Needle exchange programme
A needle and syringe programme (NSP), syringe-exchange programme (SEP), or needle exchange program (NEP) is a social service that allows injecting drug users (IDUs) to obtain hypodermic needles and associated paraphernalia at little or no cost. It is based on the philosophy of harm reduction that attempts to reduce the risk factors for diseases such as HIV/AIDS and hepatitis.
A comprehensive 2004 study by the World Health Organization (WHO) found a "compelling case that NSPs substantially and cost effectively reduce the spread of HIV among IDUs and do so without evidence of exacerbating injecting drug use at either the individual or societal level." WHO's findings have also been supported by the American Medical Association (AMA), which in 2000 adopted a position strongly supporting NSPs when combined with addiction counseling.
History and development
Needle-exchange programmes can be traced back to informal activities undertaken during the 1970s. The idea is likely to have been rediscovered in multiple locations. The first government-approved initiative (Netherlands) was undertaken in the early to mid-1980s, followed closely by other initiatives. While the initial programme was motivated by an outbreak of hepatitis B, the AIDS pandemic motivated the rapid adoption of these programmes around the world.
Harm reduction begins with the assumption that it is not reasonable to assume that individuals make healthy decisions. Advocates hold that those trapped in dangerous behaviors are often unable and/or unwilling to break free of them, and should at least be enabled to continue these behaviors in a less harmful manner. A tendency in the medical profession has been to treat drug dependency as a chronic illness like diabetes, hypertension and asthma, to be treated, evaluated and even insured in like manner.
NEPs typically support the health and well-being of people who use drugs through awareness, education, and empowerment; for example, programs in Australia use the community development (CD) discipline as a basis for their work. NEPs treat recreational drug use as a health issue and neither condemn nor condone the practice. Some US states ordinarily require a prescription to buy needles and syringes, as they are considered drug paraphernalia rather than medical equipment. NEPs provide access in such areas.
National District Attorneys Association (NDAA)'s view is that denial of human agency offends common sense as well as criminal statutes, in that adults are responsible for their actions. Where individual decisions impact public health and welfare, criminal sanctions are appropriate and necessary. Catholic Church doctrine asserts that harm reduction protocols treat persons as objects not in control of their own actions and gives the impression that certain types of irresponsible behavior have no moral content. Former US President George W. Bush wrote: "Drug use in America, especially among children, increased dramatically under the Clinton-Gore Administration, and needle exchange programs signal nothing but abdication, that these dangers are here to stay. Children deserve a clear, unmixed message that there are right choices in life and wrong choices in life, that we are responsible for our actions, and that using drugs will destroy your life."
It is estimated that the average annual cost of HIV care per person in the United States is US$15,745. Those with advanced HIV had an annual estimated cost of US$40,678. Depending on when infection is detected and when the treatment process begins, it is estimated that, as of November 2006, the total lifetime healthcare costs of HIV care are between US$303,000 and $619,000.
In addition to sterile needles, syringe-exchange programmes typically offer services such as HIV and Hepatitis C testing; alcohol swabs; bleach water and normal saline (often as eye drops); aluminium "cookers"; citric acid powder (an imperative agent that enables heroin to dissolve in water); containers for needles and many other items. A survey conducted by Beth Israel Medical Center in New York city and the North American Syringe Exchange Network, among 126 surveyed SEPs that 77% provided material abuse therapy, 72% provided voluntary counselling and HIV testing, and more than two-thirds provided supplies such as bleach, alcohol pads and male and female condoms.
According to the Centers for Disease Control (CDC), around 1/5 of all new HIV infections and the vast majority of Hepatitis C infections are the result of injection drug use.
Needle-exchange programmes are supported by the CDC and the National Institute of Health. The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C.
Proponents of harm reduction argue that the provision of a needle exchange provides a social benefit in reducing health costs and also provides a safe means to dispose of used syringes. For example, in the United Kingdom, proponents of SEPs assert that, along with other programs, they have reduced the spread of HIV among intravenous drug users. These supposed benefits have led to an expansion of these programmes in most jurisdictions that have introduced them, increasing geographical coverage and operating hours. Vending machines that automatically dispense injecting equipment "packs" have been successfully introduced.
Another advantage cited by program supporters is that SEPs protect both users and their support network such as attenders, sexual partners, children or neighbours. SEPs can also have an indirect influence to control transmission risks. Nurses are important for spreading knowledge about HIV among users. These programmes provide physical protection from HIV and facilitate education by teaching users about blood-borne pathogens as well as how to protect themselves and others.
Other promoted benefits of these programmes include providing a first point of contact for formal drug treatment, access to health and counselling service referrals, the provision of up-to-date information about safe injecting practices, access to contraception and sexual health services and providing a means for data collection from users about their behaviour and/or drug use patterns. SEP outlets in some settings offer basic primary health care. These are known as 'targeted primary health care outlets', because they primarily target people who inject drugs and/or 'low-threshold health care outlets', because they reduce common barriers to health care from the conventional health care outlets,. Clients frequently visit SEP outlets for help accessing sterile injecting equipment. These visits are used opportunistically to offer other health care services.
A clinical trial of needle exchange found that needle exchange did not cause an increase in drug injection. These findings were endorsed by then United States Surgeon General Davis Satcher, then Director of the National Institutes of Health Harold Varmus and then Secretary of the Department of Health and Human Services, Donna Shalala.
These services can take on a wide range of configurations:
- Primary needle and syringe programme ("stand alone" service)
- Secondary needle and syringe programme (such as incorporated within a pharmacy or health service)
- Mobile or on-call Service
- Dispensing machine distribution ("vending machine")
- Peer service: distribution networks
- Peer service: "flooding" or mass distribution
- Peer service: underground
- Prison-based facilities
- Distribution of bleach or other cleaning equipment (rather than needles and syringes)
- Ad hoc or informal distribution
Countries where these programmes exist include: Australia, Brazil, Canada, the Czech Republic, Netherlands, New Zealand, Norway, Portugal, Spain, Switzerland, United Kingdom, Ireland, Iran and the United States. In the United States such programmes may not receive federal funding, but this ban was briefly lifted in 2009 before being re-instated in 2010.
