THE PUBLIC HEALTH BENEFITS AND SOCIAL EFFECTS OF NEEDLE EXCHANGE PROGRAMS ARE AT BEST UNCERTAIN, AND AT WORST ARE DEVASTATING TO BOTH ADDICTS AND THEIR COMMUNITIES

A. NEEDLE EXCHANGE PROGRAMS ARE NOT SCIENTIFICALLY

PROVEN TO REDUCE THE EPIDEMIC OF HIV OR HCV INFECTION

AMONG INJECTION DRUG USERS

B. NEEDLE EXCHANGE PROGRAMS DO NOT REDUCE SUBSTANCE

ABUSE, BUT IN FACT FACILITATE AND ENCOURAGE SUBSTANCE

ABUSE

C. NEEDLE EXCHANGE PROGRAMS ARE DESTRUCTIVE TO THE

COMMUNITIES IN WHICH THEY ARE USED

D. NEEDLE EXCHANGE SENDS A BAD MESSAGE TO SCHOOL CHILDREN.

PROVISION OF NEEDLES TO ADDICTS WILL ENCOURAGE DRUG USE.

THE MESSAGE IS INCONSISTENT WITH THE GOALS OF OUR

NATIONAL YOUTH-ORIENTED ANTI-DRUG CAMPAIGN.

A. NEEDLE EXCHANGE PROGRAMS ARE NOT SCIENTIFICALLY PROVEN TO REDUCE THE EPIDEMIC OF HIV OR HCV INFECTION AMONG INJECTION DRUG USERS

(i) The New Haven Study

NEP activists frequently cite the results of a New Haven, Conn., study, published in the American Journal of Medicine, which reported a one-third reduction of HIV among NEP participants. However, the New Haven researchers tested needles from anonymous users, rather than the addicts themselves, for HIV. They never measured “seroconversion rates,” which determine the portion of participants who become HIV positive during the study. Also, sixty percent of the New Haven study participants dropped out; those who remained were presumably more motivated to protect themselves, while the dropouts likely continued their high risk behavior.1

Essentially, the New Haven study merely reported a one-third decrease in HIV-infected needles themselves, which, considering the fact that the NEP flooded the sampling pool with a huge number of new needles, is hardly surprising. Even Peter Lurie, a University of Michigan researcher and avid NEP advocate, admits that “the validity of testing syringes is limited.”2

Furthermore, the New Haven study was based on a mathematical model of anonymous needles using six independent variables to predict the rate of infection. The unreliability of any of the variables invalidates the result. The New Haven study also assumed that any needle returned by a participant other than the one to whom it had been given had been shared, and that any needle returned by the original recipient had not been shared. Both assumptions are suspect.3

Also, the role of HIV transmission through sexual activity is downplayed. Prostitution often finances a drug habit. Non-needle using crack addicts have high incidence of HIV. Recent studies reveal that the greatest HIV threat among heterosexuals is from sexual conduct, not from dirty needles.4
Less than one-third of the New Haven subjects practiced safe sex. In the New Haven study, sampling
error alone could account for the 30 percent decline.5

(ii) The HHS / NAS Study

In 1992, Congress directed the U.S. Department of Health and Human Services (HHS) to study NEPs. HHS in turn commissioned the National Academy of Sciences (NAS), an independent, congressionally chartered, non-government research center, to conduct the study. According to the Congressional directive, if the NAS could show that NEPs worked and did not increase drug use, the Surgeon General could lift the ban on federal funding. The study was completed in 1995, and it concluded that well run NEPs could be effective in preventing the spread of HIV, and do not increase the use of illegal drugs. The NAS panel further recommended lifting the ban on federal funding for NEPs and legalization of injection paraphernalia.

 

Now, seven years after the NAS study, Congress has yet to lift the NEP funding ban, clearly indicating that Congress maintains serious doubts as to the validity of the NAS/HHS conclusions regarding NEPs. Of note is that study chairman Dr. Lincoln E. Moses cites the dubious New Haven study as a basis for the NAS findings.6

The NAS panel admitted that its conclusions were not based on reviews of well-designed studies, and the authors admitted that no such studies exist. Incredibly, the panel reported that “[t]he limitations of individual studies do not necessarily preclude us from being able to reach scientifically valid conclusions.”7

Two of the physicians on the NAS panel, Herbert D. Kleber, M.D. and Lawrence S. Brown, M.D., say the news media exaggerated the NAS’s findings. “NEPs are not the panacea their supporters hope for…We personally believe that the spread of HIV is better combated by the expansion and improvement of drug abuse treatment rather than NEPs, and any government funds should be used instead for that purpose.”8

Dr. Kleber, executive vice president for medical research at Columbia University, added: “The existing data is flawed. NEPs may, in theory, be effective, but the data doesn’t prove that they are.”9

This questionable NAS study represents the cornerstone research data used by the notoriously-politicized U.S. Department of Health and Human Services. The pro-NEP advocacy of HHS, and its supporting data, has yet to convince Congress that NEPs are scientifically proven to reduce HIV infection while not increasing drug usage.

(iii) The CDC Study

The Centers for Disease Control (CDC) conducted a study whose chief architect, Dr. Peter Lurie, recommended NEPs. The CDC report calls for federal funds for NEPs and the repeal of drug paraphernalia laws.

