A Comprehensive Approach:
Preventing Blood-Borne Infections Among Injection Drug Users
Chapter 2, Section 2: Negative Attitudes Toward
IDUs Affect Public Policy and Treatment Approaches
Public and provider attitudes and perceptions
about drug use and users color attitudes toward appropriate responses
to the problem of injection drug use. The substantial investment in
prisons and criminal justice institutions, the relatively limited public
support for substance abuse treatment, and laws and regulations limiting
sterile syringe sales and syringe exchange programs appear to reflect
a national inclination to respond to drug users in a punitive and dehumanizing
fashion. For example, active drug users are disqualified from the federal
Supplemental Security Income program if their addiction is considered
to be a contributing factor to their disability (Bluthenthal et al.,
1999; Lorvick et al., 1999), and welfare recipients are tested for drug
use and may lose their benefits if the test is positive (though in some
areas they may retain food and rent vouchers) (Friedman, 1998). Pregnant
drug-using women still face barriers in obtaining treatment and, should
they be incarcerated, in obtaining prenatal care and retaining custody
of their child after delivery (Breitbart et al., 1994; GAO, 1999).
The impact of these public and personal attitudes
on current laws, regulations, and policies can be seen in several ways:
Emphasis on criminal
penalties rather than treatment. With several notable exceptions
(alcohol and tobacco use by adults), the use of addictive drugs is
illegal and users are subject to arrest and incarceration. Punitive
laws for drug possession and dealing channel users and IDUs into prison
rather than substance abuse treatment. This, combined with the criminal
activities that many IDUs pursue to maintain their addictions, means
that they are frequently arrested and imprisoned. This tends to reinforce
the public's perception of them as "bad" people and of drug use as
a crime rather than a medical and behavioral problem.
Funding priorities. The federal
government currently spends nearly twice as much on programs to stop
drugs from entering the U.S. as on programs to reduce the demand for
drugs. In 1998, two-thirds of the $16.18 billion federal drug control
budget was allocated for "supply reduction" activities, such as border
control efforts, and one-third for "demand reduction" activities,
such as prevention and treatment programs (ONDCP, 1999 in Amaro, 1999).
The drug control budget for fiscal year 2000 is expected to increase
by over $1.6 billion, but the proportion dedicated to demand reduction
will be only slightly augmented (Amaro, 1999).
Limited substance
abuse treatment services. It is clear that the people who
need substance abuse treatment far outnumber the people who are able
to receive it. For example, data from the Substance Abuse and Mental
Health Services Administration's (SAMHSA) National Household Survey
on Drug Abuse (NHSDA) show that in 1996, more than 5.3 million people
with severe substance abuse problems needed treatment services. However,
only 37 percent received such treatment (Epstein and Gfroerer, 1998).
Of the estimated 600,000 opiate-dependent individuals in the U.S.,
only about 115,000 (19.2 percent) are in methadone maintenance treatment
(NIH, 1997). Part of this results from a lack of funding. Other contributing
issues include a shortage of physicians and other health care professionals
who are trained and able to provide treatment; complex federal regulations
that limit the flexibility and responsiveness of treatment programs;
limitations in health insurance coverage for treatment; and an existing
patchwork of federal, state, and local regulations and funding mechanisms
that limit providers' ability to provide the continuum of services
necessary to meet the complex substance abuse treatment, medical,
and social service needs of injection drug users (AED, 1999; NIH,
1997).
Community resistance to substance abuse treatment
facilities and programs-the "not-in-my-backyard" (NIMBY) factor-
also plays an important role in limiting the availability of treatment
and other services for IDUs. Common objections to these facilities
are that they contribute to an increase in crime in the area, attract
undesirable groups of people, and import the drug culture. As a
result, treatment facilities are often located in industrial or
run-down parts of town to avoid the presence of residential neighbors
and diminish the possibility of community resistance. Treatment
program counselors also may routinely patrol the area around their
facility to ensure that clients do not loiter and cause problems
with neighbors.
General Barry McCaffrey, Director
of the Office of National Drug Control Policy (ONDCP), proposed
a new strategy of integrating drug testing and substance abuse
treatment into almost every phase of the criminal justice process,
from arrest to the return to community after prison. Gen. McCaffrey
outlined this strategy at a "National Assembly on Drugs, Alcohol
Abuse and the Criminal Offender," which was sponsored by the ONDCP,
the Department of Justice, and the Department of Health and Human
Services to bring together 900 law enforcement, prison, and public
health specialists from around the country to discuss ways to
break the seemingly unbreakable link between substance abuse and
crime. The assembly advocated better collaboration between substance
abuse, public health, and criminal justice, much greater reliance
on substance abuse treatment to address the cause of most involvement
with criminal justice, and better programs to ease inmates' return
to their home communities after prison (Wren, 1999).