The Melbourne, Australia inner-city suburbs of Richmond and Abbotsford are locations in which the use and dealing of heroin has been concentrated. The Burnet Institute research organisation completed the 2013 'North Richmond Public Injecting Impact Study' in collaboration with the Yarra Drug and Health Forum and North Richmond Community Health Centre and recommended 24-hour access to sterile injecting equipment due to the ongoing "widespread, frequent and highly visible" nature of illicit drug use in the areas. Between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. In the surrounding City of Yarra, an average of 1,550 syringes per month were collected from public syringe disposal bins in 2012. Paul Dietze stated, "We have tried different measures and the problem persists, so it's time to change our approach".
On 28 May 2013, the Burnet Institute stated that it recommended 24-hour access to sterile injecting equipment in the Melbourne suburb of Footscray after the area's drug culture continued to grow after more than ten years of intense law enforcement efforts. The Institute's research concluded that public injecting behaviour is frequent in the area and injecting paraphernalia has been found in carparks, parks, footpaths and drives. Furthermore, people who inject drugs have broken into syringe disposal bins to reuse discarded equipment.
The British public body, the National Institute for Health and Care Excellence (NICE), introduced a recommendation in April 2014 due to an increase in the number of young people who inject steroids at UK needle exchanges. NICE previously published needle exchange guidelines in 2009, in which needle and syringe services were not advised for people under 18, but the organisation's director Professor Mike Kelly explained that a "completely different group" of people were presenting at programs. In the updated guidance, NICE recommended the provision of specialist services for “rapidly increasing numbers of steroid users”, and that needles should be provided to people under the age of 18—a first for NICE—following reports of 15-year-old steroid injectors seeking to develop their muscles.
Portland, Oregon was the first city in nation to expend public funds on a needle exchange which opened in 1989. It is also one of the longest running program in the country. Despite the word "exchange" in the program name, the Portland needle exchange operated by Multnomah County hands out syringes to addicts who do not present any to exchange. The exchange program reports 70% of their users are transients who experience "homelessness or unstable housing" It was reported that during the fiscal year 2015-2016, the county dispensed 2,478,362 syringes and received 2,394,460, a shortage of 83,902 needles.
As of 2011, at least 221 programs operated in the US. Most (91%) were legally authorized to operate; 38.2% were managed by their local health authorities.
More than 36 million syringes were distributed annually, mostly through large urban programs operating a stationary site. More generally, US NEPs distribute syringes through a variety of methods including mobile vans, delivery services and backpack/pedestrian routes that include secondary (peer-to-peer) exchange.
The use of federal funds for needle-exchange programs was banned in 1988, but this ban was overturned in 2009. In the time before the federal funding ban was re-instated in 2011, at least three programs were able to obtain federal funds and two thirds reported planning to pursue such funding. A 1997 study estimated that while the funding ban was in effect, it "may have led to HIV infection among thousands of IDUs, their sexual partners, and their children." US NEPs continue to be funded through a mixture of state and local government funds, supplemented by private donations. The funding ban was effectively lifted for every aspect of the exchanges except the needles themselves in the omnibus spending bill passed in December 2015 and signed by President Obama. This change was first suggested by Kentucky Republicans Hal Rogers and Mitch McConnell, according to their spokespeople.
Many states criminalized needle possession without a prescription, arresting people as they left private needle exchange facilities. In jurisdictions where syringe-prescription status presented a legal barrier, physician-based prescription programs showed promise. Epidemiological research demonstrating that syringe access programs are both effective and cost-effective helped to change state and local NEP-operation laws, as well as the status of syringe possession more broadly. As of 2006, 48 states authorized needle exchange in some form or allowed the purchase of sterile syringes without a prescription at pharmacies.
By 2012, legal syringe exchange programs existed in at least 35 states. In some settings, syringe possession and purchase is decriminalized, while in others, authorized NEP clients are exempt from certain drug paraphernalia laws. However, despite the legal changes, gaps between the formal law and environment mean that many programs continue to face law enforcement interference and covert programs continue to exist within the U.S.
Colorado allows covert syringe exchange programs to operate. Current Colorado laws leave room for interpretation over the requirement of a prescription to purchase syringes. Based on such laws, the majority of pharmacies do not sell syringes without a prescription and police arrest people who possess syringes without a prescription. Volunteer-run groups such as The Works (Boulder) and The Underground Syringe Exchange of Denver (the USED) operate covertly to avoid prosecution and are entirely funded by donations. Due to the illegal nature of the organization, the USED website specifies that new clients must be referred in order to exchange syringes. According to The Works website, between January 2012 and March 2012, the group received over 45,000 dirty needles and distributed around 45,200 sterile syringes.
Removal of legal barriers to the operation of NEPs and other syringe access initiatives has been identified as an important part of a comprehensive approach to reducing HIV transmission among IDUs. Legal barriers include both "law on the books" and "law on the streets," i.e., the actual practices of law enforcement officers, which may or may not reflect relevant law. Changes in syringe and drug control policy can be ineffective in reducing such barriers if police continue to treat syringe possession as a crime or participation in NEP as evidence of criminal activity.
Although most US NEPs operate legally, many report some form of police interference. In a 2009 national survey of 111 US NEP managers, 43% reported at least monthly client harassment, 31% at least monthly unauthorized confiscation of clients’ syringes, 12% at least monthly client arrest en route to or from NEP and 26% uninvited police appearances at program sites at least every 6 months. In multivariate modeling, legal status of the program (operating legally vs illegally) and jurisdiction’s syringe regulation environment were not associated with frequency of police interference. This finding confirms a substantial gap between law and law enforcement.