However, although the CDC study endorses NEPs, Dr. Lurie, the study’s author, acknowledges numerous problems: None of the studies were randomized, and self-reported behavior was often the basis for outcomes. Poor follow up and rough measurement of risk behavior also present problems, and he notes that syringe studies have limited validity. The report concludes: “Studies of needle exchange programs on HIV infection rates do not, and in part due to the need for large sample sizes and the multiple impediments to randomization, probably cannot provide clear evidence that needle exchange programs decrease HIV infection rates.”10 randomization, probably cannot provide clear evidence that needle exchange programs decrease HIV infection rates.”11

 

(iv) The Montreal Study

A 1995 Montreal study, published in the American Journal of epidemiology, showed that IDUs who used the NEP were more than twice as likely to become infected with HIV as IDUs who did not use the NEP. Thirty three percent of NEP users and 13 percent of nonuser became infected. There was an HIV seroconversion rate of 7.9 per 100 person years among NEP participants, and a rate of 3.1 per 100 person years among non-participants.12

A high percentage of both groups shared intravenous equipment in the last six months: 78 percent of NEP users and 72 percent of non-NEP users. Risk factors identified as predictors of HIV infection included previous imprisonment, needle sharing and attending an exchange in the last six months. The study authors stated: “We caution against trying to prove directly the causal relation between NEP use and reduction in HIV incidence. Evaluating the effect of NEPs per se without accounting for other interventions and changes over time in the dynamics of the epidemic may prove to be a perilous exercise.” The study concluded: “Observational epidemiological studies…are yet to provide unequivocal evidence of benefit for NEPs.”13

(v) The Vancouver Study

Vancouver has the largest NEP in North America, and was praised in the 1993 CDC report. It is financed by public funds, and by 1996 was distributing over 2 million needles per year. A 1997 evaluation of the needle exchange program in Vancouver showed that since the program began in 1988, AIDS prevalence in intravenous users rose from approximately 2% to 27%. This occurred despite the fact that 92% of the intravenous addicts in that jurisdiction participated in the needle exchange program.14

The Vancouver study also found that 40% of the HIV-positive addicts who participated in the program had lent a used syringe in the previous six months, and that 60% of HIV-negative addicts had borrowed a used syringe in the previous six months. Despite the enormous number of clean needles provided free of charge, active needle sharing continued at an alarming rate. After only eight months, 18.6 percent of those initially HIV negative became HIV positive.15

The Vancouver study corroborates a previous Chicago study which also demonstrated that its NEP did not reduce needle-sharing and other risky injecting behavior among participants. The Chicago study found that 39% of program participants shared syringes, compared to 38% of non-participants; 39% of program participants, and 38% of non-participants “handed off” dirty needles; and 68% of program participants displayed injecting risks vs. 66% of non-participants.16

The Vancouver report noted that “it is particularly striking that 23 of the 24 seroconverters reported NEP as their most frequent source of sterile syringes, and only five reported having any difficulty accessing sterile syringes.”17

The authors continue: “Our data are particularly disturbing in light of two facts: first, Vancouver has the highest volume NEP in North America; second, HIV prevalence among this city’s IDU population was relatively low until recent years. The fact that sharing of injection equipment is normative, and HIV prevalence and incidence are high in a community where there is an established and remarkably active NEP is alarming.”18

What should be obvious from all of the studies above is that there is no conclusive scientific evidence that NEP’s arrest HIV infection. Indeed, there is evidence that NEP’s breed HIV infection.

Some claim that the federal government supports NEPs. While the previous administration’s Department of Health and Human Services actively favored NEPs, those who were actually in charge of our national drug policy do not. General Barry McCaffrey, then director of the Office of National Drug Control Policy (ONDCP), when addressing the issue of NEPS stated “we have a responsibility to protect our children from ever falling victim to the false allure of drugs. We do this, first and foremost, by making sure that we send them one clear, straightforward message about drugs: They are wrong and they can kill you.” McCaffrey’s strong views influenced President Clinton not to approve federal aid money for NEPs.19

A further elaboration of the ONDCP’s policy was provided by James R. McDonough, Director of Strategic Planning for ONDCP, who wrote:

The science is uncertain. Supporters of needle exchange frequently gloss over gaping holes in the data — holes which leave significant doubt regarding whether needle exchanges exacerbate drug use and whether they uniformly lead to decreases in HIV transmission. It would be imprudent to take a key policy step on the basis of yet uncertain and insufficient evidence.

The public health risks may outweigh potential benefits. Each day, over 8,000 young people will try an illegal drug for the first time. Heroin use rates are up among youth. While perhaps eight persons contract HIV directly or indirectly from dirty needles, 352 start using heroin each day, and more than 4,000 die each year from heroin/morphine-related causes (the number one drug-related cause of death).Even assuming that NEWS can further accelerate the already declining rate of HIV transmission, the risk that such programs might encourage a higher rate of heroin use clearly outweighs any potential benefit.

Treatment should be our priority. Treatment has a documented record of reducing drug use as well as HIV transmission. Our fundamental obligation is to provide treatment for those addicted to drugs. NEPS should not be funded at the expense of treatment.

Supporting NEPS will send the wrong message to our children. Government provision of needles to addicts may encourage drug use. The message sent by such government action would be inconsistent with the goals of our national youth-oriented anti-drug campaign.

NEPS do nothing to ameliorate the impact of drug use on disadvantaged neighborhoods. NEPS are normally located in impoverished neighborhoods. These programs attract addicts from surrounding areas and concentrate the negative consequences of drug use, including of criminal activity.20

(vi) Among IV drug users, HIV is transmitted primarily through high-risk sexual contact

Another reason why NEPs may not retard the spread of HIV is that HIV is transmitted primarily through high-risk sexual contact, even among IV drug users. Contrary to prior assumptions, recent studies on the efficacy of NEPs have discovered that it is not needle exchange, but instead, high-risk sexual behavior which is the main factor in HIV infection for men and women who inject drugs, and for NEP participants. A recently released 10-year study has found that the biggest predictor of HIV infection for both male and female injecting drug users (IDUs) is high-risk sexual behavior and not sharing needles. High-risk homosexual activity was the most significant factor in HIV transmission for men and high-risk heterosexual activity the most significant for women. The study noted that in the past the assumption was that IDUs who were HIV positive had been infected with the virus through needle sharing.21

The researchers collected data every 6 months from 1,800 IDUs in Baltimore from 1988 to 1998. Study participants were at least 18 years of age when they entered the study, had a history of injection drug use within the previous 10 years, and did not have HIV infection or AIDS. More than 90 percent of them said they had injected drugs in the 6 months prior to enrolling in the study. In their interviews, the participants reported their recent drug use and sexual behavior and submitted blood samples to determine if they had become HIV POSITIVE since their last visit. The study showed that sexual behaviors, which were thought to be less important among IDUs, are the major risk for HIV seroconversion for both men and women.22

If the above conclusions are correct, the very presumption of NEP efficacy becomes suspect. Indeed, the use of needle exchange programs to address a problem which is caused primarily by high-risk sexual behavior would seem to be highly misguided.

