According to the CDC during the 12-month period ending in April 2021, there were an estimated 100,306 drug overdose deaths in the United States, which is a 28.5% increase from the previous year (1). It has become clear that our current methods for addressing drug addiction are beyond insufficient, and we as a society have failed to recognize drug addiction for the medical condition that it is. Two solutions that have been highly debated, especially in terms of their ethicality, are needle exchange programs (NEPs) and safe injection sites. Based on the evidence from various studies and evaluations of various stances on these intervention methods, I will argue that these solutions are ethical because of the harm reduction they both provide.
Drug addiction is a chronic disease in which an individual displays compulsive drug-seeking and drug-use behavior despite any harmful consequences. While many people initially use drugs voluntarily, the addictive aspect can quickly take effect. This development is marked by brain changes that disrupt an individual’s ability to exercise self-control, which produces behaviors commonly associated with addiction (2). Drug addiction is not a disease that discriminates; it can affect any person whether it is someone who was prescribed opioids after an invasive life-saving surgery and lost control because of the addictive nature of the medication, someone who was trying to self-medicate to withstand their mental illness, or someone who was just going to try doing drugs once at a party. There is no moral failure of those who develop drug addiction as it is a condition that alters the brains of those affected(3).
Within the past year, 22% of males and 17% of females above age 18 participated in the use of illegal drugs or the misuse of prescription drugs in the US(4). Furthermore, at any time there are 350,000 regular injection drug users in America all of which are at an increased risk of contracting blood-borne infectious diseases along with experiencing an overdose and various drug-related complications (5). When it comes to overdoses, over 70% of them involve some sort of opioid, whether that be prescription opioids, heroin, or synthetic opioids (like fentanyl)(6). Heroin users in particular are at a significantly higher risk of overdose because the opioid content and strength of the drug can widely vary, which means it is easy for individuals to not know how much they have taken (3). Another consequence of the opioid crisis is an increased rate of blood-borne infections including hepatitis B, hepatitis C, human immunodeficiency virus (HIV), AIDS, and other bacterial and fungal infections (7). Thirty-five percent of AIDS infections in the US can be linked to injection drug use when mother-to-child HIV transmission is taken into account (5). These infections are primarily spread through drug use in unsanitary conditions and the sharing of injection drug equipment (7).
One way of addressing this epidemic is through needle exchange programs (NEPs). NEPs are community-based programs created with the goal of reaching drug users, specifically intravenous drug users, to reduce a variety of risks. These programs allow for the safe disposal of used syringes and needles, dispense sterile needles and syringes, and provide other services such as referral to treatment, education about overdose prevention, wound care, and so much more (8). In the United States, there are approximately 185 NEPs in operation in 38 states even though federal law prohibits the use of federal funds to support them (5). There are 3 primary arguments made by opponents of NEPs: the availability of sterile drug paraphernalia would cause a rise in drug use and reduce public health, removing strong opposition and obstacles to drug use would be a corrupting influence on children; and allowing NEPs, especially through federal funding, would contradict the government's “war on drugs” by indirectly signaling governmental approval of drug use (9).
However, these claims are highly refuted by a plethora of scientific evidence and those in support of NEPs. A study by the National Institute of Health (NIH) found that NEPs result in an estimated 80% reduction rate in risk behaviors among injection drug users (5). Furthermore, there is a decrease in blood-borne infectious disease transmission among injection drug users with the presence of NEPs (9). Around the country, NEPs have decreased the rate of transmission of HIV by between one-third and two-fifths. Not only do supporters of NEPS push back on the idea that these programs increase drug use, but actually point ot the fact that NEP participants are about 5 times more likely to enter drug treatment services than those who had never used an exchange.(5). Finally, supporters of NEPs assert that NEPs can actually protect nonusers as well, like law enforcement officers and health care workers, by removing unsterile and potentially infected needles from rotation (9).
To evaluate the ethicality of NEPs, we can consider the bioethical principles of beneficence and nonmaleficence. Beneficence means to do good and nonmaleficence means to do no harm (10). I believe that these principles are being met with the use of needle exchange programs because providing sterile equipment and allowing for the safe disposal of used needles reduces the harm to these addicted groups of people. This is especially the case when you consider that NEPs are not shown to increase the amount of drug use. The alternative to NEPs is that people already struggling with addiction will use unsanitary drug equipment without access to resources or education to deal with injury or overdose if they occur. We must frame addiction not as a choice or an action in need of punishment but instead as an addiction wrapped in some form of mental health issue. It is in the best interest of everyone that drug users are as safe as possible. For the moment, that means focusing on harm reduction by providing access to sterile equipment to reduce some of the negative impacts of drug use until there is a more concrete solution to address the root of drug use in America.
An even more controversial approach to addressing the current risks experienced by those who struggle with drug addiction is safe injection sites. Safe injection sites are locations where individuals can bring their own drugs to use in the presence of trained staff without fear of receiving punishment. This setup helps to prevent accidental overdoses and the spread of infectious diseases like HIV (11). Ultimately, safe injection sites provide many of the benefits of NEPs but with the added benefit of monitoring individuals after they have used drugs in order to be able to respond to an overdose. Furthermore, it provides a safe space for people, especially vulnerable populations like women or LGBTQIA+ individuals, to take drugs without the danger of being taken advantage of while their inhibitions are lowered. These facilities are built on the principle of harm reduction, so they also provide resources to help connect those struggling with substance use disorder to treatment options and boxes of supplies (3). Boxes to reduce infectious diseases often include a variety of things like needle kits with sterile needles to reduce sharing, condoms for safe sex, bandages and topical treatments for infections and injuries, and even sometimes little sterile cups to freebase injectable drugs. Freebasing is when people boil the base form of a drug to increase potency. Safe injection sites also provide free Naloxone (overdose antidote) kits to users so that they can respond to an overdose themselves when not under supervision. It is important to note, however, that as federal law stands in the US, it is illegal for individuals to actually inject in safe injection sites. Instead, they must inject outside the building and then are welcome to come inside to be monitored (3).
