A message from Allan Clear, Executive Director of the Harm Reduction Coalition:
Late last month Congressman Mark Souder sent a letter to the Director of the NIH addressing his concerns about harm reduction. His fanciful, inflammatory and inaccurate letter is posted below. Underneath his letter is HRC's response. To view more responses see the Drug Policy Alliance's website.
Also check out :
His opinions on drugs, especially medical marijuana
His excitement over that major drug dealer Peter Jennings, and a more balanced view of the same program
His ACLU report card
I'm sending this message out to encourage you to write to Dr. Zerhouni. I think it would be helpful for him to hear from the wider community. We can also look at this as an opportunity to have the science around syringe exchange looked at and to raise the issue again of lifting the Federal ban on the funding of syringe exchange.
Here's Congressman Souder's initial letter, and Allan's response to Dr. Zerhouni:
Rep. Souder's letter to Dr. Zerhouni:
April 27, 2004
Honorable Elias A. Zerhouni, M.D.
National Institutes of Health
9000 Rockville Pike
Bethesda, Maryland 20892
Dear Dr. Zerhouni:
As you know, "harm reduction" is an ideological position that assumes individuals cannot or will not make healthy decisions. Advocates of this position hold that dangerous behaviors, such as drug abuse, should be accepted by society and those who choose such lifestyles -- or become trapped in them -- should be enabled to continue these behaviors in a less harmful manner. Often, however, these lifestyles are the result of addiction, mental illness of other conditions that should and can be treated rather than accepted as normative, healthy behaviors. Sadly, harm reduction largely ignores these realities and programs driven by this ideological position have not been adequately reviewed with unbiased, scientific rigor.
I am concerned that harm reduction programs that sustain continued drug abuse, such as injection rooms and needle distributions, likely weaken drug abusers' defenses against infection, sustain drug abusers' long term risk for disease, and minimize the benefits of the available treatments for HIV disease.
These dangers seem to have received insufficient attention by some federal health agencies. Yet, peer-reviewed scientific and anecdotal evidence appear to support this assertion.
Needle exchange is the most visible harm reduction program for injection drug users (IDUs). The first needle exchange programs (NEPs) in the United States were established in Tacoma, Portland, San Francisco, and New York City in the late 1980s in an effort to prevent HIV infection among IDUs. By 1997, there were 113 such programs in more than 30 states.
Vancouver, British Columbia, administers the largest NEP in North America, distributing nearly three million needles every year. The city has a publicly sanctioned site specifically designated for addicts to inject under medical supervision absent of law enforcement. The results of this approach have been horrific. When the Vancouver NEP was established in the late 1980s, the estimated HIV prevalence in Vancouver was 1 to 2 percent among the city's population of 6,000 to 10,000 IDUs. While the expectation was for needle exchange to decrease HIV rates, the opposite has occurred. Both HIV and Hepatitis C have reached "saturation" among the injection drug using population, meaning few if any of those who are not already infected are left to become newly infected, according to the Vancouver Drug Use Epidemiology report published by the city in July 2003. The HIV prevalence among the Vancouver Injection Drug User Study (VIDUS) cohort is 35 percent with "one of the highest incidence rates reported worldwide," according to the 2003 Vancouver Drug Use Epidemiology report. The VIDUS has an astounding 82 percent prevalence of Hepatitis C.
While both HIV and Hepatitis C rates have increased in Vancouver since the establishment of the NEP, research has directly linked the NEP to this trend. A study published in the journal AIDS in 1997 found that "frequent NEP attendance" was actually one of the "independent predictors of HIV-serostatus" among IDUs. The study found that HIV-positive IDUs were more likely to have attended NEP and to attend NEP on a more regular basis compared with HIV-negative IDUs. Of those IDUs observed who became HIV infected during the course of the study, about 80 percent said they had no difficulty accessing syringes. And with only one lone exception, the NEP was the main source of syringes for all of those who became infected. Needle sharing by IDUs in Vancouver is normative, and quite widespread. VIDUS data published in 1997 found 76 percent of HIV-positive IDUs studied admitted to borrowing used needles as did 67 percent of HIV-negative IDUs. Thirty-nine percent of HIV-positive IDUs lent used needles (Strathdee S.A., et. al. "Needle exchange is not enough: lessons from the Vancouver injecting drug use study." AIDS. 1997; 8: F56-65).
The failure of harm reduction to control infectious disease is not limited to Vancouver. Researchers in Montreal studied nearly 1,600 needle-exchange participants for an average of 21.7 months. The study revealed seroconversion probability of 33 percent among needle exchange users and 13 percent among non-users. The case-control study suggested that consistent needle exchange use continued to be associated with HIV seroconversions during follow-up. Despite adjustments for confounders, the researchers noted that HIV risk elevations related to needle exchange remained both substantial and consistent in their cohort of intravenous drug users (Bruneau J., et. al. "High rates of HIV infection among injection drug users in needle exchange programs in Montreal: results of a cohort
study." Am J Epidermal. 1997; 146: 904-1002).
