Anderson, Neil M. Flynn, & Ricky N. Bluthenthal, “Injection Risk Behaviors Among Clients of Syringe Exchange Programs With Different Syringe Dispensation Policies,” Journal of Acquired Immune Deficiency Syndromes, 37(2) (October 1, 2004), 1307–1312. On syringe disposal under different regimes, see Jennifer Lorvick, Ricky N. Bluthenthal, Lauren Gee, Rachel Anderson, Neil M. Flynn, Andrea Scott, Mary-Lou Gilbert, & Alexis Martinez, “Disposal of Used Syringes by Clients of Syringe Exchange programs, California, 2003,” presentation at the National Harm Reduction Conference, New Orleans, November 2004, which suggested that although unsafe disposal practices may increase somewhat with need-based programs, the differences are not significant. At the same time, 1–1 exchange programs were associated with a greater level of needle sharing.
6The acronyms can be confusing, since “S” may dummy for “syringe,” “satellite,” or “secondary.” Satellite needle distribution is defined as: “receiving a new syringe from another individual through trading, purchasing, borrowing, or being given the syringe outright, or supplying a syringe to another individual through trading, selling, lending, or giving a syringe outright.” Secondary needle exchange occurs when programs allow users to exchange needles not only for themselves but also for others. See Mark W. Tyndall, J. Bruneau, S. Brogley, P. Spittal, M.V. O'Shaughnessy, & M.T. Schechter, “Satellite Needle Distribution Among Injection Drug Users: Policy and Practice in Two Canadian Cities,” Journal of Acquired Immune Deficiency Syndromes, 31(1) (Sept 1, 2002); 98–105; Mark W. Tyndall, J. Bruneau, S. Brogley, P. Spittal, M.V. O'Shaughnessy, & M.T. Schechter, “The Role Of Secondary Needle Exchange: Policy And Practice In Two Canadian Cities,” <http://www.pulsus.com/cahr2002/abs/abs325.htm>.
7See, for example, Mark Danner, Torture and Truth: America, Abu Ghraib, and the War on Terror (New York: New York Review of Books, 2004).
8One might, for example, question the appropriateness of permitting owners of private “shooting galleries” to operate such programs, given what we know of their history and the difficulties of ensuring that sterile needles are exchanged.
9Alex Wodak, “Needle Exchange and Bleach Distribution Programmes: The Australian Experience,” International Journal of Drug Policy, 6(1) (1995), 46–56; N. Crofts, C.K. Aitken, & M.J. Kaldor, “The Force of Numbers: Why Hepatitis C is Spreading Among Australian Injecting Drug Users while HIV is Not,” Medical Journal of Australia 170 (1999), 220–221.
10George W. Bush, Response of Governor George W. Bush to the AIDS Foundation of Chicago (2000): http://www.aidschicago.org/pdf/GWB_response.pdf
11Needle vending machines—unlike condom dispensers—may have other problems associated with them, given that needles are inherently dangerous. Nevertheless, if, as may be the case, the clientele of vending machines differs significantly from that of staffed NSPs, that may be a reason for having both. See Alex Wodak & Annie Cooney, Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users (Geneva: World Health Organization, 2004), 21.
12This is not to reject them—only to say that they probably cannot be reconciled to the outlook of those who take this position. It might be open to their defenders to argue that whatever the merits of that outlook, it ought not to be translated into social policy. However, those who take such a position often hold in addition that their views ought to be legislatively enforced. See, for a helpful overview, “Syringe- Dispensing Machines,” anex bulletin, 3(2) (n.d.): 1+.
13Here I follow the World Health Organization in using the term “drug dependence” to cover what it previously distinguished as “addiction,” “habituation,” and “drug dependence.” The virtue of the old distinction was that it recognized a range of drug-related “dependencies,” with varying implications for ethically appropriate responses. The problem with the old categorization was the artificial way in which it divided up drug users: Dependent users display varying degrees of control (or lack thereof) with respect to their condition, and ethical social responses need to regard this.
14R. Heimer, “Can Syringe Exchange Serve as a Conduit to Substance Abuse Treatment?” Journal of Substance Abuse Treatment, 15(3) (1998), 183–191; H. Hagan, J.P. McGough, H. Thiede, S. Hopkins, J. Duchin, & E.R. Alexander, “Reduced Injection Frequency and Increased Entry and Retention in Drug Treatment Associated with Needle-Exchange Participation in Seattle Drug Injectors,” Journal of Substance Abuse Treatment 19 (3) (2000), 247–252; R.N. Bluthenthal, A. Gogineni, D. Longshore, & M. Stein, “Factors Associated with Readiness to Change Drug Use Among Needle-Exchange Users,” Drug & Alcohol Dependence 62 (2001), 225–230. Merely entering a program of course is no guarantee of its success—a “therapeutic engagement” or “alliance” is often critical. There is evidence, however, that retention is also improved for those who enroll through NSPs.
