Reduction of the medical and public health consequences of drug abuse
Note: This report, written in response to Resolutions 416 (I-94), 409 (I-95), and 405 (I-96), represents the medical/scientific literature and AMA policy on this subject as of June 1997.
Full text
The AMA has stated repeatedly that drug dependencies, including alcoholism, are diseases and that their treatment is a legitimate part of medical practice (Policy 95.983, AMA Policy Compendium). Although illicit drug use is a criminal action, drug addiction is a disease amenable to treatment (Policy 420.970). Government and other public and private organizations are urged to base their policies on the recognition that drug dependencies are diseases (Policy 95.983). The AMA urges federal, state, and local governments to increase funding for drug treatment so that drug abusers can have immediate access to appropriate care, regardless of ability to pay. This is the most important step that can be taken to reduce the spread of human immunodeficiency virus (HIV) infection among intravenous drug abusers (Policy 20.977).
The AMA continues to monitor trends in HIV transmission among intravenous drug injectors and to "pinpoint effective strategies (including needle-exchange programs)" for control of HIV infection (Policy 20.977). The AMA encourages needle-exchange programs (Policy 95.958).
The AMA urges the expansion of drug rehabilitation programs (Policy 95.980) and urges Congress to "substantially increase its funding for drug treatment programs" (Policy 95.973). The AMA "encourages the availability of methadone maintenance for persons addicted to opioids" and calls for the removal of federal and state regulations that restrict or inhibit methadone maintenance (Policy 20.966). To help control the spread of HIV infection, the AMA supports the development of interim methadone maintenance clinics, which include appropriate medical services, for persons with opioid dependence awaiting transfer to a full-service clinic (Policy 95.959). The AMA suggests the development of new methadone treatment regulations with a shift of emphasis from administrative process to performance-based standards with greater reliance on the physician's clinical judgment (Policy 95.964). The Council on Scientific Affairs (CSA) produced a report in 1994 on "Methadone Maintenance in Private Practice." This report reaffirms a position of the AMA recommending further evaluation of the use of properly trained practicing physicians as an extension of organized methadone maintenance programs in the management of those patients whose needs for allied services are minimal (called "medical" maintenance). The CSA supported the position that "medical" methadone maintenance may be an effective measure in controlling the spread of infection with HIV and other blood-borne pathogens.
At the same time, the AMA condemns illicit drug use and encourages physicians to do all in their power to discourage the use of illegal drugs (Policy 95.961). Within that context, the AMA discourages marijuana use (Policy 95.995) and believes that the sale and possession of marijuana should not be legalized (Policy 95.998), but supports the modification of state laws to reduce the severity of penalties for possession of marijuana (Policy 95.995). The AMA opposes drug legalization (Policy 95.981) and the manufacture, sale, and use of drug paraphernalia (Policy 95.989).
Harm reduction goals
Harm reduction is a term with disparate meanings and connotations. To an alcoholism treatment professional, it can be a "code word" for controlled drinking, a goal not widely accepted in the medical community. To others, it is synonymous with legalization of marijuana, heroin, cocaine, and other drugs. To still others, it means tailoring treatment to the needs of individual patients to achieve optimal outcomes.
There are some nonmedical users of psychoactive substances who, for any of several reasons, may not be willing or able to cease use at a particular time. For the purposes of this report, harm reduction is defined as those practices that are employed to reduce the medical and/or public health consequences associated with such use.
Harm reduction, in this light, becomes important in cases where prevention fails. It can coexist, and is not incompatible, with a goal of abstinence for a drug-dependent person, or a policy of "zero-tolerance" for society.
Addiction treatment that is accessible and responsive to the needs of patients can be a major harm reduction mechanism. Because early treatment is so important to successful outcomes, screening for alcohol and other drug use becomes an effective intervention when used to indicate which individuals should be evaluated for substance use disorders and possible treatment. Screening methods, including laboratory tests, history taking, and administration of questionnaires on substance use, may be applied in a variety of settings, such as emergency rooms, trauma centers, prisons and jails, community agencies, the workplace, etc.