Another reason that Needle Exchange Programs do not effectively address the issue of “saving lives” is that HIV (regardless of how it is contracted) is not the primary cause of death for IVUs. A study conducted at the University of Pennsylvania followed 415 IV drug users in Philadelphia over four years. Twenty eight died during the study. Only five died from causes associated with HIV. Most died of overdose, homicide, suicide, heart or liver disease, or kidney failure.23

Clean needles, even if they in fact prevent HIV, will do nothing to protect the addict from numerous more imminent fatal consequences of his addiction. It is both misleading and unethical to give addicts the idea that they can live safely as IV drug abusers. Only treatment and recovery will save the addict. The myth of “safe IV drug use” is a lie which is perpetuated by NEPs, and it is a lie which will tend to kill the addict, although his corpse may be free of HIV, for whatever consolation that will provide to the NEP proponent.

B. NEEDLE EXCHANGE PROGRAMS DO NOT REDUCE SUBSTANCE ABUSE, BUT IN FACT FACILITATE AND ENCOURAGE SUBSTANCE ABUSE.

The rise of NEPs, with their inherent facilitation of drug use (coupled with the provision of needles in large quantities), may also explain the rapid rise in binge cocaine injection which may be injected up to 40 times a day. Some NEPs encourage cocaine and crack injection by providing “safe crack kits” with instructions on how to inject crack intravenously. Crack cocaine can be, and generally had been, ingested through smoking. But the easy and plentiful availability of needles facilitates crack injection, creating a new segment of IV drug users, subject to health dangers they would otherwise have been spared exposure to. In some NEPS, needles are provided in huge batches of 1000, and although there is supposed to be a one-for-one exchange, the reality is that more needles are put out on the street than are taken in.24

NEPs also facilitate drug use through lax law enforcement policies. Police are instructed not to harass addicts in areas surrounding NEPs. Addicts are exempted from arrest because they are given an anonymous identification code number. Since police in these areas must ignore drug use, and obvious and formidable disincentive to drug use disappears. As the presence of law enforcement declines in these areas, the supply of drugs rises, with increased purity and lower prices, attracting new and younger consumers.25

Many drug prevention experts have warned that the proliferation of NEPS would result in a rise in heroin use, and indeed, this has come to pass. (However, the increase in drug use was ignored by the federally-funded studies which recommended federally funding NEPS). The National Center on Addiction and Substance Abuse at Columbia University reported August 14, 1997 that heroin use by American teens doubled from 1991 to 1996. In the past decade, experts estimate that the number of US heroin addicts has risen from 550,000 to 700,000. 26

In 1994, a San Francisco study regarding a local NEP falsely concluded that there was no increase in community heroin use because there was no increase in young users frequenting the NEP. The actual rate of heroin use in the community was not measured, and the lead author, needle provider John Watters, was found dead of an IV heroin overdose in November 1995. According to the Public Statistics Institute, hospital admissions for heroin in San Francisco increased 66% from 1986 to 1995.27

In Vancouver, site of the largest NEP in North America, heroin use has risen sharply. In 1988 when the NEP started, 18 deaths were attributed to drugs. In 1993, 200 deaths were attributed to drugs. A 1998 report notes that drug deaths were averaging 10 per week. Now Vancouver has the highest heroin death rate in North America, and is referred to as Canada’s “drug and crime capital.”28

The 1997 National Institutes of Health Consensus Panel Report on HIV Prevention praised the NEP in Glasgow, Scotland, but the report failed to note Glasgow’s massive resultant heroin epidemic. Subsequently, as revealed in an article entitled “Rethinking Harm Reduction for Glasgow Addicts,” Glasgow took the lead in the United Kingdom in deaths from heroin overdose, and its incidence of AIDS continues to rise.29

Boston’s NEP opened in July 1993, and the city became a magnet for heroin. Logan Airport has been branded the country’s “heroin port.” Boston soon led the nation in heroin purity (average 81%), and heroin samples of 99.9% are found on Boston streets. Subsequently, Boston developed the cheapest, purest heroin in the world and a serious heroin epidemic among the youth. The Boston NEP was supposed to be a “pilot study,” but there was no evaluation of seroconversion rates in the addicts nor of the rising level of heroin use in the Boston area.30

Similarly, the Baltimore NEP is praised by those who run it, but the massive drug epidemic in the city is overlooked. The National Institute of Health reports that heroin treatment and ER admission rates in Baltimore have increased steadily from 1991 to 1995. At one open-air drug supermarket (open 9 a.m. to 9 p.m.) customers were herded into lines sometimes 20 or 30 people deep. Guarded by persons armed with guns and baseball bats, customers are frisked for weapons, and then allowed to purchase $10 capsules of heroin.31

One thing should be clear from the foregoing: since the implementation of NEPs, heroin use in our country has boomed. It is obvious: a public policy of giving needles to heroin addicts facilitates and encourages heroin use.

C. NEEDLE EXCHANGE PROGRAMS ARE DESTRUCTIVE TO THE COMMUNITIES IN WHICH THEY ARE USED.

Most citizens oppose NEPs in their communities, and are concerned about the prospect of dirty needles being discarded in public places. These fears are not without merit. NEPs distribute millions of needles every year, and there is little or no accountability for needles once they have been distributed. A survey conducted in 1998 revealed that in million needles unaccounted for.32

Carelessly discarded needles create a well-documented public hazard:

* On February 11, 2001, a six-year old from Glade View, Florida, stabbed five children with a discarded syringe. (Kellie Patrick/Scott Davis, “Playground Attack Raises Health Worries,” Sun Sentinal, 2/9/00, p 1B).

* On February 2, 2001, a nine year old from the Bronx stabbed four children with a discarded needle. (Diane Cardwell, “Boy Accused of Needle Attack,” The New York Times, 2/2/01, p. A17.)

* On February 13, 2001, a syringe left at a bus station stuck a four year old boy. (Mike Hast, “Big Fines for Syringe Litterers,” Frankson & Hastings Independent, February 13, 2001,www.mapinc.org/drugnews/v01/n304/ a08.html.)33

Besides the physical hazard created by discarded needles, there is a commonsense perception that NEPs bring an air of decay to the communities that host them. After several years of operation, 343 Massachusetts towns and cities (out of a total of 347) continue to decline the option of approving a local NEP, although of the 10 available slots, only 4 are taken.

