In 1987 New Zealand established its Needle Exchange Programme (NEP), perhaps the first country to do so on such a comprehensive scale. Now, 20 years on, there are 212 outlets operating nationally and 17 dedicated exchange outlets utilising a peer service model. There are 182 pharmacies and health related organisations providing new, sterile injecting equipment and collection of used items. In our Guest Editorial, Needle Exchange Programme National Manager Charles Henderson writes about the programme’s current status and what should happen to ensure its future.

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It needs to be understood right from the outset. Drug use has always been part of the human condition, and will be for the foreseeable future. Even in our distant past, we used drugs ranging from alcohol to opiates and hallucinogens to induce altered states of mind or assist in spiritual quests.

The grim reality of harmful drug use is apparent to NEP workers on a daily basis. Regardless of our opinions or world view, illicit drug users continue to risk ill-health, addiction, disease and prosecution. Those who have become dependant have a career of narrowing choices. With the knowledge and understanding we now have about drugs and what they do to people, it is an oxymoron to say that those dependant on drugs lack willpower or could stop if they wanted to.

Ongoing prohibition has had many implications in our society. Fear of prosecution means that illicit drug users are forced to act covertly; often resorting to unsafe methods in their attempts to remain hidden. Even though we have been authorised to supply clean injecting equipment since 1987, NEP clients still must run a legal gauntlet because possessing the very equipment we supply is against the law. This has huge implications on the personal and public health objectives of the NEP as we attempt to minimise the spread of blood borne viruses (BBVs) within the IV drug using population, and from there to the wider community.

This is why New Zealand’s Needle Exchange Programme has always taken the pragmatic approach of reducing the harm that can result from drug use. Providing clean needles and decirculating contaminated ones is not condoning drugs. It’s a way of reducing suffering and loss of life, and it often provides the only point of contact through which drug users can be educated, informed, and assisted with access to treatment options. Individuals often turn to drug use as a way of coping at a particular point in their lives. They should not then be condemned to a life of despair and worthlessness. The majority get through it with the right assistance and continue on the path as productive and participating members of society.

One of NEP’s greatest strengths is its emphasis on peer service. Dedicated exchange outlets are run and staffed largely by people who have themselves been injecting users. They understand the lifestyle and how best to impart information by showing genuine empathy and understanding, and by taking a non-judgemental approach. More than 75 percent of the national distribution of sterile injecting equipment is through the 17 outlets using the peer service model.

We have to recognise illicit drug use as a health issue if we’re serious about minimising its related harm - from a Government and policy level through to doctors, pharmacists and public attitude. Treatment must acknowledge that drug addiction is a chronic relapsing condition which may require several interventions over a lifetime, but that there are many ways of reducing its harm. Longer prison sentences and harsher penalties only further prevent these individuals from receiving a health based solution.

So where is NEP now?

Over the last 20 years we’ve had some very real and measurable success. In 2004 I personally headed a study into the prevalence of HIV, Hepatitis B and Hepatitis C amongst injectors attending the programme. We examined trends in their injecting practices, sexual behaviours and other risk factors associated with BBVs. The study consisted of an anonymous questionnaire completed by 412 people and a finger-prick blood test. We were able to compare results with two more limited studies done in the late 90's. Many of the results were robust, indicating that drug users are changing their behaviours.

The table above compares risk behaviour survey results for 1997, 1998 and 2004.

Needle exchange was instigated early in New Zealand, mainly as a response to the potnetial HIV/AIDS epidemic. As a result we have the lowest rate of HIV transmission amongst injectors attending the NEP in the world. HIV prevalence of 0.3 percent is an outstanding result!

No blood tests were positive for Hepatitis B, but Hepatitis C results were more concerning. It is a difficult virus to control and is easily transmitted via shared injecting equipment. Seventy percent returned positive, and the longer a user had been injecting, the more likely they were to carry Hepatitis C. Of note was that the prevalence amongst injecting drug users under 25 was less than 30 percent, indicating that early education and intervention may reduce the overall pool of Hepatitis C infection amongst them over time.

There is no doubt in my mind that we have saved the country millions of dollars in disease prevention and downstream health costs. This is endorsed by the 2002 NZ NEP Review which stated that New Zealand’s NEP is both effective and efficient, particularly with respect to prevention of HIV infections among injecting drug users and every dollar spent on the programme between 1988 and 2001 avoided $20 in lifetime treatment costs.

However, it also seems clear that the programme must be maximised so that it reaches a greater proportion of injecting drug users if we are to effectively reduce Hepatitis C transmission and prevalence in the future.

So what is the future for NEP?

While needle exchange must remain is core activity, NEP must also continue to develop to incorporate ancillary services via the dedicated outlets. These should include Hepatitis C clinics, vaccination programmes, provision of food, and more education on sexual behaviour, injecting techniques and wound management. NEP needs increased national awareness to encourage participation, particularly amongst young people and those in more remote areas.