Dr. Alan Leshner, Director of the
National Institute on Drug Abuse (NIDA), made the case that as
a society we should no longer focus on unanswerable questions
about the morality of treating versus punishing those addicted
to drugs, but instead should focus on the practical benefits to
individuals and society as a whole of treating drug addiction.
"If we are ever going to significantly reduce the tremendous price
that drug addiction exacts from every aspect of our society, drug
treatment for all who need it must be a core element of our society's
strategies" (Leshner, 1999).
Dr. Hortensia Amaro of Boston University
School of Medicine argued that limited funding for substance abuse
treatment is an expensive long-term policy. She noted that the
federal government's policy of spending nearly twice as much on
reducing the supply of drugs as on reducing the demand for them
through prevention and treatment programs is "perplexing" given
that treatment has been shown to be more effective than law enforcement
and incarceration in reducing the demand for illegal drugs. "Providing
treatment to all in need could save more than $150 billion over
the next 15 years, at a price tag of just $21 billion in treatment
costs. Funding treatment for persons addicted to drugs is prudent
fiscal policy: every dollar invested in drug treatment generates
$7 in savings of future costs" (Amaro, 1999; California Department
of Alcohol and Drug Programs, 1994; Rydell and Everingham, 1994).
Restrictive syringe prescription and
paraphernalia laws and regulations. In the interest of limiting
drug use, a number of lawsrestrict the purchase and possession of
equipment used to prepare and administer injection drugs. They fall
into several major categories:
Drug paraphernalia laws in
many states make it illegal to distribute or possess any equipment
intended for injecting, smoking, or otherwise consuming illegal
substances (AED, 1997; Case et al., 1998; Gostin, 1998; Koester,
1994). Currently, 44 states have such laws.
Prescription laws require that
a person wishing to buy syringes have a valid medical prescription
for syringes. In addition, some states require that syringe purchasers
show identification and provide their name, address, and other
identifying information (AED, 1997). Until recently, eight states
had prescription statutes (Gostin, 1998). In 2000, New York, Rhode
Island, and New Hampshire partially or completely removed their
prescription laws. In the states in which these laws are in effect,
physicians are allowed to prescribe hypodermic equipment only
for medical purposes (AED, 1997).
Pharmacy regulations or practice guidelines
in 23 jurisdictions restrain pharmacists from selling sterile
syringes or impose additional requirements on customers for their
purchases. In addition, some drug stores have corporate or individual
policies that limit over-the-counter sales of syringes (Jones
and Taussig, 1999).
Other related laws and restrictions include the
Mail Order Drug Paraphernalia Act, which permits federal enforcement
against individuals who knowingly sell or distribute syringes to IDUs,
and a Congressional prohibition against federal funding for syringe
exchange programs (SEPs) (Gostin, 1998).
A fragmented and polarized
atmosphere. Current public policies and restrictive laws and
regulations are an important factor constraining efforts to develop
comprehensive and effective interventions for IDUs. Another critical
factor is the profound differences in training, experience, attitude,
and approach among the various professionals who provide services to
IDUs (for example, those working in infectious disease prevention, substance
abuse treatment, mental health, criminal justice, and primary care).
These philosophical and practical gulfs foster an atmosphere of polarization,
work against a coordinated, collaborative approach, and hinder system-wide
efforts to reach IDUs. The gulfs emerge from lack of knowledge about
issues outside of one's own expertise, specific training and education
perspectives, attitudes held toward users, personal experience with
addiction and recovery, and experience working with IDUs.
One example of these differences is the debate
over the relative merits of various substance abuse treatment approaches.
Recovery from addiction is a day-by-day, minute-by-minute, sometimes
precarious balancing act in which the user makes repeated, sequential
decisions not to use. Relapse can be common. Traditional substance
abuse treatment models have focused exclusively on abstinence as the
only acceptable short- and long-term out-come. A person or program
that appears to tolerate any use of drugs is seen as enabling the
user to continue his or her addiction. Treatment approaches that focus
on abstinence from alcohol and drug use include detoxification programs,
inpatient and outpatient programs, and peer-based residential treatment
settings (called therapeutic communities). These approaches are usually
complemented by self-help or "12-Step" programs, such as Alcoholics
Anonymous, Narcotics Anonymous, or Cocaine Anonymous (AED, 1997).
All have the ultimate goal of helping an individual achieve and maintain
a drug-free recovery (to become "clean and sober").
Another approach, methadone maintenance treatment,
has been used for more than 30 years to treat tens of thousands of
individuals addicted to opiates. Consistent participation in methadone
maintenance programs over time diminishes and often eliminates use
of other opiates, with consequent benefits of reduced transmission
of HIV and other blood-borne infections and reduced criminal activity
(NIH, 1997). The effectiveness of this approach is dependent on a
number of issues, including adequate dosage, the length and continuity
of treatment, and the presence of associated psychosocial support
services. Though considerable research supports the effectiveness
of methadone maintenance treatment and it is a legally sanctioned
treatment in most states, its use is very highly regulated by federal
and state agencies, it is still controversial, and less than 20 percent
of opiatedependent individuals have access to it (NIH, 1997).
