researchers have found that initiation is often strongly tied to social and peer influences, whereas biological and psychological processes appear to be associated with abuse (Carman, 1979; Kandel et al., 1978; Newcomb and Bentler, 1990; Paton et al., 1977). Even though data may as yet be too sparse to establish firmly that the causes of use are different from the causes of abuse, the evidence consistent with this hypothesis is accumulating (Glantz and Pickens, 1992).

Moreover, the more risk factors to which someone is exposed that encourage use, the more likely he or she is to use or abuse drugs. Exposure to a greater number of risk factors is not only a reliable correlate of use, but it also influences the increase in drug use over time, implying a true causal role for those variables that together make for increased risk (Schreier and Newcomb, 1991). It appears that the presence of particular factors that can encourage drug use are not as important as the accumulation and interaction of such factors in a person's life.

The existing knowledge about risk and protective factors suggests that certain social influences to use drugs have the potential to be impacted by needle exchange programs (Hawkins et al., in press; Clayton and Leukefeld, 1994). Impacting such factors can theoretically either increase or decrease the risk of nondrug users moving from nonuse to use and abuse. Known risk factors include peers who use drugs, current involvement of parents and siblings in drug use, favorable societal and community norms regarding drug use, and favorable personal attitudes toward drug use, which include perceived risk of harm. The effect of needle exchange programs on other risk and protective factors is not likely.

On the positive side, needle exchange and bleach distribution programs may decrease the number of new initiates to drug use or abuse. As described earlier in this chapter, treatment referral and entrance has been a documented result of such programs. Since parental and peer drug use are risk factors for drug initiation and abuse, needle exchange and bleach distribution program participants who are referred to treatment and become abstinent are likely to reduce the likelihood that their children and their close family and friends make the transition from nondrug to drug user.

On the negative side, the presence of needle exchange programs may affect risk factors for drug use and abuse. This includes an increase in favorable community or personal norms and attitudes toward drug use. An increase in clean needles and syringes may lead to a reduction in the perceived risk of AIDS and other blood-borne diseases associated with injection drug use. Furthermore, changes in federal regulations banning the use of federal funds for needle exchange programs may result in the perception that societal resolve against drug use is weakened. However, there is no evidence of an impact of needle exchange programs on these community attitudes and, in general, little evidence of an increase in the number of

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