Needle Exchanges Further Challenged

The fraud of needle exchange programs continues. As one of the drug policy experts who has voiced concerns about the effectiveness of needle exchange programs (NEPs) internationally, I continue to contend that there exists an “emperor’s clothes” effect around NEPs. It is remarkable that the public health community would accept, relatively carte blanche, alleged effectiveness of NEPs without reliable study design, without requisite randomized comparison to treatment, and without factoring the effect of social interventions.

The study by Wood et al. (1) does little to eliminate concerns that policy experts have around the higher incidence of HIV and Hepatitis C in needle exchange programs.

The point is made that one of the reasons for a high HIV incidence of 18% in the NEP users was that those addicts using the NEP daily constituted a sicker and less functional addict population. However, the fact remains that the longer the exposure to the NEP and continuing cocaine use, the greater the risk of HIV conversion. Conversion rates are higher for addicts who take cocaine daily and who also use the NEP daily, but even the non-daily use of cocaine and non-daily NEP use demonstrated increasing risk from 4% at 12 months to 9% at 48 months.

The most vexing question is how would such statistics look if NEPs were compared to aggressive outreach and mandatory intervention and treatment?

The public health community admires the supposed successes of NEPs based on shaky and generally poorly designed research, but when an occasional well-designed evaluation raises questions (2,3), they often scurry to find fault and further rationalize the existence of NEPs.

Unfortunately, the state of the literature does not alleviate concerns about the intrinsic risks and lack of benefit of needle exchange programs. Significant efforts are warranted to reduce the actual use of cocaine and other intravenous drugs.

Eric A. Voth, M.D., FACP
Chairman
The Institute on Global Drug Policy

Editor, The Journal of Global
Drug Policy and Practice.

1. Wood E, Lloyd-Smith E, Li K, Strathdee SA, Small W. Tyndall MW, Montaner JSG, Kerr T. Frequent needle use and incidence in Vancouver, Canada. Am J. Med 2007;120:172-179

2. Strathdee SA, Patrick DM, Currie SL, Cornelisse PG, Rekart ML, Montaner JS, et al. Needle exchange is not enough: lessons from the Vancouver Injecting Drug Use Study. AIDS 1997;11(8):F59-F65.

3. Bruneau J, Lamothe F, Franco E, Lachance N, Desy M, Soto J, et al. High rates of HIV infection among injection drug users participating in needle exchange programs in Montreal: results of a cohort study. Am J Epidemiol 1997;146(12):994-1002.

Table 1
Probability of HIV conversion:

Daily use of cocaine risk of HIV at 12-48 mos:

Daily use of NEP increased from 10% at 12 mos to 13.5 % at 48 mos
Nondaily use of NEP increased from 10% at 12 mos to 17% at 48 mos

Non daily use of cocaine 12-48 mos:

Daily use of NEP 5.5% at 12 mos to 11% at 48 mos
Nondaily use of NEP 4% at 12 mos to 9% at 48 mos

The Dangers of Legalizing Medical Marijuana: A Physician’s Perspective

Testimony of Mark L. Kraus*, M.D., FASAM, Past President, Connecticut Chapter of the American Society of Addiction Medicine to the Judiciary Committee, Hartford Connecticut, February 26, 2007

On behalf of the members of the Connecticut Chapter of the American Society of Addiction Medicine (ASAM) and the Connecticut State Medical Society, I am delighted for this opportunity to voice our strong opposition to the continuing efforts being made in Connecticut to legislate marijuana for medical use. The members of ASAM have devoted their medical careers to further the development of treatment for addictive disorders and the associated medical / psychiatric consequences. We are concerned that marijuana, a dangerous chemical, with life altering properties, is being considered for use as a viable medicine.

For those who are inclined to support medical use of marijuana, it is usually not the scientific evidence they consider, but only the unfounded self-reports of how marijuana relieved pain, chemotherapy induced nausea and vomiting or HIV-AIDS Wasting Syndrome. We are deeply concerned that the myths surrounding the medical use of marijuana pose a grave danger to patients. Proponents of the legalization of medical marijuana create the impression that it is a reasonable alternative to conventional drugs. But unlike conventional drugs, smokable marijuana has not passed the rigorous scrutiny of scientific investigation and has not been found safe and effective in treating pain, nausea and vomiting, or wasting syndrome.

1. Unlike most drugs administered orally, intravenously, intramuscularly, or by epidermal patch, marijuana is smoked. Like tobacco, smoked marijuana contains many of the same toxic or carcinogenic compounds that have been linked to lung cancer and emphysema. Current findings indicate that the evidence suggests that the marijuana cigarette, in contrast with the tobacco cigarette, delivers over four times the amount of tar and much higher concentration of polycyclic aromatic hydrocarbons, such as the carcinogen benzopyrene.

