nondrug users that move to drug use as a result of such programs in their community. If the effect of needle exchange programs on nondrug users is evident only over the long term because of an extended temporal causal chain—including weakened societal antidrug abuse resolve first affecting community norms and personal attitudes, which, in turn, affect the transition from nonuse to use—then the effect on nondrug users may not be evident in the short term. Although this long-term effect may be possible and should be investigated, there is also reason to believe that the existing evidence of no effect will hold in more controlled and long-term investigations. The relationship between drug-use norms and perceived risk of drug use indicates that the effect of these norms and attitudes is drug specific (Bachman et al., 1990). Since needle exchange programs are likely to affect only risk due to injection, and because nondrug users are extremely unlikely to begin their drug-using careers by using injectable drugs (Kandel et al., 1978, 1992), it is not likely that changes in community or personal norms and attitudes as a result of having needle exchange and bleach distribution programs will increase the risk of the transition of nondrug users into drug use.

Alternatively, it may be possible to curtail the emergence of these theoretical potential negative effects of needle exchange programs on norms and attitudes. There is evidence that drug-use norms and attitudes are manipulable by intervention (Hansen et al., 1988; Hansen and Graham, 1991), and it may be possible, through active norm change strategies, to avoid the potential negative effects of needle exchange programs on norms and attitudes. By stressing to the public the fact that these programs are health approaches taken to curb the spread of contagious diseases (e.g., AIDS, HBV, HCV), rather than remaining neutral or leaving interpretation solely to community and personal impressions, it may be possible to avoid potentially adverse community norm changes.

All of these issues need to be properly addressed in future research to clarify whether possible long-term harms associated with the implementation of needle exchange programs are tenable.

SUMMARY

The following conclusions and recommendations are necessarily built on the progressive presentation of information and research data found in this and earlier chapters. This presentation reflects the cumulative development of the panel's understanding about issues inherent in the establishment of needle exchange and bleach distribution programs and, ultimately, their anticipated effects, based on the pattern of evidence discerned by the panel from its collective activities, primarily its reviews of pertinent studies.



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