State law AB136, which took effect Jan. 1, 2000, decriminalized needle exchange programs operated by public entities provided the City or County declares a local health emergency. On Oct. 16, 2000, the San Diego City Council declared a local health emergency in response to the rapid spread of the Hepatitis C Virus (HVC) and the Human Immunodeficiency Virus (HIV) through the shared use of needles and syringes. The Council has continued to declare the local health emergency periodically in accordance with state law.
The City Council also directed the City Manager to develop and implement a one-year Clean Syringe Exchange Pilot Program with a drug abuse treatment referral component and directed the Manager to convene a Clean Syringe Exchange Program Task Force to determine the proper steps to assure implementation of a program that would benefit the community as a whole. The Task Force provided recommendations after extensive investigation and study of local conditions and of programs implemented in other cities facing a similar crisis.
Disclaimer: The City of San Diego does not endorse or condone the use of illegal drugs. The Clean Syringe Exchange Pilot Program has been created to address a public health crisis related to Hepatitis C and HIV epidemics which are exacerbated by the shared use of needles and syringes by injection drug users.
- Jan. 1, 2000: New state law (AB 136) takes effect; decriminalizes needle exchange programs operated by public entities if City or County has declared a health emergency.
- Oct. 16, 2000: San Diego City Council declares a local health emergency related to Hepatitis C and HIV epidemics exacerbated by the shared use of needles and syringes by injection drug users. The decision directs the City Manager to develop and implement a one-year Clean Syringe Exchange Pilot Program with a drug abuse treatment referral component. A Clean Syringe Exchange Program Task Force is convened to develop the practices and procedures of the Syringe Exchange Pilot Program.
- Oct. 30, 2000: Letters are sent to the County of San Diego, as well as to 16 other cities within the region to solicit their interest in participating in the development and implementation of a clean syringe exchange program. No positive responses were received.
- Nov. 15, 2000: First meeting of the Clean Syringe Exchange Program Task Force is held; the Task Force conducts research, visits and studies needle exchange programs in the cities of Baltimore and Los Angeles.
- June 12, 2001: Task Force issues Clean Syringe Exchange Pilot Program Final Report.
- Nov. 27, 2001: San Diego City Council votes 5-4 to accept the recommendations of the Clean Syringe Task Force outlined in their Final Report dated June 12, 2001, and requires a progress report six months after implementation. (PDF of Final Report)
- Dec. 14, 2001: The privately funded Alliance Healthcare Foundation issues a Request for Proposals for the operation of the San Diego Clean Syringe Exchange Program with all the elements recommended by the Task Force.
- April 1, 2002: Family Health Centers of San Diego is awarded a $367,000 contract with Alliance Healthcare Foundation for a one-year pilot Clean Syringe Exchange Program that includes no of City funds. A contract for program evaluation is awarded to the San Diego Association of Governments (SANDAG) and Johns Hopkins University School of Public Health.
- July 18, 2002: Clean Syringe Exchange Pilot Program is launched in downtown's East Village. The program operates from a mobile unit one night a week for a three-hour period.
- Oct. 7, 2002: The City Manager appoints a 12-member Clean Syringe Exchange Program Facilitation Committee, which is charged with monitoring the one-year pilot program.
- Feb. 14, 2003: A second Clean Syringe Exchange Program site is opened in the community of North Park. The programs operates from a mobile unit one day a week for a three-hour period. A third program site, proposed for the City Heights community, is abandoned due to time and funding restraints.
- August 2003: In response to a request from the CSEP Facilitation Committee, Family Health Centers of San Diego contracts with San Diego State University Foundation's Social Services Research Laboratory to conduct a telephone survey of North Park residents to determine their attitudes about needle exchange programs in general and the City's Clean Syringe Exchange Program specifically.
- Feb. 14, 2004: The pilot study period ends.
- March 8, 2004: In response to a request from the CSEP Facilitation Committee, the City Council continues to declare a local health emergency in the City to allow the CSEP to operate while the Facilitation Committee prepares its final report and recommendations.
- May 17, 2004: The San Diego Association of Governments (SANDAG) Releases the City of San Diego Pilot Clean Syringe Exchange Program: Final Evaluation Report.
- July 16, 2004: San Diego State University Foundation's Social Services Research Laboratory releases the North Park Needle Exchange Program Survey: Final Report.
- Aug. 5, 2004: Clean Syringe Exchange Program Facilitation Committee begins formulating recommendations to City Council for a permanent exchange program.