A study of needle exchange programs in Seattle found no protective effect of needle/syringe exchange on the transmission of Hepatitis B or Hepatitis C among participants. The highest incidence of infection with both viruses occurred among current users of the exchange (Hagan H, et. al. "Syringe exchange and risk of infection with Hepatitis B and C viruses." Am J Epidermal. 1999; 149: 203-218).
Needle exchanges focus almost exclusively upon a single mode of transmission among IDUs-sharing of contaminated needles-and largely ignore other important factors such as the individual, the behaviors that cause risk taking, the impact of the substance on the individual and the substance being abused itself.
Studies are increasingly finding these factors play significant harm to IDUs that cannot be reduced by merely providing an unlimited supply of clean needles. A 10-year study published in the Archives of Internal Medicine found that the biggest predictor of HIV infection for both male and female IDUs is high-risk sexual behavior, not sharing needles used to inject drugs. High-risk homosexual activity was the most important factor in HIV transmission for men; high-risk heterosexual activity was most significant for women. Risky drug-use behaviors also were strong predictors of HIV transmission for men but were less significant for women, the study found.
"In the past, we assumed that IDUs who were HIV-positive had been infected with the virus through needle-sharing," noted Dr. Steffanie Strathdee of the Johns Hopkins University Bloomberg School of Public Health in Baltimore, who conducted the study. "Our analysis indicates that sexual behaviors, which we thought were less important among IDUs, really carry a heavy weight in terms of risks for HIV seroconversion for both men and women." (Strathdee, S.A., et al. "Sex differences in risk factors for HIV seroconversion among injection drug users." Archives of Internal Medicine 161:1281-1288, 2001)
Another recent study has found that drug abuse reduces the benefits of AIDS therapy. "There is evidence that HIV-positive injecting drug users benefit less than other risk groups from highly active antiretroviral therapy that has been available since 1996," according to a study published in the European Journal of Public Health ("Limited effect of highly active antiretroviral therapy among HIV-positive injecting drug users on the population level." European Journal of Public Health, 2003;13(4):347-349).
Previous research has also demonstrated that "club drugs" can adversely affect AIDS treatment outcomes, both through drug interactions and by affecting adherence to HIV drugs. Methamphetamines and MDMA have a potential interaction with all of the protease inhibitors and delavirdine used to treat HIV infection. Both GHB and marijuana have also demonstrated potential interaction with AIDS medications.
Recently, there has also been some discussion about the possibility that continued drug abuse by those being treated for HIV infection could potentially spawn drug resistant strains of HIV. This could result from the negative impact of illegal drugs on the body's natural defenses and from insufficient adherence to drug taking regimens by those under the influence of controlled substances.
Now investigators at the McLean Hospital Alcohol and Drug Abuse Research Center in Belmont, Massachusetts, have found that cocaine itself has a direct biological effect that may decrease an abuser's ability to fight off infections.
"This research suggests a link between cocaine use and compromised immune response and could help explain the high incidence of infectious disease among drug abusers," observes Dr. Steven Grant of NIDA's Division of Treatment Research and Development (Halpern, J. H., et al. "Diminished interleukin-6 response to proinflammatory challenge in men and women after intravenous cocaine administration." Journal of Clinical Endocrinology and Metabolism 88(3):1188-1193, 2003).
Research has demonstrated that MDMA is immunosuppressive (Connor, T.J., Methylenedioxymethamphetamine (MDMA, 'Ecstasy'): a stressor on the immune system." Immunology 111(4):357- 367, April 2004) and there is a relationship between meth abuse and immune dysfunction (Qianli, Y., et. al. "Heart disease, methamphetamine and AIDS." Life Sciences 73(2):129-140, May 2003).
This scientific and anecdotal evidence appears to indicate that harm reduction programs have failed to provide a prevention panacea for drug abusers against the dangers of HIV, hepatitis and other health risks.
Please provide a summary of the available scientific data demonstrating:
The impact of drug abuse on the body's immune system;
Impaired decision making that increases HIV risk as a result of drug intoxication;
HIV risk by drug users attributable to risky sexual behavior in exchange for drugs and drug money;
Cultural or normative needle sharing behaviors by drug using populations; and
Inferior health outcomes among those being treated for HIV infection.
The finding that continued drug abuse may impair treatment benefits of those infected with HIV while further damaging the immune system raises the alarming possibility that sustained drug abuse may incubate resistant strains of HIV. Have there been or are there any studies, ongoing or planned, examining the possibility that continued drug abuse by those being treated for HIV infection could contribute to the development of drug resistant strains of the virus?
