Last year, this journal brought up the discussion of whether a needle exchange program should be implemented, both in this city as well as at a national level. I am sure that both of you who regularly read this column remember it vividly. In case you don't remember, the logic behind needle exchange was that by turning in used needles and getting them off the street, we may cut down on the rate of nonhomosexual HIV transmission. If the infected needles are off the street, there is less risk of user acquired disease. Sounds good in theory. What is the potential downside? Certainly, tolerance toward needle exchange implies tolerance towards IV drug use. What has happened in other cultures where a philosophy of tolerance has developed toward drugs?

Larry Collins recently addressed this issue.¹ Collins looked at the results of cannabis tolerance in Holland. For those of you out there who don't know, Holland has developed a very progressive attitude towards cannabis consumption. In fact, at "coffee shops" it is possible to consume marijuana derivatives. How has cannabis consumption affected Dutch society? First of all, one thing leads to another. Legal tolerance towards personal consumption has lead to legal indifference towards growth and distribution of marijuana. New strains of marijuana have been developed 5-7 times the THC concentration of that previously available. Use of this stronger marijuana has been associated with impaired memory function and withdrawal symptoms when users stopped smoking the substance. It doesn't end there. Growing and distributing marijuana has become big business and Holland now serves as a major point of distribution for the substance throughout Europe. In addition, tolerance towards drugs has extended to non marijuana drugs. When discussing synthetic horrors such as LSD, amphetamines and ecstacy, Holland has become a major point of synthesis and distribution; Holland is to synthetic drugs what Columbia is to cocaine. The number of heroin addicts seeking methadone treatment has gone up 300% in 25 years. One cannot assume a linear relationship between heroin addiction and methadone treatment. I think assuming a 300% increase in heroin addiction is being conservative.

Is this a valid relationship? How does this relate to needle exchange? If we sanction needle exchange, by action we are condoning the use of IV drugs — pure and simple. Certainly, those out there who call for a more progressive and compassionate approach to many of our social maladies point to European models. In fact, in this column last year we made a similar reference. Sorry. If you are going to use a model to support one side of the equation, the same model must be applied to the other side of the equation. I think that tolerance breeds progressive indifference. Once you diminish the significance of one brick in the wall against drug abuse, the cracks widen and the flood expands. Needle exchange is the first step towards drug tolerance and further decriminalization of dangerous, addictive drugs. If we were to experience the same staggering increase in heroin addiction that tiny Holland has, our rate of increase in needle transmitted HIV would also have a corresponding increase. Sorry, but quite often drug addicts are not model citizens concerned about doing the proper civic duty. Their first thought is the next fix and they will use anything they can to get that fix, even a contaminated needle. Yes we have a drug abuse problem in this country. Yes have a needle transmitted HIV problem in this country. But as bad as things are, they can always get worse; the Dutch have already shown this to us. No one wants this horror to continue to spread. I don't think needle exchange is the answer for containing the spread of HIV in the drug addicted population.

REFERENCE

1. Collins L. How the Dutch do drugs. Foreign Affairs. 1999; May/June: 82-99.

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