Other interventions designed to reduce harm attendant upon alcohol, nicotine, and other psychoactive drug use may include attempts to:
- Reduce the direct toxicity of drugs or the indirect toxicity caused by co-ingestion of contaminants, including microorganisms;
- Reduce the consequences of drug use on others, e.g., by reducing the likelihood of transmitting HIV infection to sexual partners or the impact of violent criminal behavior on persons unrelated to drug dealing;
- Demarginalize the user and transport his or her life into productive pursuits by lessening the time, effort, and money spent on acquiring drugs.
Techniques for accomplishing these ends might include provision of drugs to persons who are drug dependent; substitution of other drugs for the drugs to which the person is addicted; modification of use patterns and routes of administration; and provision of safer techniques, tools, and locations for drug self-administration.
Criticisms of harm reduction
Critics of harm reduction approaches to substance abuse point out that harm reduction has "downside" risks, and could actually be harmful in itself.
Some critics take the position that harm reduction is often a poor alternative to prevention. If, for example, a smoker who would otherwise quit smoking, either on his/her own or through treatment, is persuaded to use cigarettes with reduced tar content, the health risks are greater not only for that individual but for those who are subject to passive smoke inhalation. Diminishing harm does not eliminate it.
Even when harm reduction is incorporated into treatment, such as in methadone maintenance for opiate addicts, there have been complaints about diversion of drug supplies for "street" sales to naive users, or charges that maintenance programs perpetuate a two-tiered system of drug-free middle class patients versus drug-dependent underclass patients.1,2
Finally, harm reduction may be opposed because of belief that it "sends the wrong message," especially to young people, raising doubts about the undesirablity and dangers of drug use. Indeed, if harm reduction methods are perceived to be readily available as safety nets or damage control, a potential drug user might be less reluctant to experiment with drugs, or, later on, less inclined to seek needed treatment.
Harm reduction in a risk-filled world
On the face of it, there appear to be numerous analogies to reducing the harmful consequences of nonmedical drug use, rather than eliminating such use itself. Safety standards, such as traffic rules and automobile speed limits, occupant restraints (seat belts, air bags), shatterproof glass, and anti-lock braking systems, reduce the inherent dangers of automobile travel. The placement of lifeguards at public beaches reduces the likelihood of drowning. The development of protective gear for athletes, the requirement that motorcyclists wear helmets, and the placement of expiration dates on processed foods are harm reduction strategies. Although not without critics, such measures have been widely accepted in American society. They seek not to prohibit potentially dangerous activities, but to alter the conditions under which such activities occur and, thereby, reduce the incidence of negative consequences for individual participants and society as a whole.
There is, however, a logical flaw in equating harm reduction measures for these activities with harm reduction strategies for drug use. Despite their risks, these activities involve socially acceptable, or even necessary, behavior. Because it would be neither desirable nor realistic to attempt to prohibit these activities, harm reduction is the only realistic option. The nonmedical use of drugs, on the other hand, does not constitute socially acceptable behavior and, therefore, it is not undesirable or unrealistic to try to prevent such use.
Harm reduction and drug use
Since the early 20th century, harm reduction strategies have become an important part of public policy concerning legal drugs. For medicinal drugs, this includes standards for evaluation and approval, requirements that some drugs be available only by prescription, and use of warning labels on over-the-counter home remedies. While none of these strategies completely eliminates medicine-related harm, they reduce the level of harm to within acceptable limits.
More recently, harm reduction ideas have influenced approaches to tobacco users. Possible harm reduction interventions with tobacco include behavioral, pharmacological, and public health interventions. Less hazardous products (e.g., low tar and nicotine cigarettes) can be used, nicotine replacement preparations (e.g., gum, patch, nasal spray) can be used, or intake can be reduced (e.g., decrease number of puffs per cigarette or reduce the number of cigarettes smoked per day). (However, see Criticisms of Harm Reduction above.) A growing number of businesses and municipalities confine smoking to specially ventilated areas of buildings or outdoor locations to reduce the amount of second-hand smoke inhaled by nonsmokers.
