Pubdate: 9 May 1999
Source: Sunday Times (UK)
Copyright: 1999 Times Newspapers Ltd.
Author: Ian Oliver, former chief constable of Grampian Police


In 1998, three pharmacies on the fringes of Aberdeen distributed more than
120,000 hypodermic syringes to people who were injecting illicit drugs. It
is a common and rising statistic throughout the UK's big cities.

The original intention behind the introduction of needle exchange
programmes (NEPs) was based on the hypothesis that they would play an
important part in the prevention of HIV transmission and thus reduce the
spread of Aids.

At the time the Scottish Office was sounding out opinions on NEPs,
Edinburgh was widely described as the "Aids capital of Europe". The first
programmes in Scotland began in 1987 and the time has come to question
their effectiveness. For example, there are grounds to argue that they have
not stopped the spread of infection and may have exacerbated the problem of
drug abuse.

General Barry McCaffrey, the American "drugs czar", recently blocked the
federal funding of NEPs. His reasoning was based on a report on the
Vancouver NEP, the largest in North America, which currently distributes
more than 2.5m needles a year, a figure that is expected to grow to an
estimated 10m at present user rates. Vancouver has been described as the
"drugs and crime capital of North America".

In summary, McCaffrey's concerns were:

* The science is uncertain. Currently there is no scientific or empirical
evidence to demonstrate that NEPs reduce the spread of infection and there
are concerns that they may exacerbate drug use. When the programme started
in Vancouver in 1988, only 1%-2% of addicts were HIV positive; in 1998 that
percentage had increased to 30%.

* Public health risks may outweigh potential benefits. There is strong
evidence to suggest that heroin and cocaine use is increasing among
intravenous drug users and the risk that needle exchanges might promote
that use outweighs any possible benefits. Research has shown that the
Aids/HIV rate is declining, as a result of improved education, in areas
where there are no NEPs. Vancouver has the highest heroin death rate in
North America and there is evidence that needles are now used in cocaine
abuse (previously "snorting" was the norm for this drug), where an addict
may make up to 50 "hits" a day. Coincidentally, heroin abuse has increased
significantly with the proliferation of NEPs in North America.

* Treatment must be a priority. Where budgets are restricted, it is better
to treat addicts than to support a strategy that may directly or indirectly
encourage addiction.

* Federal support of NEPs may undermine support for drug-control
programmes. Spending federal money on NEPs detracts from spending on Aids
research, treatment and prevention programmes. Such expenditure on drug
paraphernalia could seriously undermine support for effective drug
prevention and treatment programmes.

* Supporting NEPs sends the wrong message to children. Lending official
support to a programme that appears to encourage addiction and illegal
conduct is inconsistent with the goals of a national youth-orientated,

campaign and sending a mixed message will threaten to undermine the
credibility of other anti-drug initiatives.

* NEPs do nothing to ameliorate the impact of drug use on disadvantaged
neighbourhoods. NEPs are usually located in impoverished neighbourhoods.
The programmes attract addicts and result in a concentration of the
negative consequences of drug use, including criminal activity.

The biggest concerns in North America seem to turn on the lack of any
evidence that they are beneficial. In fact, there is every indication from
the Vancouver experience that it created thousands of extra "shared" needles.

In Scotland there is no official information available that assesses the
efficacy or otherwise of needle exchanges. Separate budgetary allocations
are made for health authorities who undertake NEPs and the Scottish Office
is reviewing the HIV health-promotion strategy. In 1997, the National
Institutes of Health Consensus Panel Report on HIV Prevention praised the
NEP in Glasgow but made no reference to the heroin epidemic that appears to
reflect the Aberdeen experience and that of North America.

Evidence from Australia has raised serious doubts about the hypothesis that
ready access to clean injecting equipment would play an important role in
the control of HIV transmission. It points to a contemporaneous rise in the
spread of hepatitis C among intravenous drug users, which is also apparent
in Glasgow and other UK cities.

Much of the support for NEPs in North America and the UK appears to be
based on anecdotal evidence and the use of statistics, which have been
demonstrated to be unreliable. What is of great concern is that after 12
years there has been no official assessment of this "act of faith" when
there has been a concomitant rise in drug use. A trawl of the scientific
literature has failed to produce any conclusive evidence that NEPs reduce
the spread of Aids/HIV and hepatitis C or that they discourage drug use.
Indeed, the reverse of that hypothesis might well be true, given the
evidence that there is a massive increase in heroin use and that
drug-related deaths among intravenous drug users are "sky-rocketing" across
Scotland, particularly in Aberdeen and Glasgow.

There are fears in North America that the support for NEPs is part of an
international drug legalisation campaign which will lead to the free supply
of heroin as has occurred in Switzerland and the Netherlands. There are
also legitimate concerns that NEPs are acting directly in contradiction to
the philosophy behind the drugs courts which depend on a "carrot and stick"
approach in order to persuade users to refrain from drug use.

A recent survey in 1997 by the Family Research Council in America has
indicated that, by very large majorities across the social spectrum, there
is opposition to NEPs. This opposition rests on the belief that they are
not the most effective use of public funds to prevent Aids/HIV and they are
thought to exacerbate other social problems. The survey found substantial
majorities of Americans believed Aids prevention should focus on drugs
treatment instead of "needle giveaways" with strong evidence that thousands of

these clean needles will become "dirty" when shared with other addicts.

Simultaneously maintaining and trying to reduce the harm in an inherently
destructive practice and lifestyle is thought to be both unsuccessful and
hypocritical. By a margin of 56% to 34%, Americans concluded that
government-funded NEPs represented an official endorsement of illegal drug

If we are serious in our attempts to enhance public health and reduce the
demand for dangerous drugs as part of our anti-drug strategy, then it is
surely sensible to undertake a scientific audit of a programme that has
been promoted in Scotland for more than a decade. Before continuing to
spend money on such programmes we should assess how they are controlled and
apply "performance indicators" to demonstrate beyond doubt that they are
achieving what they set out to achieve.

We cannot continue to spend money and divert resources away from other
projects such as the much-needed treatment centres on the assumption that a
well-intentioned hypothesis propounded in 1987 continues to be valid at the
end of the millennium.

There are other, more effective and less controversial ways to prevent the
spread of infection. If these NEPs represent little other than a public
funding of an illegal and self-damaging activity, which itself is the cause
of too many deaths and serious public health concerns, then the question
has to be asked: "Where is the point?"

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