In March 1997, accompanied by a New York Times reporter, a member of the Coalition for a Better Community, a New York City group opposed to NEPs, visited the Lower East Side Needle Exchange. She was not asked for identification and was promptly given 40 syringes (without having to produce any to exchange). She was also given alcohol wipes and “cookers” for mixing the drugs, and she was given an exchange ID card that would exempt her from arrest for possession of drug paraphernalia. She was then shown how to inject herself.34

Community opposition to the Lower East Side Needle Exchange arose soon after implementation of the local NEP due to an increase in dirty syringes on neighborhood streets, in school yards and in parks. There was observed to be a dramatic increase in the public display of injecting drugs. NEP users were seen selling their syringes to buy more drugs. Exchange workers themselves were photographed selling needles offsite. Neighbors perceived the Lower East Side NEP as little more than a wholesale distribution center for clean needles and a social club for addicts. Pro-needle activist Donald Grove concurred: “Most needle exchange programs actually provide a valuable service to users beyond sterile
injection equipment. They serve as sites of informal organizing and coming together. A user might be able to do the networking to find good drugs in the half an hour he spends at the street based needle exchange site networking that might otherwise have taken half a day. [Grove, D. The Harm Reduction Coalition, N.Y.C., Harm Reduction Communication, Spring 1996].35

In 1998, a U.S. Government official was sent to Vancouver, site of the largest NEP in North America, to assess the high incidence of HIV among NEP participants, and the skyrocketing death rate due to drug overdose. He reported that the highest rates of property crime in Vancouver were within two blocks of the needle exchange. He also observed, pursuant to a tour with the Vancouver Police, that there was a 24 hour drug market and plain view injection activity in the area immediately adjacent to the needle exchange. Most poignantly, he was told, in a private interview with an elementary school teacher, that the children at area schools are not allowed outside at recess for fear of needles.36

CONCLUSION

There is ample evidence to suggest that very fundamental premises used to justify and support NEPs are seriously flawed.

First, NEP participants routinely continue to share needles, and large percentages of the NEP participants are HIV positive, meaning that NEPs do nothing more than continue the spread of HIV (and HCV). Significantly, no one has been able to explain satisfactorily why enhanced needle availability in and of itself would discourage needle sharing: needle sharing is an intrinsic aspect of IV drug use, and a NEP-issued needle will transmit HIV as well as any other needle.

Second, NEP studies have discovered (inadvertently) that needle sharing is not even the primary cause of HIV infection for IVUs. It is primarily through high-risk sexual behavior that IVUs contract HIV; free needles do nothing to prevent sexually transmitted disease.

Furthermore, HIV (regardless of how it is contracted) is not even the primary cause of death for IVUs. Most die of overdose, homicide, suicide, heart or liver disease, or kidney failure. Clean needles may protect an addict from HIV, but they do nothing to protect him from the more numerous, and more imminent fatal threats of his addiction. Several key NEP proponents have died of heroin overdose; no doubt their needles were very clean.

Third, the science is inconclusive. Although the proponents of NEPs uniformly aver that the scientific debate regarding the efficacy of NEPs is over, in truth, even the reports favoring NEPs are burdened with imprecise methodology, and many of the authors of those reports caution that their results should not be deemed conclusive. Today, there is still no conclusive scientific evidence: (1) that NEPs reduce the spread of HIV and HCV, or (2) that NEPs do not encourage IV drug use. Indeed, the correlation between the rise of NEPs and the explosion of IV drug use, if it is a coincidence, is a remarkable one.

Dispassionate observers will look at the current epidemic of heroin and IV cocaine use as a tragedy which might have been averted, or mitigated, but for the misguided mercies of the NEP concept.

Fourth, while the benefits of NEPs may be in doubt, the costs to the surrounding communities are very real. The overwhelming majority of communities dread the prospect of a local NEP, for self-evident and well-documented reasons.

Notes

1New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, New Jersey Family Policy Council, POB 6011, Parsippany, NJ 07054, 973-263-5258, www.njfpc.org/research-papers/needle.htm 2. Loconte, Joe, Killing Them Softly,” Policy Review, The Heritage Foundation, 214 Massachusetts Ave. NE, Washington, DC 20002, p. 19 (August, 1998) 3. See New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, supra, note 1. 4.Mathias, Robert, high-Risk Sex Is Main Factor in HIV Infection for Men and Women Who Inject Drugs@, NIDA NOTES Staff Writer, NIDA Notes, (National Institute on Drug Abuse, Washington, DC) Volume 17, Number 2 (May 2002) (Source: Strathdee, S.A., et al.

Sex differences in risk factors for HIV seroconversion among injection drug users.@ Archives of Internal Medicine 161:1281-1288, 2001)

1

See New Jersey Family Policy Council, Needle Exchange Programs- Panacea or Peril, supra, note 1.

1 Id.

1See Loconte, Joe, Policy Review, supra, note 2.

1

See New Jersey Family Policy Council, ANeedle Exchange Programs – Panacea or Peril, supra, note 1.

1

See New Jersey Family Policy Council, Needle Exchange Programs- Panacea or Peril, supra, note 1.

4 Id.

4See Loconte, Joe, Policy Review, supra, note 2.

4 See New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, supra, note 1. 4 Sex differences in risk factors for HIV seroconversion among injection drug users.@ Archives of Internal Medicine 161:1281-1288, 2001) 5 See New Jersey Family Policy Council, Needle Exchange Programs- Panacea or Peril, supra, note 1.

6 Id.

7See Loconte, Joe, Policy Review, supra, note 2.

8 See New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, supra, note 1.

9 See Loconte, Joe, Policy Review, supra, note 2.

10See New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, supra, note 1. 11See New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, supra, note 1.

12 Bruneau J, Lamothe F, Franco E, Lachance N, Desy M, Soto J, et al. High rates of HIV infection among injection drug users participating in needle exchange programs in Montreal: results of a cohort study. Am J Epidemiol 1997;146(12):994-1002.