Thank you for your assistance with this request. Please provide a response by September 1, 2004.
Mark E. Souder
Chairman, Subcommittee on Criminal Justice,
Drug Policy and Human Resources
Allan's letter to Dr. Zerhouni:
Honorable Elias A. Zerhouni, M.D.
National Institutes of Health
9000 Rockville Pike
Bethesda, Maryland 20892
Dear Dr. Zerhouni:
As you know, the application of public health in the United States is sometimes inhibited by ideological positions that are fashioned by personal belief systems rather than science. Congressman Souder’s letter of April 27th regarding the value of harm reduction programs for substance users offers a selective review and distorted interpretation of the wealth of available research on the subject. I would like to address eight inaccurate assertions by Congressman Souder about harm reduction programs and the science evaluating those programs.
1. "…’harm reduction’ is an ideological position that assumes individuals cannot or will not make healthy decisions.”
The harm reduction model asserts that individuals will make healthy choices if provided with accurate information and with access to tangible resources such as injection equipment, drug treatment and other health services. Harm reduction is not a deficit model.
2. “Advocates of this position hold that dangerous behaviors, such as drug abuse, should be accepted by society and those who choose such lifestyles - or become trapped in them - should be enabled to continue these behaviors in a less harmful manner.”
Implicit in the term harm reduction is the belief that drugs can cause real harms. However, these harms are not an inevitable consequence of drug use, and can be prevented or ameliorated through a range of strategies that include but do not invariably require complete cessation from all drug use. Indeed, history suggests that narrowly focusing health promotion and disease prevention efforts on eliminating the use of all psychoactive substances would be neither feasible or effective. Therefore harm reduction posits that reducing damage from consumption of drugs (including alcohol and nicotine) is a more realistic and pragmatic approach. In many cases, reducing drug-related harm entails reduction of drug consumption, through interventions that include prevention of initiating drug use, abstinence, maintenance and substitution therapies, and substance abuse treatment. Harm reduction practice in fact encompasses the promotion of all of these interventions, tailored to meet individual needs and circumstances. Yet the harm reduction model also recognizes that cessation of drug use can be extremely difficult and can take multiple attempts, with recurring cycles of reduced consumption and relapse. Therefore individuals caught in these cycles need support to stave off unnecessary death and disease and other social harms during periods of active drug use. Congressman Souder mischaracterizes harm reduction practice by constructing a false dichotomy between harm reduction and abstinence-oriented approaches, when in fact these strategies would be more accurately described as overlapping elements within a continuum of care.
3. “These lifestyles are the result of addiction, mental illness of other conditions that should and can be treated rather than accepted as normative, healthy behaviors. Sadly, harm reduction largely ignores these realities…”
On the contrary, harm reduction workers are perhaps the only people effectively addressing these conditions among the majority of drug users not currently receiving treatment. Indeed, harm reduction takes on all the greater urgency for this population given the limited success of alternate strategies in the United States. The harms and risks of addiction and mental illness are too often compounded by policies that respond to drug use through incarceration, expulsion from public housing, exclusion from shelter, discrimination and structural barriers to accessing medical care and social services, permanent removal of children, and denial of public welfare and other benefits and financial assistance programs. Harm reduction practitioners recognize and respond to addiction and mental illness as critical health problems that develop and function within an array of cultural contexts and social forces that cannot be reduced or responded to solely through medical models. Harm reduction attempts to promote and facilitate access to care for addiction and mental illness while recognizing the impact of structural impediments to effective and appropriate treatment.
4. “Sadly, harm reduction largely ignores these realities and programs driven by this ideological position have not been adequately reviewed with unbiased, scientific rigor.”
Congressman Souder’s contention is insupportable. The most cursory review of research on harm reduction and syringe exchange programs cannot fail to acknowledge the impeccable reputations of leading researchers from world-renowned institutions, the rigorous peer review process of journals publishing their work, and the reviews conducted by various governmental, medical, public health, and research entities over the last fifteen years validating the design and analysis of this research and endorsing conclusions that support the efficacy of needle exchange and harm reduction approaches to disease prevention.
5. “I am concerned that harm reduction programs that sustain continued drug abuse, such as injection rooms and needle distributions, likely weaken drug abusers' defenses against infection, sustain drug abusers' long term risk for disease, and minimize the benefits of the available treatments for HIV disease.”