- Clean Syringe Exchange Task Force Final Report and Recommendations to be presented to City Council's Public Safety and Neighborhood Services Committee (expected January 2005).
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Clean Syringe Exchange Task Force
The mission of the Clean Syringe Exchange Program Task Force was to develop a one-year clean syringe exchange pilot program, coupled with a drug abuse treatment referral component. The Task Force explored many issues associated with operating a clean syringe exchange program in San Diego, such as the availability of substance abuse treatment opportunities within San Diego County. In addition, Task Force members traveled to the cities of Baltimore, Maryland, and Los Angeles to meet with city staff, police, substance abuse treatment providers, and clean syringe exchange program staff currently operating programs within these two cities.
The Task Force members were:
- Wm. Christopher Mathews, M.D. (Chair), Director of UCSD Owen Clinic/Professor of Clinical Medicine at the UCSD School of Medicine
- Michael Franz, McAlister Institute
- Bill Harris, Office of the Mayor
- Bruce Herring, City Manager's Office
- Phyllis Jackson, Harm Reduction Study Group
- Linda Lloyd, Dr. P.H., Alliance Healthcare Foundation
- Captain Larry Moratto, San Diego Police Department
- Michael Rivo, City Attorney's Office
- Gary Stephany, Healthcare Association of San Diego
- Ian Trowbridge, Ph.D., Salk Institute/UCSD
Clean Syringe Task Force Recommendations
The implementation of a privately funded, one-year pilot model recommended by the Clean Syringe Exchange Task Force includes the following elements:
- A mobile system with the use of a small motor home. This method allows for reduced visual impact of the program on the neighborhoods as well as the ability to process participants and deliver services in an efficient and confidential manner.
- A laminated identification card to be issued to participants of the program in order to track participants and enable them to provide proof of participation to police officers.
- An on-site computer for real-time documentation of participant characteristics and outcomes.
- A standardized script that describes guidelines for participation in the program and provides a consistent risk reduction educational message.
- Risk reduction services and kits to be provided in the vehicle. These kits include a one-time baseline harm reduction kit with two sterile syringes, given the success of the Baltimore program at enrolling and retaining new participants by this outreach strategy. The number of syringes exchanged per visit should be sufficient to provide the typical client with a clean syringe for each injection for one week. Based upon the types of drugs commonly used in San Diego, no more than 50 syringes will be exchanged per visit.
- A variety of printed educational materials to be available on the mobile unit for distribution to participants.
- Case management as an integral part of the services provided through the program, including active referrals into detoxification and recovery programs.
- Written guidelines for the selection and training of program staff.
- Training of all staff in universal precautions following the Centers for Disease Control and Prevention recommendations.
- The identification of external evaluators to work with program staff to determine effectiveness at reducing sharing of injection equipment, utilization of services by program participants and, to the extent possible, trends in criminal activity at the sites.
- Based on recommendations from Police Department staff, two areas of the City where drug use levels are high enough to warrant establishing such a program will be evaluated for participation in the pilot program.
- The establishment of cooperative relationships between pilot program staff and Police Department staff, in particular with officers stationed at the nearest area stations.
- The establishment of a Program Facilitation Committee to monitor program implementation.
The City Council imposed additional direction that:
- The initial "prevention kits" include no more than two syringes.
- The program is not implemented within three blocks of any school.
- The process for determining the two sites citywide is done only with the concurrence of the council member representing the district within which the site would be located.
- Specific information is collected for the purposes of program evaluation.
- The language on the proposed identification card states "This card has been issued to a participant in the City of San Diego's Clean Syringe Exchange Program."
- The program managers return to the Public Safety and Neighborhood Services Committee six months after implementation for a progress report on the pilot sites and consideration of additional sites if warranted.