13 Id.

14Strathdee SA, Patrick DM, Currie SL, Cornelisse PG, Rekart ML, Montaner JS, et al. Needle exchange is not enough: lessons from the Vancouver Injecting Drug Use Study. AIDS 1997;11(8):F59-F65. British Columbia Centre for Excellence in HIV/AIDS.

15 Id.

16 National Research Council/ Institute of Medicine, Preventing HIV Transmission: the Role of Sterile Needles and Bleach, National Academy Press, Washington DC, p. 302-304, 1995.

17 See: Strathdee SA,et, al., supra, note 14.

18Id.

19Drug Czar Statement on Administration Decision to Continue Ban on Use of Federal Funds for Needle Exchange Programs,” Press Release, Office of National Drug Control Policy (ONDCP), Washington, D.C., April 24, 1998.

20 James R. McDonough, Director of Strategic Planning, Executive Office of the President, Office of National, Drug Control Policy, Washington, DC. 20503 to Ms. Elizabeth Edwards, Arizonans for a Drug-Free Workplace, P.O. Box 13223, Tucson, AZ 85732; Letter dated April 14, 1998.

21Mathias, Robert, High-risk Sex Is Main Factor in HIV Infection for Men and Women Who Inject Drugs@, NIDA NOTES Staff Writer, NIDA Notes, (National Institute on Drug Abuse, Washington, DC) Volume 17, Number 2 (May 2002) (Source: Strathdee, S.A., et al. Sex differences in risk factors for HIV seroconversion among injection drug users. Archives of Internal Medicine 161:1281-1288, 2001.

22 Id.

23 See Loconte, Joe, Policy Review, supra, note 2.

24Janet D. Lapey, MD, Needle Exchange Programs: 1998 Report, April 1998, Drug Watch, P.O. Box 45218, Omaha, Nebraska 68145-0218

25 Id. 26Id. 27 Id.

28 Id. 29 Id. 30Id. 31Id.

32Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, HHS, Washington, DC 2001;50:384-388.

33Maginnis, Robert L., 2001 Update On The Drug Needle Debate, Insight, Number 235, July 16, 2001, Family Research Council, 801 G. St. NW, Washington, DC 2001.

34See New Jersey Family Policy Council, ANeedle Exchange Programs – Panacea or Peril, supra, note 1.

35D.B. Des Roches, Information, Memorandum for the Director, Through: the Deputy Director, Subject: Vancouver Needle Exchange Trip Report, Executive Office of the President, Office of National Drug Control Policy, Washington, D.C. 20503, April 6, 1998.

 

Source: Testimony of David G. Evans, Esq.

Executive director, Drug-free Schools Coalition before the Health and Human Services

Committee of the New Jersey Assembly, Trenton, NJ in opposition to a-3256

September 20, 2004

“No One Has Died of an Overdose”

This remains the most outrageous claim of the pro-legalization movement. It is not only dangerously misleading, it is a slap in the face to the families who have lost children, spouses and parents. Everyone admits that people are dying in traffic crashes because of stoned drivers, and that some people have died in butane hash oil explosions, but too many people are turning a blind eye to the other deaths caused by what can only be called an overdose. Tachycardia – a racing heart – is a common, well-known side effect of using marijuana. So is increased blood pressure. A growing body of evidence, here and in other countries, is revealing that marijuana has caused previously overlooked deaths through heart attack and stroke. In Colorado last fall, an 11-month-old infant brought to the ER after being exposed to marijuana died from an inflamed heart muscle (myocarditis) caused by the exposure.

Marijuana can also overwhelm the emotional centers of the brain causing paranoia, delusions, and acute psychosis. The National Academy of Sciences (NAS) report released last January states, “There is substantial evidence of a statistical association between cannabis use and the development of schizophrenia or other psychoses, with the highest risk among the most frequent users.” (The Health Effects of Cannabis and Cannabinoids, Chapter Highlights NAS 2017)

Emergency rooms in Colorado reported a 44 percent increase in marijuana-related visits between 2012 and 2014. Many of these were cases of acute psychosis, particularly in young men, who had to be restrained to keep from harming themselves or others.

Other evidence of marijuana overdose

A growing body of evidence indicates that marijuana is not just associated with suicide but can be a causative factor. The NAS report cited above found an “Increased incidence of suicidal ideation and suicide attempts with a higher incidence among heavier users” and an “Increased incidence of suicide completion.” One of the studies they listed found a seven-fold increase in risk for suicide even after controlling for a prior history of mood disorders.

In 2014, a young man in Colorado either jumped or unwittingly tumbled to his death from a fourth-floor balcony during a psychotic outburst. In July this year, a Vermont father clutching his son to his chest jumped out of a fourth-floor window shortly after smoking marijuana. He said it was God who made him jump.

When a drug drives all sense of reality from your brain, it’s an overdose. In marijuana’s case, these overdoses can and do lead to death.

Dean Whitlock is a freelance writer whose book, Finn’s Clock, a historical fantasy will be coming this fall in paperback. www.deanwhitlock.com.Read the full article in Vermont Digger. Also read why Vermont physicians propose caution with legalization.

Source: http://www.poppot.org/2017/10/18/truth-deaths-by-marijuana-overdose/

Washington’s pot is a bit more potent than the national average. And the state’s teens are more likely to smoke marijuana than young people nationwide.

Although we have the same problems with marijuana as we do with liquor abuse, no blockbuster conclusions came from a recent report on Washington’s marijuana universe.

But a couple of somewhat unexpected environmental wrinkles from Washington’s marijuana industry — both legal and illegal — also emerge in the second annual look at the state’s experience since passage of a 2012 initiative allowing recreational pot sales.

Marijuana growers and processors use 1.63 percent of the state’s electricity, which is a lot, according to the report by the Northwest High Intensity Drug Trafficking Area — a combined effort by several federal, state and local government agencies. By way of comparison, all forms of lighting — in homes, commercial buildings and manufacturing — account for just 7 to 11 percent of electrical consumption nationally. Or, as the report puts it, the power is enough for 2 million homes.

The high power consumption stems from the heat lamps and the accompanying air conditioning for indoor marijuana growing operations. “They are exceedingly energy-consumptive,” said Steven Freng, manager for prevention and treatment for the High Intensity Drug Trafficking Area.