Harm reduction also has become part of society's approach to alcohol. Campaigns that encourage the use of "designated drivers" and urge people to "not let friends drive drunk" are clear attempts to lessen the harm of alcohol consumption on individual users and others. These campaigns have been successful because they do not necessarily seek to restrict alcohol consumption but, instead, offer reasonable suggestions for the consumption of alcohol in a less damaging way.
Outside the United States, harm reduction approaches to the use of "illegal" drugs have gained the support of some politicians and governmental leaders. In the Netherlands, Australia, Germany, England, and Switzerland, harm reduction has become a principle for drug policy formation at local and national levels. This change was driven, in large part, by the acquired immunodeficiency syndrome (AIDS) epidemic and growing awareness that HIV was spreading rapidly among injection drug users and, from them, to the rest of the population. Thus, policies to control the spread of AIDS have been at the heart of the harm reduction movement. However, in recent years, the movement has broadened substantially and now includes strategies for reducing various kinds of drug-related harm, particularly within hard-core addict populations.
Harm reduction through improved treatment outcomes
A harm reduction approach to drug treatment acknowledges that, just as there is a spectrum of patterns of drug use, there is a range of outcome measures that are reasonable to assess when evaluating the effectiveness of professional treatment services.
Quantity and frequency of substance use--pre- and post-treatment--is but one outcome measure. Abstinence is not an invariable outcome of a given professional intervention, and failure to achieve abstinence should not necessarily be interpreted as treatment failure. Reduction of use and increase in the number of use-free days are both measurable treatment outcomes that can be regarded as beneficial and harm reducing.
Yet, because the vast majority of individuals who meet diagnostic criteria for substance dependence are not able to achieve a state of nonproblematic controlled use of alcohol or other drugs, it is reasonable to recommend a goal of total abstinence to these patients. Many studies have demonstrated substantial success rates for abstinence-based treatment in both inpatient and outpatient settings.
Relapse to drug using often accompanies dropout from treatment. A common reason for ending treatment is the lack of available reimbursement for ongoing services. Only recently have data become available confirming the benefits, if not the necessity, of sustained professional care.
Methadone maintenance
The most widely implemented harm reduction program in the United States, begun in the late 1960s, is methadone maintenance therapy (MMT). This is a form of drug substitution or maintenance therapy (OMT) for opioid dependence. Another form uses the longer-acting agent levo-alpha-acetyl-methadol (LAAM) instead of methadone. OMT is a specific modality of treatment for opiate dependence, and is highly effective in resolving the signs and symptoms of addiction: e.g., preoccupation with substance procurement and self-administration, loss of control over amount and routes of consumption, and persistent or increasing use despite adverse consequences. The developers of MMT in the United States, Dole and Nyswander, argue that the lives of many chronic heroin injectors could be improved by providing them with "maintenance doses" of a substitute opiate drug.3 The synthetic opioid methadone was chosen because of its relatively good bioavailability when consumed orally and its relatively long persistence in the body. In sufficient doses, once-a-day administration promised to prevent opiate withdrawal, diminish "drug craving," and free heroin users from the necessity of obtaining street drugs. And because of tolerance, methadone clients would not be chronically intoxicated, making it possible for them to live more stable and productive lives.3
Methadone maintenance was expanded in the United States during the 1970s. In subsequent years, numerous evaluation studies have produced evidence of significant positive outcomes. Retention rates have been much higher than those for other treatment modalities, and methadone patients have had lower rates of criminality, arrest, and imprisonment. In addition, even when methadone patients continue using heroin and other illicit drugs, such use is substantially below pre-treatment levels.4,5 Another important benefit of methadone patients' decrease in illicit drug consumption is reduced risk for the various adverse health consequences that accompany repeated injection, including HIV infection.6