Congressman Souder is conflating the risks and harms of drug use with the effects of participation in harm reduction programs. Harm reduction programs do not sustain drug abuse, but rather engage drug users in a continuum of care from which they would otherwise be excluded. Harm reduction and syringe exchange programs have proven to be excellent pathways into drug treatment and medical care, and much of the work and successes of these programs lies in their unique ability to help drug users prepare for, access, benefit from, and remain in appropriate health care and substance abuse treatment. The notion that participation in harm reduction programs can “sustain continued drug abuse” is completely unsupported by any evidence. Contrary to Congressman Souder’s assertion, harm reduction programs can help maximize the benefits of HIV treatments through education, adherence counseling, and other forms of support.
6. Congressman Souder levels criticism against syringe exchange programs by citing research from Montreal and Vancouver.
It is interesting to note that Congressman Souder could not find any data from the United States questioning the role of syringe exchange programs in HIV prevention. Equally disappointing Congressman Souder’s misrepresentation of the findings and conclusions of the Canadian studies, even though lead investigators Strathdee and Schechter have publicly asserted that politicians from the United States have been willfully misinterpreting their research since publication of initial findings in 1997.
By now you will have received letters from prominent researchers in response to Congressman Souder’s factual distortions, and these researchers are better placed to defend their field and work.
7. “Needle exchanges focus almost exclusively upon a single mode of transmission among IDUs - sharing of contaminated needles - and largely ignore other important factors such as the individual, the behaviors that cause risk taking, the impact of the substance on the individual and the substance being abused itself.”
Virtually all existing syringe exchange programs also address sexual risk among injectors. Syringe exchange programs have helped reduce HIV prevalence among injectors in New York City from 60% to approximately 15% since 1990. This dramatic reduction in HIV rates could not have occurred had programs failed to address sexual transmission in tandem with injection-related risk through education, support, and individual and group counseling. These interventions do not focus solely on injection practices or sexual risk, but rather address the array of conditions jeopardizing the health of drug users, including homelessness, poverty, and lack of adequate health care and access to effective drug treatment.
8. “This scientific and anecdotal evidence appears to indicate that harm reduction programs have failed to provide a prevention panacea for drug abusers against the dangers of HIV, hepatitis and other health risks.”
No one has ever suggested that harm reduction or syringe exchange is a prevention panacea for drug users against the dangers of HIV, hepatitis and other health risks. Nor would it be possible to argue that substance abuse treatment or criminal justice policies targeting drug use and drug users have provided such a panacea. Harm reduction and syringe exchange programs provide another tool, alongside drug treatment and drug prevention, in reducing the damage that drug use causes in the lives of individuals.
Congressman Souder does not provide a plan to combat these difficult issues. In the absence of better tools than those provided by harm reduction programs, it is vital to expand upon existing harm reduction services and service modalities. However, I do endorse Congressman Souder’s request for a summary of the available scientific data demonstrating: (1) The impact of drug abuse on the body's immune system; (2) Impaired decision making that increases HIV risk as a result of drug intoxication; (3) HIV risk by drug users attributable to risky sexual behavior in exchange for drugs and drug money; (4) Cultural or normative needle sharing behaviors by drug using populations; and (5) Inferior health outcomes among those being treated for HIV infection.
In addition, I am requesting that the NIH compile an authoritative review of all US based, federally funded research demonstrating the impact of syringe exchange programs on: (1) The spread of HIV among injection drug users; (2) The spread of Hepatitis B and Hepatitis C among injection drug users; (3) The frequency of injection among injection drug users; (4) The reuse and sharing of injection equipment among drug injectors; (5) The disinfection of used syringes; (6) The entry into drug treatment via syringe exchange programs and associated treatment outcomes; (7) The number of discarded contaminated syringes in the vicinity of syringe exchange programs; (8) The initiation of non-injectors into injection. I also request that this review also include an evaluation of research examining the community consequence and public health impact upon the closing of a syringe exchange program. This data collectively provides a crucial context for the issues raised by Congressman Souder.
I am requesting that this compilation be not only forwarded to the Subcommittee on Criminal Justice, Drug Policy and Human Resources but also to Health and Human Services Secretary Tommy G. Thompson and also to Surgeon General Richard H. Carmona. If you find the evidence compelling that syringe exchange programs have a significant role to play in reducing HIV and other viral infections among drug injectors, their sexual partners and the wider community, then I also request that you make a very strong recommendation that the current congressional ban on the Federal funding of syringe exchange programs be lifted and that harm reduction and syringe exchange programs be recognized and supported as a vital part of a comprehensive strategy to prevent disease and reduce drug-related harm.
Sound science and good public health demands that public policy be guided by the best available research, and that research be pursued free of ideological constraints. These principles have all too often been discarded in the history of harm reduction and syringe exchange programs in the United States. I trust that your response to Congressman Souder will help to rectify this scandal.
Harm Reduction Coalition
22 W 27th St. 5th Floor
New York City, NY 10001
Tel: 212 213 6376
Fax: 212 213 6582