Editorials

Prescribing Syringes to Injection Drug Users: What the Family Physician Should Know

Am Fam Physician. 2003 Jul 1;68(1):45-47.

Injection drug use (IDU) is currently the single largest factor contributing to the spread of human immunodeficiency virus (HIV) infection in the United States.1 The Centers for Disease Control and Prevention (CDC) reports that one third of all cases of acquired immunodeficiency syndrome (AIDS) are caused by IDU.2 Transmission to other family members through heterosexual and perinatal contact, and the impact of addiction on the family, makes this a family disease. In addition to HIV infection, injection drug users (IDUs) face many health risks, including viral and bacterial infections (e.g., hepatitis, tuberculosis, endocarditis, abscesses), overdoses, violence, and suicide. Many IDUs have complex medical, social, and psychiatric problems and face tremendous difficulties in accessing the appropriate services.3

Several strategies to increase access to sterile injection equipment among IDUs have been tried. Needle/syringe exchange programs (SEPs) have been widely promoted to prevent syringe sharing, including the American Academy of Family Physicians' (AAFP) policy that “supports SEPs as a vital component of a comprehensive strategy to prevent infectious diseases associated with illicit injection drug use.”4 SEPs are an example of harm reduction, based on the public health acknowledgment that there is no way to completely eliminate IDU and, therefore, the reduction of adverse consequences of IDU is vital. SEPs have been shown to save lives,5 reduce HIV and hepatitis virus transmission,6,7 and decrease risky injection practices.8 The population of IDUs in this country cannot adequately be served by the existing number of SEPs.9 However, despite ample scientific evidence to support their effectiveness, political opposition and lack of federal funding have severely hampered expansion of this HIV prevention strategy.

Critics have questioned whether SEPs might increase illicit drug use, disease spread, or the number of used syringes in public places. Abundant data are available to alleviate these concerns. Numerous studies have shown that SEPs do not increase drug use,10,11 the number of IDUs,12,13 or the problem of discarded syringes.1416 Yet, unfounded fears have translated into the current ban on federal funding for SEPs. This ban has prevented expansion of SEPs, likely contributing to HIV infection among thousands of IDUs, their sexual partners, and their children.17

In addition to federal laws impacting SEPs, many programs are obligated to run under dubious statewide legal status.9 As of 1997, 52 SEPs were legal (operating in states that do not have a law that regulates the purchase of syringes or are exempt from this law), 16 were illegal/tolerated (have received formal approval from a local elected body in states with prescription laws), and 32 were illegal/underground (have not received formal approval from a local elected body in states with prescription laws.)18 Legally sanctioned SEPs tend to be more effective,9 because they have greater resources, size, site numbers, and availability of medical services. Increasing awareness of SEPs among IDUs and expanding hours of operation and the number of locations augment the influence of SEPs.19 Removing fear of policy harassment or arrest also increases the effectiveness of SEPs.12,20 Therefore, improving the legal status of SEPs at local, state, and national levels is an important goal.

A second solution to the problem of disease transmission through syringe sharing is the deregulation and legalization of syringe sales in pharmacies.21 However, this approach does not usually include the provision of drug treatment referrals and information that SEPs often offer. In addition, neither pharmacy sales of syringes nor SEPs provide access to medical care.

A third public health strategy, syringe prescription by physicians, has recently been promoted. This approach allows for direct physician contact providing IDUs with medical care, substance abuse treatment referrals, and access to sterile syringes.

In 1999, a pilot physician syringe prescription program was initiated in Providence, R.I., to reduce syringe sharing and reuse, increase safe disposal, provide medical care, and facilitate entry into drug treatment for IDUs.22 At each visit, a physician conducts a clinical examination, addresses medical concerns, and prescribes syringes free of charge, usually 200 at a time. IDUs enrolled in the program are educated about the dangers of sharing and reusing syringes and other paraphernalia (cotton, cookers, and rinse water); proper disposal of syringes; and safe injection practices.

Syringe prescription is an extremely effective way to address the need of IDUs to gain increased access to both syringes and health care. A 1995 report from the National Research Council and the Institute of Medicine stated, “the once-only use of sterile needles and syringes” remains the safest approach “for limiting HIV infection.”23 The provision of syringes to IDUs and the associated reduction of disease transmission are only part of the potential benefit of syringe prescription. By definition, prescription of syringes involves a physician-patient relationship in which injection is acknowledged. This opens the door for discussion of a variety of injection-related activities, including commercial sex, participation in an underground economy, violence, and abuse. Often, an addict only feels comfortable talking openly and honestly about drug use with other drug users, or with the addict's drug dealer or pimp, people who typically have a vested interest in the addict's continued drug use. A physician who is open and nonjudgmental in discussing drug use can play an important role in empowering IDUs to begin drug treatment. In addition, the sterile syringes provided by syringe prescription can entice the marginalized IDU population to enter into a primary care setting.

Physician syringe prescription as a means of preventing disease transmission is legal in 48 states in the United States as well as in the District of Columbia and Puerto Rico.24 This approach has been endorsed by the American Medical Association and the Infectious Disease Society of America.25,26 A detailed analysis for each jurisdiction studied is available on the Internet at www.temple.edu/lawschool/aidspolicy/default.htm.24 This information may be useful in convincing state regulatory agencies of the legality and appropriateness of syringe prescription to prevent the transmission of disease.