The carbon footprint, according to the report, equals that of about 3 million cars.

And illegal pot growers siphoned off 43.2 million gallons of water from streams and aquifers during the 2016 growing season — water that tribes, farmers and cities would otherwise use as carefully as possible, in part to protect salmon.

Sixty percent of Washington’s illegal pot was grown on state-owned land in 2016. That’s because black-market growers tend to worry about gun-toting owners on private lands, according to Freng and Luci McKean, the organization’s deputy director. The black-market operations use the water during a roughly 120-day growing season.

Marijuana purchases have boomed in Washington. Legal marijuana sales were almost $1 billion in fiscal year 2016 and were on track to be about $1.5 billion in fiscal 2017, which ended June 30. As of February, the state had 1,121 licensed producers, 1,106 licensed processors and 470 licensed retailers.

What Washington’s marijuana users are getting is above average in potency. According to the report, nationwide marijuana products average a THC percentage of 13.2 percent, while Washington state’s THC average percentage was 21.6 percent.

Teen use of marijuana has grown slightly. Depending on how the numbers are crunched, marijuana use among Washington’s young adults and teens ranges from 2 to 5 percent above the national average. Five percent of Washingtonians age 18-to-25 use pot daily, slightly above the national average, the report said.

According to a survey cited in the report, 17 percent of high school seniors and 9 percent of high school sophomores have driven within three hours after smoking pot.

Adult use before driving is still a fuzzy picture. A third of Washingtonians arrested for driving under the influence had THC, the active ingredient in marijuana, in their bloodstreams. One study found an increase in dead drivers with THC above the legal limit in their blood from 7.8 percent in 2013 to 12.8 percent in 2014.

“Adults still don’t understand the effects of impairment behind the wheel of a car,” Freng said.

McKean said that one major unknown is marijuana-laced edibles, which authorities believe have become a significant factor in THC-impaired drivers, but has not been studied enough to provide solid numbers.

Another major unknown, McKean and Freng said, is how marijuana consumption contributes to emergency room and hospital cases because the state hospitals have not agreed to release that data to government officials.

Source: http://crosscut.com/2017/10/washingtons-pot-industry-not-environmentally-friendly-marijuana/

Executive Summary

Purpose

Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA) is tracking the impact of marijuana legalization in the state of Colorado. This report will utilize, whenever possible, a comparison of three different eras in Colorado’s legalization history:

· 2006 – 2008: Medical marijuana pre-commercialization era

· 2009 – Present: Medical marijuana commercialization and expansion era

· 2013 – Present: Recreational marijuana era

Rocky Mountain HIDTA will collect and report comparative data in a variety of areas, including but not limited to:

· Impaired driving and fatalities

· Youth marijuana use

· Adult marijuana use

· Emergency room admissions

· Marijuana-related exposure cases

· Diversion of Colorado marijuana

This is the fifth annual report on the impact of legalized marijuana in Colorado. It is divided into ten sections, each providing information on the impact of marijuana legalization. The sections are as follows:

Section 1 – Impaired Driving and Fatalities:

· Marijuana-related traffic deaths when a driver was positive for marijuana more than doubled from 55 deaths in 2013 to 123 deaths in 2016.

· Marijuana-related traffic deaths increased 66 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization.

o During the same time period, all traffic deaths increased 16 percent.

· In 2009, Colorado marijuana-related traffic deaths involving drivers testing positive for marijuana represented 9 percent of all traffic deaths. By 2016, that number has more than doubled to 20 percent.

Section 2 – Youth Marijuana Use:

· Youth past month marijuana use increased 12 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012).

· The latest 2014/2015 results show Colorado youth ranked #1 in the nation for past month marijuana use, up from #4 in 2011/2012 and #14 in 2005/2006.

· Colorado youth past month marijuana use for 2014/2015 was 55 percent higher than the national average compared to 39 percent higher in 2011/2012.

Section 3 – Adult Marijuana Use:

· College age past month marijuana use increased 16 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012).

· The latest 2014/2015 results show Colorado college-age adults ranked #2 in the nation for past-month marijuana use, up from #3 in 2011/2012 and #8 in 2005/2006.

· Colorado college age past month marijuana use for 2014/2015 was 61 percent higher than the national average compared to 42 percent higher in 2011/2012.

· Adult past-month marijuana use increased 71 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012).

· The latest 2014/2015 results show Colorado adults ranked #1 in the nation for past month marijuana use, up from #7 in 2011/2012 and #8 in 2005/2006.

· Colorado adult past month marijuana use for 2014/2015 was 124 percent higher than the national average compared to 51 percent higher in 2011/2012.

Section 4 – Emergency Department and Hospital Marijuana-Related Admissions:

· The yearly rate of emergency department visits related to marijuana increased 35 percent after the legalization of recreational marijuana (2011-2012 vs. 2013-2015).

· Number of hospitalizations related to marijuana:

o 2011 – 6,305

o 2012 – 6,715

o 2013 – 8,272

o 2014 – 11,439

o Jan-Sept 2015 – 10,901

· The yearly number of marijuana-related hospitalizations increased 72 percent after the legalization of recreational marijuana (2009-2012 vs. 2013-2015).

Section 5 – Marijuana-Related Exposure:

· Marijuana-related exposures increased 139 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization.

· Marijuana-Only exposures more than doubled (increased 210 percent) in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization.

Section 6 – Treatment:

· Marijuana treatment data from Colorado in years 2006 – 2016 does not appear to demonstrate a definitive trend. Colorado averages 6,683 treatment admissions annually for marijuana abuse.

· Over the last ten years, the top four drugs involved in treatment admissions were alcohol (average 13,551), marijuana (average 6,712), methamphetamine (average 5,578), and heroin (average 3,024).

Section 7 – Diversion of Colorado Marijuana:

· In 2016, RMHIDTA Colorado drug task forces completed 163 investigations of individuals or organizations involved in illegally selling Colorado marijuana both in and out of state.

o These cases led to:

§ 252 felony arrests

§ 7,116 (3.5 tons) pounds of marijuana seized

§ 47,108 marijuana plants seized

§ 2,111 marijuana edibles seized

§ 232 pounds of concentrate seized

§ 29 different states to which marijuana was destined

· Highway interdiction seizures of Colorado marijuana increased 43 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization.

