Needle Syringe Programs in prisons have proven successful across the globe, including in Iran.
Gains are directly transferred to
individuals, family members, community members, custodial officers, law enforcement officers and health professionals.
Australia once led the world in Harm Reduction initiatives, a number of which pertain to safe injecting of illicit drugs.
Because of the illegality, potential for tragedy and high risk associated with IV drug use it is very easy to be led astray from the evidence base supporting harm reduction initiatives. Primary amongst these is the funding of over 1,000 Needle, Syringe Programs (NSPs) across Australia. Although introduced against considerable opposition, community acceptance is now very high. More to the point, similar misinformation and conservative opposition was raised against another harm reduction initiative when introduced. Condom use amongst men having sex with men (MSM).
Harm Reduction measures were introduced by then federal health minister, Neal Blewett in 1985, ushering in unprecedented acceptance, understanding and management of high risk behaviour leading to the spread of HIV in Australia.
Led by the Minister for Health under the Hawke government, Neal Blewett, Australia undertook several unprecedented and pragmatic steps: it introduced a needle exchange program for intravenous drug users, encouraged open discussion of safe sex, and created the famous Grim Reaper advertising campaign.
There was fierce opposition from the religious right, but 25 years after the initial AIDS outbreak, Australia’s decision to accept human nature in policy making has saved thousands of lives – especially when compared to the USA where ‘morality’ has outweighed practicality in dealing with the illness.
Harm Reduction (HR) is one of the three major prongs of Australia’s illicit drug policy. The policy is called Harm Minimisation. Not “tough on drugs”, not “zero tolerance”. Harm Minimisation includes Supply Reduction, Demand Reduction and Harm Reduction. Over the years the gay lobby and LGBTQ community has forged itself a formidable legal and social identity. I pity the conservative zealot who would insult their ontology. Not so for IV drug users. This is due to many reasons, the more obvious being the transient nature of drug use (experimentation), the social, professional and personal cost of outing oneself as a chronic addict, the complete lack of intention to politically mobilise and the volume of comorbid mental health problems.
To be rather crude whilst it is demonstrably bigoted to discriminate against Australia’s disabled population they are not a force of reckoning. Our communities remain poorly suited to accommodate disabilities. Stigma persists leading to discrimination and inequality.
Similarly whilst we clinically accept the disease model of addiction, many community members still remain blinded to this very real health problem in favour of pop culture “bad guy” stereotypes. This is sheer manna for those with political interests to be seen to be “tough on drugs” or who seek to exploit individuals with a range of disabilities, including drug dependence.
Most Aussie addicts are alcoholics and cigarette smokers. The bulk of public health money dealing with drug induced harm is spent here. Illicit drug addiction consumes under 5% of the total expense. Writing in, Redefining Addiction in MJA Insight Paul Haber noted:
The American Society of Addiction Medicine (ASAM) grappled with this problem for 5 years before releasing its new definition of addiction, which has stimulated interest from around the world with commentaries in The Lancet, Time and elsewhere. ASAM proposes that addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. It is a chronic relapsing and remitting disorder that manifests in continuing use of substances or alcohol despite accumulating harm to the individual and to others. [….]
This addiction disease concept facilitates a medical approach to management, including the need for quality evidence to support clinical interventions and it encourages engagement of medical professionals in this field. Acceptance of the disease model can also reduce the stigma of the disorders. Specific neurobiological abnormalities have been identified such as certain dopamine receptors in the reward system and these are targets for therapeutic intervention.
The funding pittance that is dealt to illicit drug harm reduction in part reflects the dwarfing of this demographic alongside drinkers, smokers and gamblers. The rest is explained in that the lions share is consumed by futile supply reduction efforts in the endless cycle of importation, distribution, dealing and administration. Demand reduction – fighting the demand for drugs through education, rehabilitation and disincentives also receives more money than harm reduction. It remains far, far too easy to raise a voice of ignorance and accuse HR initiatives of “allowing” or “encouraging” drug use.
The ABC news items below discuss the need for needle exchange programs in Australian prisons and the potential for a trial beginning in Canberra’s Alaxander Maconochie prison. It’s probable an HIV epidemic beginning in injecting drug users, and placing the wider Australian community at risk, would begin in Australian prisons. Questions are also raised as to the “shameful” state of Australia’s Harm Reduction initiatives that have fallen behind what is considered effective evidence based practice for prison population health. This is further evidenced by successful programs in other countries around the world. Needle Syringe Programs are strongly supported by a large global evidence base. Significantly, one public health success story is Australia.
Indeed return on investment research in 2009 [PDF] show that “investments in needle and syringe programs were yielding a twenty seven fold return in health, productivity and other gains.” Gino Vumbaca, Executive Director of the Australian National Council on Drugs wrote at the time:
What is striking is the level of public support for the program. The largest regular survey on drug use issues we have, the National Household Survey on Drugs, now records public opposition to the program at less than 20%. The Hawke, Keating, Howard and now Rudd Governments, as well as a myriad of state and territory governments of varying hues over the past 20 years have all lent their support to the program. For some this was in the face of strident opposition. A truly admirable achievement based on evidence, common sense and humanitarian grounds
Discussing the 2009 report findings Anex wrote:
The World Health Organization commissioned a review of evidence of the effectiveness of Needle and Syringe Programs to reduce HIV which concluded:
There is compelling evidence that increasing the availability and utilisation of sterile injecting equipment for both out-of-treatment and in-treatment injecting drug users contributes substantially to reductions in the rate of HIV transmission. Research from around the world clearly indicates that NSPs make a significant contribution to preventing the spread of HIV/AIDS and hepatitis C.