A detailed 2011 analysis of NEP client experiences in Los Angeles suggested that as many as 7% of clients report negative encounters with security officers in any given month. Given that syringes are not prohibited in the jurisdiction and their confiscation can only occur as part of an otherwise authorized arrest, almost 40% of those who reported syringe confiscation were not arrested. This raises concerns about extrajudicial confiscation of personal property. Approximately 25% of the encounters detailed by respondents involved private security personnel, rather than local police.
Similar findings have emerged internationally. For example, despite instituting laws protecting syringe access and possession and adopting NEPs, IDUs and sex workers in Mexico’s Northern Border regions report frequent syringe confiscation by law enforcement personnel. In this region as well as elsewhere, reports of syringe confiscation are correlated with increases in risky behaviors, such as groin injecting, public injection and utilization of pharmacies. These practices translate to risk for HIV and other blood-borne diseases.
NEPs serving predominantly IDUs of color may be almost 4 times more likely to report frequent client arrest en route to or from the program and almost 4 times more likely to report unauthorized syringe confiscation. A 2005 study in Philadelphia found that African-Americans accessing the city's legally operated exchange decreased at more than twice the rate of white individuals after the initiation of a police anti-drug operation. These and other findings illustrate a possible mechanism by which racial disparities in law enforcement can translate into disparities in HIV transmission. Notably, the majority (56%) of respondents reported not documenting adverse police events; those who did were 2.92 times more likely to report unauthorized syringe confiscation. These findings suggest that systematic surveillance and interventions are needed to address police interference.
Police interference with legal NEP operations may be partially explained by training defects. A study of police officers in an urban police department four years after the decriminalization of syringe purchase and possession in the US state of Rhode Island suggested that up to a third of police officers were not aware that the law had changed. This knowledge gap parallels other areas of public health law, underscoring pervasive gaps in dissemination.
Even police officers with accurate knowledge of the law, however, reported intention to confiscate syringes from drug users as a way to address problematic substance abuse. Police also reported anxiety about accidental needle sticks and acquiring communicable diseases from IDUs, but were not trained or equipped to deal with this occupational risk; this anxiety was intertwined with negative attitudes towards syringe access initiatives.
Training and interventions to address law enforcement barriers
US NEPs have successfully trained police, especially when framed as addressing police occupational safety and human resources concerns. Preliminary evidence also suggests that training can shift police knowledge and attitudes regarding NEPs specifically and public health-based approaches towards problematic drug use in general.
According to a 2011 survey, 20% of US NEPs reported training police during the previous year. Covered topics included the public health rationale behind NEPs (71%), police occupational health (67%), needle stick injury (62%), NEPs’ legal status (57%), and harm reduction philosophy (67%). On average, training was seen as moderately effective, but only four programs reported conducting any formal evaluation. Assistance with training police was identified by 72% of respondents as the key to improving police relations.
Organizations ranging from the NIH, CDC, the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organization and many others endorsed low-threshold programs including needle exchange.
Needle exchange programs have faced opposition on both political and moral grounds. Advocacy groups including the National District Attorneys Association (NDAA), Drug Watch International, The Heritage Foundation, Drug Free Australia, and so forth, religious organizations such as the Catholic Church, and many individuals in important policy-making positions have united to oppose these programs.
In the United States NEP programs have proliferated, despite lack of public acceptance. Internationally, needle exchange is widely accepted.
Needle exchanges have achieved acceptance by some churches and other religious groups, as the House of Bishops of the Episcopal Church, the Central Conference of American Rabbis, the Presbyterian Church and the Society of Christian Ethics.
Two 2010 ‘reviews of reviews’ by a team originally led by Norah Palmateer that examined systematic reviews and meta-analyses on the topic found insufficient evidence that NSP prevents transmission of the Hepatitis C virus, tentative evidence that it prevents transmission of HIV, and sufficient evidence that it reduces self-reported risky injecting behaviour. In a comment Palmateer warned politicians not to use her team's review of reviews as a justification to close existing programs or to hinder the introduction of new needle-exchange schemes. The weak evidence on the programs' disease prevention effectiveness is due to inherent design limitations of the reviewed primary studies and should not be interpreted as the programs lacking preventive effects.
The second of the Palmateer team's 'review of reviews' scrutinised 10 previous formal reviews of needle exchange studies, and after critical appraisal only four reviews were considered rigorous enough to meet the inclusion criteria. Those were done by the teams of Gibson (2001), Wodak and Cooney (2004), Tilson (2007) and Käll (2007). The Palmateer team judged that their conclusion in favour of NSP effectiveness was not consistent with the results from the HIV studies they reviewed.
The Wodak and Cooney review had, from 11 studies of what they determined as demonstrating acceptable rigour, found 6 that were positive regarding the effectiveness of NSPs in preventing HIV, 3 that were negative and 2 inconclusive. However a review by Käll et al. disagreed with the Wodak and Cooney review, reclassifying the studies on NSP effectiveness to 3 positive, 3 negative and 5 inconclusive. The US Institute of Medicine evaluated the conflicting evidence of both Drs Wodak and Käll in their Geneva session and concluded that although multicomponent HIV prevention programs that include needle and syringe exchange reduced intermediate HIV risk behavior, evidence regarding the effect of needle and syringe exchange alone on HIV incidence was limited and inconclusive, given "myriad design and methodological issues noted in the majority of studies." Four studies that associated needle exchange with reduced HIV prevalence failed to establish a causal link, because they were designed as population studies rather than assessing individuals.
NEPs successfully serve as one component of HIV prevention strategies. Multi-component HIV prevention programs that include NSE reduce drug-related HIV risk behaviors and enhance the impact of harm reduction services.