As drug-related deaths continue to rise, there is increasing consideration of amending the limitations put on safe injection sites in the US. This changing perspective can also be partially attributed to the fact that there are many examples of safe injection sites working effectively in other nations. Around the world, mainly in Europe, Canada, and Australia, there are over 100 supervised injection sites. A 2014 review of 75 studies about safe injection sites showed that they resulted in safer injection conditions and less outdoor drug use. Furthermore, there was no “honey pot effect,” meaning there was no increased drug use or crime surrounding safe injection sites. It is also significant to mention that there have been no reported deaths at a safe injection site and the fatal overdose rate has decreased in the areas surrounding safe injection sites (12).
If we are able to recognize as a society that drug addiction is a medical disorder that requires treatment, then our methods of intervention should be centered on compassion and providing medical care. The question of this situation is whether it is better for those struggling with addiction to hide in shame, risking transmission of infectious diseases like HIV, or use in a monitored environment where they have access to treatment whenever they are ready (3). For those working in the field, their answer to the question is clear; the value of a non-judgemental supervised injection facility supersedes the unsubstantiated fears of increasing drug use and crime. As Darwin Fisher, the program coordinator of Insite, a safe injection site in Canada, said, "it's about making a space where drug users are allowed to feel like people (12)." One of the goals of providing healthcare to those struggling with disease (including addiction) is to humanize them and allow them to be defined by something more than their disease.
It is important to reform our mentality as a society when it comes to drug use and addiction. For far too long, drug use has been painted as a crime that deserves punishment instead of the health issue that it is. As we would handle any other health issue, it is important to prioritize the safest route to treatment, and at the moment safe injection sites and needle exchange programs are those solutions. Humans have a long history of separating from, condemning, and excluding people who are sick and appear to not be healthy out of self-preservation. However, when we overcome that gut response and care for those struggling, health outcomes increase significantly. Especially because addiction is not a disease that is transmissible, caring for those struggling with addiction is not putting ourselves at risk it is society's duty. While treatment is an important aspect of combating drug addiction, there needs to be intervention focused on harm reduction in the meantime until addicted individuals are ready to seek medical treatment. The response to drug addiction and the opioid crisis should be rooted in compassion and focused on the health of those struggling, not our own preconceived notions and fear of disease.
Work Cited
Centers for Disease Control and Prevention. (2021, November 17). Drug Overdose Deaths in the U.S. Top 100,000 Annually. Www.cdc.gov. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm
National Institute on Drug Abuse. (2018, June 6). Understanding drug use and addiction drug facts. National Institute on Drug Abuse. https://nida.nih.gov/publications/drugfacts/understanding-drug-use-addiction
MD, S. W. (2017, June 2). Safe injection sites and reducing the stigma of addiction. Harvard Health Blog. https://www.health.harvard.edu/blog/safe-injection-sites-reducing-stigma-addiction-2017060211826
National Center for Drug Abuse Statistics. (2019). NCDAS: Substance abuse and addiction statistics [2020]. National Center for Drug Abuse Statistics; National Center for Drug Abuse Statistics. https://drugabusestatistics.org/
Needle Exchange Programs Promote Public Safety. (n.d.). American Civil Liberties Union. Retrieved February 15, 2023, from https://www.aclu.org/fact-sheet/needle-exchange-programs-promote-public-safety#:~:text=Needle%20Exchange%20Programs%20Promote%20Public%20Safety%3A%20A%20study
CDC. (2019, September 4). America’s Drug Overdose Epidemic - Data to Action. Centers for Disease Control and Prevention. https://www.cdc.gov/injury/features/prescription-drug-overdose/index.html
Centers for Disease Control and Prevention. (2019). Persons Who Inject Drugs (PWID). Cdc.gov. https://www.cdc.gov/pwid/index.html
Center for Disease Control and Prevention. (2019, May 23). Syringe Services Programs (SSPs) FAQs. Www.cdc.gov. https://www.cdc.gov/ssp/syringe-services-programs-faq.html
Needle Exchange Programs Promote Public Safety. (n.d.). American Civil Liberties Union. Retrieved February 15, 2023, from https://www.aclu.org/fact-sheet/needle-exchange-programs-promote-public-safety#:~:text=Needle%20Exchange%20Programs%20Promote%20Public%20Safety%3A%20A%20study
Burks, D. (n.d.). Beauchamp and Childress The Four Principles. https://www.uc.edu/content/dam/refresh/cont-ed-62/olli/22-winter/bioethics%20four%20principles.pdf
Health Canada. (2017). Supervised consumption sites explained - Canada.ca. Canada.ca. https://www.canada.ca/en/health-canada/services/substance-use/supervised-consumption-sites/explained.html
GORDON, E. (2018, September 7). NPR Choice page. Npr.org. https://www.npr.org/sections/health-shots/2018/09/07/645609248/whats-the-evidence-that-supervised-drug-injection-sites-save-lives