We’ve made a definite start with all of the above, but the future will largely be determined by two things: funding and targeted interventions based on best evidence.

In terms of funding, we simply cannot allow NEP to be seen as a poor cousin to other approaches in our national drug policy. The recent National Drug Policy 2006-2011 consultation document has relegated our approach of harm reduction to “problem limitation” thereby lessening its importance in respect to the internationally accepted three-pillar approach of supply, demand and harm reduction. Internationally, in places that do not accept harm reduction programmes such as the NEP, HIV/ AIDS rates of over 50 percent have been reported.

Household Drug Surveys indicate two percent of New Zealanders inject or have injected drugs in the last 12 months. This means 85,000 people are potentially susceptible to bloodborne viruses from drug use, and these people will have contact with other New Zealanders. We cannot ignore these issues and hope they will go away.

Increased funding is needed to improve the outreach capabilities of the programme. Outreach is fundamental to the successful future of NEP, yet it is relatively ignored as attention and resourcing is concentrated on law enforcement and border interdiction.

Outreach takes the concept of harm minimisation to the most isolated and vulnerable users around the country, often providing a lifeline for those who would otherwise find it near impossible to learn about the help available.

A trial mobile needle exchange has recently begun operating on the West Coast. This service makes contact with those in the injecting community who are well-placed to publicise its availability to their peers. It’s another example of the sorts of effectiveness only possible through the groundlevel, evidence-based approach the peer-based dedicated exchanges can provide. The service is currently being evaluated and it is hoped it can be rolled out to other areas as part of a broad range of interventions to maximise NEP’s effectiveness now and into the future.

While many New Zealanders, including many politicians, remain blissfully unaware or perhaps a little fearful of NEP, its importance as an effective means of minimising harm to all New Zealanders cannot be underestimated. The 2004 survey indicates that on the whole we are getting it right, and we are making an incredible difference.

The introduction of a free one-for one (new for old) distribution scheme in 2004 is an example of the continued investment and support NEP does receive from Government. Removing the economic barrier (previously distribution of injecting equipment was on a user-pays basis) is crucial if we are to reduce the sharing and re-using of injecting equipment. Such behaviours are devastatingly efficient ways of transmitting BBVs, and other ways may arise in the future.

The future of the Needle Exchange Programme must be centred on consolidating its ground-level approach, providing solid scientific evidence, and through this expanding the service’s reach and effectiveness. This will take increased funding, continued strategic management and planning and robust evaluation of any targeted intervention that is implemented. Money well spent in my view.

• Matters of Substance, guest editorial, February 2007

“Give needles to inmates” was the Dominion Post’s provocative headline when reporting on our “Alcohol and other drugs in the criminal justice system” policy, and a proposed Australian prison needle exchange has just been sunk after media controversy.

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We answer some questions behind the controversy.Needle exchange programmes (NEPs) started as a public health response to high rates of HIV infection among injecting drug users within the general population.

Within the prison population, however, rates of blood-borne diseases, including HIV, hepatitis C and other viruses, occur at a greater ratio. The reason why is obvious. There is a higher rate of imprisonment among injecting drug users. No country has yet been able to stop prisoners using drugs, especially those with existing addictions.

While New Zealand has well developed methods for reducing the supply of drugs in prisons, 15 percent of prisoners still had positive drug tests in 2006. A recent New Zealand study of community needle exchange clients found 25 percent had been imprisoned in the last year, and 40 percent of that group had continued to inject while in prison. Eighty percent of those who had been in prison tested positive for hepatitis C exposure, compared to 60 percent of those who had never been imprisoned.

Inmates who acquire blood-borne diseases in prison take them back to their families and communities on release.  Prison needle exchanges aim to stop both the spread of communicable diseases among prisoners and the consequent spread to the community.

If it’s a public health measure, why is needle exchange so controversial?
Prison needle exchanges are an admission that drugs can’t be kept out of prisons, which goes against the “zero-tolerance” approach of most prisons systems. Opponents also claim that they encourage inmates to start using drugs and may undermine efforts to get prisoners into treatment.

Which countries have a prison needle exchange, and how does it work?
Switzerland was the first country to start in 1992, followed by Germany in 1994 and Spain in 1997. Eastern European countries such as Moldavia and Armenia have recently introduced them to stem the rising rate of HIV, and Scotland is considering a pilot. Perhaps the most unexpected country to start prison needle exchange is Iran.

In some prisons, medical staff exchange equipment; others have vending machines, where prisoners insert used syringes and new ones are released, along with other safe injection equipment. Generally, prisoners register with a programme and receive secure boxes in which to store their equipment.

Do prison needle exchanges make a difference?
Researchers have monitored prison NEPs over more than a decade. A 2006 international review concluded that prison needle exchanges:

• do not lead to increased drug use
• do not undermine abstinence-based
• drug treatment programmes reduce risk behaviours, prevent disease transmission and otherwise improve the health of prisoners who inject drugs.

