Can needle exchange programs help prevent the spread of human immunodeficiency virus among intravenous drug users? Drug czar Bob Martinez does not want to know.

Instead of asking this crucial question, Martinez and his Office of National Drug Control Policy issued a bulletin in July entitled "Needle Exchange Programs. Are They Effective?" that took aim at research findings that have bolstered a movement towards wider experimentation with such programs.

The cold, hard reality is that 32 percent of all reported U.S. AIDS cases were caused by transmission of HIV via infected needles. Every year since President Bush took office, the number of AIDS diagnoses related to IV drug use has increased — rising from 11,602 new cases in 1989 to 15,685 in 1991, a 26 percent jump.

A broad range of efforts is necessary to stop the spread of AIDS in the addict community and to help protect others who have contact with addicts. Ample, peer-reviewed evidence exists that shows needle exchange can be a helpful part of overall anti-AIDS strategy.

But don't tell the drug czar, who has provided a remarkable example of the dodging, dissembling and deception the Bush administration will resort to rather than support something it fears would sacrifice the ideological purity of the drug war.

New Attack in Old War

For drug czar Martinez, this report represented something of a shift in anti-needle-exchange strategy. It was his first attempt to attack the case for needle exchange on the merits.

Martinez has been extremely vocal in his opposition to needle exchange, at one point even publicly criticizing the mayors of New York and Washington, D.C., for their decisions to support trial exchanges in their cities. Fighting needle exchange appears to be a high priority for the ONDCP.

However, his moral arguments largely failed to stem wider acceptance of needle exchange. Thus, Martinez decided to fight on the intellectual turf, challenging the needle exchange research with a cavalier approach to science and fact.

Martinez sees needle exchange as threatening to the fundamental philosophy of current drug policy. In the introduction to the report he lays bare his view: "we [cannot] allow our concern for AIDS to undermine our determination to win the war on drugs."

Perhaps needle exchange advocates should be thankful to the drug czar for his willingness to say bluntly that the sanctity of war-on-drugs dogma is more important than saving lives. It is always helpful when an opponent frames the debate on one's own terms.

Yet Martinez's successful political activities on this issue should be a spur to action. There is perhaps no area of drug policy where the federal government's stonewalling has been more costly in terms of lives and of failure to control the spread of disease. Martinez's maneuvering has already had some effect:

•    In 1992, Martinez worked with key congressmen to keep in effect a ban on the use of some federal funds for needle exchange.
•    On Sept. 30, California Gov. Pete Wilson vetoed a bill that would have legalized San Francisco's underground needle exchange program. Wilson quoted Martinez's needle exchange report directly and borrowed its perspective, saying, "without clear and convincing evidence that these projects will successfully reduce the AIDS epidemic, we cannot afford to threaten the credibility of our ongoing anti-drug efforts."

Analyzing the Analysis

News stories described the drug czar's report as a systematic analysis of all the major studies indicating needle exchange's usefulness. In reality, the report has one major target: a 1991 interim study of the New Haven needle exchange conducted by Yale University researchers which has been widely cited as proof that needle exchange works. Martinez and his office believed it necessary to rip the study apart. While the ONDCP report cites 12 other studies in a footnote, it only discusses them in two general paragraphs.
In attacking the Yale study, Martinez relies on several misinterpretations of needle exchange and the supporting research, and even resorts to outright falsehoods to make his case.

Claim #1: Treatment Recruiting More Effective

The first deception in the drug czar's analysis is the idea that there is a choice to be made between his favored anti-AIDS approach — increasing efforts to bring IV drug users into drug-free treatment — and needle exchange. In fact, these two strategies can be complementary, and are often combined within comprehensive programs. But Martinez hopes to prove that recruiting drug users into treatment by dispatching squads of social workers in heavy drug-using areas is so much more effective than needle exchange that the latter idea should be dismissed entirely.