Tilson (2007) concluded that only comprehensive packages of services in multi-component prevention programs can be effective in reducing drug-related HIV risks. In such packages, it is unclear what the relative contribution of needle exchange may be to reductions in risk behavior and HIV incidence.
Multiple examples can be cited showing the relative ineffectiveness of needle exchange programs alone in stopping the spread of blood-borne disease. Many needle exchange programs do not make any serious effort to treat drug addiction. For example, David Noffs of the Life Education Center wrote, "I have visited sites around Chicago where people who request info on quitting their habit are given a single sheet on how to go cold turkey -- hardly effective treatment or counseling."
A 2013 systematic review found support for the use of NEPs to prevent and treat HIV and HCV infection. A 2014 systematic review and meta-analysis found evidence that NEPs were effective in reducing HIV transmission among injection drug users, but that other harm reduction programs have probably also contributed to the decrease in HIV incidence. NEPs appear to be as effective in low- and middle-income countries as in high-income ones.
Lemon and Shah presented a 2013 paper at the International Congress of Psychiatrists that highlighted lack of training for needle exchange workers and also showed the workers performing a range of tasks beyond contractual obligations, for which they had little support or training. It also showed how needle exchange workers were a common first contact for distressed drug users. Perhaps the most concerning finding was that workers were not legally allowed to provide Naloxone should it be needed.
According to a 2019 NBER paper by Miami University economist Analisa Packham, syringe exchange program reduce HIV rates up to 18.2 percent but lead to greater drug use. Syringe exchange programs increased drug-related mortality rates by 11.6 percent and opioid-related mortality rates by 25.4 percent.
Arguments for and against
- NSPs that only replace used needles reduce improper needle discards and all NSPs safely dispose of exchanged needles.
- The few studies that specifically evaluated the effects of NEPs produced "modest" evidence of no impact on improper needle discards and injection frequency and "weak" evidence on lack of impact on numbers of drug users, high-risk user networks and crime trends.
- Many NSPs do not operate on a strict one-for-one basis, increasing supply of both contaminated and sterile needles.
- A 2003 Australian bi-partisan Federal Parliamentary inquiry published recommendations, registering concern about the lack of accountability of Australia’s needle exchanges, and lack of a national program to track needle stick injuries. Community concern about discarded needles and needle stick injury led Australia to allocate $17.5 million in 2003/4 to investigating retractable technology for syringes.
Treatment program enrollment
- IDUs risk multiple health problems from non-sterile injecting practices, drug complications and associated lifestyle choices. Unrelated health problems such as diabetes may be neglected because of drug dependence. IDUs are typically reluctant to use conventional health services. Such reluctance/neglect implies poorer health and increased use of emergency services, creating added costs. Harm reduction based health care centers, also known as targeted health care outlet or low-threshold health care outlet for IDUs have been established to address this issue.
- NSP staff facilitate connections among people who use drugs and medical facilities, thereby exposing them to voluntary physical, psychological and emotional treatment programs.
- Social services for addicts can be organized around needle exchanges, increasing their accessibility.
As of 2011, CDC estimated that every HIV infection prevented through a needle exchange program saves an estimated US$178,000+. Separately it reported an overall 30 percent or more reduction in HIV cases among IDUs.
- Although participants in a needle exchange program may experience reduced HIV incidence, they can still die of causes such as overdose, collapsed veins, contaminated dope and street violence. Drug-addicted mothers will still deliver drug-addicted babies. Training drug addicts in safer injection protocols enables them to continue to support the violent and criminal drug trade. The root causes of addiction continue to be untreated. In a 1993 mortality study among 415 injection drug users in the Philadelphia area, over four years, 28 died: 5 from HIV-related causes; 7 from overdose, 5 from homicide, 4 from heart disease, 3 from renal failure, 2 from liver disease, 1 from suicide and 1 from cancer, showing that reducing harm from HIV was dominated by continuing harms from other causes.
- NSP effectiveness studies usually focused on addict health effects, while neglecting effects on the broader community. NSPs may encourage drug use, or increase the number of dirty needles.
- NSPs may concentrate drug activity into communities in which they operate. Only a small number of short-term studies considered whether NSPs have such effects. To the extent that this happens, they may negatively affect property values, increase localized crime rates and damage broader perceptions about the host community. In 1987 in Platzspitz Park. "...authorities chose to allow illegal drug use and sales at the park, in an effort to contain Zurich's growing drug problem. Police were not allowed to enter the park or make arrests. Clean needles were given out to addicts as part of the Zurich Intervention Pilot Project, or ZIPP-AIDS program. However, lack of control over what went on in the park caused a multitude of problems. Drug dealers and users arrived from all over Europe, and crime became rampant as dealers fought for control and addicts (who numbered up to 20,000) stole to support their habit."
- In Australia, which is considered a leading proponent of harm reduction, a survey showed that one-third of the public believed that NSPs encouraged drug use, and 20% believed that NSPs dispensed drugs.
- Wodak, A.; Cooney, A. (2004). "Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users" (PDF). World Health Organization. Retrieved 18 July 2013.
- Yoast, R.; Williams, M. A.; Deitchman, S. D.; Champion, H. C. (2001). "Report of the Council on Scientific Affairs". Journal of Addictive Diseases. 20 (2): 15–40. doi:10.1300/J069v20n02_03. PMID 11318395.
- Stancliff, S.; Agins, B.; Rich, J. D.; Burris, S. (2003). "Syringe access for the prevention of blood borne infections among injection drug users". BMC Public Health. 3: 37. doi:10.1186/1471-2458-3-37. PMC 317318. PMID 14633286.
- Ritter, A and Cameron, J (2006) A Systematic Review of Harm Reduction, Drug Policy Modeling Project, Monograph 06, Turning Point Alcohol and Drug Center, University of Melbourne, December.