The review specifically studied whether greater availability of needles caused more needle-stick injuries and more cases of injecting equipment being used as weapons.

The case of a NSW prison officer dying from HIV/AIDS in 1991, following a deliberate needle stabbing, was raised in Australia as an argument against needle exchange in a new Canberra prison. However, the review found no cases of needles being used as weapons in any prison using needle exchange. Swiss prison wardens said that, since needles were not being hidden from staff, accidents during cell searches had stopped.

What makes prison needle exchange work?
The review identified key elements that make prison-based exchanges effective. Some of these are:

• connecting the needle exchange to comprehensive harm-reduction services, including education on blood-borne viruses, and substitution therapy
• consulting with and educating prison staff about needle exchange services
• making sure exchange services are confidential and easily accessible – for instance, having several access points inside a prison
• evaluating pilot programmes to be sure services are effective and meet prisoners’ needs.

• Matters of Substance, November 2007

"Harm reduction increases the likelihood that drugs will be avaliable...It increases the drug harm that results from it. It decreases the efficacy of police and disempowers parents and the community." New Zealand 'war on drugs' zealot

So-called harm reduction leads to liberalisation of the use of drugs." The Vatican

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Ignorance is all too common in drug policy discussions, but it’s something we could do without, especially when it comes to life saving health interventions such as needle exchange programmes and opioid substitution therapy.

In the lead-up to the March UN drug policy meeting, the scale of individual, institutional and member state ignorance knew no bounds when various players sought to undermine the importance of harm reduction programmes which have proven critical to addressing drug harm.

A very small minority of member states even succeeded in striking references to harm reduction from the Political Declaration agreed at the High Level Segment of the 52nd meeting of the Commission on Narcotic Drugs.

It is estimated that 15.9 million people inject drugs in 158 countries and territories around the world. Up to 10 percent of all HIV infections occur through unsafe injecting drug use and evidence suggests that over 3 million people who inject drugs are living with HIV.

International evidence strongly supports harm reduction interventions as effective methods of preventing HIV transmission and improving the lives of injecting users.

This evidence has been compelling enough for harm reduction to receive endorsement by a raft of high level organisations such as the United Nations General Assembly, UNAIDS, the UN Office of Drugs and Crime, the World Health Organization and many others.

At least 84 countries (including New Zealand) explicitly support or provide harm reduction programmes such as needle exchanges, opioid substitution and drug consumption rooms. Further, the Legal Affairs Section of the UN Drug Control Programme has declared harm reduction programmes legal under international drug conventions, authoritatively refuting continued allegations by obstructionist  governments that harm reduction is incompatible with treaty obligations.

While there is not a formal, internationally agreed definition of harm reduction, most commentators agree on its key features: a focus on harms rather than use; a pragmatic and achievable approach; an assumption that drugs are part of society; an underlying public health framework; and the use of an evidence base to evaluate interventions in terms of net harm.

In a systematic review of needle exchange programmes, the Drug Policy Modelling Programme (DPMP) concluded, “The body of evidence is very strongly weighted towards their effectiveness and cost-efficiency.” New Zealand needle exchanges have been world leaders in limiting HIV infections among injecting drug users.

Studies and clinical trials have found the provision of needles does not cause a rise in drug use or injection. In the US, federally funded reports conducted by the many reputable organisations such as the National Commission on AIDS and the Centers for Disease Control and Prevention have all concluded that needle exchanges reduce the transmission of HIV while not increasing drug use.

Far from “disempowering communities”, as critics claim, studies have also found needle exchanges highly successful in reducing the rate of unsafe disposal of injecting equipment in areas where they operate.

Tony Trimingham, Head of Australia’s Family Drug Support, says harm reduction interventions support the otherwise powerless families of drug users because they focus on helping rather than punishing those affected by drugs. “I’d rather my child was drug-dependent than dead, because while there’s life there’s hope,” he says.

Evidence suggests a number of public health and community benefits of supervised injecting facilities, including prevention of overdoses, reduced transmission of blood-borne viruses and better access to medical, welfare or treatment services.

Many critics argue that harm reduction has iatrogenic effects. Needle exchanges, for example, encourage users to inject more and result in greater numbers of new initiates to injecting. However, the DPMP review concluded: “Fears that harm reduction ‘sends the wrong message’ have no evidentiary basis.”

In light of the overwhelming supportive evidence, Mythbusters struggles to understand how the Pope, some member states and others can maintain such ignorant views of harm reduction. Surely everyone’s interests are best served when people who use drugs are provided high-quality, effective health services.

Reference:

Drug Policy Modelling ProgramMonograph #6 A systematic review of harm reduction

• Matters of Substance, mythbusters, May 2009