Wednesday, January 30, 2008

A (Sterile) Needle in a Haystack

As much as I hate to flagellate a deceased equine, I really don't think my last entry drove home the point about why we need to provide clean syringes and needles to injectable drug abusers.

There are numerous arguments made by those opposed to selling (or even giving) syringes and needles to drug users. It "doesn't work; addicts will use dirty needles anyway." It "sends the wrong moral message about drug use," which we all know is of primary concern to good, patriotic citizens. And, my personal favorite, it encourages drug abuse by making it "safer."

The first argument can be refuted with science. The second can't be strictly refuted because it relies entirely on subjective opinion; despite what some people seem to think, morals are cultural values, and they vary from person to person instead of being absolute or inherent.

The last argument annoys me more than the others because it blatantly ignores reality. IV drug users may be concerned with their safety, but what constitutes "acceptable risk" for abusers of illegal drugs is not the same as it is for you and I. In clinical practice, we never have patients self-administer IV injections, partly because it is considerably more difficult than giving a subcutaneous or intramuscular injection. Not only is the technique more complicated, but the risks are considerably greater. Forget about dirty needles for a moment; let's look at all the other "safety" issues being bypassed.

1: No way to verify purity of product. You don't know how much heroin you actually have and how much of that product is fillers--many of which do not belong in your veins. Even seemingly innocuous fillers such as talc or cellulose can cause tissue death.

2: Product concentration considerations. Injectable products have to be carefully balanced so that their osmolarity does not disrupt existing tissues. A solute (drug + additives) concentration that is too high will cause cells to shrink as water is sucked out of them to equalize the concentration gradient. A concentration that is too low will result in water rushing into cells and bursting their membranes.

3: Product and injection prep environment sterility. Even if you're using a clean needle, I doubt most IV drug users prepare their doses in a laminar flow hood. When pharmacists or technicians prepare injectable drug products they must meet many standards. You can potentially contaminate your product by touching any one of various critical needle/syringe areas, failing to wipe injection ports with alcohol, cleaning the hood improperly before use, taking your hands out of the sterile environment, leaning too far into the hood...the list goes on.

A "clean" needle is just the first step to sterility. You don't buy heroin in multidose glass vials that meet USP standards for purity and stability, buffered to appropriate pH and preserved with appropriate IV-safe additives. You buy heroin from a shady drug dealer in a back alley somewhere. You have no idea where he got it. There's no one you can complain to about manufacturing standards or product flaws. The fact is that drug users are willing to introduce a substance they bought in a back alley directly into their veins, bypassing all the body's barriers against infection and introducing contaminants or particles that can directly damage blood vessels.

It is so risky to abuse IV drugs that denying addicts access to clean needles is not going to be the straw that breaks the camel's back and turns them away from their dangerous habits forever. It is going to be added to the laundry list of hazards that addicts have already classified as "acceptable risks." And it isn't just addicts; new users aren't really concerned about their safety, either, and if they tell you that they are, they're lying, whether they realize it or not. There's a serious contradiction between "I prioritize being safe" and "I'm willing to inject substances of indeterminate origin and quality directly into my veins."

So we can ignore the reality that hard-core addicts are going to shoot up whether we give them clean needles or not and live in a political fantasyland where people don't do dangerous things. Or we can face the facts.

The fact is that IV drug users don't tend to pay their medical bills when they OD or contract hepatitis. They wind up in the ER, where they cannot be legally denied care, and everyone else absorbs the shock through increased healthcare costs. When addicts end up on Medicaid, you are paying for their AZT. You are paying for their hospital stays when they're suffering from liver failure. Your healthcare costs more when you deny clean syringes to drug users and more of them become seriously ill. I'm not saying you have to approve of their habits. I'm saying that you have to consider the economic ramifications of disease control. More sick people who can't pay their hospital bills means higher hospital fees for everyone so that hospitals can recoup their losses.

The fact is that the moral paternalists who oppose needle programs--and Narcan--don't care about the lives of drug addicts. They cloak their lack of empathy with layers of political doubletalk. But even if you can't bring yourself to have basic human empathy--or honesty--look at the situation from a pragmatic perspective. You are increasing costs for the entire healthcare system every time you deny that syringe sale because Johnny the addict doesn't have an insulin prescription.

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