Program Facilitation Committee
The City Manager appointed a 12-member Clean Syringe Exchange Program Facilitation Committee on Oct. 7, 2002. The Committee is charged with monitoring the pilot program and making final recommendations to the City Manager and City Council. Committee members as of January 2005 are:
- James Dunford, M.D., UCSD Medical Center and City of San Diego Emergency Medical Services - (CHAIR)
- Cynthia Burke, Ph.D./Sandy Keaton (Alternate), San Diego Association of Governments (SANDAG)
- Fran Butler-Cohen/Robert Lewis (Alternate), Family Health Centers of San Diego
- Kathy Evans-Calderwood/David Bowen (Alternate), City Heights Area Planning Committee
- Debra Fischle-Faulk/Staajabu Heshimu (Alternate), City of San Diego Community and Economic Development Department
- Michael Franz/Jeanne McAlister (Alternate), McAlister Institute
- Linda Lloyd, Dr. P.H./Adrian Kwiatkowski (Alternate), Alliance Healthcare Foundation
- Michael Powers/Vicki Granowitz (Alternate), Greater North Park Community Planning Committee
- Lt. Cesar Solis/Sgt. James Kurupas (Alternate), San Diego Police Department
- Leslie Wade, East Village Association
Funding and Operation
All funding for the Clean Syringe Exchange Pilot Program is provided by the Alliance Healthcare Foundation. No City funds have been allocated for the operation of the pilot program. Finding solutions to community health needs is at the heart of Alliance Healthcare Foundation's purpose. The Foundation's work in grant making, community education and advocacy is dedicated to improving access to basic healthcare, preventing violence and substance abuse, controlling communicable diseases, enhancing mental health services and generating public awareness about environmental and community health issues.
The Family Health Centers was awarded a $367,000 contract for the one-year pilot program. The contract for program evaluation was awarded to San Diego Association of Governments (SANDAG) and Johns Hopkins University School of Public Health.
Frequently Asked Questions
Scientific studies have concluded that clean syringe programs do not increase crime in the neighborhoods where they are located. Trends in arrests were compared in clean syringe exchange areas and equivalent areas without such programs before and after a clean syringe exchange program was introduced in Baltimore. No significant differences in arrest trends were seen in any of the arrest categories.
Monitored impact of current programs indicates no. In Baltimore, 85 percent of the participants attending a clean syringe exchange program lived in the same ZIP code as the location where they visited the mobile clean syringe exchange program. In Los Angeles, staff at one of the exchange sites told task force members that 75 percent of their participants lived in the same neighborhood. Crime was not increased in the vicinity of the mobile programs, and in a carefully controlled scientific study it was shown that the number of discarded syringes did not increase in the vicinity of clean syringe exchange programs.
A survey of high school students from four Baltimore high schools conducted by Johns Hopkins University researchers was conducted to determine what factors influenced their attitudes about illicit drug use. Among the 1,110 students who responded to the survey, 49.9 percent thought that peers using drugs promoted drug use, and 43.5 percent thought parents using drugs promoted drug use. Nearly half of the students (46 percent) viewed seeing drug users at clean syringe exchange sites as a deterrent to drug use and almost as many (43 percent) viewed seeing drug users at a clean syringe exchange site as having no impact.
The well-known medical maxim primum non nocere, "Above all, do no harm," has been replaced in modern bioethics by the concept of beneficence. Beneficence supports harm reduction programs across a variety of public health issues, including clean syringe exchange programs.
The principle of beneficence has been explained in the following terms:
"Those engaged in both medical practice and research know that risks presented by interventions must constantly be weighed against possible benefits for patients, subjects and the public. The physician who professes to 'do no harm' is not pledging to never cause harm, but rather to strive to create a positive balance of good over inflicted harm." Additionally, beneficence in interpreted to mean that, "When a life is at stake, it may be justified to take high risks of harm." - Contemporary Issues In Bioethics
This principle recognizes that in a complex world we are faced with the prospect of cooperating to some degree with individuals or groups whose goals we may not fully share. Therefore, it is arguable that permitting or even cooperating with clean syringe exchange programs would be allowed by traditional moral principles.
A public opinion poll of San Diego County registered voters regarding attitudes about clean syringe exchange programs was conducted by the Social and Behavioral Research Institute at California State University, San Marcos, in July and August 1996. The results of the survey indicated strong support for a clean syringe exchange program. Of those surveyed, 85 percent either fully supported syringe exchange programs or felt that San Diego needed a syringe exchange program provided it reduced the transmission of HIV and served as a bridge to drug treatment. In addition, approximately 70 percent of respondents believed that syringe exchange programs save taxpayers money on health care and protect children and the community from the spread of AIDS.
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Facts - A Community Epidemic
- Injection drug use is now the major mode of transmission of HCV through the sharing of contaminated syringes and needles or drug preparation equipment. Others modes include: sexual activity, tattooing and body piercing, as well as perinatal transmission from mother to unborn child.
- HCV infection is the most common chronic blood-borne infection in the United States.
- There is an estimated 50,000 infected individuals in the County of San Diego (1.8 percent of the population).
- Between 1998 and 1999 there was a 50 percent increase in the number of reported HCV cases countywide and in the City of San Diego.
- In San Diego, on average six new pediatric patients with HCV infection are seen at the University of California, San Diego (UCSD) Medical Center annually.