The AAFP recently updated its policy to support physician syringe prescription to prevent disease transmission in conjunction with education of IDUs to use a new, sterile syringe for each injection.27 Family physicians have an opportunity to link IDUs into both primary medical care and substance abuse services.4,28 Through support of SEPs and syringe prescription with direct counseling and medical follow-up for IDUs, physicians can help to reduce the spread of HIV and increase disease awareness in this high-risk population.

This work was supported by the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (CSAT) No. 1KD1 TI 12037-01; American Foundation for AIDS Research (amfAR) No. 10630-26-EG; Open Society Institute (OSI) No. 282941581 with partial support from the National Institutes of Health/ Center for AIDS Research (NIH/CFAR) No. P30-42853; Dr. Rich is supported by the National Institute on Drug Abuse (NIDA) No. K20DA00268. The content of this work is solely the responsibility of the authors and does not necessarily represent the official view of the funders.

Address correspondence to Josiah D. Rich, M.D., M.P.H., Division of Infectious Diseases, The Miriam Hospital/Brown University, 164 Summit Ave., Providence, RI 02906. Reprints are not available from the authors.

REFERENCES

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2. Academy for Educational Development. Injection drug users play a key role in the transmission of HIV and other blood-borne infections. In: A comprehensive approach: preventing blood-borne infections among injection drug users. Academy for Educational Development. Palo Alto: 2000:3–11. Retrieved June 4, 2003, online at www.healthstrate-gies.org/pubs/publications/aedbook.pdf.

3. Haverkos HW, Stein MD. Identifying subtance abuse in primary care. Am Fam Physician. 1995;52:2029–35.

4. AAFP Policy Statement on Syringe Exchange Programs, 1998. Retrieved online June 4, 2003, at www.aafp.org/x7096.xml.

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12. Lurie P, Reingold AL, Bowser B, et al. The public health impact of needle exchange programs in the United States and abroad. School of Public Health, University of California, Berkeley [and] Institute for Health Policy Studies, University of California, San Francisco. Regents of the University of California, 1993.

13. Drucker E, Lurie P, Wodak A, Alcabes P. Measuring harm reduction: the effects of needle and syringe exchange programs and methadone maintenance on the ecology of HIV. AIDS. 1998;12(suppl A):S217–S30.

14. Broadhead RS, vanHulst Y, Heckathorn DD. The impact of a needle exchange's closure. Public Health Rep. 1999;114:439–47.

15. Doherty MC, Garfein RS, Vlahov D, Junge B, Rathouz PJ, Galai N, et al. Discarded needles do not increase soon after the opening of a needle exchange program. Am J Epidemiol. 1997;145:730–7.

16. Oliver KJ, Friedman SR, Maynard H, Magnuson L, Des Jarlais DC. Impact of a needle exchange program on potentially infectious syringes in public places. J Acquir Immune Defic Syndr. 1992;5:534–5.

17. Lurie P, Drucker E. An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA. Lancet. 1997;349:604–8.

18. Centers for Disease Control and Prevention. Update: syringe exchange program — United States, 1997. JAMA. 1998;280:1217–8.

19. Rich JD, Strong L, Towe CW, McKenzie M. Obstacles to needle exchange participation in Rhode Island. J Acquir Immune Defic Syndr. 1999;21:396–400.

20. Bluthenthal RN, Kral AH, Lorvick J, Watters JK. Impact of law enforcement on syringe exchange programs: a look at Oakland and San Francisco. Med Anthropol. 1997;18:61–83.

21. Novotny G. DeBoer J, Collison E, Nelson R, Moore S. Minnesota Department of Health. Minnesota pharmacy syringe/needle access initiative (SAI) implementation. Presented at: 1999 National HIV Prevention Conference, August 29-September 1, 1999. Atlanta. Abstract 141. Retrieved June 5, 2003, online at www.cdc.gov/hiv/conferences/hiv99/abstracts/141.pdf.

22. Rich JD, Macalino GE, McKenzie M, Taylor LE, Burris S. Syringe prescription to prevent HIV infection in Rhode Island: a case study. Am J Public Health. 2001;91:699–700.

23. Panel of Needle Exchange and Bleach Distribution Programs. National Research Council (U.S.) and Institute of Medicine. Normand J, Vlahov D, Moses LE, eds. In: Preventing HIV transmission: the role of sterile needles and bleach. Washington, DC: National Academy Press, 1995:1–8.

24. Burris S, Lurie O, Abrahamson D, Rich JD. Physician prescribing of sterile Iinjection equipment to prevent HIV infection: time for action. Ann Intern Med. 2000;133(3):218–26.

25. American Medical Association. Joint statement on HIV prevention and access to sterile syringes. Adopted at Annual Meeting, June 2000. Available at: www.ama-assn.org/ama/pub/printcat/1808.html.

26. Infectious Diseases Society of America. IDSA policy statement on syringe exchange, prescribing and paraphernalia laws. 2000. Available at: www.idsociety.org/PA/PS&P/Syringe_11-17-00.htm.

27. AAFP Policy Statement on Syringe Prescribing and Dispensing, 2002. Available at www.aafp.org/x7096.xml.

28. Friedmann PD, McCullough DD, Saitz R. Screening and intervention for illicit drug abuse. Arch Intern Med. 2001;161:248–51.


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