behavior (van Ameijden et al., 1994). Many of the Amsterdam needle exchanges are operated out of the "low-threshold" methadone programs. These programs provide services to both heroin injectors and heroin smokers and do not require abstinence from illicit drug use as a condition for remaining in the program. Thus, these combined methadone treatment and needle exchange sites do provide frequent opportunities for social interactions between heroin injectors and heroin smokers. Despite this, the proportions of heroin users who smoke and those who inject have remained constant since the exchanges were implemented.

Recent U.S. data also support the conclusion that needle exchange programs do not lead to any detectable increase in drug injection. The recent San Francisco study (Watters, 1994) found an increase in the mean age of injection drug users in the city during the years of operation of the needle exchange programs (i.e., mean age in 1986 was 36 compared with 42 in 1992). Moreover, the author reported that during that 5.5-year period, the median reported frequency of injection declined from 1.9 to 0.7 injection per day and that the percentage of new initiates into injection drug use decreased from 3 to 1 percent. In Portland (Oliver et al., 1994), under 2 percent of program participants had histories of injecting of less than a year. The average duration of injection drug use was 14 years, and more than 75 percent had been injecting for 5 years or more. The presence of a needle exchange program does not appear to cause any increase in the number of new initiates to drug injection. Identifying what factors lead individuals to initiate injection drug use, despite knowing about AIDS, remains an important question for future research.

Discarded Needles and Syringes

Since the University of California report was issued, only one study has dealt with needle exchange programs and improperly discarded needles. Doherty et al.. (1995) conducted a survey of a random sample of city blocks in areas of high drug use in Baltimore before and after implementation of the needle exchange program; their results are consistent with the University of California conclusion that needle exchange programs do not increase the total number of discarded syringes.

THE NEW HAVEN STUDIES

After extended legislative debate, Public Act 90-214 allowed the City of New Haven, Connecticut, to implement—on an experimental basis—a legal needle exchange for injection drug users. On November 13, 1990, the New Haven Needle Exchange Program began operation. This program operated



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