Deregulating needle sale and possession would reduce morbidity and mortality associated with blood-borne diseases including HIV, according to a major report in the January 1 Journal of the American Medical Association (JAMA).

The report by Lawrence Gostin, J.D., and colleagues summarizes how a nationwide network of laws and regulations hinders access to sterile needles for intravenous drug users (IDU's) and hence increases the risk of HIV transmission.

The evidence suggests that deregulation of needle sale and possession "could be implemented without harmful social repercussions," it concludes.

The report strengthens the hand of those, including APA and the AMA, who have backed needle exchange programs as a strategy to reduce HIV transmission. But it goes beyond simply endorsing needle exchange by documenting the legal obstacles to needle exchange programs and distribution of needles by local pharmacies.

Last September APA's Board of Trustees approved a policy statement backing needle exchange programs. That statement said, in part, that APA "supports the removal of government restrictions on the availability of sterile syringes specifically within the structure of organized needle exchange programs, encourages government-sponsored efforts to broaden the availability of these programs in targeted areas and provide public health education to promote safer hygiene practices among injection drug users, and continues to endorse the core strategy of increasing the availability of quality detoxification and treatment programs for all substance users."

The concluding paragraph of the JAMA article reflects a similar sentiment, stating that "deregulation of syringe sale and possession should constitute only one component of a comprehensive, well-financed strategy to impede the dual epidemics of drug use and HIV/AIDS." A sound national policy must also devote adequate resources to quality treatment for drug and alcohol dependency and better drug education and counseling, the statement continues.

T. Stephen Jones, M.D. M.P.H., an epidemiologist at the federal Centers for Disease Control and Prevention (CDC), was one of the authors of the JAMA survey.

"The most important part of the article was the idea of legitimate medical use based on the now widespread institutional support for providing sterile syringes" to IDU's, Jones told Psychiatric News. "Our major interest is in calling attention to the fundamental problems for HIV prevention by IDU's posed by the network of laws and regulations. The underlying principle is that access to sterile syringes makes good public health sense."

The authors of the JAMA article named a variety of steps that could be implemented to reduce the spread of HIV and other blood-borne diseases caused by needle sharing among IDU's.

The steps include clarifying the legitimate medical purposes of sterile needles, modifying drug paraphernalia laws, repealing needle prescription laws, repealing restrictive pharmacy regulations and practice guidelines, promoting professional training, permitting local discretion in establishing needle exchange programs, and designing programs for safe needle disposal. The authors conclude that it would be possible to continue to punish drug dealers who sold needles without impeding needle access by IDU's.

Some of the conclusions have drawn criticism.

"The [study's] language on needle exchange remains weak, presumably as a result of ongoing federal opposition to needle exchange and the presence of a CDC author on the paper," said Peter Lurie, M.D., M.P.H., an assistant professor of family and community medicine at the University of California, San Francisco. The conclusion that the law could continue to criminalize provision of needles by drug dealers without impeding needle access for IDU's is naive, Lurie asserted. That "would be wrong-headed because some people are both drug dealers and providers of sterile syringes to other drug users," said Lurie. "In fact, the drug dealer has a potentially useful public role here, and this would cut it out. The result is that the police could use the drug dealer exemption to continue to restrict the availability of sterile syringes."

Despite widespread support for giving IDU's access to sterile needles, the issue remains politically, if not medically, controversial. Conflict erupted recently when public health advocates including Lurie and Public Citizen Health Research Group Executive Director Sidney Wolfe, M.D., called unethical a proposed needle exchange study funded by the National Institutes of Health (NIH) (Nature Medicine, December 1996).

Because there is a consensus among public health officials that needle exchange programs are effective, the study proposed for Anchorage, Alaska, would unnecessarily and unethically expose half the participants to AIDS and hepatitis B, they contended. NIH Director Harold Varmus, M.D., hastily agreed to have the agency do an additional review despite two prior extensive reviews.

In December NIH gave the study a green light with the proviso that more would be done to provide IDU's with hepatitis vaccinations. But the revised protocol still failed to address Lurie's and Wolfe's concerns adequately and will needlessly limit access by IDU's to clean needles and hence increase the risk of HIV transmission, Lurie told Psychiatric News. Defenders of the study said that IDU's barred from getting clean needles at the experimental needle exchange could easily get clean needles from local pharmacies. But a random survey of Anchorage pharmacies by Public Citizen found that only 14 percent would sell needles without a prescription, Lurie said. --R.B.K. (Psychiatric News, February 7, 1997)