Martinez notes that the Yale study found that 15 percent of the individuals who contacted the New Haven needle exchange entered treatment (25 percent requested treatment, but waiting lists prevented them all from getting it immediately). He then offers a result from a study of NIDA treatment recruiting efforts between 1987 and 1992: 31 percent of the individuals subjected to intensive follow-ups and interventions enrolled in treatment programs. With these numbers, the treatment-recruiting approach could be described as twice as effective, assuming here that the only desirable outcome of a given program is getting users into treatment.

It turns out that the drug czar is using data that are not scientifically comparable. The 107 New Haven needle exchange contactees who entered treatment represented 15 percent of the 720 total individuals who made contact with the program over an eight-month period.The 31 percent figure from the NIDA effort was the percentage of so-called "program participants" — people who received follow-up attention from outreach workers — not just those who were contacted at some point.

If the number of treatment enrollments resulting from the NIDA effort is given as a percentage of total contacts, as was the "success rate" for the New Haven needle exchange, the figure drops to 9 percent.' This figure still assumes that the only "success" is getting users into treatment.

The fact that the numbers used by the drug czar do not show what he claims they do demonstrates how eager he is to portray needle exchange in a bad light.

#2: Attrition Rates High

Many studies of U.S. needle exchange programs note that as many as one-third of the intravenous drug users who make at least one contact with the programs never return. Most, but not all, of those who do return at least once become regular users of the programs or, in the research terminology, "program participants." Drug czar Martinez labels this problem "high levels of attrition," and implies that it is a fatal flaw of needle programs, not simply a hurdle to be overcome.

To make the problem seem worse than it is, he misstates the "attrition rate" of the New Haven needle exchange, stating: "of the 720 addicts who initially contacted the New Haven program over an eight-month period, only 288 (40 percent) returned at least once to exchange a used needle." That figure is flatly incorrect.

What the Yale study actually found was that 66 percent of one-time contacts returned to exchange a needle at least once, while 38 percent made at least five visits to the exchange. The 40 percent figure misused by the ONDCP report actually referred to the percentage of one-time contacts who were still participating in the program at the end of the study period, factoring out the number of people who had enrolled in drug treatment.

Ultimately, the attrition rate argument is the equivalent of saying that since some high schools have high dropout rates, they should be closed. The fact that not all program participants remain involved simply limits the benefits derived from exchanges; it does not cancel them.

#3: Needles Available; Addicts Irresponsible

Martinez resorts to another disingenuous argument against the need for needle exchange programs by pointing out that only 11 states ban over-the-counter sales of hypodermic syringes. He writes, "The fact that addicts can purchase clean needles cheaply, without prescription, in many pharmacies in most states, but often fail to do so, is evidence of their irresponsible behavior."

Martinez must know how slippery this argument is. The 11 states referred to by the drug czar happen to be home to 92.1 million Americans, nearly 40 percent of the U.S. population. These states also contain most of the nation's large urban areas — including Chicago, New York, Los Angeles and San Francisco — where IV drug use is most prevalent.

Yet even in those states where it is hypothetically possible for addicts to walk into local drug stores and pick up clean needles, they are still subject to drug paraphernalia laws that make it a crime to possess syringes with the intent of using illegal drugs.

The drug czar is obviously aware of this fact. Earlier in his report he notes that it may be against the law to run needle exchanges in many areas because of the paraphernalia laws, in the course of which he notes that these laws also ban possession. This admission torpedoes his point that addicts are too irresponsible to get clean needles for themselves.

#4: Insufficient Proof Needles not Shared

Another of Martinez's criticisms of the needle exchange research is that there is not adequate proof that program participants have not shared the needles they return. Most studies ask participants whether they have shared, and record the answer. Martinez does not trust this method, because "[n] matter what addicts promise when they are not on drugs, they may still share needles when they shoot up heroin or cocaine ... often, a drug-induced state overwhelms rational thinking."

The director of the Yale study, Professor Edward H. Kaplan, has said the crucial issue is not how many addicts share needles, but how many addicts each needle shares. Needle exchanges do not always succeed in changing needle-sharing behavior, but they do markedly increase the number of clean needles in circulation, decreasing the likelihood that a given needle will be infected.

