Editing Needle and syringe programmes

{{Short description|Method of providing drug users with uninfected equipment}}
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{{Update |Legal Aspects|date=July 2013}}
{{Infobox medical intervention
| name         = Needle exchange programme
| synonym      = Syringe-exchange programme (SEP), needle exchange program (NEP)
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| caption      = Contents of a needle-exchange kit
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A '''needle and syringe programme''' ('''NSP'''), also known as '''needle exchange program''' ('''NEP'''), is a [[social service]] that allows [[Drug injection|injection]] drug users (IDUs) to obtain clean and unused [[hypodermic needle]]s and associated [[paraphernalia]] at little or no cost. It is based on the philosophy of [[harm reduction]] that attempts to reduce the [[Risk factor (epidemiology)|risk factor]]s for blood-borne [[disease]]s such as [[HIV/AIDS]] and [[hepatitis]].

== History==
[[File:Sharps container - cropped.jpg|thumb|[[Sharps container|"Sharps" container]] (for safe disposal of hypodermic needles)]]

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 initiatives in the [[United Kingdom]] and [[Australia]] by 1986.<ref name="ANCD">{{cite web |title=Australia commemorates 20 years of needle syringe programs |url=http://www.atoda.org.au/wp-content/uploads/2018/01/Australia-commemorates-20-years-of-needle-syringe-programs.pdf |website=atoda.org.au |publisher=Australian National Council on Drugs |access-date=4 April 2023 |archive-url=https://web.archive.org/web/20230310061135/http://www.atoda.org.au/wp-content/uploads/2018/01/Australia-commemorates-20-years-of-needle-syringe-programs.pdf |archive-date=10 March 2023 |date=17 December 2014 |url-status=live}}</ref> 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.<ref>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.</ref>

== Operation ==
Needle and syringe programs operate differently in different parts of the world; the first NSPs in Europe and Australia gave out sterile equipment to drug users, having begun in the context of the early AIDS epidemic. The United States took a far more reluctant approach, typically requiring IDUs to already have used needles to exchange for sterile ones - this "one-for-one" system is where the same number of [[syringe]]s must be returned.<ref name=":3">Public Health Impact of Needle Exchange Programs in the United States and Abroad. (1993). United States: University of California, Berkeley, School of Public Health</ref>{{Rp|192}}

According to [[Santa Cruz County, California]], exchange staff interviewed by ''Santa Cruz Local'' in 2019, it is a common practice not to count the number of exchanged needles exactly, but rather to estimate the number based on a container's volume.<ref>{{Cite web|last=Guzman|first=Kara Meyberg|date=2019-05-24|title=What we learned from looking at Santa Cruz County's needle exchange|url=https://santacruzlocal.org/2019/05/24/what-we-learned-from-looking-at-santa-cruz-countys-needle-exchange/|access-date=2020-10-10|website=Santa Cruz Local}}</ref> [[Holyoke, Massachusetts]], also uses the volume system.<ref>{{Cite web|date=2017-07-23|title=How needle exchange program needles get counted in Holyoke|url=https://www.masslive.com/news/2017/07/tapestry_healths_needle_exchan.html|access-date=2020-10-10|website=masslive.com}}</ref> United Nations Office on Drugs and Crime for South Asia suggests visual estimation or asking the client how many they brought back.<ref>{{Cite web|last=Thangsing|first=Chinkholal|year=2012|title=Needle syringe exchange program for injecting drug users|url=https://www.unodc.org/documents/southasia/publications/sops/needle-syringe-exchange-program-for-injecting-drug-users.pdf}}</ref> The volume-based method left potential for [[gaming the system]] and an exchange agency in [[Vancouver]] devoted significant effort to game the system.<ref>{{Cite book|last=Lupick|first=Travis|url=https://books.google.com/books?id=pKNoDwAAQBAJ&pg=PT140|title=Fighting for Space: How a Group of Drug Users Transformed One City's Struggle with Addiction|date=2018-06-05|publisher=arsenal pulp press|isbn=978-1-55152-713-0|quote=That left room to game the system, to which Stuerzbecher devoted significant time. "Kerstin spent hours measuring and counting needles in those disposal bins with markings on the side...}}</ref>{{Rp|140}}

Some, such as the [[Columbus Public Health]] in Ohio weigh the returned sharps rather than counting.<ref>{{Cite web|title=Discarded needles may be unintended side effect of needle access program|url=https://www.10tv.com/article/news/investigations/10-investigates/discarded-needles-may-be-unintended-side-effect-needle-access-program/530-33bdf0df-8713-4a9e-bf15-13310361571f|access-date=2020-10-10|website=10tv.com|date=20 November 2017}}</ref>

The practices and policies vary between needle and syringe program sites. In addition to exchange, there is a model called "needs-based" where the syringes are handed out without requiring any to be returned.<ref>{{Cite web|date=July 2019|title=North Dakota Department of Health Syringe Service Program Requirements & Guidance|url=https://www.ndhealth.gov/hiv/Docs/SEP/ND.SSP.FINAL.072019.pdf}}</ref>{{Rp|15–16}}

According to a report published in 1994, Montreal's CACTUS exchange which has a policy of one-for-one, plus one needle with a limit of 15 had a return rate of 75-80% between 1991 and 1993.<ref>{{Cite book|last=Programs|first=National Research Council (US) and Institute of Medicine (US) Panel on Needle Exchange and Bleach Distribution|url=https://www.ncbi.nlm.nih.gov/books/NBK236647/|title=Evaluating Montréal's Needle Exchange CACTUS-Montréal|date=1994|publisher=National Academies Press (US)}}</ref>

An exchange in [[Boulder, Colorado]], implemented a one-for-one with four starter needles and reported an exchange rate of 89.1% in 1992.<ref name=":3" />{{Rp|391}}

In the United States, where the one-for-one system still dominates, some 25% of injecting drug users are living positive with HIV; in Australia, which hands out equipment for free to anyone needing it (only charging a small fee for some more expensive equipment, like wheel filters and higher-quality tourniquets), only 1% of the IDU population is HIV-positive as of 2015, compared to over 20% in the late 1980s when NSP programs began to spread nationally and became accessible to most of the population.<ref name="ANCD"/>

== International experience ==
Programs providing sterile needles and syringes currently operate in 87 countries around the world.<ref>{{Cite web|title=Global State of Harm Reduction - 2021 Update|url=https://www.hri.global/global-state-of-harm-reduction-2021|access-date=2021-12-30|website=Harm Reduction International}}</ref> IA 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."<ref name="Wodak20042">{{cite web|title=Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users|url=https://www.who.int/hiv/pub/prev_care/effectivenesssterileneedle.pdf|author1=Wodak, A.|author2=Cooney, A.|year=2004|publisher=World Health Organization|access-date=18 July 2013}}</ref> 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.<ref>{{Cite journal|last1=Yoast|first1=R.|last2=Williams|first2=M. A.|last3=Deitchman|first3=S. D.|last4=Champion|first4=H. C.|year=2001|title=Report of the Council on Scientific Affairs|journal=Journal of Addictive Diseases|volume=20|issue=2|pages=15–40|doi=10.1300/J069v20n02_03|pmid=11318395|s2cid=23406146}}</ref><ref>{{Cite journal|last1=Stancliff|first1=S.|last2=Agins|first2=B.|last3=Rich|first3=J. D.|last4=Burris|first4=S.|year=2003|title=Syringe access for the prevention of blood borne infections among injection drug users|journal=BMC Public Health|volume=3|pages=37|doi=10.1186/1471-2458-3-37|pmc=317318|pmid=14633286 |doi-access=free}}</ref>

=== Australia ===
The Melbourne, Australia, inner-city suburbs of Richmond, and [[Abbotsford, New South Wales|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 was 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".<ref>{{cite news|title=Syringe machine push for addicts in Melbourne's heroin hot spots|url=http://www.theaustralian.com.au/news/syringe-machine-push-for-addicts-in-melbournes-heroin-hot-spots/story-e6frg6n6-1226646482548|access-date=20 May 2013|newspaper=The Australian|date=20 May 2013|author=Lucie Van Den Berg}}</ref>

On 28 May 2013, the Burnet Institute stated that it recommended 24-hour access to sterile injecting equipment in the Melbourne suburb of [[Footscray, Victoria|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.<ref>{{cite news|title=Drug experts propose needle vending machines for Footscray|url=http://www.heraldsun.com.au/leader/west/drug-experts-propose-needle-vending-machines-for-footscray/comments-fngnvmj7-1226651497633|access-date=29 May 2013|newspaper=Herald Sun Maribyrnong Leader|date=28 May 2013|author=Bridie Byrne}}</ref>