15Though it must be remembered that existing drug laws are directed against users and not simply those who are drug dependent.
16In their case the only response is to require that they defend what they assert.
17Those who believe otherwise might wish to consider the case of a program called “Snowflakes,” supported by President George W. Bush, whose members—usually conservative Christians—support what they call “embryo adoption,” that is, the implantation in volunteers of “left over” embryos from in vitro fertilization (IVF) programs. Such people are generally opposed to IVF, and if not then almost always when it involves a third party “donor” but believe that it is better (less harmful) to “adopt” an unused embryo than to dispose of it. Their actions are also intended as a rebuff to calls for stem cell research. Does this harm-reduction strategy convey a mixed message, the wrong symbolism, etc.? Surely what is sauce for the goose is sauce for the gander. See Pam Belluck, “From Stem Cell Opponents, an Embryo Crusade,” New York Times, June 2, 2005.
18This is not, of course, to deny that there may be other dependencies—some of which are socially promoted—that it is not good to have. Consistency in social policy is not one of our strong points.
19Obviously this does not accommodate the views of those who believe drug users ought to contract AIDS and die. My purpose here is to try to be responsive to positions about which reasonable people might disagree, not to satisfy every position, no matter how extreme. See the discussion in D. Buchanan, S. Shaw, A. Ford, & M. Singer, “Empirical Science Meets Moral Panic: An Analysis of the Politics of Needle Exchange,” Journal of Public Health Policy, 24(3–4), (2003), 427–44.
20This also goes for the issue of establishing NSPs in prisons. See, for example, Supply, Demand and Harm Reduction Strategies in Australian Prisons: Implementation, Cost and Evaluation <http://www.ancd.org.au/>.
21The very few studies that suggest—or are exploited to suggest—otherwise can be accounted for in other ways. See for example the discussion of increased HIV/AIDS in Vancouver in M. Schechter, S. Strathdee, P.G.A. Cornelisse, et al., “Do Needle Exchange Programs Increase the Spread of HIV Among Injection Drug Users? An Investigation of the Vancouver Outbreak,” AIDS, 13(6) (1999), F45–F51.
22Such programs often distribute literature, and provide referrals and other materials and advice that assist in diminishing the harms of drug use: safer injection practices, overdose prevention (naloxone), condom use, HIV and HCV counseling and testing, hepatitis A and B vaccination, and sexually transmitted disease testing and treatment. They may also provide additional services: meals, showers, shelter, primary medical care (including abscess wound care), bleach, social welfare, and housing assistance.
23Health Outcomes International Pty Ltd., in Association with The National Centre for HIV Epidemiology and Clinical Research and Professor Michael Drummond, Centre of Health Economics, York University, Return on Investment in Needle & Syringe Programs in Australia (Canberra, ACT: Commonwealth Department of Health and Ageing, 2002); Alex Wodak & Annie Cooney, Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users (Geneva: World Health Organization, 2004).
24In a world of limited resources, there is always a danger that ideology will blindly trump effectiveness in decision making.
25We should not see such discretionary enforcement judgments as peculiar to drug use. Police constantly make judgments about which laws to enforce and when and how to enforce them. Full enforcement is a formalistic myth. A registration card can function to distinguish persons with drug paraphernalia but choose to “shoot up clean” from those who do not.
26No society has been “drug free” any more than it has been “crime free.” There is a basic fallacy involved in responding to both in an increasingly Draconian fashion. For some history see, D.T. Courtright, Forces of Habit (Cambridge, MA: Harvard University Press, 2001); R.J. MacCoun & P. Reuter, Drug War Heresies: Learning from Other Vices, Times and Places (Cambridge, UK: Cambridge University Press, 2001; R. Porter & M. Teich, eds., Drugs and Narcotics in History (Cambridge, UK: Cambridge University Press, 1995).
28Health Outcomes International Pty Ltd., in association with The National Centre for HIV Epidemiology and Clinical Research and Professor Michael Drummond, Centre of Health Economics, York University, Return on Investment in Needle & Syringe Programs in Australia (Canberra, ACT: Commonwealth Department of Health and Ageing, 2002).
27I am, however, a bit skeptical, given other studies that suggest the value of NSPs as gateways. Here, too, I also note that much larger distributive questions are left to one side. Given that social resources are finite, do those devoted to NSPs represent a fair allocation compared with those provided for other health needs? Or, even more generally, are those allocated to health needs fairly distributed when compared with other public demands or welfare needs: education, housing, defense, roads, and so forth? Such questions deserve separate treatment.
29See Erving Goffman, “On Cooling the Mark Out: Some Aspects of Adaptation to Failure,” Psychiatry 15 (1952), 451–463, on ways in which agents of social change can be co-opted into becoming agents of social control.