· Of the 346 highway interdiction seizures in 2016, there were 36 different states destined to receive marijuana from Colorado.

o The most common destinations identified were Illinois, Missouri, Texas, Kansas and Florida.

Section 8 – Diversion by Parcel:

· Seizures of Colorado marijuana in the U.S. mail has increased 844 percent from an average of 52 parcels (2009-2012) to 491 parcels (2013-2016) in the four-year average that recreational marijuana has been legal.

· Seizures of Colorado marijuana in the U.S. mail has increased 914 percent from an average of 97 pounds (2009-2012) to 984 pounds (2013-2016) in the four-year average that recreational marijuana has been legal.

Section 9 – Related Data:

· Crime in Denver increased 17 percent and crime in Colorado increased 11 percent from 2013 to 2016.

· Colorado annual tax revenue from the sale of recreational and medical marijuana was 0.8 percent of Colorado’s total statewide budget (FY 2016).

· As of June 2017, there were 491 retail marijuana stores in the state of Colorado compared to 392 Starbucks and 208 McDonald’s.

· 66 percent of local jurisdictions have banned medical and recreational marijuana businesses.

Section 10 – Reference Materials:

This section lists various studies and reports regarding marijuana.

THERE IS MUCH MORE DATA IN EACH OF THE TEN SECTIONS. THIS PUBLICATION MAY BE FOUND ON THE ROCKY MOUNTAIN HIDTA WEBSITE; GO TO WWW.RMHIDTA.ORG AND SELECT REPORTS.

Source: WWW.RMHIDTA.ORG October 2017

Legalising marijuana can lead to increased use of the drug, according to a French study that looked at consumption levels in two US states and Uruguay in the midst of a debate over France’s narcotics laws.

The study conducted by France’s National Institute of Higher Security and Justice Studies and the French Observatory for Drugs and Drug Addiction examined data from Washington and Colorado, which in 2012 became the first two US states to legalise marijuana for recreational use.

Like several US studies on the subject it noted that legalisation in the states had not increased marijuana use among teenagers, “which nonetheless remains at a high level.”

Among adults, however, marijuana use had increased, particularly among over-25s, the French researchers found.

But in Uruguay, which in July became the first country to legalise marijuana nationwide, “all the indicators of use have risen”, including among teens, the study showed.

In the two American states, the legalisation had led to a “significant” increase in the number of people admitted to hospital with suspected cannabis poisoning, particularly tourists, it added.

On the economic front, it found that sales of recreational marijuana in Colorado and Washington had steadily increased, reaching $1 billion a year in each case.

State tax receipts from the sales had surpassed taxes on cigarettes, the report said, while noting that legalisation had not stamped out marijuana trafficking.

In Uruguay, trafficking was driven by the huge gap between demand and legal production, which accounted for just 10 to 20 percent of marijuana use.

In the American states, by contrast, the black market was being fuelled by the higher cost of over-the-counter marijuana, the report concluded.

The researchers acknowledged, however, that legalisation of marijuana had eased the caseload of the police and judiciary.

In France, marijuana use is a crime punishable by up to a year in prison and a fine of 3,750 euros ($4,400). President Emmanuel Macron has proposed easing the penalty to an on-the-spot fine.

Source: https://medicalxpress.com/news/2017-10-legalising-marijuana-french.html

Pain and pleasure rank among nature’s strongest motivators, but when mixed, the two can become irresistible. This is how opioids brew a potent and deadly addiction in the brain. Societies have coveted the euphoria and pain relief provided by opioids since Ancient Sumerians referred to opium poppies as the “joy plant” circa 3400 B.C. But the repercussions of using the drugs were ever present, too. For centuries, Chinese patients swallowed opium cocktails before major surgeries, but by 1500, they described the recreational use of opium pipes as subversive. The Chinese emperor Yung Cheng eventually restricted the use of opium for medical purposes in 1729. Less than 100 years later, a German chemist purified morphine from poppies, creating the go-to pain reliever for anxiety and respiratory conditions. But the Civil War and its many wounds spawned mass addiction to the drugs, a syndrome dubbed Soldier’s Disease. A cough syrup was concocted in the late 1800s — called heroin — to remedy these morphine addictions. Doctors thought the syrup would be “non-addictive.” Instead, it turned into a low-cost habit that spread internationally. More than 70 percent of the world’s opium — 3,410 tons — goes to heroin production, a number that has more than doubled since 1985. Approximately 17 million people around the globe used heroin, opium or morphine in 2016.

Today, prescription and synthetic opioids crowd America’s medicine cabinets and streets, driving a modern crisis that may kill half a million people over the next decade. Opioids claimed 53,000 lives in the U.S. last year, according to preliminary estimates from the Centers for Disease Control and Prevention — more than those killed in motor vehicle accidents.

How did we arrive here? Here’s a look at why our brains get hooked on opioids.

The pain divide

Let’s start with the two types of pain. They go by different names depending on which scientist you ask. Peripheral versus central pain. Nociceptive versus neuropathic pain.

The distinction is the sensation of actual damage to your body versus your mind’s perception of this injury.

Your body quiets your pain nerves through the production of natural opioids called endorphins.

Stuff that damages your skin and muscles — pin pricks and stove burns — is considered peripheral/nociceptive pain.

Pain fibers sense these injuries and pass the signal onto nerve cells — or neurons — in your spine and brain, the duo that makes up your central nervous system.

In a normal situation, your pain fibers work in concert with your central nervous system. Someone punches you, and your brain thinks “ow” and tells your body how to react.

Stress-relieving hormones get released. Your immune system counteracts the inflammation in your wounded arm.

Your body quiets your pain nerves through the production of natural opioids called endorphins. The trouble is when these pain pathways become overloaded or uncoupled.

One receptor to rule them all

Say you have chronic back pain. Your muscles are inflamed, constantly beaming pain signals to your brain. Your natural endorphins aren’t enough and your back won’t let up, so your doctor prescribes an opioid painkiller like oxycodone.