A study commissioned by the Australian Government revealed that for every [[Australian dollar|A$]]1 invested in NSPs in Australia, $4 was saved in direct healthcare costs,<ref name="ROI">{{cite web |date=2009 |title=Evaluating the cost-effectiveness of needle and syringe programs in Australia |url=https://www.acon.org.au/wp-content/uploads/2015/04/Evaluating-the-cost-effectiveness-of-NSP-in-Australia-2009.pdf |url-status=live |archive-url=https://web.archive.org/web/20230323160725/https://www.acon.org.au/wp-content/uploads/2015/04/Evaluating-the-cost-effectiveness-of-NSP-in-Australia-2009.pdf |archive-date=23 March 2023 |access-date=4 April 2023 |website=ancon.org.au |publisher=Australian Department of Health and Aging}}</ref> and if productivity and economic benefits are included, the programs returned a staggering $27 for every $1 invested. The study notes that over a longer time horizon than that considered (10 years) the cost-benefit ratio grows even further. In terms of infections averted and lives saved, the study finds that, between 2000 and 2009, 32,000 HIV infections and 96,667 hepatitis C infections were averted, and approximately 140,000 [[disability-adjusted life year]]s were gained.<ref name="ROI"/>

=== United Kingdom ===
{{expand section|date=April 2014}}

From the 1980s, [[Maggie Telfer]] from the Bristol Drugs Project advocated for needle exchanges to be established in the United Kingdom.<ref>{{cite news |last1=Ayres |first1=Rachel |title=Maggie Telfer obituary |url=https://www.theguardian.com/politics/2023/apr/21/maggie-telfer-obituary |website=[[The Guardian]] |date=21 April 2023 |access-date=23 April 2023}}</ref> 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 [[steroid]]s 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 programmes. 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.<ref>{{cite news|title=NICE: Needle exchanges should supply safe equipment to under-18 steroid users|url=https://www.independent.co.uk/life-style/health-and-families/health-news/nice-needle-exchanges-should-supply-safe-equipment-to-under18-steroid-users-9247087.html |archive-url=https://ghostarchive.org/archive/20220618/https://www.independent.co.uk/life-style/health-and-families/health-news/nice-needle-exchanges-should-supply-safe-equipment-to-under18-steroid-users-9247087.html |archive-date=2022-06-18 |url-access=subscription |url-status=live|access-date=9 April 2014|newspaper=The Independent|date=9 April 2014|author=Charlie Cooper}}</ref>

=== United States ===
The first program in the United States to be operated at public expenses was established in [[Tacoma, Washington]] in November 1988.<ref>{{Cite book |last1=DiClemente |first1=Ralph J. |url=https://books.google.com/books?id=WzqzwiHUVtIC&pg=PA216 |title=Preventing AIDS: Theories and Methods of Behavioral Interventions |last2=Peterson |first2=John L. |date=1994-03-31 |publisher=Springer Science & Business Media |isbn=978-0-306-44606-1 |language=en}}</ref><ref>{{Cite journal |last1=Sherman |first1=Susan G. |last2=Purchase |first2=Dave |date=2001-04-01 |title=Point Defiance: a case study of the United States' first public needle exchange in Tacoma, Washington |url=https://linkinghub.elsevier.com/retrieve/pii/S0955395900000748 |journal=International Journal of Drug Policy |volume=12 |issue=1 |pages=45–57 |doi=10.1016/S0955-3959(00)00074-8 |pmid=11275503 |issn=0955-3959|url-access=subscription }}</ref> The [[Centers for Disease Control and Prevention]] and the [[National Institutes of Health]] confirm that needle exchange is an effective strategy for the prevention of HIV.<ref name="United States 2005" /><ref name="United States 2002">{{cite journal |pmid=12407572 |journal=Hepatology |date=November 2002 |volume=36|issue=5 Suppl 1|pages=S3–20 |title=National Institutes of Health Consensus Development Conference Statement: Management of hepatitis C: 2002--June 10–12, 2002 |doi=10.1002/hep.1840360703 |last1=National Institutes Of |first1=Health|doi-access=free}}</ref> The NIH estimated in 2002 that in the United States, 15–20% of injection drug users have HIV and at least 70% have hepatitis C.<ref name="United States 2002" /> The [[Centers for Disease Control]] (CDC) reports one-fifth of all new HIV infections and the vast majority of hepatitis C infections are the result of injection drug use.<ref name="United States 2005">{{cite journal |title=Update:Syringe Exchange Programs |date=15 July 2005 |volume=54 |issue=27 |pages=673–6 |journal=MMWR Morb Mortal Wkly Rep |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5427a1.htm |pmid=16015218 |author1=Centers for Disease Control and Prevention (CDC)}}</ref> [[United States Department of Health and Human Services]] reports 7%, or 2,400 cases of HIV infections in 2018 were among drug users.<ref>{{Cite web|date=2020-06-30|title=U.S. Statistics|url=https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics|access-date=2020-10-10|website=HIV.gov}}</ref>

[[Portland, Oregon]], was the first city in nation to expend public funds on a NSP which opened in 1989.<ref>{{Cite news|url=https://www.bizjournals.com/portland/news/2018/03/15/a-legal-site-in-portland-to-inject-heroin-elected.html|title=A legal site in Portland to inject heroin? Elected officials, advocates explore the idea|last=Hayes|first=Elizabeth|date=May 15, 2018|work=Portland Business Journal|access-date=April 28, 2019}}</ref> It is also one of the longest running programme in the country.<ref name=":0">{{Cite news|url=https://pamplinmedia.com/pt/9-news/354711-234196-spike-in-discarded-syringes-littering-portland|title=Spike in discarded syringes littering Portland|last=Hewitt|first=Lindsey|date=April 18, 2017|work=Portland Tribune|access-date=April 27, 2019|quote=Multnomah County will give up to 10 syringes to an individual who has none to exchange.}}</ref> Despite the word "exchange" in the programme name, the Portland needle exchange operated by [[Multnomah County, Oregon|Multnomah County]] hands out syringes to addicts who do not present any to exchange.<ref name=":0" /> The exchange programme reports 70% of their users are transients who experience "homelessness or unstable housing"<ref>{{Cite web|url=https://multco.us/hiv-and-std-services/questions-about-syringe-exchange|title=Questions about Syringe Exchange|date=2018-01-30|website=Multnomah County|access-date=2019-04-28}}</ref> 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.<ref name=":0" /> In 2016, it was reported that the [[Cleveland]] needle exchange program sees "mostly white suburban kids ages 18 to 25".<ref>{{Cite web|author=<!--Staff writer(s); no by-line.-->|title=Needle exchange program sees mostly white suburban kids ages 18 to 25|url=https://www.cleveland19.com/story/32057159/needle-exchange-program-aims-to-stop-spread-of-disease|access-date=2020-09-29|website=Cleveland 19|date=25 May 2016 }}</ref>

==== San Francisco ====
Since the full sanction of syringe exchange programs (SEP) by then-Mayor [[Frank Jordan]] in 1993, the San Francisco Department of Public Health has been responsible for the management of syringe access and the proposed disposal of these devices in the city. This sanction, which was originally executed as a state of emergency to address the HIV epidemic, allowed SEPs to provide sterile syringes, take back used devices, and operate as a service for health education to support individuals struggling with [[substance use disorder]]s. Since then, it was approximated that from July 1, 2017, to December 31, 2017, only 1,672,000 out of the 3,030,000 distributed needles (60%) were returned to the designated sites.<ref name="sfw">{{Cite news|url=http://www.sfweekly.com/news/s-f-pins-down-its-needle-problem/|title=S.F. Pins Down Its Needle Problem - April 25, 2018 - SF Weekly|date=2018-04-25|work=SF Weekly|access-date=2018-11-02}}</ref> In April 2018, acting Mayor [[Mark Farrell (politician)|Mark Farrell]] allocated $750,000 towards the removal of abandoned needles littering the streets of San Francisco.<ref name="sfw" />

==== General characteristics ====
As of 2011, at least 221 programmes operated in the US.<ref name="Green TC, Martin E, Bowman S, Mann M, Beletsky, L 2012 e9-e16">{{cite journal |vauthors=Green TC, Martin E, Bowman S, Mann M, Beletsky L |title=Life After the Ban: An Assessment of US Syringe Exchange Programs' Attitudes About and Early Experiences with Federal Funding|journal=Am. J. Public Health |volume=102 |issue=5 |pages=e9–e16 |year=2012 |doi=10.2105/AJPH.2011.300595|pmid=22420810|pmc=3484785}}</ref> Most (91%) were legally authorized to operate; 38.2% were managed by their local health authorities.<ref name="Green TC, Martin E, Bowman S, Mann M, Beletsky, L 2012 e9-e16"/><ref name="Des Jarlais DC, McKnight C, Goldblatt C, Purchase D. 2009 1441–6">{{cite journal |vauthors=Des Jarlais DC, McKnight C, Goldblatt C, Purchase D |title=Doing harm reduction better: syringe exchange in the United States. |journal=Addiction |url=http://www.nasen.org/site_media/files/nasec2010/ddj_2009DoingHarmReductionBetterSEPintheUS.pdf |access-date=2012-07-05 |volume=104 |issue=9 |pages=1441–6 |year=2009 |doi=10.1111/j.1360-0443.2008.02465.x |pmid=19215605 |archive-url=https://web.archive.org/web/20110929103921/http://www.nasen.org/site_media/files/nasec2010/ddj_2009DoingHarmReductionBetterSEPintheUS.pdf |archive-date=2011-09-29 |url-status=dead}}</ref> The CDC reported in 1993 that the most significant expenses for the NSPs is personnel cost, which reports it represents 66% of the budget.<ref>{{Cite web|title=The Public Health Impact of Needle Exchange Programs in the United States and Abroad Summary, Conclusions and Recommendations|url=https://stacks.cdc.gov/view/cdc/11203/cdc_11203_DS1.pdf?|date=1993|website=CDC}}</ref>

More than 36 million syringes were distributed annually, mostly through large urban programmes operating a stationary site.<ref name="Green TC, Martin E, Bowman S, Mann M, Beletsky, L 2012 e9-e16"/> More generally, US NEPs distribute syringes through a variety of methods including mobile vans, delivery services and backpack/pedestrian routes<ref name="Des Jarlais DC, McKnight C, Goldblatt C, Purchase D. 2009 1441–6"/> that include secondary (peer-to-peer) exchange.