Methadone maintenance soon began spreading from the United States to other countries, with the emergence of the AIDS epidemic encouraging more widespread adoption in Europe and Australia. In fact, outside the United States, methadone maintenance has become an integral part of treatment and rehabilitation strategies as well as harm reduction strategies, with efforts to make the programs easily accessible and "user friendly." Heroin users are generally free to enter and leave programs at will, are not excluded upon evidence of additional drug use, have input into decisions regarding dosage levels, and can earn "take home" privileges to facilitate the development of stable work and family lifestyles. While methadone recipients are generally offered counseling or other therapeutic opportunities, they are not obligated to participate as a condition of receiving methadone. In addition, methadone is made available in a variety of ways: through clinics, mobile units that travel to areas where drug users congregate, and prescription by private physicians. The principle underlying these "low threshold" systems is to maximize methadone delivery and, thereby, decrease heroin consumption and related harms.7-11 To generate further risk reduction, some British programs also have begun to provide an injectable form of methadone to clients unwilling to consume the drug orally.12
In contrast, despite the AIDS epidemic, methadone maintenance has become increasingly restrictive in the United States--with a contraction in the number of programs and implementation of stricter regulations regarding dosage levels--despite evidence that better outcomes are often obtained when patients are maintained on higher doses.13.14
Although many of the measures instituted abroad might not be appropriate in this country, reorganization and expansion of methadone services could improve the health and social functioning of chronic heroin injectors, including those on program waiting lists, those not amenable to or eligible for standard MMT programs, and those who are patients in AIDS and tuberculosis clinics. In addition, greater methadone availability can produce positive consequences for society by reducing drug users' reliance on street drugs, reducing criminality, and reducing the spread of HIV infection.
Consistent with evidence of effectiveness in limited trials,15 federal regulations prohibiting methadone prescription for maintenance by physicians outside of formal MMT programs should be re-evaluated. Research on the "medical" model of maintenance should be supported. This was the subject of a previous CSA report ("Methadone Maintenance in Private Practice," I-94).
Needle exchange
Harm reduction among drug injectors should include a recommendation to cease drug use and the provision of effective treatment. If cessation cannot be achieved, education about the value of clean needles and syringes and information about needle-exchange can be useful. When hypodermic needles and syringes are not readily available, intravenous drug users tend to reuse injection equipment numerous times, and often share it with others. As a consequence, blood-borne diseases may spread rapidly in populations of drug users. During the past several decades, epidemics of hepatitis have been attributed to needle-sharing. Since the mid-1980s, needle-sharing has been responsible for spreading the HIV infection from one drug user to another, from drug users to their sexual partners and, eventually, from infected mothers to their neonates.
Although a variety of programs have been developed for reducing the spread of HIV infection among drug injectors, needle exchange has been one of the most important and effective. In many countries, the response to reports of escalating HIV prevalence among intravenous drug users was creation of needle and/or syringe distribution programs, most of them requiring participants to return dirty needles in exchange for sterile ones. The Netherlands was a leader in this regard; in fact, because of its early commitment to harm reduction philosophies, needle exchange was implemented there in the early 1980s, prior to emergence of the AIDS crisis.16 By the late 1980s, governments in England, Switzerland, Australia, and Germany also had begun needle-exchange programs and, within a few years, most other European countries had followed their lead.17
While differing in format and size, needle-exchange programs share a commitment to maximizing the availability of sterile needles and syringes--offering them at multiple locations, through storefronts, outreach workers, or mobile vans. In some cities, needles and syringes are distributed at drug-treatment centers18 and, in Amsterdam, even police departments have joined the effort.19 More recently, "vending machines" that yield a clean syringe if a syringe is deposited have been placed in high drug-use areas to make clean needles available around the clock.20 Pharmacists also have been encouraged to sell needles and syringes to drug users and, in Liverpool, England, some pharmacies operate needle-exchange programs.21
There is substantial evidence of reduced needle-sharing among regular participants in needle-exchange programs.22,23 More importantly, HIV infection rates among drug users have been consistently lower in cities with needle-exchange programs--as well as lower in cities that implemented programs early in the AIDS epidemic, compared with those doing so later.24,25 For example, while the HIV infection rate among injection drug users remained 1 percent to 2 percent in the Scottish city of Glasgow, where a needle-exchange program was quickly established, it reached 70 percent in nearby Edinburgh, where the response of government officials was to implement even more stringent controls over injection equipment.26,27 While the intended purpose of the increased controls was to discourage drug injection, the consequences included increased needle-sharing and escalating HIV rates.
