New NBER Working Paper Confirms Needle Exchange Programs Reduce HIV — Does It Also Make The Case For Safe Injection Facilities?

A recently released working paper from the National Bureau of Economic Research by Analisa Packham of Vanderbilt University examined the impact of needle exchange programs (referred to as Syringe Exchange Programs or SEPs) on the incidence of HIV as well as overdose hospitalizations or deaths. The author concluded that the openings of SEPs decrease the rate of new HIV diagnoses by 18.2 percent. But she also pointed to evidence suggesting that they may be associated with an increase in visits to hospital emergency rooms for overdose, and an increase in overdose deaths. The author concluded, “needle exchanges alone may be less effective than other interventions at stimulating recovery.”

This paper was recently cited in National Review as an argument against needle exchange programs. Without having had the chance to study or comment on the study’s methodology, I have a few remarks to make to those who see this as an argument against this proven harm reduction strategy.

• Needle exchange programs are a time-tested, proven method of reducing HIV and hepatitis ever since they were first implemented in this country in the 1980s. The principal goal of the program was to reduce the spread of deadly blood-borne infectious diseases. This latest working paper from the NBER provides yet more evidence of the efficacy of needle exchange programs for the reduction of HIV transmission.
• While many needle exchange programs refer clients to rehab programs, people have to be motivated to enter and stay in such programs. And not all rehab programs are the same. Some, like 12-step abstinence programs, have a high drop out rate. Other programs, like Medication Assisted Treatment, sometimes are more effective, depending upon the degree of social support and adjunctive psychotherapy.
• Not every illicit substance user is an addict in need of “recovery.” Many are recreational users. In fact, many who begin recreational use of illicit drugs after the age of 25 are not addicted, and the majority of illicit drug addicts recover without treatment by the time they reach 30.
• Needle exchange programs were never touted as a means to reduce overdose or overdose deaths—just the spread of disease. However, very recently, many needle exchange programs have started handing out naloxone to their clients to use in the event of an overdose, which still may be problematic if a drug user is alone at the time of overdose.
• This is precisely why Safe Injection Facilities, also known as Safe Consumption Sites or Overdose Prevention Sites, are being promoted in the US. Unfortunately, they are prohibited by federal law—“Crack House Statute”—which prevents several major US cities from establishing them. The Department of Justice is, at this moment, preventing a non-profit group in Philadelphia from opening a “Safehouse” for IV drug users in its Kensington district.
• Safe Injection Facilities work effectively in more than 102 major cities in Europe, Canada, and Australia—since the early 1990s—to reduce overdose deaths precisely because there are people standing close by with naloxone while a drug user injects in a clean and safe environment. Furthermore, the used needle and syringe are collected after each use so they cannot be sold or shared with others out on the street. Recent studies from the University of Pittsburgh and the Canadian Institutes of Health are among the several studies that demonstrate Safe Injection Facilities reduce overdose deaths and save lives. We had a panel on Safe Injection Facilities that featured the program director of North America’s oldest such facility in Vancouver, BC at a harm reduction conference held at the Cato Institute last March. You can view that panel here. The clean, safe, compassionate, and non-judgmental environment these facilities provide is also conducive for referrals to rehab and other social services.
• Harm reduction and addiction recovery are not the same thing. The strategy of harm reduction begins with the understanding that there will never be a drug-free society. It seeks to reduce the harm that results from the non-medical use of licit and illicit drugs. Needle exchange programs were never created for “stimulating recovery," but rather as programs designed to reduce the harm to people who continue to use. It is therefore inappropriate to judge the efficacy of needle exchange programs as a means of attaining recovery.

For these reasons, my immediate reaction to this latest NBER study is to conclude that it found, as did many other studies that preceded it, that needle exchange programs are an effective way to reduce the spread of HIV. It also pointed out the shortcomings of needle exchange programs, which is precisely why harm reduction advocates point to the need to federally decriminalize Safe Injection Sites. 

Rather than making the case against needle exchange programs, I find this study augments the argument for Safe Injection Facilities.