==== Funding ====

In the United States, a ban on federal funding for needle exchange programs began in 1988, when republican North Carolina Senator [[Jesse Helms]] led Congress to enact a prohibition on the use of federal funds to encourage drug abuse.<ref name=":5">{{Cite journal|last=Weinmeyer|first=Richard|date=2016-03-01|title=Needle Exchange Programs' Status in US Politics|url=https://journalofethics.ama-assn.org/article/needle-exchange-programs-status-us-politics/2016-03|journal=AMA Journal of Ethics|volume=18|issue=3|pages=252–257|doi=10.1001/journalofethics.2016.18.3.hlaw1-1603|pmid=27002996 |issn=2376-6980|doi-access=free}}</ref> The ban was briefly lifted in 2009, reinstated in 2010, and partially lifted again in 2015. Currently, federal funds can still not be used for the purchase of needles and syringes or other injecting paraphernalia by needle exchange programs, though can be used for training and other program support in the case of a declared public health emergency.<ref name="Davis C, Beletsky L 2009">{{Cite journal|last1=Davis|first1=C. S.|last2=Beletsky|first2=L.|year=2009|title=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|journal=Harm Reduction Journal|volume=6|pages=16|doi=10.1186/1477-7517-6-16|pmc=2716314|pmid=19602236 |doi-access=free}}</ref><ref name=":5" /><ref>{{Cite web|date=2019-07-08|title=Federal Funding for Syringe Services Programs|url=https://www.cdc.gov/ssp/ssp-funding.html|access-date=2020-08-23|website=cdc.gov}}</ref> In the time between 2010 and 2011 when no ban was in place, at least three programmes were able to obtain federal funds and two-thirds reported planning to pursue such funding.<ref name="Green TC, Martin E, Bowman S, Mann M, Beletsky, L 2012 e9-e16"/> 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."<ref>{{cite journal|last1=Lurie|first1=P|last2=Drucker|first2=E|title=An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA.|journal=The Lancet |date=1 March 1997|volume=349|issue=9052|pages=604–8|pmid=9057732|doi=10.1016/S0140-6736(96)05439-6|s2cid=37080993}}</ref> US NEPs continue to be funded through a mixture of state and local government funds, supplemented by private donations.<ref name="Des Jarlais DC, McKnight C, Goldblatt C, Purchase D. 2009 1441–6"/> 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.<ref>{{cite web | url=https://www.usatoday.com/story/news/nation/2016/01/07/funding-ban-needle-exchanges-effectively-lifted/78420894/ | title=Funding ban on needle exchanges effectively lifted | work=USA Today | date=7 January 2016 | access-date=25 January 2016 | author=Ungar, Laura}}</ref>

==== Legal aspects ====
Many states criminalized needle possession without a prescription, arresting people as they left underground needle exchange efforts.<ref>{{cite journal |vauthors=Case P, Meehan T, Jones TS |title=Arrests and incarceration of injection drug users for syringe possession in Massachusetts: implications for HIV prevention |journal=J. Acquir. Immune Defic. Syndr. Hum. Retrovirol. |volume=18 |pages=S71–5 |year=1998 |issue=Suppl 1 |pmid=9663627 |doi=10.1097/00042560-199802001-00013|doi-access=free}}</ref> In some jurisdictions, such as New York, needle exchange activists challenged the laws in court, with judges ruling that their actions were justified by a "necessity defense" which permits breaking of a law to prevent an imminent harm.<ref>{{Cite news|last=Sullivan|first=Ronald|date=1991-06-26|title=Needle-Exchangers Had Right to Break Law, Judge Rules|work=The New York Times|url=https://www.nytimes.com/1991/06/26/nyregion/needle-exchangers-had-right-to-break-law-judge-rules.html|access-date=2021-12-30|issn=0362-4331}}</ref> In other jurisdictions where syringe possession without a prescription remained illegal, physician-based prescription programmes have shown promise.<ref>{{cite journal |author1=GE Macalino |author2=D Dhawan Sachdev |author3=JD Rich |author4=C Becker |author5=LJ Tan |author6=L Beletsky |author7=S Burris. |title=A national physician survey on prescribing syringes as an HIV prevention measure. |journal=Substance Abuse Treatment, Prevention, and Policy|volume=4 |issue=1 |year=2009 |doi=10.1186/1747-597X-4-13 |pages=13 |pmid=19505336 |pmc=2700789 |doi-access=free}}</ref> Epidemiological research demonstrating that syringe access programmes 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.<ref name="S Burris, D Finucane, H Gallagher, and J Grace 1996 1161–6">{{cite journal |author1=S Burris |author2=D Finucane |author3=H Gallagher |author4=J Grace |title=The legal strategies used in operating syringe exchange programs in the United States. |journal=Am. J. Public Health |volume=86 |year=1996 |pmc=1380633 |pmid=8712281 |issue=8 |pages=1161–6 |doi=10.2105/ajph.86.8_pt_1.1161}}</ref> For example, between 1989 and 1992, three exchanges in [[New York City]] tagged syringes to help demonstrate rates of return prior to the legalization of the approach.<ref>{{Cite book|last1=Programs|first1=National Research Council (US) and Institute of Medicine (US) Panel on Needle Exchange and Bleach Distribution|url=https://www.ncbi.nlm.nih.gov/books/NBK232350/|title=Needle Exchange and Bleach Distribution Programs in the United States|last2=Normand|first2=Jacques|last3=Vlahov|first3=David|last4=Moses|first4=Lincoln E.|date=1995|publisher=National Academies Press (US)}}</ref>

By 2012, legal syringe exchange programmes existed in at least 35 states.<ref name="Green TC, Martin E, Bowman S, Mann M, Beletsky, L 2012 e9-e16"/> In some settings, syringe possession and purchase is decriminalized, while in others, authorized NEP clients are exempt from certain drug paraphernalia laws.<ref name="Beletsky L, Grau LE, White E, Bowman S, Heimer R. 2011">{{cite journal |vauthors=Beletsky L, Grau LE, White E, Bowman S, Heimer R |title=The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs. |journal=Addiction |volume=106 |issue=2 |year=2011 |doi=10.1111/j.1360-0443.2010.03149.x |pmid=21054615 |pmc=3088513 |pages=357–365}}</ref> However, despite the legal changes, gaps between the formal law and environment mean that many programmes continue to face law enforcement interference<ref name="Beletsky L, Burris S, Macalino GE. 2005 267–274">{{cite journal |vauthors=Beletsky L, Burris S, Macalino GE |title=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. |journal=International Journal of Drug Policy |ssrn=872756|volume=16 |issue=4 |pages=267–274 |year=2005 |doi=10.1016/j.drugpo.2005.01.009|s2cid=57946984}}</ref> and covert programmes continue to exist within the U.S.<ref>{{cite journal |author=Lune, H |date=December 2002 |title=Weathering the Storm: Non-profit Organization Survival Strategies in a Hostile Climate |journal=Nonprofit and Voluntary Sector Quarterly |volume=31 |issue=4 |pages=463–83 |doi=10.1177/0899764002238096|s2cid=145472945}}</ref>

Colorado allows covert syringe exchange programmes 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.<ref>[http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102187404.html]{{dead link|date=March 2012}}</ref> Boulder County health department reports between January 2012 and March 2012, the group received over 45,000 dirty needles and distributed around 45,200 sterile syringes.<ref>{{cite web |url=http://www.bouldercounty.org/health/hpe/STI/exchange.htm |archive-url=https://web.archive.org/web/20080606023305/http://www.bouldercounty.org/health/hpe/STI/exchange.htm |url-status=dead |archive-date=6 June 2008 |title=Boulder County Public Health |publisher=Bouldercounty.org |access-date=14 March 2012}}</ref>

