Needle Exchange

The Central Asian Republic of Kyrgyzstan sits along a drug trafficking route, and has an estimated 80,000-100,000 drug users, more than half of whom inject drugs. Unlike some countries in the region, Kyrgyzstan has embraced harm reduction strategies such as needle exchange and methadone maintenance. Even prisoners in Kyrgyzstan have access to these programs. By going this route, they have been able to curb the country's HIV epidemic. A new video from the Hungarian Civil Liberties Union -- in Russian, with English subtitles -- tells the story. Check it out:

	popular needle exchange logo

BIG NEWS: The infamous ban on use of federal AIDS grant funds to support needle exchange programs will soon be history, if the Subcommittee on Labor, Health and Human Services of the House Committee on Appropriations has its way. Led by Rep. David Obey (D-WI), the subcommittee left the language which has imposed the ban these many years out of the new bill. According to Obey's office:

This bill deletes the prohibition on the use of funds for needle exchange programs. Scientific studies have documented that needle exchange programs, when implemented as part of a comprehensive prevention strategy, are an effective public health intervention for reducing AIDS/AIV infections and do not promote drug use. The judgment we make is that it is time to lift this ban and let State and local jurisdictions determine if they want to pursue this approach.

The vote followed a protest at the US Capitol in which 26 AIDS activists chained themselves together in the Capitol Rotunda earlier in the day. President Obama pledged during his primary campaign to eliminate the ban. Legislation allows the president to do so if certain scientific findings are made, specifically that needle exchange programs do not increase community drug use levels, and do reduce the spread of HIV. These findings were made long ago, and the Clinton administration acknowledged them, but declined to eliminate the ban. Earlier this year the Obama administration punted the issue to Congress by including the ban in its budget proposal while verbally expressing support for needle exchange. Whether Obey's subcommittee took action because of administration support, or despite a lack of administration support, I don't know. Perhaps a greater savant than I will enlighten us. Now the bill heads to the full committee, after which it will go to the floor of the House of Representatives. Drug warriors may try to add the ban back at either stage. Victory also depends on what happens on the Senate side. Assuming the House and Senate do not approve exactly identical Labor and HHS budgets, it will go to a conference committee that includes both Reps and Senators. Elimination of the ban will neither increase nor decrease the amount of money the federal government spends on AIDS prevention, at least not directly. What it will do is allow state governments who receive federal AIDS grants to choose whether or not to spend some of that money on needle exchange. Those states which are in the habit of using scientific evidence to guide their policies will support needle exchange.

Can someone please explain to me what this means?

White House spokesman Ben LaBolt said the administration isn't yet ready to lift the ban - but Obama still supports needle exchange.

"We have not removed the ban in our budget proposal because we want to work with Congress and the American public to build support for this change," he said. "We are committed to doing this as part of a National HIV/AIDS strategy and are confident that we can build support for these scientifically-based programs." [Huffington Post]

So they're going to build support for needle exchange by telling Congress to continue the federal needle exchange ban? How's that supposed to work? And what's up with this:

The White House website no longer features the president's support of the program, however. See the before and after here.

"It's hard to imagine how removing mention of support for a proven lifesaving program from the White House website is part of a grand strategy to 'build support' for syringe exchange," said Tom Angell, a spokesman for the group Law Enforcement Against Prohibition.

Exactly. If Obama wants to promote needle exchange, he should consider not making it illegal for the government to support needle exchange.

The administration is arguing that supporting the ban at this time is necessary to avoid politicizing the budget process, yet opposing needle exchange is just as political as supporting it. You're taking a political stance either way, obviously. The only difference is that Obama is choosing the wrong side and lending legitimacy to crazy idiots who oppose needle exchange.

On the campaign trail, Obama made clear statements in support of needle exchange as a proven means of reducing transmission of AIDS and other diseases among drug users. Once in office, the President reiterated his commitment to ending the federal blockade against these life-saving programs:

The President also supports lifting the federal ban on needle exchange, which could dramatically reduce rates of infection among drug users.

That language appeared on the President's own website, until it was ominously removed a couple weeks ago. Today, the President's Budget (pg. 795) formally announces Obama's decision to continue the federal needle exchange ban:

"Notwithstanding any other provision of this Act, no funds appropriated in this Act shall be used to carry out any program of distributing sterile needles or syringes for the hypodermic injection of any illegal drug."