In the United States, HIV rates among intravenous drug users are similar to those in Edinburgh, as high as 70 percent in some cities.28,29 State regulations that require a physician's prescription for the purchase of needles and syringes prevent drug users from obtaining them at pharmacies. In addition, in most states, anti-paraphernalia laws make the possession of drug-administration equipment a criminal offense and, thus, grounds for arrest and imprisonment. As a consequence, drug users, particularly those who buy drugs on the street, tend not to carry injection equipment. Instead, they borrow it from others or rent it in communal "shooting galleries." Indeed, it has been suggested that the strikingly higher prevalence of HIV infection among African-American and Hispanic drug injectors, compared with Caucasians, may be largely due to the concentration of minority drug users in the most intensely policed urban areas.30
In the past few years, a few dozen needle-exchange programs have been started in the United States, but most are small and serve only a fraction of the nation's intravenous drug users. Federal law continues to prohibit the use of federal money for needle exchange,31 despite evidence that needle availability decreases needle-sharing and HIV transmission and does not increase the number of drug users or the frequency of injection among current users. These conclusions are supported not only by European studies, but by the results of a study of approximately 2,900 heroin injectors in Baltimore, Maryland. Included in the sample were 40 diabetic subjects who, because they had identification cards to justify their possession of hypodermic syringes, seldom shared injection equipment with others and had much lower rates of HIV infection. Furthermore, there was no evidence that they injected drugs more frequently or intensely than their non-diabetic counterparts.32
A thorough review of the impact of foreign and domestic needle-exchange programs was recently conducted by the Institute for Health Policy Studies at the University of California, San Francisco, for the US Centers for Disease Control and Prevention. Although the authors of the report had some reservations about the small amount of data available, at the time, they were unequivocal in their support of making sterile equipment available to injection drug users.33
Outreach interventions
Among the earliest organized harm reduction efforts, in response to the AIDS epidemic, were outreach programs in which workers from drug abuse service agencies left their offices and sought to engage injection drug users in local drug scenes, "copping" areas (ie, areas where drugs are purchased), prostitution areas, pool halls, bars, crack houses, and shooting galleries. They offered information on strategies for reducing the risk of HIV transmission to drug users and their sexual partners. In addition, they delivered bleach for disinfecting needles and provided condoms. In Europe and Australia, early outreach work was often tied to needle- and syringe-exchange and distribution efforts. Some American outreach programs also included needle exchange, but these actions were limited, often llegal, and sometimes resulted in criminal prosecution. In some outreach settings, intervention efforts were conducted, in part, to attract users into treatment, but a harm reduction attitude generally prevailed in that abstinence was not demanded and services were not withheld from those who continued to use drugs.34
In 1988, the National Institute on Drug Abuse (NIDA), through its Community Research Branch, began funding outreach projects in approximately 60 inner city sites. These programs provided information about HIV and distributed bleach and condoms at street sites, mobile vans, neighborhood "field stations," and storefronts. These programs often relied on "indigenous leader outreach models." The indigenous leaders are paid, community-based workers, frequently ex-addicts, who can identify and enter networks of injectors.
A major emphasis of the NIDA-funded programs was research. Program personnel attempted to gather systematic information on drug use, needle-sharing exchange, and sexual practices in networks of injection drug users. Not only was this "ethnographic" analysis useful in identifying behaviors associated with a high risk of HIV transmission, but it provided data for the development and modification of interventions. As an example, outreach workers in Chicago, who were providing bleach for needle cleansing in shooting galleries, discovered that there was often no running water and that disinfected needles were potentially being contaminated by shared rinse water. As a consequence, workers began including bottles of sterile water in the "disinfectant pack" they distributed.35
Outcome evaluation has consistently documented the success of outreach interventions. Essentially all reports confirm that injection drug users reduce risk-laden behaviors when pertinent information and services, such as counseling, are made readily available, and especially when they are offered by peers who are members of drug-using subcultures.36-38 For example, drug users often volunteer to aid outreach workers in their efforts by introducing them to other users, facilitating their entrance into unfamiliar communities, helping in the preparation of harm reduction kits, and assisting in the distribution of bleach, clean needles, and information. The principal investigator of the outreach project in Chicago stated:
We have found that as addicts become aware of the threat that AIDS poses, they are quite capable of assimilating a strong sense of social responsibility which can be readily channeled to include an assumed role of prevention advocacy.39
Harm reduction approaches have shown that when injectors and other drug users achieve some stability and normalization, they can become active participants in planning and delivering services.40-42
Outreach projects can serve as an effective catalyst for risk-reduction behaviors, including a decrease in needle-sharing, an increase in needle disinfection, and an increase in condom use. Policy makers can interact with user populations to obtain information on indigenously developed harm reduction strategies or use information from these populations to inform decision-making. Because of concern over AIDS, heroin users in New York City are increasingly smoking and sniffing the drug instead of injecting it.