2. Marijuana smoked, like tobacco smoked, contains toxins and other foreign particulates that are known to cause inflammation in the lining of the lungs. Unlike tobacco smoke, marijuana smoke substantially reduced the alveolur macrophages, the lung’s primary defense against infectious microorganisms, foreign substances and tumor cells. This is of particular concern for the immunocompromised HIV/ AIDS patients or cancer patient, who is already at great risk for opportunistic lung infections. Though the evidence is no means conclusive, chronic marijuana smoking may be a factor in the development of acute and chronic bronchitis, and increasing the risk of pneumonia.

3. Smoking marijuana can cause tachycardia and abrupt changes in blood pressure causing grave concern to those who have cardiovascular disease.

4. There is scientific evidence that long term marijuana smoking alters the reproductive system.

Contemporary medicine and pharmacology are based on the application of scientific principles and the use of extensive clinical research to determine the safety and efficacy of a drug. For each symptom or disease advocated to be treated by smokable marijuana, there is a well accepted, well researched, and more effective treatment.

Among these drugs is MarinolÒ (dronabinol), a synthetic version of the naturally occurring component of marijuana (THC or tetrahydrocannabinol), that is indicated to treat chronic pain, chemotherapy related nausea and vomiting, and HIV / AIDS associated Wasting Syndrome.  MarinolÒ, however, unlike smokable marijuana, is a pure chemical compound that has been subjected to rigorous chemical research trials that have established its efficacy, safety, side-effect profile, and proper dosing. Interestingly, the only known property MarinolÒ lacks is the effect of creating “a high”.

As Addiction Medicine Specialists that are dedicated to the treatment of those afflicted by the disease - addiction, and to furthering science-based knowledge, we believe that these proposals to legislate the use of smokable marijuana as a medicine constitutes a far greater threat than many Americans truly realize. These proposals to use smoked marijuana as a medicine convey a mixed and ambiguous message to children, adolescents and adults. These messages undermine the many years invested by public health to prevent pre- and adolescent onset of the use of tobacco, marijuana, and other drugs. These proposals provide real contradictions that are not easily addressed or resolved in school and in family discussions, especially where the images of the marijuana user intrude into the day to day lives of these young people.

Current research indicates that the use of this marijuana on a regular basis during adolescence is a strong marker for ensuring drug problems later in life. Young people are often misinformed and mislead to believe that the use of marijuana is harmless and that you can not become addicted. No thing is further from the truth. There is clear evidence that the use of marijuana can result in dependency. These young people and other individuals dependent on this drug will make the choice to use it in physically compromised situations, and will continue to use it putting their education, jobs, interpersonal relationships, and legal status at a significant risk.

In closing, I urge you to reject the proposal that would change the status quo by recognizing smokable marijuana as an accepted drug. As a practicing physician and a concerned member of my community, I can find no redeeming qualities derived from smoking a weed-marijuana.

It is unconscionable in this era, the 21st century, that our best effort to deliver effective pain relief, or to treat chemotherapy induced nausea or vomiting, or treat HIV/AIDS Wasting Syndrome would consist of prescribing smokable marijuana. We must reject these efforts to give marijuana medical credibility by equating it with other more pharmacologically advanced drugs that have passed the rigors of scientific investigation / research and demonstrate significant efficacy in treating pain, nausea, and vomiting (chemotherapeutically induced) or HIV / AIDS Wasting Syndrome. It has no credibility. It has not passed the rigors of scientific investigation. It has not demonstrated significant efficacy in symptom relief. And, it causes harm.

As physicians we have a duty to follow the tenets of the Hippocratic Oath we have taken: “Do no harm.” To lower the level of current control of marijuana would only serve to exacerbate an already grave societal and medical problem. To characterize those who do not support the legislation of medical marijuana as less than supportive of those who are “suffering” is a cynicism in the extreme. This campaign of self-serving political propaganda, misinformation and deception must stop.

*General Internist, Westside Medical Group, Waterbury, CT; Former Medical Director Addiction Medicine, Waterbury Hospital, Waterbury, CT; Assistant Clinical Professor of Medicine, Yale University School  of Medicine; New Haven, CT; Chairman, Connecticut State Medical Society Alcohol and Other Drug Education Committee; Former Co-Chairperson, Governor Rowland’s Blue Ribbon Task Force Substance Abuse; Member (Non Statutory), Connecticut Alcohol and Drug Policy Council; Member (Non Statutory), Connecticut Mental Health Policy Council; Co-Chairman, Physician Education Task Force for Association of Medical Education and Research Substance Abuse (AMERSA).  Member, Strategic Task Force ASAM; Member, Public Policy Committee ASAM; Member of Board of Directors American Society of Addiction, Primary Care Advisory Committee for the National Institute of Drug Abuse