- The rate of AIDS cases in the San Diego metropolitan area of 19.5 per 100,000 population is the third highest in the state.
- County HHSA staff has characterized local HIV/AIDS expenditures as having an enormous impact, with current estimates for all medical-related expenses approximately $152 million annually.
- Though difficult to determine, data collected by the National Institute of Drug Abuse (NIDA) through household surveys across the Untied States reveal that about 1 percent of the general population are intravenous drug users (IDUs). This translates into an estimated 25,000 to 28,000 IDUs in San Diego County.
- According to a Robert Wood Johnson Foundation study in 1993, between 75 percent and 80 percent of IDUs are not in treatment, while another 20 percent may be ready to enter treatment but have difficulty accessing services.
- Sadly, San Diego is first in the nation by a wide margin for both male and female juvenile offenders testing positive for methamphetamine, a fact that has earned San Diego the distinction of being the "Methamphetamine Capital" of the United States.
- A scientific study by Dr. John Lorenz and his colleagues at UCSD and SDSU, titled "Occupational Needle Stick Injuries in a Metropolitan Police Force," found that nearly 30 percent of San Diego police officers responding to a survey reported at least one needle injury while on the job. Nearly 28 percent of this group reported two or more needle sticks. Almost 83 percent of respondents felt that the risk of on-the-job needle stick injuries were either very or extremely significant.
- In Baltimore, 51 percent of program referrals were admitted to treatment. In addition, there was a 75 percent retention rate for participants referred by the syringe exchange program despite the fact that the participants are "among the most hard core, difficult to reach addicts in the city."
- Clean syringe exchange attendance was associated with a decrease in risky syringe sharing, and those participants who entered treatment reduced their drug use and engaged in less criminal activity for profit.
- In February 1997, a consensus panel of the National Institutes of Health indicated that syringe exchange programs led to a reduction in risk behavior of drug-injecting participants as high as 80 percent with estimates of a 30 percent reduction in HIV infections.
*Data on current drug use trends in San Diego are primarily obtained from the Arrestee Drug Abuse Monitoring (ADAM) system of the Department of Justice, administered through the San Diego Association of Governments (SANDAG), and from the Department of Alcohol and Drug Services of the San Diego County HHSA.
- "Effective prevention helps injection drug users and benefit society as a whole. Reduced transmission among injection drug users means reduced transmission among their sex partners, their children, and among the general population. The Centers for Disease Control and Prevention (CDC) recommends that all syringes used for injections be sterile."
- County Health and Human Services Agency report
- "Syringe exchange programs as part of a comprehensive HIV prevention strategy are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs."
- U.S. Surgeon General, March 17, 2000 report
- "The spread of infectious diseases such as HIV and hepatitis by intravenous drug users is not only a public health threat, police officers also have to concern themselves with these diseases during the regular performance of their duties due to accidental needle sticks."
- David Bejarano, City of San Diego Police Department
- "Most major religious traditions including Christianity are concerned for the preservation of human life and dignity."
- The Society of Christian Ethics (SCE)
Scheduled Meetings - Open to the Public
The Clean Syringe Exchange Facilitation Committee meets on the 1st Thursday of every month at noon at Civic Center Plaza, 1200 Third St., Suite 924 (Community Services). Most recent meeting agenda and minutes are posted for public review.
- San Diego State University - North Park Needle Exchange Program Survey: Final Report - July 16, 2004
- City of San Diego Pilot Clean Syringe Exchange Program: Final Report-May 2004
- City of San Diego Pilot Clean Syringe Exchange Program: Final Report
Executive Summary-May 2004
- Memorandum, March 3, 2004, Recommendation to Continue Health Emergency
- Memorandum, Feb. 10, 2003, North Park Site to Open
- Memorandum of Law, Jan. 2, 2003
- Memorandum, Nov. 25, 2003, Special Report
- Status Report to Mayor and Council, Dec. 5, 2002
- Memorandum, July 17, 2002, Downtown Site to Open
- Manager's Report No. 02-080, April 9, 2002, Clean Syringe Exchange Pilot Program Update
- Manager's Report No. 00-264, Nov. 17, 2000, Clean Syringe Exchange Program Task Force
- Task Force Final Report
For more information about the City of San Diego's Clean Syringe Exchange Pilot Program, contact:
Family Health Centers of San Diego (Program Operator)
Robert Lewis, Director
Family Health Centers of San Diego
823 Gateway Center Way
San Diego, CA 92102
City of San Diego Community and Economic Development Department
1200 Third Ave., Suite 1300
San Diego, CA 92101