Drugs and violence
The interplay between drugs and violence is complex. However, there is little doubt that drug use and violence in our society are linked. There are regular news accounts of violence and death visited upon participants in drug deals, as well as upon innocent bystanders. The nature of the relationship--the causal order--is not clear. In the aggregate, it is not known whether drugs of abuse facilitate most of this violent behavior, or whether violence-prone individuals are more likely to use or distribute drugs.
Fagan,43 reviewing the links between several drugs and aggression, found variable associations, but little evidence that any drug caused violent behavior. However, drug-seeking behavior can sometimes precipitate violent acts. Marijuana generally produces a euphoric effect and may even reduce violent behavior, although some observers attribute fearfulness and intense aggressive impulses to marijuana use.44,45 Opiates induce sedation and are not likely to lead directly to violence.
Cocaine, however, which has intense alerting and activating effects, is often tied to aggressive behavior, and amphetamines, as well as phencyclidine (PCP), have a reputation, among medical personnel and police officers, as agents that precipitate violent attacks and persistent struggling against restraint.
The AMA has previously considered the role of drugs in family violence and concluded that there is no simple link between the two.46
Drug decriminalization
Violence and other crimes associated with drug distribution and procurement often are cited as reasons for re-examining our current restrictions over the production, sale, and possession of most drugs of abuse.
Those who advocate relaxing or ending drug prohibitions also point to other negative social correlates, such as black markets, corruption of public officials, overloading the criminal justice system, and contraction of civil liberties. They contend that prohibitions drive up the costs of illegal drugs, forcing users to spend large sums of money, which they often obtain by committing crimes. Many times, they say, these drugs are of low quality, inducing users to try more potent forms or more efficient routes of administration.
While some advocates have called for outright legalization, others have proposed a more modest approach that would retain existing restrictions on production and large-scale distribution, but would decriminalize possession of small amounts for personal use.
It is not clear what the consequences of any such changes in our present drug control system would be. There might be a decrease in crime, but there might also be an increase in problematic drug use, with a greater number of persons experimenting and becoming addicted, and with supplies perhaps being more readily available to minors. Beyond that, it is possible that any public policy move toward decriminalization would be seen as a move toward legalization, and might be interpreted as sanctioning drug use as acceptable behavior.
Careful scientific studies of these questions need to be carried out to determine the potential efficacy and desirability of such changes in national policy. The AMA encourages comprehensive research into the potential positive and adverse effects of relaxing existing drug prohibitions and controls. Until these studies can be conducted, the CSA sees no reason to modify current AMA policy concerning drug legalization.
Conclusions
Harm reduction may involve various strategies directed toward diminishing the risks of psychoactive drug use. It seeks to identify options that can minimize the adverse effects of drug use on individuals and society. A treatment regimen with the sensitivity and flexibility to cope with the specific needs of an addicted patient and with the discrete nature and severity of the patient's condition is potentially a powerful harm reduction mechanism. In particular, methadone maintenance treatment for opioid-dependent persons can be especially useful not only in helping patients lead more normal and productive lives, but in reducing the spread of HIV and other pathogens that frequently results from unsterile drug injection practices and other addictive life-style behavior.
Needle exchange also has been effective in this regard, as demonstrated by extensive programs in Europe and more limited experience recently in this country. Additional efforts to make drug taking less dangerous and injurious are being successfully undertaken by outreach street projects, many of which utilize drug users or former drug users to educate and counsel their peers.