As of 2017, NSPs are illegal in 15 states.<ref name=":4">{{Cite web|last=Lopez|first=German|date=2018-06-22|title=Needle exchanges have been proved to work against opioid addiction. They're banned in 15 states.|url=https://www.vox.com/science-and-health/2018/6/22/17493030/needle-exchanges-ban-state-map|access-date=2020-10-10|website=Vox}}</ref> NSPs are prohibited by local regulations in cities in [[Orange County, California]],<ref>{{Cite web|title=Court order all but bans mobile needle exchange program in Costa Mesa, other O.C. cities|url=https://www.latimes.com/socal/daily-pilot/news/story/2019-10-25/court-order-all-but-bans-mobile-needle-exchange-program-in-costa-mesa-other-o-c-cities|date=2019-10-26|website=Daily Pilot|access-date=2020-05-24}}</ref> even though it is not disallowed by state law in California.<ref name=":4" />

== Law enforcement ==

=== Conflict with law enforcement ===
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.<ref name="S Burris, D Finucane, H Gallagher, and J Grace 1996 1161–6"/> Legal barriers include both "law on the books" and "law on the streets", i.e., the actual practices of [[law enforcement]] officers,<ref name="Beletsky L, Burris S, Macalino GE. 2005 267–274"/><ref>{{cite journal |vauthors=Burris S, Blankenship KM, Donoghoe M, Sherman S, Vernick JS, Case P|title=Addressing the 'Risk Environment' for Injection Drug Users: The Mysterious Case of the Missing Cop. |journal=Milbank Quarterly |ssrn=937013 |volume=82 |issue=1 |pages=125–156 |year=2004 |doi=10.1111/j.0887-378x.2004.00304.x|pmid=15016246 |display-authors=etal|pmc=2690204}}</ref> 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.<ref name="Beletsky L, Grau LE, White E, Bowman S, Heimer R. 2011"/>

Although most US NEPs operate legally, many report some form of police interference.<ref name="Beletsky L, Grau LE, White E, Bowman S, Heimer R. 2011"/> 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 six 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.<ref name="Beletsky L, Grau LE, White E, Bowman S, Heimer R. 2011"/>

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.<ref name="Beletsky L, Sorensen A, Wagner K, Davidson P. 2011">{{cite journal |vauthors=Beletsky L, Sorensen A, Wagner K, Davidson P |title=The State of the Row: Syringe Exchange Client's Experiences with Police and Private Security Personnel in Downtown Los Angeles. |journal=HHCLA |year=2011}}</ref>

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.<ref name=":1" /> These practices translate&nbsp;to risk for HIV and other blood-borne diseases.<ref name=":1">{{cite journal |vauthors=Beletsky L, Lozada R, Gaines T, etal |title=Syringe confiscation as an HIV risk factor: the public health implications of arbitrary policing in Tijuana and Ciudad Juarez, Mexico |journal=J. Urban Health |volume=90 |issue=2 |pages=284–98 |date=April 2013 |pmid=22806453 |pmc=3675719 |doi=10.1007/s11524-012-9741-3}}</ref><ref>{{cite journal |vauthors=Strathdee SA, Lozada R, Martinez G, etal |title=Social and structural factors associated with HIV infection among female sex workers who inject drugs in the Mexico-US border region |journal=PLOS ONE |volume=6 |issue=4 |pages=e19048 |year=2011 |pmid=21541349 |pmc=3081836 |doi=10.1371/journal.pone.0019048|bibcode=2011PLoSO...619048S |doi-access=free}}</ref>

=== Racial gradient ===
NEPs serving predominantly IDUs of color may be almost four times more likely to report frequent client arrest en route to or from the program and almost four times more likely to report unauthorized syringe confiscation.<ref name="Beletsky L, Grau LE, White E, Bowman S, Heimer R. 2011"/> 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.<ref>{{cite journal |vauthors=Davis CS, Burris S, Becher J, Lynch K, Metzger D |title=Effects of an Intensive Street-Level Police Intervention on Syringe Exchange Program Use in Philadelphia, PA |journal=American Journal of Public Health |volume=95 |issue=2 |year=2005 |doi=10.2105/AJPH.2003.033563 |pmid=15671455 |pmc=1449157 |pages=233–236}}</ref> These and other findings illustrate a possible mechanism by which racial disparities in law enforcement can translate into disparities in HIV transmission.<ref name="Beletsky L, Sorensen A, Wagner K, Davidson P. 2011"/><ref>{{cite journal |vauthors=Iguchi MY, Bell J, Ramchand RN, Fain T |title=How criminal system racial disparities may translate into health disparities. |journal=J. Health Care Poor Underserved |volume=16 |issue=4 Suppl B |pages=48–56|year=2005 |pmid=16327107 |doi=10.1353/hpu.2005.0114|s2cid=40700366}}</ref> 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.<ref name="Beletsky L, Burris S, Macalino GE. 2005 267–274"/>

=== Causes ===
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.<ref name="Beletsky L, Burris S, Macalino GE. 2005 267–274"/> This knowledge gap parallels other areas of public health law, underscoring pervasive gaps in dissemination.<ref>{{cite journal |vauthors=Burris S, Beletsky L, Burleson J, Case P, Lazzarini Z |title=Do Criminal Laws Influence HIV Risk Behavior? An Empirical Trial |journal=Arizona State Law Journal |ssrn=977274 |volume=2007 |issue=3 |year=2007}}</ref>

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 use.<ref name="Beletsky L, Burris S, Macalino GE. 2005 267–274"/> 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.<ref name="Davis C, Beletsky L 2009"/> 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.<ref>{{cite journal |vauthors=Beletsky L, Agrawal A, Moreau B, Kumar P, Weiss-Laxer N, Heimer R |title=Police training to align law enforcement and HIV prevention: preliminary evidence from the field.|journal=Am. J. Public Health |volume=101 |issue=11 |pages=2012–2015 |year=2011 |doi=10.2105/AJPH.2011.300254|pmid=21940924|pmc=3222387}}</ref>

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 programmes reported conducting any formal evaluation. Assistance with training police was identified by 72% of respondents as the key to improving police relations.<ref name="Beletsky L, Grau LE, White E, Bowman S, Heimer R. 2011 145–149">{{cite journal |vauthors=Beletsky L, Grau LE, White E, Bowman S, Heimer R |title=Prevalence, characteristics, and predictors of police training initiatives by US SEPs: Building an evidence base for structural interventions |journal=Drug and Alcohol Dependence |volume=119 |issue=1–2 |pages=145–149 |year=2011 |doi=10.1016/j.drugalcdep.2011.05.034|pmid=21705159 |pmc=3192926}}</ref>

== Advocacy ==
{{Globalize|section|United States|date=July 2020}}
Organizations ranging from the NIH,<ref name=NIH1997>{{Cite journal | title = Interventions to prevent HIV risk behaviors | journal = NIH Consensus Statement | volume = 15 | issue = 2 | pages = 1–41 | year = 1997 | pmid = 9505959}}</ref> CDC,<ref name=CDC2005>{{cite web|title=Syringe Exchange Programs|url=https://www.cdc.gov/idu/facts/aed_idu_syr.pdf|publisher=Centers for Disease Control|access-date=26 March 2012}}</ref> the [[American Bar Association]],<ref name=ABA2011>{{cite web|title=ABA Urges Federal Support for Syringe Exchange Programs|url=http://www.americanbar.org/publications/governmental_affairs_periodicals/washingtonletter/2011/april/syringeexchange.html|publisher=American Bar Association|access-date=26 March 2012}}</ref> the [[American Medical Association]],<ref>{{cite journal|last=Stapleton|first=Stephanie|title=AMA endorses needle-exchange programs|journal=American Medical News|year=1997}}</ref> the [[American Psychological Association]],<ref name=AmPsych2003>{{cite web|title=Needle Exchange Programs: Position Statement|url=http://www.psych.org/Resources/OfficeofHIVPsychiatry/HIVPolicy/PositionStatementonNeedleExchangePrograms.aspx?FT=.pdf|publisher=American Psychological Association|access-date=26 March 2012}}</ref> the [[World Health Organization]]<ref name=UNAIDS>{{cite web|title=Drug use and HIV/AIDS|url=http://data.unaids.org/publications/IRC-pub03/una99-1_en.pdf|publisher=Joint United Nations Programme on HIV/AIDS|access-date=26 March 2012}}</ref> and many others endorsed low-threshold programmes including needle exchange.