Between 2000 and 2009, the Australian Government invested $243 million in Needle and Syringe Programs. This resulted in the prevention of an estimated 32,050 new HIV infections and 96,667 cases of hepatitis C. $1.28 billion dollars were saved in direct healthcare costs. [….] The report states: “If NSPs were to decrease in size and number, then relatively large increases in both HIV and hepatitis C could be expected with associated losses of health and life and reduced returns on investment. Significant public health benefits can be attained with further expansion of sterile injecting equipment distribution.”
Countries, like Australia, that have implemented NSPs have averted HIV epidemics among injecting drug users and, therefore, the community at large. Those countries that have not implemented these measures have often experienced uncontrolled HIV epidemics. There is strong evidence to suggest that when HIV becomes endemic among the injecting drug user community it can then spread to their sexual partners and children, resulting in high mortality rates and large social and economic costs to the entire community.
Conservative ideologues and those with vested interests in punitive measures, have attempted to discredit NSP efficacy. Nations without proper NSPs, such as Sweden are deemed in breach of the UN International Right to Health. See page 3, item D. Religious fundamentalists & other totalitarian belief systems frequently reference Sweden’s “war on people” mentality, obfuscating the human rights abuse. As revealed by WIKILEAKS, the USA work actively to sabotage Harm Reduction initiatives as part of their War On Drugs policy, citing Stockholm as a reliable ally. An excellent discussion of this matter is to be found at Neurobonkers. The Global Commission on Drug Policy has demonstrated the failure of the Drug War. [CNN News]
With respect to needle exchange, rather than advance challenges to NSP efficacy with new research the tactic of a small minority is to attack existing methodology in an out of context, subjective fashion creating the illusion of an argument. An analogue today might be “pertussis diagnoses have increased, therefore the vaccine is ineffective” – a claim advanced by comparison of unrelated data sets.
In May 2010 Norah Palmateer et al. produced a meta-analysis using what they called “Critical appraisal criteria” to challenge the methodology of NSP research. However, even whilst selecting particular modes of distribution and leaving out others, a conclusion that “New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission”, was delivered. This is scarcely revolutionary, yet is falsely cited as discrediting NSP efficacy by fundamentalist conservative groups. In truth Palmateer et al actually argue for a shift in analytical focus to biological rather than behavioural data. More so, they write:
The findings of this review should not be used as a justification to close NSPs or hinder their introduction, given that the evidence remains strong regarding self-reported IRB and given that there is no evidence of negative consequences from the reviews examined here. [….] We recommend a step change in evaluations of harm reduction interventions so that future evaluations: (i) focus on biological outcomes rather than behavioural outcomes and are powered to detect changes in HCV incidence; (ii) consider complete packages of harm reduction interventions rather than single interventions; (iii) are randomized where possible (preferably at the community level); and (iv) compare additional interventions or increased coverage/intensity of interventions with current availability.
“The findings of this review should not be used as a justification to close NSPs or hinder their introduction”. Yet this is exactly what the enemies of reason have done, misquoting Palmateer at every turn. The “AVN” of Blood Borne Virus control is a group of far right evangelical lobbyists known as Drug Free Australia. Their “Meryl Dorey”, as it were is their “secretary”, young earth creationist and climate change denialist, Gary Christian. The similarities between Dorey and Christian are striking. No medical or health qualifications, citing of global conspiracies, “social experiments” – not evidence based public health, saving Australians, provision of “truth”, attacking certain research identities, cherry picking of data and outright lies.
When a 27 fold return on investment for NSPs was claculated after years of research, Mr. Christian promptly dismissed this claiming NSPs actually serve to promote drug use and spread viruses. WHO data would prove this if properly adjusted he cried, mimicking Dorey’s claims to “properly read research”. Thus he was able to immediately dismiss what is absolute proof opposition to NSPs is baseless. Indeed, Christian went further.
Harm Reduction is the “normalisation of illicit drug use” not just correlating to, but causing a rise in drug use. Hands up if knowing about NSPs motivates you to experiment with IV drugs. This new take on “condoms cause AIDS” is demonstrably flawed. Just as abstinence, not condoms will prevent STD’s, Christian claims “free HIV testing” not NSPs or harm reduction will control HIV, citing discredited non peer reviewed sources.
Thus arguments raised against the value of exchange program efficacy in cutting blood borne virus spread are emotive, supposedly backed by misrepresented, spurious and/or biased “research” and driven by discredited, conservative fringe lobby groups.
Unsurprisingly the opposition to NSPs in Aussie prisons is based on misinformation and a lack of evidence.