Another perspective on working with IDUs, called
risk reduction or harm reduction, sees the fundamental problem as
the adverse consequences of continued drug use (Des Jarlais et al.,
1993). This approach is based on a recognition that many IDUs and
other drug users are initially unwilling or unable to stop drug use
and that many things can be done to help protect them, their families,
and society from the harmful consequences of the drug use until they
are able to stop using. Because HIV, hepatitis B, and hepatitis C
infections are transmitted through shared injection equipment, it
is possible for active users to reduce the risk of or prevent infection
(Des Jarlais et al., 1993). Primary HIV-related risk reduction approaches
include a range of interventions, such as substance abuse treatment
to reduce or stop drug use; referrals to HIV-antibody testing and
medical care services; referrals to social support services; education
about ways for IDUs to increase control over when, how often, where,
and with whom they inject; and efforts to encourage active users to
switch to non-injection forms of drug use. For those IDUs who are
unable or unwilling to stop injecting, risk reduction interventions
also focus specifically on injection practices-providing access to
sterile syringes through exchange programs or over-the-counter sales
from pharmacies; emphasizing the need to never share syringes, water,
or drug preparation equipment; emphasizing bleach disinfection for
IDUs who do not have sterile syringes; and providing alcohol swabs
to clean injection sites to help prevent abscesses and other infections.
A recent analysis of the laws in the 50 states, the District of Columbia,
and Puerto Rico found that physicians in nearly all of these jurisdictions
may legally p rescribe sterile syringe equipment to prevent disease
transmission and that pharmacists in most states have a clear or reasonable
legal basis for filling the prescription. While physician prescription
will likely not result in widespread access to sterile syringes, it
may have an important beneficial impact among individual IDUs who
cannot or will not stop injecting (Burris et al., 2000).
All of these approaches have strong advocates
as well as fierce opponents. Defenders of abstinence-only interventions
argue that tolerating any drug use is unacceptable because it allows
users to continue their self-destructive behavior and prevents them
from achieving a "drug-free" status. Specifically, they express concerns
that promoting syringe exchange programs and safer injection practices
serve to encourage continued drug use, that methadone maintenance
programs merely substitute one addicting drug for another, and that
support for risk reduction approaches is an opening wedge for the
eventual legalization of drugs. Many advocates of abstinence-based
sub-stance abuse treatment are former drug users for whom this approach
was essential to recovery. Their experience is the foundation of their
conviction that abstinence is the only valid strategy for helping
IDUs to stop using drugs.
Defenders of methadone maintenance treatment
cite its effectiveness in reducing dependence on illegal drugs and
in helping users become productive members of society.
Defenders of risk reduction cite as compelling
reasons for pursuing their approach the limited number of substance
abuse treatment slots available, the fact that many users are unable
or unwilling to permanently and completely stop their drug use, the
importance of injection drug use in the HIV and hepatitis epidemics,
and the importance of injection drug use in other health problems
such as abscesses and endocarditis. Another strength, they say, is
risk reduction's underlying principle of beginning any efforts with
users at the place where they are, which then allows providers to
help them move to a new and better place where risk is reduced.
A 1998 U.S. House of Representatives debate on
legislation to prohibit federal funding for syringe exchange programs
highlights the polemics involved in the debate over approaches to
working with IDUs and illustrates some of the attitudinal and philosophical
perspectives described earlier in this chapter (U.S. House of Representatives,
1998):
"Mr. Goodlatte. Not only are needle
exchange programs inconsistent with federal law, the results of
community-based needle exchange program have been disastrous. Needle
exchange programs have resulted in communities with higher crime,
communities that are littered with used drug paraphernalia, and
communities that are magnets for drug addicts and the high-risk
behavior that accompany them. I urge my colleagues to support this
legislation, oppose the use of needle exchange programs, and make
sure that we continue the fight on drugs in a sensible way by cracking
down on drug traffickers and educating people in the country about
the dangers of using illegal drugs.
Ms. Woolsey. Maintaining the ban [on
federal funding for needle exchange programs] will not help save
our children or anyone else. In fact, the ban on needle exchange
actually threatens lives. In 1995, needle exchange programs were
found to reduce the spread of AIDS and not to lead to increased
drug use.
This bill would ignore the science by denying
public health experts a tool in the fight against AIDS, a tool that
has been proven to slow the spread of this deadly disease. And those
of my colleagues who are worried that free needles increase drug
usage have to stop and think. We have to be reassured that knowing
that the positive step by a drug user to choose clean needles is
actually a first step in a very positive way towards their recovery.
Just think about it. This is an opportunity to begin the healing
process."
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