I am a Senior Fellow at the Cato Institute where I work in the Department of Health Policy Studies. My areas of scholarship and public policy research include the opioid overdose problem, the unintended consequences of drug prohibition, and pharmaceutical regulatory reform. I have published numerous articles as well as a recent policy analysis on these subjects.
I attended Brooklyn College of the City University of New York from 1969 to 1973 and received a BA (1969) in biology. I then attended New York Medical College from 1973 to 1976, in an accelerated three-year program, receiving an MD in 1976 at which time I was inducted into Alpha Omega Alpha (the national Medical School Academic Honor Society). Upon completing my residency training I began a solo private practice as a General Surgeon in Phoenix, Arizona. I received my certification by the American Board of Surgery as a specialist in General Surgery in 1982, and shortly thereafter became a Fellow of the American College of Surgeons. In addition to my private community-based practice, I served on the trauma team at the John C. Lincoln Medical Center Trauma Center from 1981 to 1983 and served on the voluntary teaching faculty of the Maricopa County Medical Center General Surgery Residency Program from 1981 to 1985. In 1986 I joined with two other General Surgeons to form Valley Surgical Clinics, Ltd., a group general surgery practice serving multiple hospitals in metropolitan Phoenix. I am currently the senior member of that group practice. My background in public policy scholarship, particularly as it relates to the opioid overdose problem, combined with my total of forty-two years of experience in the treatment of acute and chronic surgical illnesses, including infectious illnesses, qualify me as an expert on the matter in question.
In December 2018 the Cato Institute published my policy analysis entitled, “Harm Reduction: Shifting From a War on Drugs to a War on Drug-Related Deaths.” In that paper, I examine the decades of evidence and experience that point to the advantages of Safe Syringe Services programs in reducing drug overdoses, reducing the spread of HIV, hepatitis, and other blood-borne infectious diseases and promoting and facilitating the treatment and rehabilitation of patients suffering from substance abuse disorder. The first needle exchange program was developed in the Netherlands in the 1970s in response to an outbreak of hepatitis B. The idea gained acceptance in other countries with the advent of the AIDS pandemic.
The oldest continuous needle exchange program in the United States started operating Tacoma, WA in 1988.1 By the end of 2018 needle exchange programs were operating in 39 states plus the District of Columbia and Puerto Rico.2 In many states, needle exchange centers are in clinics that offer referral for addiction therapy and counseling. But to increase outreach, some programs operate mobile vans or delivery services or have centers along pedestrian routes.3 In addition to offering referral for treatment or counseling, many offer HIV and hepatitis testing, male and female condoms, bleach and alcohol to clean drug paraphernalia, and fentanyl test strips.4 Recently many needle exchange programs have been distributing free kits of naloxone, the antidote to opioid overdose.5
Seven federally funded studies conducted between 1991 and 1997 found needle exchange programs reduce the risk of HIV infections among intravenous drug users and their partners.6 A 2013 systematic review conducted by the US Centers for Disease Control and Prevention confirmed that needle exchange programs are associated with a decreased prevalence of HIV and hepatitis C infections.7 A 2014 systematic review and meta-analysis of 12 studies comprising 12,000 person-years found that needle exchange programs coincide with a 34 percent reduction in the rate of HIV transmission, with a 58 percent reduction among the six studies that were of a “higher quality.”8
Needle exchange programs also offer the prospect of reducing state and local government health care expenditures related to the spread of communicable and infectious diseases. Researchers in Australia concluded that “not only did [needle exchange programs] reduce the incidence of HIV by up to 74 percent over a 10-year period in Australia, but found that they were cost-saving and had a return on investment of between $1.3 and $5.5 for every $1 invested.”9
A 2017 White paper by the West Virginia Department of Health and Human Resources Bureau for Public Health cited studies estimating that 15 to 33 percent of HIV cases could be averted through needle exchange programs, with a cost savings of between $20,947 and $34,278 per HIV case averted.10 And a November 2019 study published in the Journal of Acquired Immune Deficiency Syndrome found nearly 10,000 new cases of HIV were averted over a 10 year period in Philadelphia, with an estimated annual savings of $243.4 million, as a result of the city’s syringe services program. Baltimore’s syringe services program averted 1900 new cases of HIV over a 10 year period with an estimated annual savings of $62.4 million.11 Much of these costs are born by the Arizona Health Care Cost Containment System.
The Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a bibliography of needle exchange programs on its website and endorses needle exchange programs for their “efficacy and facilitating entry into treatment for intravenous drug users and thereby reducing illicit drug use.”12 The CDC endorses and promotes the implementation of needle exchange programs with guidance and, in some cases, financial assistance to local jurisdictions.13 The World Health Organization, the American Medical Association, the American Public Health Association, the American Society of Addiction Medicine, and the American Psychiatric Association all support and encourage needle exchange programs.14 Last year, in a visit to Phoenix the Surgeon General who, as Indiana’s health commissioner, promoted needle exchange programs in response to a rural HIV epidemic in that state, reiterated his support for needle exchange programs.15 Local law enforcement community members are increasingly recognizing the value of needle exchange programs in decreasing the spread of communicable and infectious disease as well as protecting first responders from accidental injury from contaminated needles.16
On January 15, 2020, the Cato Institute hosted a Policy Forum in Washington, DC featuring Jerome Adams, MD, MPH, Surgeon General of the United States. He shared with the audience his success as Indiana State Health Commissioner under then Governor Mike Pence responding to an outbreak of HIV in rural Scott County by establishing syringe services programs. Dr. Adams told the audience that syringe services programs are “proven to decrease needles found in public areas and reduce needle sticks to first responders by 60 percent.” He also reported participants in syringe services programs are “five times more likely to enter drug treatment and 3.5 times more likely to cease injecting compared to those who don’t use syringe services programs.” This last point was personally meaningful to the Surgeon General, whose brother is currently serving a 10-year prison sentence for crimes related to his heroin addiction.
At the same Policy Forum, Professor Ricky N. Bluthenthal of the University of Southern California Keck School of Medicine told participants syringe services programs have been shown to reduce needle sharing, with no risk of an increase in improper syringe disposal. He also pointed out that, while 30 states plus the District of Columbia have needle exchange programs, not all needle exchange programs are created equal. Some have severe restrictions in place requiring a declaration of a public health emergency by a public health official, often including time limits. Such restriction severely hinders the effectiveness in reducing overdose, the spread of HIV and hepatitis, and bringing people who are addicted into treatment. The fewer the restrictions, the more effectively the program can function.
One week after the Policy Conference, the National Academy of Sciences, Engineering, and Medicine (NASEM) issued a report recommending that, “States should lift the remaining bans on evidence‐based syringe services, offering syringe services at publicly funded health departments and allowing for independently operated syringe service programs.”17
Despite this broad support based upon convincing evidence, many states have drug paraphernalia laws that inhibit exchange programs.18 Arizona is one of those states.
Thus, in a 2009 national survey, a significant number of programs reported that police confiscate syringes and even arrest clients on their way to and from needle exchange centers, with confiscation and arrests reported more than four times more frequently in areas where needle exchange program clients were predominantly people of color.19
The House Health Committee is presently considering legislation to remove the barriers to the operation of needle exchange programs, allowing them to continue their work in the open, offering clean needles and syringes, referring clients for treatment and counseling, and increasing access to naloxone.
Critics view needle exchange programs as flouting the law, express discomfort with what they see as government sanctioning of intravenous drug use and other illegal activities and argue that these sites do little to deter illegal drug use. These concerns are understandable, but the evidence shows needle exchange programs save lives by reducing the spread of deadly and infectious diseases, not only to other intravenous drug users, but to intimate contacts who are not engaging in illicit drug use, and possibly to first responders as well. And now, with the advent of state laws facilitating the wider distribution of naloxone, needle exchange programs hold the promise of reducing overdose deaths as well.
In his State of the Union Address on February 5, 2019, President Trump set a national goal of ending the epidemic of HIV in the United States by 2030. The decriminalization, facilitation, and encouragement of needle exchange and safe syringe services programs throughout the country will make a major contribution toward reaching that goal.
It is my strong opinion that the overall health and well-being of the people of Arizona would benefit significantly if safe syringe services and needle exchange programs were fully decriminalized. They would see a reduction in the risk of the spread of hepatitis, HIV, and other blood-borne infectious diseases and would also likely see a savings to health-related expenditures funded by the taxpayers of the state.
Respectfully submitted,
Jeffrey A. Singer, MD, FACS
Senior Fellow
Cato Institute