Needle exchange programmes have faced opposition on both political and moral grounds. Advocacy groups including the National District Attorneys Association (NDAA),<ref name=NDAA2005>{{cite web |title=Policy Positions on Drug Control and Enforcement |url=http://www.ndaa.org/pdf/policy_position_drug_control_enforcement_july_17_05.pdf |publisher=National District Attorneys Association |access-date=13 July 2013 |archive-url=https://web.archive.org/web/20101125135211/http://ndaa.org/pdf/policy_position_drug_control_enforcement_july_17_05.pdf |archive-date=2010-11-25 |url-status=dead}}</ref> Drug Watch International,<ref name=DWIPosition>{{cite web |title=Drug Watch International Position Statement: Needle Handouts to Addicts |url=http://www.drugwatch.org/Needle%20Handout%20Position.htm |publisher=Drug Watch International |access-date=13 July 2013 |url-status=dead |archive-url=https://web.archive.org/web/20081203194706/http://www.drugwatch.org/Needle%20Handout%20Position.htm |archive-date=3 December 2008}}</ref> [[The Heritage Foundation]],<ref name=Loconte1998>{{cite journal |last=Loconte |first=Joe |title=Killing Them Softly |journal=Policy Review |date=July–August 1998 |pages=14–22 |url=http://heartland.org/sites/all/modules/custom/heartland_migration/files/pdfs/3891.pdf |access-date=13 July 2013 |archive-date=12 August 2014 |archive-url=https://web.archive.org/web/20140812170817/http://heartland.org/sites/all/modules/custom/heartland_migration/files/pdfs/3891.pdf |url-status=dead}}</ref> Drug Free Australia,<ref name=DFA2011>{{cite web|title=Needle Exchange and Hepatitis C|url=http://www.drugfree.org.au/resources/news/shownews/article/needle-exchange-hepatitis-c/|publisher=Drug Free Australia|access-date=13 July 2013|url-status=dead|archive-url=https://web.archive.org/web/20130504142111/http://www.drugfree.org.au/resources/news/shownews/article/needle-exchange-hepatitis-c/|archive-date=4 May 2013}}</ref> and so forth and religious organizations such as the [[Catholic Church]].<ref name=CatholicCulture2011>{{cite web |title=Holy See opposes condoms, needle-exchange programs in fight against AIDS|url=http://www.catholicculture.org/news/headlines/index.cfm?storyid=10703 |publisher=CatholicCulture.org |access-date=13 July 2013}}</ref>

In the United States NEP programmes have proliferated, despite lack of public acceptance. Internationally, needle exchange is widely accepted.<ref name=Bowen2012>{{cite journal |last=Bowen |first=E. A. |title=Clean Needles and Bad Blood: Needle Exchange as Morality Policy |journal=Journal of Sociology and Social Welfare |year=2012 |volume=39 |issue=2 |pages=121–141 |doi=10.15453/0191-5096.3669 |access-date=20 July 2013 |url=http://www.wmich.edu/hhs/newsletters_journals/jssw_institutional/institutional_subscribers/39.2.Bowen.pdf |archive-url=https://web.archive.org/web/20140727202350/http://www.wmich.edu/hhs/newsletters_journals/jssw_institutional/institutional_subscribers/39.2.Bowen.pdf |archive-date=27 July 2014 |url-status=dead |df=dmy-all}}</ref>

== Research ==
{{Expand section|date=May 2013}}

=== Disease transmission ===
Two 2010 'reviews of reviews' by a team originally led by Norah Palmateer that examined [[systematic review]]s and [[meta-analysis|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.<ref name="pmid20219055">{{cite journal |vauthors=Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D |title=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 |journal=Addiction |volume=105 |issue=5 |pages=844–59 |date=May 2010 |pmid=20219055 |doi=10.1111/j.1360-0443.2009.02888.x}}</ref> In a comment Palmateer warned politicians not to use her team's review of reviews as a justification to close existing programmes or to hinder the introduction of new needle-exchange schemes. The weak evidence on the programmes' disease prevention effectiveness is due to inherent design limitations of the reviewed primary studies and should not be interpreted as the programmes lacking preventive effects.<ref name=Norton2010>{{cite news |url=https://www.reuters.com/article/us-needle-exchange-idUSTRE62A4EC20100311 |title=Do needle-exchange programs really work? |author=Amy Norton |date=March 11, 2010 |work=Reuters Health |access-date=October 18, 2011}}</ref>

The second of the Palmateer team's 'review of reviews' scrutinised 10 previous formal reviews of needle exchange studies,<ref name=Kimber2010>Kimber J, Palmateer N, Hutchinson S, Hickman M, Goldberg D, Rhodes T, EMCDDA Monograph 10 'Harm Reduction – Impacts, Evidences and Challenges, Chapter 5 {{cite web |url=http://www.emcdda.europa.eu/publications/monographs/harm-reduction |title=Harm reduction among injecting drug users — evidence of Effectiveness|year=2010 |access-date=July 1, 2013}}</ref> 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),<ref name=Gibson2001>{{cite journal|last=Gibson|first=D. R.|author2=Flynn, N. M. |author3=Perales, D. |title=Effectiveness of syringe exchange programs in reducing HIV risk behavior and HIV seroconversion among injecting drug users|journal=AIDS|year=2001|volume=15|issue=11|pages=1329–1341|doi=10.1097/00002030-200107270-00002|pmid=11504954|doi-access=free}}</ref> Wodak and Cooney (2004),<ref name=Wodak2004>{{cite web |title=Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users |url=https://www.who.int/hiv/pub/prev_care/effectivenesssterileneedle.pdf|publisher=World Health Organization |access-date=18 July 2013|author1=Wodak, A. |author2=Cooney, A. |year=2004}}</ref> Tilson (2007)<ref name="usiom2006">{{cite web|title=Preventing HIV Infection Among Injecting Drug Users in High-Risk Countries|url=http://www.iom.edu/Reports/2006/Preventing-HIV-Infection-among-Injecting-Drug-Users-in-High-Risk-Countries-An-Assessment-of-the-Evidence.aspx|author=Tilson, H.|year=2007|publisher=United States Institute of Medicine|url-status=dead|archive-url=https://web.archive.org/web/20100801142925/http://www.iom.edu/Reports/2006/Preventing-HIV-Infection-among-Injecting-Drug-Users-in-High-Risk-Countries-An-Assessment-of-the-Evidence.aspx|archive-date=2010-08-01|access-date=2010-01-09|display-authors=etal}} <!-- This is from 2006. Isn't there something newer? --></ref> and Käll (2007).<ref name=Kall/> 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.<ref name=Wodak2004/> 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.<ref name=Kall>{{cite journal |last=Käll |first=K. |author2=Hermansson, U. |author3=Amundsen, E. J. |author4=Rönnbäck, K. |author5=Rönnberg, S. |title=The Effectiveness of Needle Exchange Programmes for HIV Prevention - A Critical Review |journal=The Journal of Global Drug Policy and Practice |year=2007 |volume=1 |issue=3 |url=http://www.globaldrugpolicy.com/Issues/Vol%201%20Issue%203/The%20Effectiveness%20of%20Needle%20Exchange.pdf |archive-url=https://web.archive.org/web/20151018063454/http://www.globaldrugpolicy.com/Issues/Vol%201%20Issue%203/The%20Effectiveness%20of%20Needle%20Exchange.pdf |url-status=dead |archive-date=18 October 2015 |access-date=6 July 2013}}</ref> The US [[Institute of Medicine]] evaluated the conflicting evidence of both Drs Wodak<ref>{{cite web |url=http://iom.edu/~/media/Files/Activity%20Files/PublicHealth/DrugUseHIVPrev/AlexWodakNeedlesyringeprograms.pdf |access-date=2013-07-01 |title=Do needle syringe programmes assist control of HIV among injecting drug users? |author=Wodak, A. |year=2005}}{{dead link|date=February 2018 |bot=InternetArchiveBot |fix-attempted=yes}} 2006</ref> and Käll<ref>{{cite web |url=http://iom.edu/~/media/Files/Activity%20Files/PublicHealth/DrugUseHIVPrev/KerstinK%C3%83llNeedleExchangePrograms.pdf |access-date=2013-07-01 |title=What science tells us about needle exchange programs |author=Käll, K. |year=2005}}{{dead link|date=February 2018 |bot=InternetArchiveBot |fix-attempted=yes}} 2006</ref> in their Geneva session<ref>{{cite web |url=http://www.iom.edu/Activities/PublicHealth/DrugUseHIVPrev/2005-DEC-19.aspx |access-date=2013-07-01 |title=Meeting 1: Prevention of HIV Infection among Injecting Drug Users in High Risk Countries |year=2005 |author=Tilson, H. (committee chair) |url-status=dead |archive-url=https://archive.today/20130703232251/http://www.iom.edu/Activities/PublicHealth/DrugUseHIVPrev/2005-DEC-19.aspx |archive-date=2013-07-03}} 2006</ref> and concluded that although multicomponent HIV prevention programmes 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."<ref name=usiom2006/> 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.<ref name=usiom2006/>

NEPs successfully serve as one component of HIV prevention strategies.<ref name="usiom2006" /> Multi-component HIV prevention programmes that include NSE reduce drug-related HIV risk behaviors<ref name="usiom2006" /> and enhance the impact of harm reduction services.<ref name="Rhodes2010">{{cite book|last=Rhodes|first=T.; Hedrich, D.|title=EMCDDA Monographs: Harm reduction: evidence, impacts and challenges|year=2010|publisher=European Monitoring Centre for Drugs and Drug Addiction|isbn=978-92-9168-419-9|chapter-url=http://www.emcdda.europa.eu/attachements.cfm/att_101257_EN_EMCDDA-monograph10-harm%20reduction_final.pdf|chapter=Chapter 1: Harm reduction and the mainstream|access-date=20 July 2013|archive-date=9 October 2012|archive-url=https://web.archive.org/web/20121009220146/http://www.emcdda.europa.eu/attachements.cfm/att_101257_EN_EMCDDA-monograph10-harm%20reduction_final.pdf|url-status=dead}}</ref>

