Low-threshold treatment programs
Low-threshold treatment programs are harm reduction-based health care centers targeted towards drug users. “Low-threshold” programs are programs that make minimal demands on the patient, offering services without attempting to control their intake of drugs, and providing counselling only if requested. Low-threshold programs may be contrasted with “high-threshold” programs, which require the user to accept a certain level of control and which demand that the patient accept counselling.
Low-threshold treatment programs are not to be confused with simple needle exchange programs, and may include comprehensive healthcare and counseling services. The International Journal of Drug Policy in its volume 24 published an Editorial which endeavoured to define a service known to be “low-threshold”, based on some popular and known criteria. According to that Editorial, low-threshold services for drug users can be defined as those which offer services to drug users; do not impose abstinence from drug use as a condition of service access; and endeavour to reduce other documented barriers to service access.
Injection drug users (IDUs) are at risk of a wide range of health problems arising from non-sterile injecting practices, complications of the drug itself or of the lifestyle associated with drug use and dependence. Furthermore, unrelated health problems, such as diabetes, may be neglected because of drug dependence. However, despite their increased health care needs, IDUs do not have the required access to care or may be reluctant to use conventional services. Consequently, their health may deteriorate to a point at which emergency treatment is required, with considerable costs to both the IDUs and the health system. Accordingly, harm reduction based health care centers, also known as targeted health care outlet or low-threshold health care outlet for IDUs have been established across a range of settings utilising a variety of models. These targeted outlets provide integrated, low-threshold services within a harm-reduction framework targeting IDUs, and sometimes include social and/or other services. Where a particular service is not provided, referral and assistance with access is available. In 2007, for example, 33% of all US needle-syringe programs (NSPs) provided on-site medical care, and 7% provided buprenorphine treatment. Similarly, in many European countries NSP outlets serve as low-threshold primary health care centers targeting primarily IDUs.
Health care models
These targeted outlets vary widely and may be either “distributive”, providing basic harm reduction services and simple healthcare with facilitated referrals to specialist services, or “one-stop-shops” where a range of services including specialist services are provided onsite. The services being offered by these outlets range from simple needle and syringe provision, to expanded services including basic and preventive primary healthcare, hepatitis B and A vaccinations, hepatitis C testing, counselling, tuberculosis screening and sometimes opioid maintenance therapy. Some centers offer hepatitis, HIV treatment and dental care. The goal of these outlets is to provide: (1) opportunistic health care, (2) increased temporal and spatial availability of health care, (3) trustworthy services of health care, (4) cost-effective mode of health care, (5) targeted and tailored services.
In the United States as of 2011, 211 NSPs were known to be operating in 32 states, the District of Columbia, Puerto Rico and the Indian Nations. The bulk of funding has come from state and local governments, since for most of the last several decades, federal funding for needle exchange programs has been specifically banned.
Globally, as of 2008, at least 77 countries and territories offer NSPs with varying structures, aims and goals. Some countries use needle exchange services as part of integrated programs to contain drug use, while others aim simply to contain HIV infection as their top priority, considering reduction in incidence of drug use as a much lower priority. Acceptance of NSPs vary widely from country to country. On the one hand, in Australia and New Zealand, electronic dispensing machines are available at selected locations such as the Auckland needle exchange and the Christchurch needle exchange, allowing needle exchange service 24 hours to registered users. On the other hand, over half of the countries in Asia, the Middle East, and North Africa retain the death penalty for drug offenses, although some have not carried out executions in recent years.
Low-threshold programs offering needle exchange have faced much opposition on political and moral grounds. Concerns are often expressed that NSPs may encourage drug use, or may actually increase the number of dirty needles in the community. Another fear is that NSPs may draw drug activity into the communities in which they operate. It has also been argued that in fighting disease, needle exchanges take attention away from bigger drug problems, and that, contrary to saving lives, they actually contribute to drug-related deaths. Even in Australia, which is considered a leading country in harm reduction, a survey showed that a third of the public believed that NSPs encouraged drug use, and 20% believed that NSPs dispensed drugs. In the United States, the ambivalent public attitude towards NSPs is often reflected in police interference, with 43% of NSP program managers reporting frequent (at least monthly) client harassment, 31% reporting frequent confiscation of clients’ syringes, 12% reporting frequent client arrest, and 26% reporting uninvited police appearances at program sites. A single 1997 study which showed a correlation between frequent program use and elevated rates of HIV infection among IDUs in Vancouver, Canada, has become widely cited by opponents of NSPs as demonstrating their counter-productiveness.