With that one sentence, Obama blatantly violates an important campaign promise and chooses politics over science with thousands of lives on the line. It's just disgraceful, and if he thought no one would notice, he was wrong.  

This isn't a matter of Obama not understanding the issue. He's already said that needle exchange would "dramatically reduce rates of infection among drug users," so it should be unnecessary to further debate that point or dig any deeper into the towering mountain of evidence surrounding the efficacy of needle exchange programs.

Apparently, the President simply isn't willing to spend political capital saving the lives of drug users. If this is all about politics, and I believe it is, then the question that must be asked is why the hell the President thinks needle exchange is a political liability. When Jim Ramstad's name was circulating as potential nominee for drug czar, his opposition to needle exchange was a big factor in sinking his candidacy. Moreover, the newly appointed drug czar, Gil Kerlikowske, is known for supporting needle exchange during his tenure as Seattle Police Chief. Maybe Obama should talk to his new drug czar before resurrecting the Bush Administration's failed and fatal policy of opposing harm reduction.

There is simply no serious or credible opposition to implementing proven life-saving programs in the fight against AIDS. Obama's previous statements in support of such programs provoked zero backlash on the campaign trail and obviously didn’t prevent him from becoming President. All he had to do was leave this stupid language out of the budget -- like he said he would -- and no one would even have noticed.

Instead, we're forced to come to terms with the reality that our President is willing to sacrifice human lives based on an ill-conceived perception of political convenience and nothing more.

Please contact the White House to demand that Obama keep his promise to support needle exchange and save lives.

