Syringe Prescription Study Unexpected Bonus: Helping Long-Time Users Quit Drugs.

A pilot study in Rhode Island, allowing physicians to prescribe syringes in order to reduce that state's exceptionally high rate of HIV infection among injection drug users, not only reduced needle sharing as hoped, but also helped some patients get into drug treatment programs and quit their drug abuse entirely. These people had been injecting drugs for a median of 10 years. A description of the project appeared in May issue of the American Journal of Public Health. [1]

On May 4 we spoke to principal investigator Josiah D. Rich, M.D., M.P.H., an infectious-disease specialist. He explained that until recently Rhode-Island had one of the harshest syringe laws in the nation. Possession of each syringe was a felony punishable by up to five years in prison, and the average sentence for possession of syringes alone was 11 months. As a result drug users often did not carry syringes but re-used those available where they bought their drugs, and Rhode Island is one of only four states where more than 50% of AIDS cases are due to injecting drugs. And the state spent was spending over a million of dollars a year arresting, trying, and imprisoning people for syringes.

A coalition of medical organizations and others worked to change the law, and they won a partial victory in 1998; possession of syringes was reduced to a misdemeanor, but they remained illegal (until 2000) and drug users had difficulty getting sterile syringes. Lobbyists said it would take at least two years to change the law again. Evaluation of the law revealed that doctors could prescribe syringes if approved by the state Department of Health; a drug user could have a prescription and buy and possess syringes legally, like a diabetic. So a study, the Rhode Island Blood Borne Pathogen Harm Reduction Program, was designed to see if prescribing syringes would help to reduce sharing and HIV transmission.

The program began when the director of the Rhode Island Department of Health, with the support of many medical organizations, wrote to all licensed physicians in the state, inviting them to join the program under certain conditions. At this time the program employs four physicians at two locations in Providence, Rhode Island and has enrolled 350 drug users and prescribed 50,000 syringes. The published report is preliminary, as data are still coming in, but it appears that needle re-use has dropped dramatically and that the syringes are being disposed of properly.

The surprise for researchers was the great interest among these hard-core users not only in obtaining the syringes, but also in getting into drug treatment. There was an overwhelming response, despite the fact that those who approached the program were very high risk, with most of them having injected illegal drugs for at least 10 years. Half were homeless. A large majority had hepatitis C, and many had hepatitis B as well.

"What is most remarkable is that these long-time users were very interested in drug treatment -- half said did want treatment to help them stop using drugs. We do not ask immediately. We take a medical history, do a physical, and discuss the findings. We tell them that their behavior is very dangerous because of the risk of infectious diseases, overdose, and other lifestyle problems. I recommend, as their doctor, that we work together to try to get them to stop.

"But if they are not able or willing to stop at this time, I teach them sterile technique that doctors use for injection -- including the use of a sterile syringe.

"They come to us to ask for syringes. So they have to admit that they inject drugs, and here there are no negative consequences to admitting that they are injecting drugs. Who else can have this discussion with them? Usually the people they talk to about their drug use -- their dealer, pimp, or peers -- have a vested interest in them continuing to use drugs.

"This program has a unique window into peoples' lives. We can ask them, if you decide to stop, what would you do? Would you go to detox? What was your experience in detox last time? What if there are no beds now -- would you just give up?

"It is most rewarding when patients come in and say they do not need syringes -- that they have looked at their lives and stopped their drug use because they are tired of what it is doing to them. We see that as doctors, we can really help these people."

This is the first time that a physician syringe prescription program has ever been tried (although a few physicians have prescribed syringes to individual patients). The May 2001 article [1] includes recommendations for those who want to try such a program elsewhere -- starting with knowing the local legal situation. [2]

From the article: [1]

"Because of the illicit nature of drug use, a tremendous amount of mistrust and fear often leads to poor interaction with the medical establishment. Prescription of syringes by a physician can serve as a tool for reaching out to a high-risk and often out-of-treatment population of drug users. It is a way for the health care community to tap into drug-using networks and bring those populations into a medical care system..."

"That the physician-patient interaction is based on the acknowledgement of injecting behaviors engenders trust and seems to open the door for discussion of a whole host of injecting-related activities, including commercial sex, participation in the underground economy, violence, and abuse. The participants seem to be open and honest about their drug use.

They understand that physicians are trying to help them in a non-judgmental way and are quite appreciative of the efforts. Participants are extremely willing to participate in health care including hepatitis B vaccination; testing for hepatitis, HIV, and other sexually transmitted diseases; and followup."

This study was funded in part by the American Foundation for AIDS Research (AmFAR).

References

(1.) Rich JD, Macalino GE, McKenzie M, Taylor LE, and Burris S. Syringe prescription to prevent HIV infection in Rhode Island: A case study. American Journal of Public Health. May 2001; volume 91, number 5, pages 1-2.

(2.) Burris S, Lurie P, Abrahamson D, and Rich JD. Physician prescribing of sterile injection equipment to prevent HIV infection: Time for action. Annals of Internal Medicine. August 1, 2000; volume 133, number 3, pages 218-226.