Prescription opioids and natural endorphins both land on tiny docking stations — called receptors — at the ends of your nerves. Most receptors catch chemical messengers — called neurotransmitters — to activate your nerve cells, triggering electric pulses that carry the signal forward.

But opioid receptors do the opposite. They stop electric pulses from traveling through your nerve cells in the first place. To do this, opioids bind to three major receptors, called Mu, Kappa and Delta. But the Mu receptor is the one that really sets everything in motion.

The Mu-opiate receptor is responsible for the major effects of all opiates, whether it’s heroin, prescription pills like oxycodone or synthetic opioids like fentanyl, said Chris Evans, director of Brain Research Institute at UCLA. “The depression, the analgesia [pain numbing], the constipation and the euphoria — if you take away the Mu-opioid receptor, and you give morphine, then you don’t have any of those effects,” Evans said.

Opioids receptors trigger such widespread effects because they govern more than just pain pathways. When opioid drugs infiltrate a part of the brain stem called the locus ceruleus, their receptors slow respiration, cause constipation, lower blood pressure and decrease alertness. Addiction begins in the midbrain, where opioids receptors switch off a batch of nerve cells called GABAergic neurons.

GABAergic neurons are themselves an off-switch for the brain’s euphoria and pleasure networks.

When it comes to addiction, opioids are an off-switch for an off-switch. Opioids hold back GABAergic neurons in the midbrain, which in turn keep another neurotransmitter called dopamine from flooding a brain’s pleasure circuits. Image by Adam Sarraf

Once opioids shut off GABAergic neurons, the pleasure circuits fill with another neurotransmitter called dopamine. At one stop on this pleasure highway — the nucleus accumbens — dopamine triggers a surge of happiness. When the dopamine rolls into amygdala, the brain’s fear center, it relieves anxiety and stress. Both of these events reinforce the idea that opioids are rewarding.

These areas of the brain are constantly communicating with decision-making hubs in the prefrontal cortex, which make value judgments about good and bad. When it hears “This pill feels good. Let’s do more,” the mind begins to develop habits and cravings.

Taking the drug soon becomes second nature or habitual, Evans said, much like when your mind zones out while driving home from work. The decision to seek out the drugs, rather than participate in other life activities, becomes automatic.

The opioid pendulum: When feeling good starts to feel bad

Opioid addiction becomes entrenched after a person’s neurons adapt to the drugs. The GABAergic neurons and other nerves in the brain still want to send messages, so they begin to adjust. They produce three to four times more cyclic AMP, a compound that primes the neuron to fire electric pulses, said Thomas Kosten, director of the division of alcohol and addiction psychiatry at the Baylor College of Medicine.

That means even when you take away the opioids, Kosten says, “the neurons fire extensively.”

The pendulum swings back. Now, rather than causing constipation and slowing respiration, the brain stem triggers diarrhoea and elevates blood pressure. Instead of triggering happiness, the nucleus accumbens and amygdala reinforce feelings of dysphoria and anxiety. All of this negativity feeds into the prefrontal cortex, further pushing a desire for opioids.

While other drugs like cocaine and alcohol can also feed addiction through the brain’s pleasure circuits, it is the surge of withdrawal from opioids that makes the drugs so inescapable.

Could opioid addiction be driven in part by people’s moods?

Cathy Cahill, a pain and addiction researcher at UCLA, said these big swings in emotions likely factor into the learned behaviors of opioid addiction, especially with those with chronic pain. A person with opioid use disorder becomes preoccupied with the search for the drugs. Certain contexts become triggers for their cravings, and those triggers start overlapping in their minds.

“The basic view is some people start with the pain trigger [the chronic back problem], but it gets partially substituted with the negative reinforcement of the opioid withdrawal,” Cahill said.

That’s why Cahill, Evans and other scientists think the opioid addiction epidemic might be driven, in part, by our moods.

Chronic pain patients have a very high risk of becoming addicted to opioids if they are also coping with a mood disorder. A 2017 study found most patients — 81 percent — whose addiction started with a chronic pain problem also had a mental health disorder. Another study found patients on morphine experience 40 percent less pain relief from the drug if they have mood disorder. They need more drugs to get the same benefits.

People with mood disorders alone are also more likely to abuse opioids. A 2012 survey found patients with depression were twice as likely to misuse their opioid medications.

“So, not only does a mood disorder affect a person’s addiction potential, but it also influences if the opioids will successfully treat their pain,” Cahill said.

Meanwhile, the country is living through sad times. Some research suggests social isolation is on the rise. While the opioid epidemic started long before the recession, job loss has been linked to a higher likelihood of addiction, with every 1 percent increase in unemployment linked to a 3.6 percent rise in the opioid-death rate.

Can the brain swing back?

As an opioid disorder progresses, a person needs a higher quantity of the drugs to keep withdrawal at bay. A person typically overdoses when they take so much of the drug that the brain stem slows breathing until it stops, Kosten said.

Many physicians have turned to opioid replacement therapy, a technique that swaps highly potent and addictive drugs like heroin with compounds like methadone or buprenorphine (an ingredient in Suboxone).

These substitutes outcompete heroin when they reach the opioid receptors, but do not activate the receptors to the same degree. By doing so, they reduce a person’s chances for overdosing. These replacement medications also stick to the receptors for a longer period of time, which curtails withdrawal symptoms. Buprenorphine, for instance, binds to a receptor for 80 minutes while morphine only hangs on for a few milliseconds.

For some, this solution is not perfect. The patients need to remain on the replacements for the foreseeable future, and some recovery communities are divided over whether treating opioids with more opioids can solve the crisis. Plus, opioid replacement therapy does not work for fentanyl, the synthetic opioid that now kills more Americans than heroin. Kosten’s lab is one of many working on a opioid vaccine that would direct a person’s immune system to clear drugs like fentanyl before they can enter the brain. But those are years away from use in humans.

And Evans and Cahill said many clinics in Southern California are combining psychological therapy with opioid replacement prescriptions to combat the mood aspects of the epidemic.

“I don’t think there’s going to be a magic bullet on this one,” Evans said. “It’s really an issue of looking after society and looking after of people’s psyches rather than just treatment.

Source: http://www.pbs.org/newshour/updates/brain-gets-hooked-opioids/