Earlier this year, the Harm Reduction Coalition (HRC) sent a letter to the National Institutes of Health (NIH), following an inquiry to the NIH questioning research on harm reduction, drug users, needle exchange, and HIV from Rep. Mark Souder (see background and original letters from HRC and Rep. Souder). HRC's letter challenged Rep. Souder's characterization of harm reduction and research on drug use and HIV, and called upon the NIH to affirm the body of research demonstrating the effectiveness of needle exchange.
"...the majority of studies have shown that NEPs/SEPs are strongly associated with reductions in the spread of HIV when used as a component of comprehensive approach to HIV prevention.... NIDA will continue to work with research communities and various stakeholders to ensure that the research findings surrounding NEPs/SEPs are presented in a manner consistent with the current state of science."
In the current political climate, ideologically-motivated attacks on science and research -- particularly around HIV prevention -- have become increasingly common. The NIH deserves credit for standing by the quality and integrity of research on needle exchange, and resisting the further politicization of science.
Full text of Dr. Volkow's response appears below.
August 4, 2004
Mr. Allan Clear
Harm Reduction Coalition
22 W 27th Street, 5th Floor
New York, New York 10001
Dear Mr. Clear:
Thank you for taking the time to write to Dr. Elias A. Zerhouni, Director of the national institutes of Health (NIH), regarding recent correspondence from Congressman Mark E. Souder on the topic of "harm reduction" and needle exchange programs (NEPs). As you may know, the National Institute on Drug Abuse (NIDA) supports a comprehensive research portfolio that focuses on drug abuse and addiction, including research that is responsive to the dynamic nature of the co-occurring epidemics of drug and HIV/AIDS, which includes NEPs as part of a comprehensive HIV/AIDS prevention approach. Given the breadth of NIDA's research and knowledge on this topic, Dr. Zerhouni has forwarded your letter to my office for a response.
Understanding addiction as a chronic relapsing disease that involves the brain, behavior, the environment in which an individual is raised, along with genetic factors, is critical since it frames how we must ultimately develop strategies to prevent and treat this disease. The ideal outcome of addiction treatment is the complete elimination of drug use. Not only does abstinence improve the health of the individual, but also it reduces the adverse consequences that drugs can have on the health and safety of families and communities. Addiction, however, is a complex chronic disorder that often co-occurs with problems in the domains of physical health, mental health, criminal justice, employment, and family and social functioning. All of these areas must be addressed, not just the drug use. To be effective, treatment should attend to problems of the individual that would, otherwise, jeopardize his or her recovery and participation as a productive member of society and this process should include interventions that reduce risky behaviors that can jeopardize the individual and those around him/her.
While it is not feasible to do a randomized controlled trial of the effectiveness of needle or syringe exchange programs (NEPs/SEPs) in reducing HIV incidence, the majority of studies have shown that NEPs/SEPs are strongly associated with reductions in the spread of HIV when used as a component of comprehensive approach to HIV prevention. NEPs/SEPs increase the availability of sterile syringes and other injection equipment, and for exchange participants, this decreases the fraction of needles in circulation that are contaminated. This lower fraction of contaminated needles reduces the risk of injection with a contaminated needle and lowers the risk of HIV transmission. In addition to decreasing HIV infected needles in circulation through the physical exchange of syringes, most NEPs/SEPs are part of a comprehensive HIV prevention effort that may include education on risk reduction, and referral to drug addiction treatment, job or other social services, and these interventions may be responsible for a significant part of the overall effectiveness of NEPs/SEPs. NEPs/SEPs also provide an opportunity to reach out to populations that are often difficult to engage in treatment.
NIDA will continue to work with research communities and various stakeholders to ensure that the research findings surrounding NEPs/SEPs are presented in a manner consistent with the current state of science. I would like to thank you once again for your interest and your role in reducing the health burden of these diseases on our Nation's citizens.
Nora D. Volkow, M.D.