At last, my final day in Vienna attending the United Nations' "Technical Seminar on Drug Addiction Prevention and Treatment: From Research to Practice" conference. (To read my scene-setting preamble from earlier this week, click here. Day 1 is here and day 2 is here.) It's a wind-down day for a conference that never wound up — the day when harm reduction was finally allowed to rear its head — so often unwelcome at any conference dominated, as this one is, by the United States, whose official governmental representatives are highly and categorically opposed to harm reduction. Harm Reduction appeared in that very earnest fashion whereby presenters say, "Here is the science. We need no more evidence. However, I can tell that you're not listening, so I'm going to tell you again that this all works, folks." It was also the day that I made a diplomatic faux pas (as we say in the language of diplomacy). More about that later. I missed the first couple of presenters as I was grappling with the sudden disappearance of Internet connectivity and was hoping that the coffee would kick in. The Viennese make good coffee although it's more of a utility tool than anything pleasurable, kind of like putting socks on in the morning. As I arrived, Dr. Shanti Ranganathan from TTK Ranganathan Treatment Centre in India had just finished her talk. I gather that she covered home detoxification and a camp for drug injectors (it could be fun to speculate how that camp would work). Speaking to a colleague later in the day, I learned that due to the rural nature of India, the approach to drug treatment there is very different from the way it's done in the northern hemisphere. It's very community oriented, and villages have a say-so in the process. I wish I'd caught more of Ranganathan's presentation, which was more along the lines of what I'd been hoping to get information about. How do you deliver drug services in resource poor countries? A gentleman behind me asked, "Haven't we overspecialized drug addiction treatment and shouldn't it be mainstreamed to take advantage of existing resources?" At last, a cri de coeur from the audience! Drug services including treatment, harm reduction, and diversion programs have all sprouted like varieties of weeds. They're somehow related, but the root system and the genetic coding are different. So how could countries and governments differentiate and choose among them? Or figure out how to construct the best array of services based upon what was on show? They couldn't, to my mind. After all, how could anyone possibly make sense of the patchwork quilt of treatment systems and social services in the north given that they don't necessarily make sense — or work — for drug users in their country of origin to begin with? It's as if we're displaying the leaning tower of Pisa or parading the Venus de Milo as models that they should aspire to, and then wondering why the resource poor world makes buildings that lean and statues that have no arms. One place I would not want to live is Sweden, where a random study of the kids at the youth program being trumpeted revealed that each youth suffered from an average of four mental disorders; the majority of parents had one. It must be good to have sane parents. Nothing like pathologizing the young, is there? The Dutch rolled into town with their admirably well-developed harm reduction knowledge and advocacy models. Dr. Wim van den Brink from the Academic Medical Centre at the University of Amsterdam in the Netherlands ran through the continuum of the stages of a drug user's drug taking career and discussed where, when, and which type of a wide range of interventions can and should occur. He included heroin maintenance in this list. (It is widely accepted that heroin maintenance is the fallback option for users who seek treatment but for whom methadone or buprenorphine has not worked. It's not usually a first line option. Outcomes are comparable to all other maintenance programs.) In van den Brink's view, drug-using patients should be able to talk over what their expectations are with their doctors and then negotiate their options. Fancy that. He was pretty much the first speaker who identified drug users as having a role in their own treatment. And he identified abstinence, maintenance, a safe high, and chaotic use as markers on a scale. That may be the first time in 20 years I've heard a clinician identify pleasure as part of the range of options. The legendary Dr. Franz Trautmann from the Netherlands Institute on Mental Health and Addiction ran through the evidence supporting harm reduction interventions including outreach, drop-in centers, and "drug consumption rooms" — the Dutch term for what we in the United States call safer injection facilities or medically supervised injection centers. (The panel facilitator, Gilberto Gerra, Chief of Health and Human Development Section of UNODC, chimed in to reassure everyone that drug consumption rooms do not violate international conventions). It was kind of a relief to hear Dr. Evgeny Krupitsky, head of a laboratory that conducts research on drug addiction at St. Petersburg State Pavlov Medical University, give a convoluted and amusingly wrong-headed talk about the desperate need for the Russians to make naltrexone the first-line response to drug addiction in Russia. (US rejection of harm reduction has its parallel in Russia's refusal to allow methadone.) Naltrexone is an opioid antagonist, which means you can't get high after you've taken it. The opioid receptors in the brain get too blocked up to let any more opioid in. However, as a form of treatment, it's just not very effective. So the Russians keep adding medications to the basic naltrexone dose, unwittingly creating an out of control medication pharmacopoeia for their patients. Monica Beg of UNODC had the task of informing everyone again that syringe exchange is effective in stopping the spread of HIV. Her PowerPoint showed the global distribution of exchange programs (probably limited to the UN-influenced world, to be fair) and did not cover the United States. "The science is clear. Syringe exchange works. The debate is over." Within UNODC there is no debate on the science but as mentioned in my original preamble, UNODC acts as the secretariat for the Commission on Narcotic Drugs (CND) and so when the member States of CND produce Political Declaration, those member states can completely ignore the science as is the case with the US and Russia. In fact, the HIV Prevention Unit deserve a medal for its work in pushing for support from within UNODC. And that's when I just had to speak. I pointed out that despite all of the evidence that needle exchange has been effective in the US (there are 200+ programs, with some of the larger ones federally funded; needle exchange has reversed the HIV epidemic in NYC, once the global epicenter of injection drug use and HIV; scientists at NIDA, NIH, CDC, NIAID are all on record as saying syringe exchange works), an article still appeared on CNN.com just this last July with David Murray, a supposed scientist for the Office of National Drug Control Policy, saying needle-exchange programs "do not succeed in its effort to control the contagion of disease." My point being that while the scientific debate may be over, the political debate continues in the US — not least in the way the US government has been disrupting the process leading up to this March's United Nations General Assembly Special Session on drugs. (While representatives to the UNGASS, plus numerous non-governmental agencies around the world have been calling for harm reduction to be recognized as an important part of demand reduction, US representatives have continued their war against it.) The chair responded to me by saying that there couldn't be a response to my point as it was a political question and inappropriate for this forum. And that science would win out. Stymied at not having a planned end point, I emotionally said that I was glad that this administration was now out. (Apparently it's taken as bad form to name names.) The interaction was filmed by an Iranian television crew that's covering the Iranian involvement in this meeting, which included Azarahksh Mokri of the Iranian National Center for Addiction Studies, who gave a wonderful presentation on how to introduce a methadone program into a country like Iran. He is a brilliant, charismatic speaker who was succint and on point throughout his talk. Christian Kroll of the UNODC HIV Unit, the last speaker before the closing, had that second returned from a UNAIDS Prgramme Coordinating Board meeting and was fired up from saying farewell to Peter Piot, the UNAIDS Executive Director and Under Secretary-General of the United Nations. Kroll ran through the history of the AIDS movement (accidently conflating Gay Men's Health Crisis and ACT-UP) and the importance of civil society input into the UN process. I kept waiting and waiting for the punch line. "Are you asking for more civil society input into UNODC?", I asked. Kroll's response: "Yes I am." Being practically the only representative from "civil society" at the meeting and definitely the only person that spoke, I can see his point. We then sang the Internationale and Mr. Kroll and I caught the subway home together. Allan Clear is executive director of the Harm Reduction Coalition.

