The American Public Health Association,
Being aware that injection drug use is a major risk factor for HIV,1 hepatitis B and C2 as well as additional problems including drug overdose, sexually transmitted diseases, liver disease, tuberculosis, skin and soft tissue infections, bacterial infections, mental illness, and violence, and that this represents a public health emergency;3 and
Recognizing that infections result from the reuse and sharing of syringes, and that injection drug users may fear and mistrust health care providers due to the illicit nature of their drug use and the stigma attached to it,4,5 and that injection drug users may have few or no links to regular health care or social services;6 and
Being aware that minority racial and ethnic groups are disproportionately over represented among those who suffer from diseases associated with injection drug use,7-9 thus making this issue one that pertains to a major topical area of interest for APHA; and
Having recognized, in addition to the importance of drug treatment programs, the critical importance of access to sterile syringes to prevent disease spread,6,10 and the effectiveness of increasing sterile syringe access in reducing risk behavior;11-13 and
Having previously approved policy supporting syringe access through the establishment of needle exchange programs and decriminalizing possession of injection equipment,14 as well as recognizing the importance of protection against illicit drug-related HIV15; and
Recognizing the need for a comprehensive approach to the problem of injection drug-related problems that addresses the need for drug treatment, access to sterile syringes, and the provision of primary and preventive care for people who inject drugs; and
Noting that the approaches of establishing syringe exchange programs and deregulating sales of syringes, while important,14 may be limited due to lack of funding, lack of local support, or lack of legislative action;16 and
Further noting that prescription of syringes to injection drug users represents an additional approach to stemming the spread of disease, one which was not previously considered and which reports have recently shown to be quite promising;17-18,20 and
Noting that the advantages of this approach include:
The ability to provide legal access to syringes for injection drug users in places where such access is otherwise restricted. According to a recent legal analysis,18 physician prescription of injection equipment to injection drug users is legal in 48 of 52 U.S. jurisdictions (illegal in DE and KS and questionable in OH and OK). A prescription is currently required for sale or possession of syringes in seven states: CA, DE, IL, MA (except NEP), NV, NJ, and PA. Seven states allow some sale or possession of syringes without a prescription (e.g., no more than 10 syringes). 30 states or territories have drug paraphernalia laws that could be applied to syringes and 14 more have laws that exempt some possession of syringes. Prescription of syringes to injection drug users is legal in 40 of these 44 jurisdictions and possibly legal in two more.18 Even in states where prescription is not legally mandated, having a prescription can improve access by reducing fear of harassment by pharmacists.19
The possibility of providing primary medical care to an underserved population3,21and establishing new links to health care for IDUs by offering treatment and referrals in a non-judgmental setting where drug use is acknowledged;20 The potential for health care providers who prescribe syringes to serve as a conduit to substance abuse treatment and other services;22-24 and
Appreciating that providing much needed medical and social services25,26 to injection drug users represents a strengthening of the public health system, and that syringe prescription has already been endorsed supported by the American Medical Association,27 the Massachusetts Medical Society,28 the CDC5 and others; and
Understanding that support for syringe prescription is important to reduce apprehension towards, and increase knowledge of, syringe prescription as part of a comprehensive approach to addressing a major public health problem; therefore, building on the resolutions approved in APHA Policy 9415,9 but explicitly not negating previous policy statements, APHA
- Supports the prescribing of syringes by health care providers to injection drug users who cannot or will not stop injecting, in order to prevent disease;
- Urges that, while prescription should not be required, all states that currently have laws prohibiting syringe prescription to injection drug users modify their laws so as to permit it; and urges states that criminalize possession of prescribed syringes for injection of illicit substances to modify their laws or policies to permit such possession;
- Urges medical training programs to educate their students about the importance of access to sterile syringes for injection drug users, including syringe prescription.
- Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas. Am J Public Health. 1996;86:642-54.
- Alter MJ, Moyer LA. The importance of preventing hepatitis C virus infection among injection drug users in the United States. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(Suppl 1):S6-10.
- Friedland GH, Selwyn PA. Infectious diseases (excluding AIDS) in injection drug users. In: Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, et al., eds. Harrison’s Principles of Internal Medicine. 14th ed. New York: McGraw-Hill; 1998:831-5.
- Centers for Disease Control and Prevention (CDC). A Comprehensive Approach: Prevention Blood-Bourne Infections Among Injection Drug Users. Online at: http://www.cdc.gov/idu/pubs/ca/toc.htm
- CDC, Fact Sheet: Physician Prescription of Sterile Syringes to Injection Drug Users. IDU/HIV Prevention. February 2002. Available online at: http://www.cdc.gov/idu/facts/physician.htm
- Normand J, Vlahov D, Moses LE. Preventing HIV Transmission: The Role of Sterile Needles and Bleach. Washington, DC: National Academy Pr; 1995.