Whether the crime and violence associated with drug taking and procurement could be reduced through liberalization of drug control laws and regulations, without concurrently creating other serious problems for individuals and society, is a question requiring further study.
Harm reduction in all of its aspects should be treated like any other complex medical and public health issue, with a focus on raising empirical questions that can increase our knowledge about effective interventions. Harm reduction strategies are readily amenable to scientific examination.
Recommendations
The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy at the 1997 AMA Annual Meeting.
- The AMA encourages national policy-makers to pursue an approach to the problem of drug abuse aimed at preventing the initiation of drug use, aiding those who wish to cease drug use, and diminishing the adverse consequences of drug use.
- The AMA encourages policymakers to recognize the importance of screening for alcohol and other drug use in a variety of settings, and to broaden their concept of addiction treatment to embrace a continuum of modalities and goals, including appropriate measures of harm reduction, which can be made available and accessible to enhance positive treatment outcomes for patients and society.
- The AMA encourages the expansion of opioid maintenance programs so that opioid maintenance therapy can be available for any individual who applies and for whom the treatment is suitable. Training must be available so that an adequate number of physicians are prepared to provide treatment. Program regulations should be strengthened so that treatment is driven by patient needs, medical judgment, and drug rehabilitation concerns. Treatment goals should acknowledge the benefits of abstinence from drug use, or degrees of relative drug use reduction.
- The AMA encourages the extensive application of needle and syringe exchange and distribution programs and the modification of restrictive laws and regulations concerning the sale and possession of needles and syringes to maximize the availability of sterile syringes and needles, while ensuring continued reimbursement for medically necessary needles and syringes. The need for such programs and modification of laws and regulations is urgent, considering the contribution of injecting drug use to the epidemic of HIV infection.
- The AMA encourages the undertaking of comprehensive research into the potential effects, both positive and adverse, of relaxing existing drug prohibitions and controls and, until the findings of such research can be adequately assessed, the AMA reaffirms its opposition to drug legalization.
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Resolution 416, adopted at the 1994 Interim Meeting as amended by Reference Committee D, asks that the American Medical Association (AMA) support the study of harm reduction for drug addiction, such as treatment on demand, methadone maintenance, sterile needle-exchange, decriminalization of drugs, and peer education and counseling.
While the report was in development, Resolution 409 (I-95), introduced by the Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont Delegations, and Resolution 422 (I 95), introduced by the Pennsylvania Delegation, were referred to the Board of Trustees. These resolution asked:
That the AMA support the deregulation of syringes and needles; and
That the AMA analyze the relationship between crime with its associated violence and the distribution and use of illicit drugs; and
That the AMA study the potential effects of decriminalization of illicit drugs on that relationship.
Resolution 405 (I-96), introduced by the American Association of Public Health Physicians, was referred to the Board of Trustees. It asked:
That the American Medical Association recommend that physicians advise IV drug users to (1) stop injecting and using drugs and begin substance abuse treatment, (2) never reuse or "share" syringes, water, or drug preparation equipment, (3) use only sterile syringes obtained from a pharmacy, (4) use a new syringe with each injection, (5) use sterile or clean reliable fresh tap water, (6) clean the injection site prior to injection with alcohol, and (7 safely dispose of syringes after one use; and
That the AMA urge state and local societies to join with state and local health departments, professional organizations of pharmacists and law enforcement agencies to review the current statutes and regulations that limit the availability of syringes and needles; and
That the AMA support the deregulation of syringes through the removal of prescription requirements for syringe purchase, the exclusion of syringes from the drug paraphernalia laws and the removal of regulations which substantially restrict the availability of sterile syringes; and
That the AMA urge state medical societies and physicians to join with state and local health departments, substance abuse treatment programs, and community groups to advocate for increased availability of substance abuse treatment as an important HIV prevention measure; and
That the AMA urge state medical societies and physicians to join with state and local health departments, diabetes organizations, the professional organizations of pharmacists and community groups to implement community programs to assure the safe disposal of used syringes and needles.
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