Authors from the 1997 Vancouver study have, in multiple publications, issued disclaimers against the misuse of their work by opponents of NSPs. They point out that frequent attendees of the program tended to be young and often indulged in extreme high-risk behaviors. The 1997 results were hence of a statistically biased sampling. They have emphasized that the correct message to be derived from their 1997 study can be read in the title of their work: “Needle exchange is not enough”. This is the same message presented by many other articles since.
Comprehensive, systematic surveys of the costs and effectiveness of low-threshold primary healthcare programs are not available due to the heterogeneity of these programs and the study designs. Narrower focus studies dealing solely with the needle exchange issue are abundant, however, and generally support the thesis that NSPs reduce the risk of prevalence of HIV, hepatitis and other blood-bourne diseases. These studies suggest that such outlets improve the overall health status of IDUs and save on the health budget by reducing episodes in emergency departments and tertiary hospitals. In Australia, monitoring of drug users participating in NSPs showed the incidence of HIV among NSP clients to be essentially identical to that of the general population. Fears that NSPs may draw drug activity into the communities in which they operate are contradicted by a study that showed that by far the greatest number of clients of an NSP in Chicago came to the area to exchange needles (60%) rather than to buy drugs (3.8%).
Internationally, support for the effectiveness of low-threshold programs including needle exchange have come from studies conducted in Afghanistan, China, Spain, Taiwan, Estonia, Canada, Iran, and many other countries. However, in many countries, there is strong opposition to such programs.
Despite the lack of definitive scientific evidence on the effectiveness of IDU-targeted low-threshold services, the available evidence, revealing barriers to service access and the late presentation of seriously ill IDUs to hospital, suggests the ongoing need for targeted and low-threshold services. Because of this, organizations ranging from the National Institutes of Health, the Centers for Disease Control, the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organization, and many others have endorsed low-threshold programs including needle exchange.
- Islam, M. M.; Day, C. A.; Conigrave, K. M. (2010). “Harm reduction healthcare: From an alternative to the mainstream platform?”. International Journal of Drug Policy. 21 (2): 131–133. doi:10.1016/j.drugpo.2010.01.001. PMID 20092999.
- Waal, Helge. “Risk reduction as a component of a comprehensive, multidisciplinary approach to drug abuse problems” (PDF). The Pompidou Group. Retrieved 25 March 2012.
- Rogers, S. J.; Ruefli, T. (2004). “Does harm reduction programming make a difference in the lives of highly marginalized, at-risk drug users?”. Harm Reduction Journal. 1 (1): 7. doi:10.1186/1477-7517-1-7. PMC 420490. PMID 15171790.
- Islam, MM, Topp, L, Conigrave, KM, and Day, C (2013). “Defining a service for people who use drugs as ‘low-threshold’: What should be the criteria?”. International Journal of Drug Policy. 24 (3): 220–222. doi:10.1016/j.drugpo.2013.03.005. PMID 23567101.CS1 maint: Multiple names: authors list (link)
- 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.
- 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.
- “Low-threshold services”. The European Monitoring Centre for Drugs and Drug Addiction. Retrieved 23 March 2012.
- Centers for Disease Control and Prevention (CDC) (2010). “Syringe exchange programs — United States, 2008”. Morbidity and Mortality Weekly Report. 59 (45): 1488–1491. PMID 21085091.
- 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, 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.
- “Syringe Exchange Programs in the United States 2011” (PDF). amfAR, The Foundation for AIDS Research. Retrieved 25 March 2012.
- Wilkey, Robin (4 January 2012). “Needle Exchange Programs Lose Federal Funding: Local AIDS Programs Brace For Cuts”. Huffington Post – San Francisco. Retrieved 25 March 2012.
- “Syringe exchange programs around the world: The global context” (PDF). Gay Men’s Health Crisis. Retrieved 25 March 2012.