- Souder, Mark. "Letter from Rep. Mark Souder to Dr. Elias A. Zerhouni, Director, National Institutes of Health". Retrieved 14 July 2013.
- "Drugs, Brains, and Behavior: The Science of Addiction". National Institute on Drug Abuse. Retrieved 14 July 2013.
- "Frontline: What is Addiction, and How Can We Treat It?". PBS. Retrieved 14 July 2013.
- "Welcome to Mainline Needle Exchange". Mainline. Mainline Needle Exchange. 16 July 2013. Archived from the original on 10 August 2014. Retrieved 16 July 2013.
- Dave Burrows. "Peer education and needle & syringe provision" (PDF). Australian Federation of AIDS Organisations. AFAO. Retrieved 16 July 2013.
- Franciscus, A. (2003). Retrieved March 18, 2012, from Archived June 26, 2013, at the Wayback Machine
- "Policy Positions on Drug Control and Enforcement" (PDF). National District Attorneys Association. Archived from the original (PDF) on 2010-11-25. Retrieved 13 July 2013.
- "Holy See opposes condoms, needle-exchange programs in fight against AIDS". CatholicCulture.org. Retrieved 13 July 2013.
- Bush, George W. "Response of Governor George W. Bush To the AIDS Foundation of Chicago" (PDF). Retrieved 14 July 2013.
- KA Gebo; et al. (26–28 March 2009). "Contemporary Costs of HIV Health Care in the HAART Era" (PDF). Presentation for 13th International Workshop on HIV Observational Databases March 26–28, 2009 Lisbon, Portugal. HIV Research Network. Retrieved 16 July 2013.
- Schackman, B. R., Gebo, K. A., Walensky, R. P., Losina, E., Muccio, T., Sax, P. E., Weinstein, M. C., Seage, G. R., Moore, R. D., Freedberg, K. A. The Lifetime Cost of Current Human Immunodeficiency Virus Care in the United States. Medical Care, November 2006; vol 44: pp 990-997. Retrieved from http://journals.lww.com/lww-medicalcare/Abstract/2006/11000/The_Lifetime_Cost_of_Current_Human.5.aspx
- "HIV/AIDS - Fact Sheets". Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. 2 July 2013. Archived from the original on 1 May 2013. Retrieved 16 July 2013.
- North American Syringe Exchange Network (2000). "2000 National Syringe Exchange Survey". Harm Reduction Coalition. Archived from the original on 2012-02-07.
- Centers for Disease Control and Prevention (CDC) (15 July 2005). "Update:Syringe Exchange Programs". MMWR Morb Mortal Wkly Rep. 54 (27): 673–6. PMID 16015218.
- National Institutes Of, Health (November 2002). "National Institutes of Health Consensus Development Conference Statement: Management of hepatitis C: 2002--June 10–12, 2002". Hepatology. 36 (5 Suppl 1): S3–20. doi:10.1002/hep.1840360703. PMID 12407572.
- Tilson, H.; et al. (2007). "Preventing HIV Infection Among Injecting Drug Users in High-Risk Countries". United States Institute of Medicine. Archived from the original on 2010-08-01. Retrieved 2010-01-09.
- Archived February 6, 2005, at the Wayback Machine
- McDonald, D. (2009). "The evaluation of a trial of syringe vending machines in Canberra, Australia". International Journal of Drug Policy. 20 (4): 336–339. doi:10.1016/j.drugpo.2008.06.004. PMID 18790622.
- Islam MM, Conigrave KM (2007). "Syringe vending machines as a form of needle syringe program: Advantages and Disadvantages". Journal of Substance Use. 12 (3): 203–12. doi:10.1080/14659890701249640.
- Islam MM, Stern T, Conigrave KM, Wodak A (January 2008). "Client satisfaction and risk behaviours of the users of syringe dispensing machines: a pilot study". Drug Alcohol Rev. 27 (1): 13–9. doi:10.1080/09595230701711199. PMID 18034377.
- Brooner R, Kidorf M, King V, Beilenson P, Svikis D, Vlahov D (June 1998). "Drug abuse treatment success among needle exchange participants". Public Health Rep. 113 Suppl 1 (Suppl 1): 129–39. PMC 1307735. PMID 9722818.
- Islam, MM, Topp, L, Day, CA, Dawson, A and Conigrave, KM (2012). "The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature". International Journal of Drug Policy. 23 (2): 94–102. doi:10.1016/j.drugpo.2011.08.005. PMID 21996165.CS1 maint: multiple names: authors list (link)
- Islam, MM, Topp, L, Day, CA, Dawson, A and Conigrave, KM (2012). "Primary healthcare outlets that target injecting drug users: Opportunity to make services accessible and acceptable to the target group". International Journal of Drug Policy. 23 (2): 109–110. doi:10.1016/j.drugpo.2011.11.001. PMID 22280917.CS1 maint: multiple names: authors list (link)
- Islam, MM, Reid, SE, White, A, Grummett, S, Conigrave, KM and Haber, PS (2012). "Opportunistic and continuing health care for injecting drug users from a nurse-run needle syringe program-based primary health-care clinic". Drug Alcohol Rev. 31 (1): 114–115. doi:10.1111/j.1465-3362.2011.00390.x. PMID 22145983.CS1 maint: multiple names: authors list (link)
- Islam, MM (July 2010). "Needle Syringe Program-Based Primary Health Care Centers: Advantages and Disadvantages". Journal of Primary Care & Community Health. 1 (2): 100–103. doi:10.1177/2150131910369684. PMID 23804370.
- Fisher DG, Fenaughty AM, Cagle HH, Wells RS (June 2003). "Needle exchange and injection drug use frequency: a randomized clinical trial". J. Acquir. Immune Defic. Syndr. 33 (2): 199–205. doi:10.1097/00126334-200306010-00014. PMID 12794555.
