Needle exchange programs are one of the most well-known, and subsequently most controversial, forms of harm reduction in addiction medicine. These programs provide clean needles and/or syringes for drug users, often in exchange for used needles, in efforts to curb the unsanitary reuse of needles and subsequently decrease the spread of infectious diseases such as hepatitis and HIV. Needle exchange programs, on their own, have been shown to decrease HIV transmission rates. In medicine, we create and rely upon evidence-based practices and guidelines. Objective measures and data are paramount to the practice of medicine to ensure our treatments and interventions actually work. But in practices that contribute to unhealthy behaviors (i.e. drug use), is evidence the only measure that should matter?
The morality of the intervention must be considered as well, particularly in controversial interventions such as the distribution of drug paraphernalia in needles and syringes to minimize the risk of infectious diseases. If not explicitly, these programs at a minimum implicitly send the notion that injecting drugs is acceptable by supplying the means to do so. Regardless of the intent, this gives an individual struggling with substance use disorder a means to an end, continuing to feed their addiction.
We must focus our efforts on addressing the fundamental issue, treating the individual’s substance use disorder. Infectious diseases such as hepatitis and HIV from unsanitary injection practices are an adverse effect of the actual problem at hand, which is their substance use disorder. Collective efforts to engage these patients in treatment options such as buprenorphine-naloxone or methadone treatment while also supporting the clinics that provide these treatments has the potential to contribute to more lasting changes by addressing the true problem. As a society, we will never solve the crisis that is drug addiction through proposed solutions that only seek to reduce the harm and risks by allowing the ultimately detrimental behavior to continue.
In the health care workforce, there is significant work to be done to increase the availability of treatments for substance use disorders. Among prescribers, there is persistent stigma of buprenorphine that is held over from the days when an X-waiver was required to prescribe this medication. Unfortunately, the evidence shows that buprenorphine prescriptions have only increased slightly in the immediate aftermath of the X-waiver elimination. It is safe to say that the lack of increasing treatment with buprenorphine is not due to a lack of substance use disorder, although these patients’ access to care is often limited.
Additionally, most discussions surrounding needle exchange programs present a false choice: whether to have a needle exchange program or not. But what if instead of just not having one, the funds and energy that may have otherwise been devoted to an exchange program were funneled towards lasting solutions and resources to more definitively treat substance use disorder? It does not have to be a needle exchange program or nothing. We must use resources that would have been used in this way to treat the substance use disorder itself through the support and expansion of clinics, both standing and mobile, as well as health care professionals, offering this important treatment.
While drug overdose deaths have been declining since 2023, there is still an extraordinary amount of work to be done. Tens of thousands of Americans die every year from drug overdoses. Beyond their tragic deaths, substance use disorder destroys families, endangers communities, and is a driving factor in the issue of homelessness. The problems and consequences stemming from substance use are numerous, but they will only be demonstrably impacted by solutions that address the primary underlying issue itself. It is imperative that we move towards this goal as a society, for the health and betterment of our citizens, our communities, and ultimately, our nation.
Del Carter is a family medicine resident.