- Anderton, Jim. “Needle and syringe exchange programme saves lives”. beehive.govt.nz, the official website of the New Zealand Government. Retrieved 26 March 2012.
- “Global State of Harm Reduction 2010” (PDF). International Harm Reduction Association. Retrieved 26 March 2012.
- Small, D.; Glickman, A.; Rigter, G.; Walter, T. (2010). “The Washington Needle Depot: Fitting healthcare to injection drug users rather than injection drug users to healthcare: Moving from a syringe exchange to syringe distribution model”. Harm Reduction Journal. 7: 1. doi:10.1186/1477-7517-7-1. PMC 2806876. PMID 20047690.
- “Needle Exchange FAQs”. Ontario Harm Reduction Distribution Program. Archived from the original on 30 December 2011. Retrieved 26 March 2012.
- 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.
- Aaron, Lawrence (2005-08-26). “Why a Needle-Exchange Program is a Bad Idea”. redOrbit.com. Retrieved 26 March 2012.
- “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.
- Beletsky, L.; Grau, L. E.; 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.
- Strathdee, S. A.; Patrick, D. M.; Currie, S. L.; Cornelisse, P. G.; Rekart, M. L.; Montaner, J. S.; Schechter, M. T.; O’Shaughnessy, M. V. (1997). “Needle exchange is not enough: Lessons from the Vancouver injecting drug use study”. AIDS. 11 (8): F59–F65. doi:10.1097/00002030-199708000-00001. PMID 9223727.
- Schechter, M. T.; Strathdee, S. A.; Cornelisse, P. G.; Currie, S.; Patrick, D. M.; Rekart, M. L.; O’Shaughnessy, M. V. (1999). “Do needle exchange programmes increase the spread of HIV among injection drug users?: An investigation of the Vancouver outbreak”. AIDS. 13 (6): F45–F51. doi:10.1097/00002030-199904160-00002. PMID 10397556.
- Wood, E.; Lloyd-Smith, E.; Li, K.; Strathdee, S. A.; Small, W.; Tyndall, M. W.; Montaner, J. S. G.; Kerr, T. (2007). “Frequent Needle Exchange Use and HIV Incidence in Vancouver, Canada”. The American Journal of Medicine. 120 (2): 172–179. doi:10.1016/j.amjmed.2006.02.030. PMID 17275459.
- Des Jarlais, D. C.; Arasteh, K.; Friedman, S. R. (2011). “HIV Among Drug Users at Beth Israel Medical Center, New York City, the First 25 Years”. Substance Use & Misuse. 46 (2–3): 131–139. doi:10.3109/10826084.2011.521456. PMID 21303233.
- Falster, K.; Kaldor, J. M.; Maher, L.; collaboration of Australian Needle Syringe Programs (2008). “Hepatitis C Virus Acquisition among Injecting Drug Users: A Cohort Analysis of a National Repeated Cross-sectional Survey of Needle and Syringe Program Attendees in Australia, 1995–2004”. Journal of Urban Health. 86 (1): 106–118. doi:10.1007/s11524-008-9330-7. PMC 2629525. PMID 18979201.
- Wodak, A.; Maher, L. (2010). “The effectiveness of harm reduction in preventing HIV among injecting drug users”. New South Wales Public Health Bulletin. 21 (4): 69–73. doi:10.1071/NB10007. PMID 20513304.
- Delgado, C. (2004). “Evaluation of Needle Exchange Programs”. Public Health Nursing. 21 (2): 171–178. doi:10.1111/j.0737-1209.2004.021211.x. PMID 14987217.
- Islam, M. M.; Topp, L.; Day, C. A.; Dawson, A.; Conigrave, K. M. (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.
- Shriver, M. (1998). “Needle exchange works”. Newsline (People with AIDS Coalition of New York): 35. PMID 11367470.
- Knittel, A. K.; Wren, P. A.; Gore, L. (2010). “Lessons learned from a peri-urban needle exchange”. Harm Reduction Journal. 7: 8. doi:10.1186/1477-7517-7-8. PMC 2868839. PMID 20429944.
