Dear Mr Thomas,
I have ammended the Syringe prescription policy proposal per the suggestions
of the Joint Policy Committee and have been in touch with Dr Trachtenberg.
The revised version is both attached and included in the text of this
message. I also have attached a version with the changes highlighted. Please
let me know if I need to do anything further on this.
Thank you for all your assistance.
Josiah D. Rich, MD, MPH
Associate Professor of Medicine and Community Health
Brown University School of Medicine
Providence, RI 02906
Syringe Prescription to Reduce Disease Related to Injection Drug Use
THE AMERICAN PUBLIC HEALTH ASSOCIATION,
Being aware that injection drug use is a major risk factor for HIV,1
hepatitis B and C2 as well as additional problems including drug overdose,
sexually transmitted diseases, liver disease, tuberculosis, skin and soft
tissue infections, bacterial infections, mental illness, and violence, and
that this represents a public health emergency;3 and
Recognizing that infections result from the reuse and sharing of syringes,
and that injection drug users may fear and mistrust health care providers
due to the illicit nature of their drug use and the stigma attached to
it,4,5 and that injection drug users may have few or no links to regular
health care or social services;6 and
Being aware that minority racial and ethnic groups are disproportionately
over represented among those who suffer from diseases associated with
injection drug use,7-9 thus making this issue one that pertains to a major
topical area of interest for APHA; and
Having recognized, in addition to the importance of drug treatment programs,
the critical importance of access to sterile syringes to prevent disease
spread,6,10 and the effectiveness of increasing sterile syringe access in
reducing risk behavior;11-13 and
Having previously approved policy supporting syringe access through the
establishment of needle exchange programs and decriminalizing possession of
injection equipment14, as well as recognizing the importance of protection
against illicit drug-related HIV15; and
Recognizing the need for a comprehensive approach to the problem of
injection drug-related problems that addresses the need for drug treatment,
access to sterile syringes, and the provision of primary and preventive care
for people who inject drugs; and
Noting that the approaches of establishing syringe exchange programs and
deregulating sales of syringes, while important,14 may be limited due to
lack of funding, lack of local support, or lack of legislative action;16 and
Further noting that prescription of syringes to injection drug users
represents an additional approach to stemming the spread of disease, one
which was not previously considered and which reports have recently shown to
be quite promising;17-18,20 and
Noting that the advantages of this approach include:
· The ability to provide legal access to syringes for injection drug
users in places where such access is otherwise restricted. According to a
recent legal analysis,18 physician prescription of injection equipment to
injection drug users is legal in 48 of 52 U.S. jurisdictions (illegal in DE
and KS and questionable in OH and OK). A prescription is currently required
for sale or possession of syringes in seven states: CA, DE, IL, MA (except
NEP), NV, NJ, and PA. Seven states allow some sale or possession of syringes
without a prescription (e.g., no more than 10 syringes). 30 states or
territories have drug paraphernalia laws that could be applied to syringes
and 14 more have laws that exempt some possession of syringes. Prescription
of syringes to injection drug users is legal in 40 of these 44 jurisdictions
and possibly legal in two more.18 Even in states where prescription is not
legally mandated, having a prescription can improve access by reducing fear
of harassment by pharmacists.19
· The possibility of providing primary medical care to an underserved
population3,21and establishing new links to health care for IDUs by offering
treatment and referrals in a non-judgmental setting where drug use is
· The potential for health care providers who prescribe syringes to
serve as a conduit to substance abuse treatment and other services;22-24 and
Appreciating that providing much needed medical and social services25,26 to
injection drug users represents a strengthening of the public health system,
and that syringe prescription has already been endorsed supported by the
American Medical Association,27 the Massachusetts Medical Society,28 the
CDC5 and others; and
Understanding that support for syringe prescription is important to reduce
apprehension towards, and increase knowledge of, syringe prescription as
part of a comprehensive approach to addressing a major public health
problem; therefore, building on the resolutions approved in APHA Policy
9415,9 but explicitly not negating previous policy statements, APHA
1. Supports the prescribing of syringes by health care providers to
injection drug users who cannot or will not stop injecting, in order to
2. Urges that, while prescription should not be required, all states that
currently have laws prohibiting syringe prescription to injection drug users
modify their laws so as to permit it; and urges states that criminalize
possession of prescribed syringes for injection of illicit substances to
modify their laws or policies to permit such possession;
3. Urges medical training programs to educate their students about the
importance of access to sterile syringes for injection drug users, including
1. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US
metropolitan areas. Am J Public Health. 1996;86:642-54.
2. Alter MJ, Moyer LA. The importance of preventing hepatitis C virus
infection among injection drug users in the United States. J Acquir Immune
Defic Syndr Hum Retrovirol. 1998;18(Suppl 1):S6-10.
3. Friedland GH, Selwyn PA. Infectious diseases (excluding AIDS) in
injection drug users. In: Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD,
Martin JB, Kasper DL, et al., eds. Harrison's Principles of Internal
Medicine. 14th ed. New York: McGraw-Hill; 1998:831-5.
4. Centers for Disease Control and Prevention (CDC). A Comprehensive
Approach: Prevention Blood-Bourne Infections Among Injection Drug Users.
