Time for legalized distribution of illegal drugs?
CMAJ 1997;157:1345
See response from: C. Hankins
Dr. Catherine Hankins' thought-provoking editorial "Needle exchange: Panacea or problem?" (CMAJ 1997;157[3]:275-7 [full text / résumé]) summarizes many of the issues concerning HIV infection among injection drug users (IDUs) and the possible benefits of needle exchange programs (NEPs).
It appears that NEPs decrease HIV transmission rates by reducing the amount of time needles are in circulation.1 However, a California evaluation2 concluded that NEPs are associated with decreased HIV risk behaviour and an absence of negative outcomes but found no clear evidence that the exchange programs actually reduce HIV infection rates. A recent Australian review3 found that cities with NEPs tended to experience a decrease in HIV seroprevalence among IDUs, compared with cities without such programs. However, the sale of injection equipment by pharmacies can have a similar impact. Therefore, the difference in rate of change of HIV seroprevalence between cities with and without NEPs may not be due solely to the exchange programs.3
Hankins discusses increases in the use of cocaine relative to heroin by Canadian IDUs. In Vancouver some 2.38 million needles were distributed through NEPs in 1996.4 Assuming that an average of 3000 IDUs received sterile needles daily, this figure translates into 800 needles a year for each IDU or about 2 per day. This supply would fall far short of meeting the needs of the average cocaine user.
Counselling, treatment and rehabilitation services for IDUs are inadequate across Canada. It makes no sense to have long waiting lists for those interested in rehabilitation and to reduce the resources for such services over time. This situation has major implications for the spread of HIV in IDUs in the future, as well as concomitant spread into the heterosexual population.
It may be time to seriously consider harm reduction by the controlled distribution of narcotics to IDUs. This seems to be a valuable part of the HIV-reduction strategy in places such as Liverpool, Glasgow and Zurich. Could it be considered here, initially on a pilot basis in a major city?
Timothy Johnstone, MB, BS, DPH
Consulting Epidemiologist
Victoria, BC
References
- Kaplan EH. A method for evaluating needle exchange programmes. Stat Med 1994;13:2179-87.
- Institute for Health Policy Studies. The public health impact of needle exchange programs in the United States and abroad. Berkeley: School of Public Health, University of California; 1993.
- Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchange programmes for prevention of HIV infection. Lancet 1997;349:1797-800.
- Jimenez M. Official challenges notion needle program spreads AIDS. Vancouver Sun 1997 Aug 6; Sect B:1,4.
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