- "Surgeon General's Needle Exchange Review" (PDF). Archived from the original (PDF) on 2016-03-04. Retrieved 2016-02-08.
- Syringe/Needle Exchange Programs Archived 2016-04-03 at the Wayback Machine, DrugWarFacts, accessed 06-02-2010.
- Davis, C. S.; Beletsky, L. (2009). "Bundling occupational safety with harm reduction information as a feasible method for improving police receptiveness to syringe access programs: Evidence from three U.S. Cities". Harm Reduction Journal. 6: 16. doi:10.1186/1477-7517-6-16. PMC 2716314. PMID 19602236.
- Lucie Van Den Berg (20 May 2013). "Syringe machine push for addicts in Melbourne's heroin hot spots". The Australian. Retrieved 20 May 2013.
- Bridie Byrne (28 May 2013). "Drug experts propose needle vending machines for Footscray". Herald Sun Maribyrnong Leader. Retrieved 29 May 2013.
- Charlie Cooper (9 April 2014). "NICE: Needle exchanges should supply safe equipment to under-18 steroid users". The Independent. Retrieved 9 April 2014.
- Hayes, Elizabeth (May 15, 2018). "A legal site in Portland to inject heroin? Elected officials, advocates explore the idea". Portland Business Journal. Retrieved April 28, 2019.
- Hewitt, Lindsey (April 18, 2017). "Spike in discarded syringes littering Portland". Portland Tribune. Retrieved April 27, 2019.
Multnomah County will give up to 10 syringes to an individual who has none to exchange.
- "Questions about Syringe Exchange". Multnomah County. 2018-01-30. Retrieved 2019-04-28.
- Green TC, Martin E, Bowman S, Mann M, Beletsky, L (2012). "Life After the Ban: An Assessment of US Syringe Exchange Programs' Attitudes About and Early Experiences with Federal Funding". Am. J. Public Health. 102 (5): e9–e16. doi:10.2105/AJPH.2011.300595. PMC 3484785. PMID 22420810.CS1 maint: multiple names: authors list (link)
- Des Jarlais DC, McKnight C, Goldblatt C, Purchase D (2009). "Doing harm reduction better: syringe exchange in the United States" (PDF). Addiction. 104 (9): 1441–6. doi:10.1111/j.1360-0443.2008.02465.x. PMID 19215605. Archived from the original (PDF) on 2011-09-29. Retrieved 2012-07-05.
- Sharon, Susan (2009-12-09). "Ban Lifted On Federal Funding For Needle Exchange". NPR. Retrieved 2011-03-25.
- Lurie, P; Drucker, E (1 March 1997). "An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA". The Lancet. 349 (9052): 604–8. doi:10.1016/S0140-6736(96)05439-6. PMID 9057732.
- Ungar, Laura (7 January 2016). "Funding ban on needle exchanges effectively lifted". USA Today. Retrieved 25 January 2016.
- Case P, Meehan T, Jones TS (1998). "Arrests and incarceration of injection drug users for syringe possession in Massachusetts: implications for HIV prevention". J. Acquir. Immune Defic. Syndr. Hum. Retrovirol. 18 Suppl 1: S71–5. doi:10.1097/00042560-199802001-00013. PMID 9663627.
- GE Macalino; D Dhawan Sachdev; JD Rich; C Becker; LJ Tan; L Beletsky; S Burris. (2009). "A national physician survey on prescribing syringes as an HIV prevention measure". Substance Abuse Treatment, Prevention, and Policy. 4 (1): 13. doi:10.1186/1747-597X-4-13. PMC 2700789. PMID 19505336.
- S Burris; D Finucane; H Gallagher; J Grace (1996). "The legal strategies used in operating syringe exchange programs in the United States". Am. J. Public Health. 86 (8): 1161–6. doi:10.2105/ajph.86.8_pt_1.1161. PMC 1380633. PMID 8712281.
- Chris Barrish (10 June 2006). "To stop AIDS 'breeding ground' needle exchange a must, many say". The News Journal. pp. A1, A5. Archived from the original on 2 September 2006. Retrieved 2006-06-10. Note: this article contains a picture of the interior of a "shooting gallery"
- Beletsky L, Grau LE, White E, Bowman S, Heimer R (2011). "The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs". Addiction. 106 (2): 357–365. doi:10.1111/j.1360-0443.2010.03149.x. PMC 3088513. PMID 21054615.
- Beletsky L, Burris S, Macalino GE (2005). "Attitudes of Police Officers Towards Syringe Access, Occupational Needle-Sticks, and Drug Use: A Qualitative Study of One City Police Department in the United States". International Journal of Drug Policy. 16 (4): 267–274. doi:10.1016/j.drugpo.2005.01.009. SSRN 872756.
- Lune, H (December 2002). "Weathering the Storm: Non-profit Organization Survival Strategies in a Hostile Climate". Nonprofit and Voluntary Sector Quarterly. 31 (4): 463–83. doi:10.1177/0899764002238096.
- "Boulder County Public Health". Bouldercounty.org. Archived from the original on 6 June 2008. Retrieved 14 March 2012.
- Burris, S., Blankenship, K. M., Donoghoe, M., Sherman, S., Vernick, J. S., Case, P.; et al. (2004). "Addressing the 'Risk Environment' for Injection Drug Users: The Mysterious Case of the Missing Cop". Milbank Quarterly. 82 (1): 125–156. doi:10.1111/j.0887-378x.2004.00304.x. PMC 2690204. PMID 15016246. SSRN 937013.CS1 maint: multiple names: authors list (link)
- Beletsky L, Sorensen A, Wagner K, Davidson P (2011). "The State of the Row: Syringe Exchange Client's Experiences with Police and Private Security Personnel in Downtown Los Angeles". HHCLA.