The Drug Czar's blog has been very concerned about harm reduction lately. They've taken the counterintuitive position of opposing efforts to save the lives of drug users, which seems like a strange choice. Now I understand why: they think harm reduction is the opposite of what it actually is.

These so-called "harm reduction" strategies are poor public policy because their underlying philosophy involves giving up on those who can successfully recover from drug addiction. [PushingBack.com]

This is wrong for a very simple reason: you cannot recover from addiction if you're dead. Harm reduction programs are not an alternative to treatment, rather they go hand in hand. Harm reduction keeps people healthy and alive, thereby creating opportunities for them to subsequently recover from addiction.

We could do nothing. That would be "giving up." We could ask drug addicts to either quit or die. That would be "giving up." Instead, harm reduction activists have taken to the streets and attacked this problem directly. They've studied the leading causes of death among drug users and created programs to reduce those casualties. That's the opposite of giving up.

Just pretend for a moment that you're cruel and you want drug users to die in large numbers. How would you go about it? Well, you would begin by eliminating regulated distribution so that users are forced to obtain unsafe products from criminals on the street. You would reduce access to clean needles in order to spread AIDS. You would enforce criminal sanctions against users so that they're afraid to seek help. And you would lobby aggressively against anyone who's studied the problem and proposed programs to reduce AIDS and overdoses.

Now I'm not saying the Drug Czar wants to kill people. I'm just saying he presides over a policy that is perfectly tailored to achieve that outcome. And he dares to suggest that the people out there working with addicts and saving lives are the ones who've given up.

Last spring at the National African American Drug Policy Coalition summit here in Washington, the question was asked of Donna Christian-Christensen (Congressional Delegate from Guam, the closest thing the territories have to US Representatives), a physician and chair of the Congressional Black Caucus’ Health Braintrust, what the prospects were for repealing the ban on use of federal AIDS grant funds to support needle exchange. Her answer was, "We're going to give it a good try." I took that to mean "it's not going to happen this time." The issue has made some progress however, at least as it affects us here in the District of Columbia, where a particularly infamous part of the annual appropriations bill prevents DC from spending even its own locally-collected tax funds on needle exchange appears to be on its way to getting repealed, thanks to positive action by a House subcommittee that drafted the new appropriations bill. I know better than to take it as a given that repeal will make it all the way through. But it is looking pretty good, and at the PreventionWorks! anniversary party this evening -- attended by new PW executive director Ken Vail -- AIDS Action lobbyist Bill McColl informed the crowd that it could hit the floor within a few days. Earlier this year we reported that Hillary Clinton was noncommittal about lifting the ban during a videotaped exchange at a private forum with prominent AIDS activists. The exchange was fascinating; after several pointed back-and-forths with Housing Works executive director Charles King, Sen. Clinton directly acknowledged that it was political concerns only that accounted for her position (though the kinds of concerns that can't necessarily be dismissed offhand). Sen. Obama, by contrast, had stated his support for lifting the ban. This week Clinton took the plunge and made strong pro-needle exchange promises in a campaign statement on AIDS funding. What would ultimately happen with this in a Clinton presidency, or any Democratic presidency, is probably hard to predict -- politics is still politics. But the fact that the Democratic candidates are lining up to support the issue has McColl feeling cautiously optimistic that the Democratic Congress won't drop the ball on the DC language at least. And it's encouraging for all of us about the long-term. The federal needle exchange restriction came to a boil during the Clinton administration, when the findings needed to lift the ban -- needle exchange doesn't increase drug use, but does reduce the spread of HIV -- were made by the administration, but not acted on. Some advocates believe that if Donna Shalala had been on a certain Air Force One flight, instead of Barry McCaffrey, that it would have happened. It took a change in Congress to even get the issue back onto the radar screen; more may be needed to actually get the law changed. Still, let's keep our fingers crossed for the DC ban to be lifted, maybe even by the end of the year. Assuming that happens: Let's Do Heroin! (That was sarcasm, in case anyone didn't realize.)