5. CDC, Fact Sheet: Physician Prescription of Sterile Syringes to Injection
Drug Users. IDU/HIV Prevention. February 2002. Available online at:
6. Normand J, Vlahov D, Moses LE. Preventing HIV Transmission: The Role of
Sterile Needles and Bleach. Washington, DC: National Academy Pr; 1995.
7. Karon JM, Fleming PL, Stekette RW, DeCock KM. HIV in the United States at
the Turn of Century: An Epidemic in Transition. AJPH.2001;91(7):1060-1068.
8. Friedman SR, Jose B, Neaigus A, Goldstein M, Mota P, Des Jarlais, DC.
Multiple Minority status as an HIV risk factor among drug injectors. Int
Conf AIDS, 9:811 (abstract no. PO-D05-3560), June 6-11, 1993.
9. Kottiri BJ, Friedman SR, Neaigus A, et al. Risk networks and
racial/ethnic differences in the prevalence of HIV infection among injection
drug users. J Acq Immun Def Synd 30 (1): 95-104 May 1 2002
10. U.S. Public Health Service. HIV Prevention Bulletin: Medical Advice for
Persons Who Inject Illicit Drugs. Rockville, MD: U.S. Public Health Service;
8 May 1997.
11. CDC, Fact Sheet: Access to Sterile Syringes. IDU/HIV Prevention; Jan
2002. Available online at:
12. Lurie P et al. A sterile syringe for every drug user injection. Journal
of Acquired Immune Deficiency Syndromes and Human Retrovirology
13. Burris S, Lurie P, Abrahamson, D, Rich JD. Physician Prescribing of
Sterile Injection Equipment To Prevent HIV Infection: Time for Action.
Annals of Internal Medicine. 2000;133:(Number 3) 218-226.
14. APHA Policy Statement: Syringe and Needle Exchange and HIV Disease. No.
15. APHA Policy Statement: Illicit Drug Use and HIV Protection. No. 8931
16. Lurie P, Drucker E. An opportunity lost: HIV infections associated with
lack of a national needle-exchange programme in the USA. Lancet.
17. Rich JD, Macalino GE, McKenzie M, Burris S. Syringe Prescription to
Prevent HIV Infection in Rhode Island: A Case Study. American Journal of
Public Health. 2001;91(No. 5)1-2.
18. Burris, S, et al., Legality of Prescribing and Dispensing Sterile
Injection Equipment to IDUs to Prevent Disease Transmission. Available
online at: http://www.temple.edu/lawschool/aidspolicy/default.htm
Burris S, Lurie P, Ng M. Harm reduction in the health care system: the
legality of prescribing and dispensing syringes to drug users.
Health Matrix Clevel. 2001 Winter;11(1):5-64.
20. Rich JD, Macalino G, Gaydos M, Stein J, Salas C, McKenzie M,
Runnarsdottir V, Mehrotra M, Whitlock T, Burris S. The genesis of syringe
prescription to prevent HIV in Rhode Island. 11 Health Matrix 129-145
21. Knowlton AR. Hoover DR. Chung SE. Celentano DD. Vlahov D. Latkin CA.
Access to medical care and service utilization among injection drug users
with HIV/AIDS. Drug & Alcohol Dependence. 64(1):55-62, 2001 Sep 1.
22. Strathdee SA, Celentano DD, Shah N, Lyles C, Stambolis VA, Macalino G,
Nelson K, Vlahov D. Needle Exchange Attendance and Health Care Utilization
Promote Entry into Detoxification. Journal of Urban Health, 1999; 76(4):
23. Heimer, R. Can Syringe Exchange Serve as a conduit to Substance Abuse
Treatment? Journal of Substance Abuse Treatment, 1998: 15(3): 183-191.
24. Rich JD, McKenzie M, Macalino G, Mehrotra M, Gaydos ME, Stein J,
Whitlock, Runarsdottir V. Physician Syringe Prescription as a Conduit to
Substance Abuse Treatment: A Pilot Intervention. Addictions 2000 (poster
presentation) Hyannis, Cape Code, MA, September 22-24, 2000
25. Haverkos HW, Stein MD. Identifying Substance Abuse in Primary Care.
American Family Physician, 1995 Nov 15; 52(7): 2029-35.
26. O'Connor, P; Seilwyn, P; Schottenfeld, R. Medical Care for Injection
Drug Users with HIV Infection. New England Journal of Medicine, 1994:
27. American Medical Association (AMA). Access to sterile syringes. Chicago
(IL): AMA; June 2000; Available online at:
28. Massachusetts Medical Society (MMS), Physician Prescription of Sterile
Syringes for Injection Drug Users Can Have Important Benefits. Vital Signs
February 2002. Available online at:
stronger statement in support of physician prescription at their May 2002
meeting, not yet available for citation.
Josiah D. Rich, M.D., M.P.H.
Associate Professor of Medicine and Community Health, Brown University
School of Medicine,
Attending Physician, The Miriam Hospital
164 Summit Avenue Providence, RI 02906
PH: (401) 793-4770
fax: (401) 793-4779