- Beletsky L, Lozada R, Gaines T, et al. (April 2013). "Syringe confiscation as an HIV risk factor: the public health implications of arbitrary policing in Tijuana and Ciudad Juarez, Mexico". J. Urban Health. 90 (2): 284–98. doi:10.1007/s11524-012-9741-3. PMC 3675719. PMID 22806453.
- Strathdee SA, Lozada R, Martinez G, et al. (2011). "Social and structural factors associated with HIV infection among female sex workers who inject drugs in the Mexico-US border region". PLoS ONE. 6 (4): e19048. doi:10.1371/journal.pone.0019048. PMC 3081836. PMID 21541349.
- Davis CS, Burris S, Becher J, Lynch K, Metzger D (2005). "Effects of an Intensive Street-Level Police Intervention on Syringe Exchange Program Use in Philadelphia, PA". American Journal of Public Health. 95 (2): 233–236. doi:10.2105/AJPH.2003.033563. PMC 1449157. PMID 15671455.
- Iguchi MY, Bell J, Ramchand RN, Fain T (2005). "How criminal system racial disparities may translate into health disparities". J. Health Care Poor Underserved. 16 (4 Suppl B): 48–56. doi:10.1353/hpu.2005.0114. PMID 16327107.
- Burris S, Beletsky L, Burleson J, Case P, Lazzarini Z (2007). "Do Criminal Laws Influence HIV Risk Behavior? An Empirical Trial". Arizona State Law Journal. 2007 (3). SSRN 977274.
- Beletsky L, Agrawal A, Moreau B, Kumar P, Weiss-Laxer N, Heimer R (2011). "Police training to align law enforcement and HIV prevention: preliminary evidence from the field". Am. J. Public Health. 101 (11): 2012–2015. doi:10.2105/AJPH.2011.300254. PMC 3222387. PMID 21940924.
- Beletsky L, Grau LE, White E, Bowman S, Heimer R (2011). "Prevalence, characteristics, and predictors of police training initiatives by US SEPs: Building an evidence base for structural interventions". Drug and Alcohol Dependence. 119 (1–2): 145–149. doi:10.1016/j.drugalcdep.2011.05.034. PMC 3192926. PMID 21705159.
- "Interventions to prevent HIV risk behaviors". NIH Consensus Statement. 15 (2): 1–41. 1997. PMID 9505959.
- "Syringe Exchange Programs" (PDF). Centers for Disease Control. Retrieved 26 March 2012.
- "ABA Urges Federal Support for Syringe Exchange Programs". American Bar Association. Retrieved 26 March 2012.
- Stapleton, Stephanie (1997). "AMA endorses needle-exchange programs". American Medical News.
- "Needle Exchange Programs: Position Statement" (PDF). American Psychological Association. Retrieved 26 March 2012.
- "Drug use and HIV/AIDS" (PDF). Joint United Nations Programme on HIV/AIDS. Retrieved 26 March 2012.
- "Drug Watch International Position Statement: Needle Handouts to Addicts". Drug Watch International. Archived from the original on 3 December 2008. Retrieved 13 July 2013.
- Loconte, Joe (July–August 1998). "Killing Them Softly" (PDF). Policy Review: 14–22. Retrieved 13 July 2013.
- "Needle Exchange and Hepatitis C". Drug Free Australia. Archived from the original on 4 May 2013. Retrieved 13 July 2013.
- Bowen, E. A. (2012). "Clean Needles and Bad Blood: Needle Exchange as Morality Policy" (PDF). Journal of Sociology and Social Welfare. 39 (2): 121–141. Archived from the original (PDF) on 27 July 2014. Retrieved 20 July 2013.
- Friedman, Sara (23 March 2008). "Needle Exchange Gets Religion". Religion Dispatches. Archived from the original on 20 July 2013. Retrieved 20 July 2013.
- Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D (May 2010). "Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews". Addiction. 105 (5): 844–59. doi:10.1111/j.1360-0443.2009.02888.x. PMID 20219055.
- Amy Norton (March 11, 2010). "Do needle-exchange programs really work?". Reuters Health. Retrieved October 18, 2011.
- Kimber J, Palmateer N, Hutchinson S, Hickman M, Goldberg D, Rhodes T, EMCDDA Monograph 10 ‘Harm Reduction – Impacts, Evidences and Challenges, Chapter 5 "Harm reduction among injecting drug users — evidence of Effectiveness". 2010. Retrieved July 1, 2013.
- Gibson, D. R.; Flynn, N. M.; Perales, D. (2001). "Effectiveness of syringe exchange programs in reducing HIV risk behavior and HIV seroconversion among injecting drug users". AIDS. 15 (11): 1329–1341. doi:10.1097/00002030-200107270-00002. PMID 11504954.
- Käll, K.; Hermansson, U.; Amundsen, E. J.; Rönnbäck, K.; Rönnberg, S. (2007). "The Effectiveness of Needle Exchange Programmes for HIV Prevention - A Critical Review" (PDF). The Journal of Global Drug Policy and Practice. 1 (3). Archived from the original (PDF) on 18 October 2015. Retrieved 6 July 2013.
- Wodak, A. (2005). "Do needle syringe programmes assist control of HIV among injecting drug users?" (PDF). Retrieved 2013-07-01. 2006
- Käll, K. (2005). "What science tells us about needle exchange programs" (PDF). Retrieved 2013-07-01. 2006
- Tilson, H. (committee chair) (2005). "Meeting 1: Prevention of HIV Infection among Injecting Drug Users in High Risk Countries". Archived from the original on 2013-07-03. Retrieved 2013-07-01. 2006
- Rhodes, T.; Hedrich, D. (2010). "Chapter 1: Harm reduction and the mainstream" (PDF). EMCDDA Monographs: Harm reduction: evidence, impacts and challenges. European Monitoring Centre for Drugs and Drug Addiction. ISBN 978-92-9168-419-9. Retrieved 20 July 2013.
