Worth Every Penny?

Compare this legitimate injection kit obtained...
Compare this legitimate injection kit obtained from a needle-exchange program to the user-compiled one above. (Photo credit: Wikipedia)

Preventing HIV is a very good thing.

The Atlantic has a post about the role of needle exchanges in preventing HIV. It makes a pretty compelling case that needle exchanges reduce HIV infection rates among injection drug users. I don’t doubt this. And, provided it serves as an engagement point for recovery, I have no objection to needle exchanges.

However, there are a few things that bug me about these stories.

First, there’s not a single mention of addiction treatment or recovery. Not one word.

Second, one would walk away from this article assuming that injection drug users make up a huge portion of HIV infections. Not true. CDC numbers suggest that, nationally, injection drug users make up around 8% of all new infections.

Third, there’s not a single mention of overdose. The article focuses on LA as a success story, and they have been successful in reducing infections. In 2005, they had 83 new infections among injection drug users. How many overdose deaths? 508. Not a single mention of overdose. We’re busy bragging about the success of the surgery while the patient has died.

Fourth, while I don’t doubt that needle exchanges reduce infection rates, what else also reduces infection rates? We don’t really know. The only research that’s done on the matter focuses on methadone.

Finally, the story was prompted by a new report about infections in Washington DC. The writer says:

According to the department’s research, the repeal of a decade-long ban that prevented D.C. from using local funding for clean needle exchanges led to a major reduction of needle-caused HIV infections. The city is now reporting an astonishing 80 percent decrease in the number of newly diagnosed HIV cases where the reported mode of transmission was injection drug use. In 2007, the year Congress lifted the 1998 ban on D.C.’s needle exchanges, there were 149 cases of needle-caused HIV. In 2011, there were just 30.

That’s pretty great, right? Fewer infections is a great thing. However there’s one very big problem with the way this story frames the data. In 2007, injection drug users made up 29% of new infections. In 2011, they made up 27% of new infections. The big story is that new HIV infections dropped dramatically. Injection drug users are a slightly smaller portion of new infections.

It took me two minutes of googling and reading his own source documents to find this data. Why do so many of these stories fail to provide this context? Why didn’t a reporter spend a couple minutes with a search engine before submitting this? There are lots of stories like this every year. I don’t understand it.

“Giving Drug Addicts Free Clean Needles Is Worth Every Penny” is a good headline, but what’s the rest of the story? There’s more to HIV and addiction than an accounting exercise.

Harsh enforcement has failed

drug policy by mmcrae01

This Foreign Policy article provides a concise snapshot of the failure of the “harsh enforcement” approach to drug policy:

As a domestic policy, a harsh enforcement approach has done little to control drug use, but has done a lot to lock up a growing portion of the U.S. population. Cocaine and opiate prices are about half their 1990 levels in in America today. And 16 percent of American adults have tried cocaine — that’s about four times higher than any other surveyed country in a list that includes Mexico, Colombia, Nigeria, France, and Germany. And while criminalization has a limited impact on price and use, it has a significant impact on crime rates. Forty percent of drug arrests in the United States are for the simple possession of marijuana. Nearly half a million people are behind bars in the United States for a drug offense — that’s more than ten times the figure in 1980.

It’s easy to write with certainty when you are vague. It’s also easier when you are only addressing a narrow set of values:

Conversely, the Global Commission on Drug Policy report compiled evidence suggesting that approaches based on treatment rather than punishment were far more effective in reducing consumption, HIV prevalence, and crime rates among users. For example, Britain and Germany, both of which long ago adopted harm reduction strategies for people injecting drugs — programs that include needle exchange programs and medication — see HIV prevalence among people who inject drugs below 5 percent. The United States and Portugal, by contrast, where such strategies were introduced later or only partially, see HIV prevalence among a similar community at above 15 percent.

“Reduced consumption” is a good thing, I suppose. But, is that a good indicator of the welfare of addicts? I’m not so sure.

Based on my knowledge of the UK system, would I rather be a heroin addict in the US or the UK? Easy call—the US recovery model or UK harm reduction model—recovery.

The US’s incarceration rates for drug offenses are terrible, indecent and stupid. However, I’m not certain that a system that believes addicts can’t recover, offers only methadone even though patients express a preference for abstinent recovery is better even if it does reduce crime and disease. Does this show more restraint in the exercise of social control? Not clear to me.

The sands are shifting in both the UK and the US. It’d be nice if we could stop having these either/or discussions and consider entertaining a both/and conversation.