- Topp, L.; Day, C. A.; Iversen, J.; Wand, H.; Maher, L.; Collaboration Of Australian, N. (2011). “Fifteen years of HIV surveillance among people who inject drugs: The Australian Needle and Syringe Program Survey 1995–2009”. AIDS. 25 (6): 835–842. doi:10.1097/QAD.0b013e32834412cc. PMID 21192232.
- 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.
- Todd, C. S.; Nasir, A.; Stanekzai, M.; Fiekert, K.; Rasuli, M.; Vlahov, D.; Strathdee, S. A. (2011). “Prevalence and correlates of HIV, syphilis, and hepatitis B and C infection and harm reduction program use among male injecting drug users in Kabul, Afghanistan: A cross-sectional assessment”. Harm Reduction Journal. 8: 22. doi:10.1186/1477-7517-8-22. PMC 3180253. PMID 21867518.
- Zhang, L.; Yap, L.; Xun, Z.; Wu, Z.; Wilson, D. P. (2011). “Needle and syringe programs in Yunnan, China yield health and financial return”. BMC Public Health. 11: 250. doi:10.1186/1471-2458-11-250. PMC 3102626. PMID 21507267.
- Ferrer-Castro, V.; Crespo-Leiro, M. R.; García-Marcos, L. S.; Pérez-Rivas, M.; Alonso-Conde, A.; García-Fernández, I.; Lorenzo-Guisado, A.; Sánchez-Fernández, J. L.; Seara-Selas, M.; Sanjosé-Vallejo, R. (2012). “Evaluation of needle exchange program at Pereiro de Aguiar prison (Ourense, Spain): Ten years of experience”. Revista Espanola de Sanidad Penitenciaria. 14 (1): 3–11. doi:10.4321/s1575-06202012000100002. PMID 22437903.
- Lee, H. Y.; Yang, Y. H.; Yu, W. J.; Su, L. W.; Lin, T. Y.; Chiu, H. J.; Tang, H. P.; Lin, C. Y.; Pan, R. N.; Li, J. H. (2012). “Essentiality of HIV testing and education for effective HIV control in the national pilot harm reduction program: The Taiwan experience”. The Kaohsiung Journal of Medical Sciences. 28 (2): 79–85. doi:10.1016/j.kjms.2011.10.006. PMID 22313534.
- Uusküla, A.; Des Jarlais, D. C.; Kals, M.; Rüütel, K.; Abel-Ollo, K.; Talu, A.; Sobolev, I. (2011). “Expanded syringe exchange programs and reduced HIV infection among new injection drug users in Tallinn, Estonia”. BMC Public Health. 11: 517. doi:10.1186/1471-2458-11-517. PMC 3146432. PMID 21718469.
- Pinkerton, S. D. (2010). “Is Vancouver Canada’s supervised injection facility cost-saving?”. Addiction. 105 (8): 1429–1436. doi:10.1111/j.1360-0443.2010.02977.x. PMID 20653622.
- Zamani, S.; Vazirian, M.; Nassirimanesh, B.; Razzaghi, E. M.; Ono-Kihara, M.; Mortazavi Ravari, S.; Gouya, M. M.; Kihara, M. (2008). “Needle and Syringe Sharing Practices Among Injecting Drug Users in Tehran: A Comparison of Two Neighborhoods, One with and One Without a Needle and Syringe Program”. AIDS and Behavior. 14 (4): 885–890. doi:10.1007/s10461-008-9404-2. PMID 18483849.
- Chatterjee, A.; Sharma, M. (2010). “Moving from a project to programmatic response: Scaling up harm reduction in Asia”. International Journal of Drug Policy. 21 (2): 134–136. doi:10.1016/j.drugpo.2009.12.004. PMID 20079618.
- Ngo, A. D.; Schmich, L.; Higgs, P.; Fischer, A. (2009). “Qualitative evaluation of a peer-based needle syringe programme in Vietnam”. International Journal of Drug Policy. 20 (2): 179–182. doi:10.1016/j.drugpo.2007.12.009. PMID 18242971.
- Auerbach, J. D.; Smith, W. (2008). “Confronting the ‘evidence’ in evidence-based HIV prevention: Current scientific and political challenges”. BETA Bulletin of Experimental Treatments for AIDS. 20 (4): 44–49. PMID 18814374.
- “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.