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U.S. Department of Health and Human Services

Archival Content: 1999-2005

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:Legal and policy

  • 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.

    During 1999, a number of prominent voices spoke out on these issues and in favor of major increases in the funding and attention devoted to substance abuse treatment:

    • 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:

      Legal and Public Policy

    • 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").Differences among providers of services to IDUs

    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.Traditional substance abuse treatment

    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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