Tilson (2007) concluded that only comprehensive packages of services in multi-component prevention programmes 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.<ref name=usiom2006/>

Multiple examples can be cited showing the relative ineffectiveness of needle exchange programmes alone in stopping the spread of blood-borne disease.<ref name=Wodak2004/><ref name=usiom2006/><ref name="pmid20219055"/><ref name=Kimber2010/> Many needle exchange programmes 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."<ref name=MoyersCloseToHome>{{cite web |title=Q: Should needle exchange be publicly funded? |url=http://www.thirteen.org/closetohome/viewpoints/html/needle.html#noffs |publisher=PBS Online |access-date=14 July 2013 |archive-url=https://web.archive.org/web/20130924094851/http://www.thirteen.org/closetohome/viewpoints/html/needle.html#noffs |archive-date=24 September 2013 |url-status=dead |df=dmy-all}}</ref>

A 2013 systematic review found support for the use of NEPs to prevent and treat HIV and HCV infection.<ref>{{cite journal|last1=Abdul-Quader|first1=Abu S.|last2=Feelemyer|first2=Jonathan|last3=Modi|first3=Shilpa|last4=Stein|first4=Ellen S.|last5=Briceno|first5=Alya|last6=Semaan|first6=Salaam|last7=Horvath|first7=Tara|last8=Kennedy|first8=Gail E.|last9=Des Jarlais|first9=Don C.|title=Effectiveness of Structural-Level Needle/Syringe Programs to Reduce HCV and HIV Infection Among People Who Inject Drugs: A Systematic Review|journal=AIDS and Behavior|date=22 August 2013|volume=17|issue=9|pages=2878–2892|doi=10.1007/s10461-013-0593-y|pmid=23975473|pmc=6509353}}</ref> 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 programmes have probably also contributed to the decrease in HIV incidence.<ref>{{cite journal|last1=Aspinall|first1=EJ|last2=Nambiar|first2=D|last3=Goldberg|first3=DJ|last4=Hickman|first4=M|last5=Weir|first5=A|last6=Van Velzen|first6=E|last7=Palmateer|first7=N|last8=Doyle|first8=JS|last9=Hellard|first9=ME|last10=Hutchinson|first10=SJ|title=Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis.|journal=International Journal of Epidemiology|date=February 2014|volume=43|issue=1|pages=235–48|doi=10.1093/ije/dyt243|pmid=24374889|doi-access=free}}</ref> NEPs appear to be as effective in low- and middle-income countries as in high-income ones.<ref>{{cite journal|last1=Des Jarlais|first1=DC|last2=Feelemyer|first2=JP|last3=Modi|first3=SN|last4=Abdul-Quader|first4=A|last5=Hagan|first5=H|title=High coverage needle/syringe programs for people who inject drugs in low and middle income countries: a systematic review.|journal=BMC Public Health|date=19 January 2013|volume=13|pages=53|doi=10.1186/1471-2458-13-53|pmid=23332005|pmc=3567947 |doi-access=free}}</ref>

=== Worker training ===
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.<ref>{{Cite journal | last1 = Lemon | first1 = T. I. | last2 = Shah | first2 = R. | doi = 10.1016/j.jpsychores.2013.03.057 | title = Needle exchanges: An important yet forgotten outpost in suicide and self-harm prevention | journal = Journal of Psychosomatic Research | volume = 74 | issue = 6 | pages = 551–552 | year = 2013}}</ref>

=== Drug use ===
According to a 2022 study by Vanderbilt University economist Analisa Packham, syringe exchange programs reduce HIV rates by 18.2 percent but lead to greater drug use.<ref name=":2">{{Cite journal |last=Packham |first=Analisa |date=2022 |title=Syringe exchange programs and harm reduction: New evidence in the wake of the opioid epidemic |url=https://www.sciencedirect.com/science/article/pii/S0047272722001359 |journal=Journal of Public Economics|volume=215 |pages=104733 |doi=10.1016/j.jpubeco.2022.104733 |s2cid=250444383 |issn=0047-2727 |archive-url=https://web.archive.org/web/20230512000000/https://www.sciencedirect.com/science/article/pii/S0047272722001359 |archive-date=2023-05-12|url-access=subscription }} [https://apackham.github.io/mywebsite/opioidpaper_webcopy.pdf Alt URL]</ref><ref>{{Cite news |date=2022 |title=America's syringe exchanges kill drug users |newspaper=The Economist |url=https://www.economist.com/united-states/2022/12/01/americas-syringe-exchanges-kill-drug-users |issn=0013-0613}}</ref> Syringe exchange programmes increased drug-related mortality rates by 11.7 percent and opioid-related mortality rates by 21.6 percent.<ref name=":2" />

== Arguments for and against ==

=== Needle disposal ===
{{See also|Biomedical waste|Drug disposal|Sharps waste}}

==== NSPs do not increase litter: broad arguments ====
Activist groups claim there is no way to ensure SEP users will be properly disposed of.<ref name=":03">{{Cite web |last=Bluth |first=Rachel |date=2021-10-06 |title=Needle Exchanges Are Targets of Eco-Rooted Lawsuits. A New Law Will Stop That. |url=https://californiahealthline.org/news/article/needle-exchanges-environmental-lawsuits-california-law-newsom/ |access-date=2022-04-29 |website=California Healthline}}</ref> Peer reviewed studies suggest that there are less improperly disposed of syringes in cities with needle exchange programs than in cities without.<ref name="Tookes 255–259">{{Cite journal |last1=Tookes |first1=Hansel E. |last2=Kral |first2=Alex H. |last3=Wenger |first3=Lynn D. |last4=Cardenas |first4=Gabriel A. |last5=Martinez |first5=Alexis N. |last6=Sherman |first6=Recinda L. |last7=Pereyra |first7=Margaret |last8=Forrest |first8=David W. |last9=Lalota |first9=Marlene |last10=Metsch |first10=Lisa R. |date=2012-06-01 |title=A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs |journal=Drug and Alcohol Dependence |volume=123 |issue=1–3 |pages=255–259 |doi=10.1016/j.drugalcdep.2011.12.001 |issn=0376-8716 |pmc=3358593 |pmid=22209091}}</ref> Other studies of similar design find that syringe exchange program drop boxes were associated with an overall decrease of improper syringe disposal (over 98% decrease) and going further from said syringe exchange sites increases the amount of improperly disposed needles.<ref name="Tookes 255–259"/> Other ethnographic studies find evidence that criminal related drug possession laws further serve to increase improperly disposed of needles, and decreasing the severity of possession laws may positively impact proper syringe disposal, this corroborates the [[Centers for Disease Control and Prevention|CDC's]] own guidelines on syringe disposal, which claim "Studies have found that syringe litter is more likely in areas without SSPs".<ref>{{Cite journal |last1=Burris |first1=Scott |last2=Welsh |first2=Joseph |last3=Ng |first3=Mitzi |last4=Li |first4=Mei |last5=Ditzler |first5=Alyssa |date=November 2002 |title=State syringe and drug possession laws potentially influencing safe syringe disposal by injection drug users |url=https://pubmed.ncbi.nlm.nih.gov/12489625/ |journal=Journal of the American Pharmaceutical Association |volume=42 |issue=6 Suppl 2 |pages=S94–98 |doi=10.1331/1086-5802.42.0.s94.burris |issn=1086-5802 |pmid=12489625}}</ref><ref>{{Cite web |last=CDC |title=Needs-Based Syringe Distribution and Disposal at Syringe Services Programs |url=https://www.cdc.gov/ssp/docs/CDCSSP-FAQ_508.pdf}}</ref>