After hilariously claiming that she needed to see more evidence of its effectiveness, democratic presidential hopeful Hillary Clinton seems to have found the answers she was looking for.* Her campaign has announced support for harm reduction, including needle exchange:

She also supports using U.S. funding to support proven harm reduction efforts - including needle exchange - to help hard-to-reach populations, and will continue to support new evidence-based prevention methods as additional scientific research helps us understand how to best address this epidemic. [HillaryClinton.com]

We've heard similar pledges from Obama and Edwards, and it's likely safe to assume other democratic candidates will toe the line on this one (possibly excluding drug war hall-of-famer Joe Biden).

It's nice to see Washington politicians getting it right on needle exchange. Of course, this is really about whether or not we want huge numbers of people to die from AIDS in the name of drug war politics. We needn't fall to our knees in gratitude when someone understands such an obvious humanitarian concern. Rather, we should be demanding answers from any candidate who hasn’t yet spoken out against the federal government's catastrophic ban on life-saving intervention programs.

*By "hilarious," I meant that the mountain of evidence showing that needle exchange saves lives is so huge that I couldn't imagine Hillary Clinton actually had time to read it.

As part his new proposed plan to combat AIDS, democratic presidential hopeful John Edwards is speaking out in favor of needle exchange:

"And I think we also ought to promote programs that prevent harm and specifically needle exchange, which I support. We ought to get rid of the federal ban on needle exchange." [NPR]

Drug war absolutists have long opposed needle exchange, despite overwhelming evidence that it prevents AIDS and saves lives. It is just amazing that the people in charge of protecting Americans from drugs support policies that spread AIDS and kill people.

Edwards deserves credit for calling out one of our nation's most ill-conceived drug policies. It's a no-brainer for sure, but at least he got it right.

And in the process, John, you may have stumbled upon a nifty device for drafting a superb drug policy platform for your campaign: simply check what the federal policy is on any drug issue and advocate the opposite. You will be correct every time.

Update: At the risk of further emboldening the hysterical Obama fans who freaked out over my last post, and irrationally implied that he's good on drug policy, it's only fair to add that Barack Obama has also spoken in favor of needle exchange. Hillary Clinton, who's otherwise sounded good on drug policy (for a front-runner, anyway) wants to see more proof that it works, which, at this point, is like demanding proof that the sun will rise tomorrow.

Ben Smith's blog on The Politico web site today discussed an important exchange of comments between Hillary Clinton and Charles King, the executive director of Housing Works, at a private appearance earlier this month, as well as comments by Barack Obama at a different meeting in the same series. King had asked Clinton if she would lift the ban on use of federal AIDS funds to support needle exchange programs, an issue that previously came to a boil in 1998 during her husband's second term. (Some activists believe that Bill Clinton would have lifted the ban if Donna Shalala rather than Barry McCaffrey had boarded a certain Air Force One flight.) According to Smith:

Clinton responded to King's question, after some prodding, by saying, "I want to look at the evidence on it" to see whether needle exchange would prevent the spread of HIV without increasing drug abuse. Shalala, King responded, had "certified" the safety and effectiveness of the programs. "And then she refused to order it, as you remember," Clinton said. King replied that that had been her husband's decision. "Well, because we knew we couldn't maintain it politically," Clinton said, and went on to discuss the trade-offs in that dispute with Congress. "I wish life and politics were easier," she said. King then referred back to Clinton's opening remarks. "You made a great comment earlier about how our next president needs to have some spine," he said. "We’ll have as much spine as we possibly can, under the circumstances," Clinton responded.

Obama, by contrast, had responded that he supports lifting the ban. Click here to read Smith's full post, which includes the video footage. A little background: Housing Works has for years been a stalwart in the harm reduction movement. (Harm reduction is the idea that people who use drugs should be helped in reducing the harm they do, to themselves or others, whether they are about to stop using drugs or not.) The organization is very well known in New York City, which successfully beat back a late 1990s attempt by then Mayor Rudy Giuliani to bankrupt them. In 2000, activists from Housing Works stormed the Ashcroft confirmation hearings to denounce his record on needle exchange. King's co-founder and co-executive director of Housing Works for years, the late Keith Cylar, was a member of DRCNet's board of directors (and a friend).