- "Q: Should needle exchange be publicly funded?". PBS Online. Archived from the original on 24 September 2013. Retrieved 14 July 2013.
- Abdul-Quader, Abu S.; Feelemyer, Jonathan; Modi, Shilpa; Stein, Ellen S.; Briceno, Alya; Semaan, Salaam; Horvath, Tara; Kennedy, Gail E.; Des Jarlais, Don C. (22 August 2013). "Effectiveness of Structural-Level Needle/Syringe Programs to Reduce HCV and HIV Infection Among People Who Inject Drugs: A Systematic Review". AIDS and Behavior. 17 (9): 2878–2892. doi:10.1007/s10461-013-0593-y. PMC 6509353. PMID 23975473.
- Aspinall, EJ; Nambiar, D; Goldberg, DJ; Hickman, M; Weir, A; Van Velzen, E; Palmateer, N; Doyle, JS; Hellard, ME; Hutchinson, SJ (February 2014). "Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis". International Journal of Epidemiology. 43 (1): 235–48. doi:10.1093/ije/dyt243. PMID 24374889.
- Des Jarlais, DC; Feelemyer, JP; Modi, SN; Abdul-Quader, A; Hagan, H (19 January 2013). "High coverage needle/syringe programs for people who inject drugs in low and middle income countries: a systematic review". BMC Public Health. 13: 53. doi:10.1186/1471-2458-13-53. PMC 3567947. PMID 23332005.
- Lemon, T. I.; Shah, R. (2013). "Needle exchanges: An important yet forgotten outpost in suicide and self-harm prevention". Journal of Psychosomatic Research. 74 (6): 551–552. doi:10.1016/j.jpsychores.2013.03.057.
- Packham, Analisa (2019). "Are Syringe Exchange Programs Helpful or Harmful? New Evidence in the Wake of the Opioid Epidemic". doi:10.3386/w26111. Cite journal requires
- Franciscus, Alan. "Needle Exchange - A Matter of Public Health". Hepatitis C Support Project. Archived from the original on 26 June 2013. Retrieved 20 July 2013.
- "Road to recovery: Report on the inquiry into substance abuse in Australian communities". Australian House of Representatives Standing Committee on Family and Community Affairs. Retrieved 6 July 2013.
- "Drug-injecting hotspot near Collingwood childcare center". Melbourne Leader. 8 March 2010. Archived from the original on 23 October 2010. Retrieved 2010-05-01.
- Latt, N.; Conigrave, K.; Marshall, J.; Saunders, J.; Marshall, J.; Nutt, D. (2009). Addiction Medicine. Oxford University Press. ISBN 9780199539338. Archived from the original on 2011-06-04.
- McCoy, C. B.; Metsch, L. R.; Chitwood, D. D.; Miles, C. (2001). "Drug use and barriers to use of health care services". Substance Use & Misuse. 36 (6–7): 789–806. doi:10.1081/ja-100104091. PMID 11697611.
- McDonald, P (2002). "From streets to sidewalks: developments in primary care services for injecting drug users". Australian Journal of Primary Health. 8: 65–69. doi:10.1071/PY02010.
- "Needle Exchange and Harm Reduction". Avert. Avert. 2013. Retrieved 16 July 2013.
- Des Jarlais, D. C.; McKnight, C.; Goldblatt, C.; Purchase, D. (2009). "Doing harm reduction better: Syringe exchange in the United States". Addiction. 104 (9): 1441–1446. doi:10.1111/j.1360-0443.2008.02465.x. PMID 19215605.
- "Needle exchange options; pros and cons". Canada.com. 21 March 2008. Archived from the original on 24 September 2015. Retrieved 20 July 2013.
- McLean, K (2011). "The biopolitics of needle exchange in the United States". Critical Public Health. 21 (1): 71–79. doi:10.1080/09581591003653124. PMC 3291106. PMID 22389572.
- Aaron, Lawrence (2005-08-26). "Why a Needle-Exchange Program is a Bad Idea". redOrbit.com. Retrieved 26 March 2012.
- Perkins, Joseph (27 Sep 2000). "False Compassion: Needles". The Rockmart Journal. Retrieved 14 July 2013.
- Woody, G. E.; Metzger, D. S. (1993). "Causes of Death in Injection-Drug Users". New England Journal of Medicine. 329 (22): 1661. doi:10.1056/NEJM199311253292220. PMID 8232452.
- "Needle Exchange FAQs". Ontario Harm Reduction Distribution Program. Archived from the original on December 30, 2011.
- Keyl, P. M.; Gruskin, L.; Casano, K.; Montag, H.; Junge, B.; Vlahov, D. (1998). "Community support for needle exchange programs and pharmacy sale of syringes: A household survey in Baltimore, Maryland". Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 18 Suppl 1: S82–S88. doi:10.1097/00042560-199802001-00015. PMID 9663629.
- Williams, C. T.; Ouellet, L. J. (2010). "Misdirected opposition: Evidence opposing "not in my back yard" arguments against syringe exchange programmes". International Journal of Drug Policy. 21 (5): 437–439. doi:10.1016/j.drugpo.2010.02.003. PMID 20233654.
- Strike, C. J.; Myers, T.; Millson, M. (2004). "Finding a place for needle exchange programs" (PDF). Critical Public Health. 14 (3): 261–275. CiteSeerX 10.1.1.495.4618. doi:10.1080/09581590400004386. Retrieved 14 July 2013.
- Islam, M. M. (2010). "Needle Syringe Program-Based Primary HealthCare Centers: Advantages and Disadvantages". Journal of Primary Care & Community Health. 1 (2): 100–103. doi:10.1177/2150131910369684. PMID 23804370.
- "Community consulted for the first time on attitudes towards drugs" (PDF). Anex. Archived from the original (PDF) on 28 July 2014. Retrieved 26 March 2012.