==== NSPs do increase litter: broad arguments ====
On the other hand, there is data to suggest SEPs do increase improper syringe disposal. Opposition groups contribute their own proof through photographic evidence of increased needle litter, additionally, opponents argue that programs which do not mandate a 1:1 needle exchange encourage the more convenient improper discarding of needles when the programs are not open or are not accepting needle returns.<ref>{{Cite web |last=Lopez |first=German |date=2018-05-29 |title=Needle exchanges help combat the opioid crisis. So why was the one in Orange County shut down? |url=https://www.vox.com/science-and-health/2018/5/29/17389048/needle-exchange-opioid-epidemic-orange-county |access-date=2022-05-10 |website=Vox}}</ref> Additionally, many programs allow for unlimited access to needles, which opponents argue increases litter to a much higher degree on the basis of increasing total needles in circulation.<ref>{{Cite web |last=Ross |first=Matier & |date=2018-05-09 |title=Those needles littering the streets? The city gave them out |url=https://www.sfchronicle.com/bayarea/matier-ross/article/Those-needles-littering-the-streets-The-city-12898656.php |access-date=2022-05-10 |website=San Francisco Chronicle}}</ref> Portland residents in areas where syringe acquisition is unlimited claim to be "drowning in needles" and picking up upwards of 100 per week. Opposition groups also argue government action in increasing the amount of syringe disposal boxes is slow.<ref>{{Cite web |last=Budnick |first=Nick |title=Used syringes litter Portland as needle exchanges grow |url=https://pamplinmedia.com/pt/9-news/389032-279230-used-syringes-litter-portland-as-needle-exchanges-grow |access-date=2022-05-10 |website=joomlakave.com|date=8 March 2018 }}</ref> 
* NSPs that strictly adhere to one-for-one policy and do not furnish starter syringes/needles do not increase the number of them in circulation.<ref name=":3" />{{Rp|387}}
* 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.<ref name=usiom2006/>
* Some NSPs hands outs needles without an expectation of used syringes being returned. One NSP in Portland, Oregon, hands out syringes without question. Neighbors near the NSP are routinely finding discarded syringes and the neighborhood organization to which they are a part of, the [[University Park, Portland, Oregon|University Park]] park neighborhood association, desires the needle handout operation to stop.<ref>{{Cite web|title=University Park residents fed up with crime, drugs, trash|url=https://www.koin.com/news/civic-affairs/university-park-residents-fed-up-with-crime-drugs-trash/|date=2020-01-31|website=KOIN.com|access-date=2020-05-25}}</ref> A local resident visited a NSP in [[Chico, California]], and she was handed 100 syringes without question. The City Council in Chico is discussing banning the operation.<ref>{{Cite web|title=Some Residents, Officials Gang Up Against Syringe Exchange in Chico, CA|url=https://filtermag.org/chico-syringe-exchange/|date=2020-02-19|website=Filter|access-date=2020-05-25}}</ref>
* 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.<ref>{{cite web|title=Road to recovery: Report on the inquiry into substance abuse in Australian communities |publisher=Australian House of Representatives Standing Committee on Family and Community Affairs |url=http://www.aph.gov.au/Parliamentary_Business/Committees/House_of_Representatives_Committees?url=fca/subabuse/report.htm |access-date=6 July 2013}}</ref> 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.<ref>{{cite news |url=http://melbourne-leader.whereilive.com.au/news/story/drug-injecting-hotspot-near-collingwood-childcare-centre/ |title=Drug-injecting hotspot near Collingwood childcare center |work=Melbourne Leader |date=8 March 2010 |access-date=2010-05-01 |url-status=dead |archive-url=https://web.archive.org/web/20101023094044/http://melbourne-leader.whereilive.com.au/news/story/drug-injecting-hotspot-near-collingwood-childcare-centre/ |archive-date=23 October 2010}}</ref>

=== Treatment program enrollment ===
* IDUs risk multiple health problems from non-sterile injecting practices, drug complications and associated lifestyle choices.<ref>{{cite book|last=Latt|first=N.; Conigrave, K.; Marshall, J.; Saunders, J.; Marshall, J.; Nutt, D.|title=Addiction Medicine|year=2009|publisher=Oxford University Press|isbn=9780199539338|url=http://www.oup.com/us/catalog/general/subject/Medicine/PsychiatryPsychology/?view=usa&ci=9780199539338|url-status=dead|archive-url=https://web.archive.org/web/20110604154155/http://www.oup.com/us/catalog/general/subject/Medicine/PsychiatryPsychology/?view=usa&ci=9780199539338|archive-date=2011-06-04}}</ref> Unrelated health problems such as [[diabetes]] may be neglected because of drug dependence. IDUs are typically reluctant to use conventional health services.<ref>{{Cite journal | last1 = McCoy | first1 = C. B. | last2 = Metsch | first2 = L. R. | last3 = Chitwood | first3 = D. D. | last4 = Miles | first4 = C. | title = Drug use and barriers to use of health care services | journal = Substance Use & Misuse | volume = 36 | issue = 6–7 | pages = 789–806 | year = 2001 | pmid = 11697611 | doi=10.1081/ja-100104091| s2cid = 23220436}}</ref> Such reluctance/neglect implies poorer health and increased use of emergency services,<ref>{{cite journal |author=McDonald, P |title=From streets to sidewalks: developments in primary care services for injecting drug users |journal=Australian Journal of Primary Health |volume=8 |pages=65–69 |year=2002|doi=10.1071/PY02010}}</ref> creating added costs. Harm reduction based health care centres, also known as ''targeted health care outlet'' or ''low-threshold health care outlet'' for IDUs have been established to address this issue.<ref name="IslamTopp2012">{{cite journal|vauthors=Islam MM, Topp L, Day CA, Dawson A, Conigrave KM|year=2012|title=The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature|journal=International Journal of Drug Policy|volume=23|issue=2|pages=94–102|doi=10.1016/j.drugpo.2011.08.005|pmid=21996165}}</ref>
* NSP staff facilitate connections among people who use drugs and medical facilities, thereby exposing them to voluntary physical, psychological and emotional treatment programmes.<ref name=jarlais2008>{{Cite journal | last1 = Des Jarlais | first1 = D. C. | last2 = McKnight | first2 = C. | last3 = Goldblatt | first3 = C. | last4 = Purchase | first4 = D. | title = Doing harm reduction better: Syringe exchange in the United States | doi = 10.1111/j.1360-0443.2008.02465.x | journal = Addiction | volume = 104 | issue = 9 | pages = 1441–1446 | year = 2009 | pmid = 19215605}}</ref>
* Social services for addicts can be organized around needle exchanges, increasing their accessibility.<ref name=NeedleExchangeOptions2008>{{cite news |title=Needle exchange options; pros and cons |url=http://www.canada.com/victoriatimescolonist/story.html?id=%2085931cb6-3c0a-4a10-95dd-ee19fd6cbb39 |access-date=20 July 2013 |newspaper=Canada.com |date=21 March 2008 |archive-url=https://web.archive.org/web/20150924143613/http://www.canada.com/victoriatimescolonist/story.html?id=%2085931cb6-3c0a-4a10-95dd-ee19fd6cbb39 |archive-date=24 September 2015 |url-status=dead |df=dmy-all}}</ref>

=== Cost effectiveness ===
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.<ref>{{Cite journal | pmid = 22389572| pmc = 3291106| year = 2011| last1 = McLean| first1 = K| title = The biopolitics of needle exchange in the United States| journal = Critical Public Health| volume = 21| issue = 1| pages = 71–79| doi = 10.1080/09581591003653124}}</ref>

=== Proponents ===
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 programmes, they have reduced the spread of HIV among [[intravenous drug]] users.<ref name="usiom2006" /> 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 machine]]s that automatically dispense injecting equipment have been successfully introduced.<ref>{{Cite journal|last1=McDonald|first1=D.|year=2009|title=The evaluation of a trial of syringe vending machines in Canberra, Australia|journal=International Journal of Drug Policy|volume=20|issue=4|pages=336–339|doi=10.1016/j.drugpo.2008.06.004|pmid=18790622|hdl=1885/17339|hdl-access=free}}</ref><ref>{{cite journal|vauthors=Islam MM, Conigrave KM|year=2007|title=Syringe vending machines as a form of needle syringe program: Advantages and Disadvantages|journal=Journal of Substance Use|volume=12|issue=3|pages=203–12|doi=10.1080/14659890701249640|s2cid=71726629}}</ref><ref>{{cite journal|vauthors=Islam MM, Stern T, Conigrave KM, Wodak A|date=January 2008|title=Client satisfaction and risk behaviours of the users of syringe dispensing machines: a pilot study|journal=Drug Alcohol Rev.|volume=27|issue=1|pages=13–9|doi=10.1080/09595230701711199|pmid=18034377|s2cid=45935377}}</ref>

Other promoted benefits of these programmes include providing a first point of contact for formal drug treatment,<ref>{{cite journal|vauthors=Brooner R, Kidorf M, King V, Beilenson P, Svikis D, Vlahov D|date=June 1998|title=Drug abuse treatment success among needle exchange participants|journal=Public Health Rep.|volume=113|issue=Suppl 1|pages=129–39|pmc=1307735|pmid=9722818}}</ref> 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 treatment programs|low-threshold health care outlet]]s', because they reduce common barriers to health care from the conventional health care outlets,.<ref name="IslamTopp2012" /><ref>{{cite journal|vauthors=Islam MM, Topp L, Day CA, Dawson A, Conigrave KM|year=2012|title=Primary healthcare outlets that target injecting drug users: Opportunity to make services accessible and acceptable to the target group|journal=International Journal of Drug Policy|volume=23|issue=2|pages=109–110|doi=10.1016/j.drugpo.2011.11.001|pmid=22280917}}</ref> Clients frequently visit SEP outlets for help accessing sterile injecting equipment. These visits are used opportunistically to offer other health care services.<ref>{{cite journal|vauthors=Islam MM, Reid SE, White A, Grummett S, Conigrave KM, Haber PS|year=2012|title=Opportunistic and continuing health care for injecting drug users from a nurse-run needle syringe program-based primary health-care clinic|journal=Drug Alcohol Rev.|volume=31|issue=1|pages=114–115|doi=10.1111/j.1465-3362.2011.00390.x|pmid=22145983}}</ref><ref>{{cite journal|author=Islam, MM|date=July 2010|title=Needle Syringe Program-Based Primary Health Care Centers: Advantages and Disadvantages|journal=Journal of Primary Care & Community Health|volume=1|issue=2|pages=100–103|doi=10.1177/2150131910369684|pmid=23804370|s2cid=8663924|doi-access=free}}</ref>