Martinez suggests that "objective" tests, namely blood tests, be done on all returned needles, to ensure that the blood type on the needle matches that of the person returning it. That would be a prohibitively expensive measure given the cost of testing each needle.

In addition, blood testing could worsen the existing problem of attrition rates. An exchange program would be unwise to force all program participants — especially first-time contacts — to submit to a blood test for tracking purposes. This might further dissuade addicts who are already skeptical about working with the programs.

Later in his report, Martinez says he could find no study of a U.S. or foreign needle exchange that used the kind of blood-type testing he advocates to prove there had been no needle sharing. He fails to observe that there is a very good reason for that.

#5: No Control Groups

In an apparent oversight, Martinez complains that needle exchange research does not follow the standard scientific procedure of using a control group. Wrong again.

The Yale study did make relevant comparisons between needles distributed by and returned to the program and "street needles," concluding that those circulated by the New Haven needle exchange had a significantly lower rate ofIIW infection than needles in general circulation. Indeed, the percentage of program needles infected with HIV steadily declined during the study period.

Tracking program needles versus a control group of non-program needles was consistent with the researchers' goal of understanding whether the program participants' risk of contracting HIV declined. Martinez seems to be saying that he would rather see a comparison using a control group of addicts who do not receive clean needles over the same period that others do. He seems unconcerned that his approach would commit members of the control group to a continuation of the game of Russian roulette in which they were engaged before joining the program — and that many adicts would unwittingly select the AIDS bullet.

#6: 'Treatment is the Real Solution'

In a press release distributed as the ONDCP's needle exchange bulletin was issued, drug czar Martinez was quoted saying:

"Needle exchange programs are a false promise — an act of desperation, a product of frustration ... . [These programs] put the weapons of destruction into the hands of addicts who need treatment, not another fix. If we are to help drug addicts, we must address the drug addiction that fosters needle exchange efforts. Treatment is the real solution here, and it must be more widely available."

Martinez is essentially saying that addiction is the problem, not AIDS, and that we should not distract ourselves with needle exchange. The question he fails to address throughout his report and in the above-quoted passage is what to do about those addicts
who are not in treatment now and risk contracting HIV at any moment.

Poring over the great majority of the drug czar's statements on needle exchange and having examined his report on the issue, one can only conclude that he believes that addicts who are not in treatment should be left for dead. "If we are to help addicts," he says (emphasis added), we should only do so by offering treatment. He seems to portray AIDS risk as a natural counterpart to the problem of addiction, not something which can be dealt with independently from treating addiction or as a prelude to treating it.

Roots of Opposition Ideological

Rigidly ideological drug warriors like Martinez oppose needle exchange because they find harm-reduction measures threatening to their core ideas. They see no room for compromise — even if it means preventing deaths — in a drug war that is as important for its rhetoric and posturing as it is for its programs.

Even though the recent ONDCP report fails to build the credibility of the anti-needle exchange position, it does help create the impression that there is an even-keeled debate on the issue, in which reasonable people can disagree. That impression ignores the fact that the overwhelming majority of critical scientific opinion now weighs in favor of needle exchange, and that this consensus — combined with the urgency of stopping the spread of AIDS — has led reasonable people to ignore the hard-liners and to get on with the hard work of saving lives.

Oddly enough, the main reason for hope that needle exchange can be implemented more widely is contained within the drug czar's report. Martinez has proved only one thing: that those who oppose needle exchange are incapable of defending their position honestly. It ought to be a small step from intellectual bankruptcy to total defeat.

DF

Footnote
'Martinez summarizes the results of the NIDA outreach efforts as follows: "Between 1987 and 1992, outreach workers contacted approximately 150,000 intravenous drug users. Of these, 45,000 addicts ... were provided with information on treatment, counseling and methods for reducing the risk of infection." A rough calculation from these figures: 31 percent of 45,000 gives 13,950, which is 9 percent of 150,000.