- Karon JM, Fleming PL, Stekette RW, DeCock KM. HIV in the United States at the Turn of Century: An Epidemic in Transition. Am J Public Health. 2001;91(7):1060-1068.
- Friedman SR, Jose B, Neaigus A, Goldstein M, Mota P, Des Jarlais, DC. Multiple Minority status as an HIV risk factor among drug injectors. Int Conf AIDS, 9:811 (abstract no. PO-D05-3560), June 6-11, 1993.
- Kottiri BJ, Friedman SR, Neaigus A, et al. Risk networks and racial/ethnic differences in the prevalence of HIV infection among injection drug users. J Acq Immun Def Synd 30 (1): 95-104 May 1 2002
- U.S. Public Health Service. HIV Prevention Bulletin: Medical Advice for Persons Who Inject Illicit Drugs. Rockville, MD: U.S. Public Health Service; 8 May 1997.
- CDC, Fact Sheet: Access to Sterile Syringes. IDU/HIV Prevention; Jan 2002. Available online at: http://www.cdc.gov/idu/facts/aed_idu_acc.htm
- Lurie P et al. A sterile syringe for every drug user injection. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(Suppl I):S45-S51.
- Burris S, Lurie P, Abrahamson, D, Rich JD. Physician Prescribing of Sterile Injection Equipment To Prevent HIV Infection: Time for Action. Annals of Internal Medicine. 2000;133:(Number 3) 218-226.
- APHA Policy Statement: Syringe and Needle Exchange and HIV Disease. No. 9415
- APHA Policy Statement: Illicit Drug Use and HIV Protection. No. 8931
- Lurie P, Drucker E. An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA. Lancet. 1997;349:604-608.
- Rich JD, Macalino GE, McKenzie M, Burris S. Syringe Prescription to Prevent HIV Infection in Rhode Island: A Case Study. Am J Public Health. 2001;91(No. 5)1-2.
- Burris, S, et al., Legality of Prescribing and Dispensing Sterile Injection Equipment to IDUs to Prevent Disease Transmission. Available online at: http://www.temple.edu/lawschool/aidspolicy/default.htm. See also: Burris S, Lurie P, Ng M. Harm reduction in the health care system: the legality of prescribing and dispensing syringes to drug users. Health Matrix Clevel. 2001 Winter;11(1):5-64.
- Rich JD, Macalino G, Gaydos M, Stein J, Salas C, McKenzie M, Runnarsdottir V, Mehrotra M, Whitlock T, Burris S. The genesis of syringe prescription to prevent HIV in Rhode Island. 11 Health Matrix 129-145 (2001).
- Knowlton AR. Hoover DR. Chung SE. Celentano DD. Vlahov D. Latkin CA. Access to medical care and service utilization among injection drug users with HIV/AIDS. Drug & Alcohol Dependence. 64(1):55-62, 2001 Sep 1.
- Strathdee SA, Celentano DD, Shah N, Lyles C, Stambolis VA, Macalino G, Nelson K, Vlahov D. Needle Exchange Attendance and Health Care Utilization Promote Entry into Detoxification. J Urban Health, 1999; 76(4):448-459.
- Heimer, R. Can Syringe Exchange Serve as a conduit to Substance Abuse Treatment? Journal of Substance Abuse Treatment, 1998:15(3):183-191.
- Rich JD, McKenzie M, Macalino G, Mehrotra M, Gaydos ME, Stein J, Whitlock, Runarsdottir V. Physician Syringe Prescription as a Conduit to Substance Abuse Treatment: A Pilot Intervention. Addictions 2000 (poster presentation) Hyannis, Cape Code, MA, September 22-24, 2000
- Haverkos HW, Stein MD. Identifying Substance Abuse in Primary Care. Am Fam Physician, 1995 Nov 15;52(7):2029-35.
- O’Connor, P; Seilwyn, P; Schottenfeld, R. Medical Care for Injection Drug Users with HIV Infection. New Engl J Med, 1994:450-7.
- American Medical Association (AMA). Access to sterile syringes. Chicago (IL): AMA; June 2000; Available online at: http://www.ama-assn.org/ama/pub/category/1808.html.
- Massachusetts Medical Society (MMS), Physician Prescription of Sterile Syringes for Injection Drug Users Can Have Important Benefits. Vital Signs February 2002. Available online at: http://www2.mms.org/vitalsigns/feb02/ph1.html. Note: the MMS approved a stronger statement in support of physician prescription at their May 2002 meeting, not yet available for citation.
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