A clinical trial of needle exchange found that needle exchange did not cause an increase in drug injection.<ref>{{cite journal|vauthors=Fisher DG, Fenaughty AM, Cagle HH, Wells RS|date=June 2003|title=Needle exchange and injection drug use frequency: a randomized clinical trial|journal=J. Acquir. Immune Defic. Syndr.|volume=33|issue=2|pages=199–205|doi=10.1097/00126334-200306010-00014|pmid=12794555|doi-access=free}}</ref>

=== California Environmental Quality Act (CEQA) ===
Within California, those opposed to syringe exchange programs have frequently invoked the [[California Environmental Quality Act]] (CEQA) as a means to bar syringe exchange programs from operating, citing the environmental impact of improper syringe disposals. Most notably SEP opposition within Santa Cruz,<ref name=":03"/> and [[Orange County, California|Orange County]]—whose only syringe exchange program [https://ocnep.org/ The Orange County Needle Exchange Program (OCNEP)] was blocked from operating in October, 2019 by an Orange County lawsuit which charged the program with creating hazardous conditions and litter for residents.<ref>{{cite web |last=Ridge |first=Kristine |date=September 15, 2020 |title=ADOPT AN ORDINANCE ADDING ARTICLE XV (SYRINGE EXCHANGE PROGRAMS) TO CHAPTER 18 OF THE SANTA ANA MUNICIPAL CODE ( HEALTH AND SANITATION) PROHIBITING SYRINGE EXCHANGE PROGRAMS IN THE CITY OF SANTA ANA |url=https://santaana.granicus.com/MetaViewer.php?view_id=2&clip_id=2983&meta_id=124646}}</ref> The OCNEP contests that public needle litter still exists after the shutdown of their program.<ref>{{Cite web |title=Orange County Needle Exchange Program: Home |url=https://ocnep.org/ |access-date=2022-04-29 |website=ocnep.org}}</ref>

Legislation in California signed by governor [[Gavin Newsom]] in 2021, [https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220AB1344 AB-1344], aimed to block the use of CEQA to challenge SEPs. The provision states that "Needle and syringe exchange services application submissions, authorizations, and operations performed pursuant to this chapter shall be exempt from review under the California Environmental Quality Act, Division 13 (commencing with Section 21000) of the Public Resources Code."<ref>{{Cite web |title=Bill Text - AB-1344 State Department of Public Health: needle and syringe exchange services. |url=https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220AB1344 |access-date=2022-04-29 |website=leginfo.legislature.ca.gov}}</ref>

The provision was passed on the basis of curtailing the [[opioid epidemic]].<ref>{{Cite web|date=2021-10-06 |title=CEQA lawsuits are blocking needle exchange programs. A new law will stop that |url=https://www.latimes.com/california/story/2021-10-06/ceqa-lawsuits-are-blocking-needle-exchange-programs-a-new-law-will-stop-that |access-date=2022-04-29 |website=Los Angeles Times}}</ref> There is no part of the bill which explicitly addresses the environmental concerns of the plaintiffs.

=== Scope ===
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.<ref name=Woody1993>{{Cite journal | last1 = Woody | first1 = G. E. | last2 = Metzger | first2 = D. S. | doi = 10.1056/NEJM199311253292220 | title = Causes of Death in Injection-Drug Users | journal = New England Journal of Medicine | volume = 329 | issue = 22 | pages = 1661 | year = 1993 | pmid = 8232452| doi-access = free}}</ref>

=== Community issues ===
* NSP effectiveness studies usually focused on addict health effects; the United States National District Attorneys Association argues that they neglect effects on the broader community.<ref name=NDAA2005/><ref name=OHRDP>{{cite web|title=Needle Exchange FAQs |url=http://www.ohrdp.ca/resources/needle-exchange-faqs/ |publisher=Ontario Harm Reduction Distribution Program |url-status=dead |archive-url=https://web.archive.org/web/20111230133201/http://www.ohrdp.ca/resources/needle-exchange-faqs/ |archive-date=December 30, 2011}}</ref>
* NSPs may concentrate drug activity into communities in which they operate.<ref name=Keyl1998>{{Cite journal | last1 = Keyl | first1 = P. M. | last2 = Gruskin | first2 = L. | last3 = Casano | first3 = K. | last4 = Montag | first4 = H. | last5 = Junge | first5 = B. | last6 = Vlahov | first6 = D. | title = Community support for needle exchange programs and pharmacy sale of syringes: A household survey in Baltimore, Maryland | journal = Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology | volume = 18 | pages = S82–S88 | year = 1998 | issue = Suppl 1 | pmid = 9663629 | doi=10.1097/00042560-199802001-00015| doi-access = free}}</ref> Only a small number of short-term studies considered whether NSPs have such effects.<ref name=Williams2010>{{Cite journal | last1 = Williams | first1 = C. T. | last2 = Ouellet | first2 = L. J. | doi = 10.1016/j.drugpo.2010.02.003 | title = Misdirected opposition: Evidence opposing "not in my back yard" arguments against syringe exchange programmes | journal = International Journal of Drug Policy | volume = 21 | issue = 5 | pages = 437–439 | year = 2010 | pmid = 20233654}}</ref> To the extent that this happens, they may negatively affect property values, increase localized crime rates and damage broader perceptions about the host community.<ref name=Strike2004>{{cite journal |last=Strike |first=C. J. |author2=Myers, T. |author3=Millson, M.|title=Finding a place for needle exchange programs |journal=Critical Public Health |year=2004 |volume=14 |issue=3 |pages=261–275|url=http://courses.ttu.edu/jkoch/ETOH/Readings/Needle%20Exchange%20policy.pdf|access-date=14 July 2013 |doi=10.1080/09581590400004386|citeseerx=10.1.1.495.4618 |s2cid=54742780}}</ref> In 1987 in the [[Platzspitz park]] in [[Zürich]] "...authorities chose to allow illegal drug use and sales at the park, in an effort to contain Zürich'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 Zürich 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,<ref name=Islam2010>{{Cite journal | last1 = Islam | first1 = M. M. | title = Needle Syringe Program-Based Primary HealthCare Centers: Advantages and Disadvantages | doi = 10.1177/2150131910369684 | journal = Journal of Primary Care & Community Health | volume = 1 | issue = 2 | pages = 100–103 | year = 2010 | pmid =23804370| s2cid = 8663924 | doi-access = free}}</ref> a survey showed that one-third of the public believed that NSPs encouraged drug use, and 20% believed that NSPs dispensed drugs.<ref name=Anex2009>{{cite web |title=Community consulted for the first time on attitudes towards drugs |url=http://www.australiandrugsconference.org.au/2009/downloads/Community%20Consulted%20for%20the%20First%20Time.pdf |publisher=Anex |access-date=26 March 2012 |url-status=dead |archive-url=https://web.archive.org/web/20140728204222/http://www.australiandrugsconference.org.au/2009/downloads/Community%20Consulted%20for%20the%20First%20Time.pdf |archive-date=28 July 2014}}</ref>

=== Diversion ===
[[NPR]] interviewed a syringe exchange program Prevention Point Philadelphia in [[Philadelphia]], United States, and some of its clients. The program Prevention Point allows anyone presenting syringes to exchange for the same quantity without limitation and this has led to drug addicts selling clean syringes to other drug addicts to make drug money. Some drug dealers use the needle exchange to obtain a supply of large quantities of needles to sell or give to their drug buyers.<ref>{{Cite news|last=Jacobs|first=Emma|date=January 3, 2015|title=Needle Exchange Program Creates Black Market In Clean Syringes|work=NPR|url=https://www.npr.org/2015/01/03/374560431/needle-exchange-program-creates-black-market-in-clean-syringes|access-date=January 16, 2020}}</ref>

Some participants interviewed by a ''[[The Baltimore Sun]]'' in February 2000 revealed that they sell some of the new syringes obtained from the exchange in order to make drug money and did not always stop needle sharing among drug addicts.<ref>{{Cite news|last=Levine|first=Daniel|date=February 6, 2000|title=Addicts use needle swap to buy drugs; Abuse: The city health commissioner concedes that the needle exchange program is flawed but maintains that its benefits far outweigh its drawbacks.|work=The Baltimore Sun|url=https://www.baltimoresun.com/news/bs-xpm-2000-02-06-0002090303-story.html|url-status=live|access-date=March 8, 2020|archive-url=https://web.archive.org/web/20200524073549/https://www.baltimoresun.com/news/bs-xpm-2000-02-06-0002090303-story.html|archive-date=May 24, 2020}}</ref>

== See also ==
* [[Supervised injection site]]

== References ==
{{Reflist}}

{{Authority control}}

[[Category:Addiction medicine]]
[[Category:Drug culture]]
[[Category:Drug paraphernalia]]
[[Category:Drug safety]]
[[Category:Harm reduction]]
[[Category:Medical hygiene]]
[[Category:Infection-control measures]]
[[Category:Medical waste]]
[[Category:Prevention of HIV/AIDS]]
[[Category:Public policy]]
[[Category:Public services]]