Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

426 IV. SPECIAL POPULATIONSfuture planning should be addressed in a timely and appropriate manner. Again,consultation psychiatrists are in a unique position to assist patients who aregrappling with such difficult and serious matters. Many avenues and alternativescan be explored. Patients themselves prefer that physicians broach thesesubjects, and earlier rather than later (Kennedy & Hill, 1997).PREVENTION AND PUBLIC HEALTHPrevention is the strongest defense against spread of this blood-borne and sexuallytransmitted infection. Behavioral change studies indicate that some IDUsare attempting risk reduction, especially in needle sharing (Des Jarlais & Friedman,1987; Des Jarlais, Friedman, Choopanya, Varichseni, & Ward, 1992; Selwyn &Cox, 1985). There is evidence that IDUs can reduce their risk by alteringneedle-sharing behaviors. Attending a methadone-maintenance program promotesrisk reduction (Des Jarlais & Friedman, 1987). More recently, IDUs withAIDS knowledge reported that their consistent use of sterile new needlesdepended on availability (Des Jarlais et al., 1992; Gostin et al., 1997). Whensterile needles are unavailable, however, they use whatever is available. Needlesharing is common but not universal among IDUs. Sharing practices are influencedby many factors, including economics, regional drug norms, needle availability,length of habit, drug of choice (i.e., heroin, cocaine, or drug combinations),and others. A large national survey of the regulation of syringes andneedles concluded that deregulation of syringe sale and possession would reducethe morbidity and mortality associated with blood-borne infections, includingHIV, among IDUs, their sexual partners, and their children (Gostin et al.,1997). Regulations vary throughout the United States, but despite a U.S. GeneralAccounting Office (1993) report and numerous other government taskforce recommendations pointing out that new infections in IDUs plateau whereneedle exchanges have been tried, widespread support or federal backing forsuch strategies has been lacking. International studies show that needle exchangecoupled with other risk-reduction education and available treatmentslots has been successful (Des Jarlais et al., 1992). One evaluation of an experimentalU.S. needle exchange program showed that it was quickly adopted byIDUs, and an increase in injection and use did not occur (Watters, Estilo,Clark, & Lorvick, 1994). Lurie and Drucker (1997) estimated that from 4,000to 10,000 HIV infections in the United States, which cost between $250,000and $500,000 each, and untold amounts of human misery might have been preventedby needle exchange programs.Prevention strategies to reduce the risk of exposure to contaminated needlesinclude cessation of injection drug use, cessation of needle sharing, andimplementation of harm reduction methods, methadone maintenance, outpatientdetoxification, and drug-free treatment programs and needle exchange