Tag Archive: needle exchange

Kidnappings, incarceration and the world’s worst heroin habit

In a country with more than two million heroin addicts, Irina Teplinskaya was one of the first. It was back in 1981, as a 14-year-old girl in the Baltic port of Kaliningrad, that she first tried the drug. She came from a prestigious family of senior Communists and was one of just a few who could afford the exciting new drug. She became addicted and suddenly, instead of a move to Moscow to study, her life began to take a very different path. She spent over a decade in prison and contracted hepatitis C, tuberculosis and HIV. right align image
During her last stay in jail, which ended in 2007, her HIV transitioned into full-blown Aids. Her life could have been very different, she says, if people had treated her drug addiction as an illness rather than a crime.
„The answer for me and for millions of others is simple,“ says Ms Teplinskaya, 44, who now works for an organisation advocating a more humane drug policy in Russia – substitution therapy. Almost every country in Europe allows treatment using methadone. Like heroin, it is an opiate, but is administered orally, meaning no risk of HIV transmission through needles.

Russia is the world’s largest heroin consumer and, to add to that, risky injecting practices have fuelled one of the world’s fastest-growing HIV epidemics. With tens of thousands of people dying every year, in a country where the population is shrinking, the twin epidemics are a catastrophe.
Campaigners say methadone would help tame both the heroin and HIV epidemics. As well as preventing HIV transmission, giving addicts methadone also brings them into the medical system, help steer them away from committing crimes to fund their habit and takes trade away from illegal dealers. Even China uses the technique to treat drug addicts. But Russian officials will have none of it. Government figures say it is perverse to treat drug addiction with other drugs and favour methods based on full withdrawal, sometimes against an addict’s will. It’s risky even to discuss methadone – advocates can be accused of „pro-drugs propaganda“ and taken to court.

„There is no logical reason behind Russia’s opposition to substitution therapy,“ says Anya Sarang, a campaigner who advocates the introduction of methadone. „I’ve been fighting this battle for 12 years and I don’t understand the mentality at all. The scientific evidence is all there to prove that it works.“

Ms Sarang and a group of Western academics published a study in the British Medical Journal last year which found that the widespread introduction of substitution therapy could cut rates of HIV transmission in Russia by up to 55 per cent. Estimates vary, but it’s thought that more than two million Russians inject heroin and the drug causes 30,000 deaths per years, as well as tens of thousands of new HIV cases. Russia is located on the transit route for drugs from Afghanistan to Europe and cheap heroin is readily available – a dose of heroin on the streets costs about 600 roubles (£12). If methadone therapy is not available, activists say programmes that offer addicts clean needles and syringes to avoid HIV transmission are essential.

The government, however, is adamant that only aggressive punitive measures can work to tackle drug use. Needle-exchange programmes funded by foreign donors have been discontinued in recent years, leading many addicts to share injecting equipment.
While there is some discussion about whether needle exchanges should be reintroduced, methadone is completely taboo. Leading Russian drugs specialists denounce substitution therapy as a failed Western imposition and see it as a „legalisation“ of drug use.

„We have no evidence from the international community that methadone is effective,“ said the Health minister, Tatyana Golikova, this week, reiterating a long-held government policy.
Others go further. Evgeny Roizman is a former Russian MP from the city of Yekaterinburg in the Ural mountains. He runs a series of clinics there where drug addicts go cold turkey, without methadone or any other drugs to ease the withdrawal symptoms.

He insists that methadone advocates are simply being disingenuous. „These people will say anything to get Western funding,“ says Mr Roizman. „I have worked with drug addicts for years, and I can tell you: methadone doesn’t work.“

He wants to bring in a range of policies, including harsher penalties for drug dealers and compulsory drugs testing in all Russian schools and colleges. „We need forced treatment for drug addicts,“ he says. „We need to force them into special institutions where there are no drugs and where they can be treated. This is the answer, not methadone.“

Last year, a disciple of Mr Roizman was sentenced to three-and-a-half years in prison for kidnapping drug addicts. Yegor Bychkov said addicts‘ parents had given him permission to „cure“ their children. „Patients were tortured, chained up to steel beds, starved,“ says Ms Sarang. „It was absolutely outrageous and when the court case against him started, we thought there would be a scandal.“

But a huge wave of support for Mr Bychkov swept through the country. Even many from Russia’s beleaguered human rights community joined with church figures and government officials to condemn his trial and in the end the court suspended his sentence and he was released. Mr Bychkov was „overenthusiastic“, said Mr Roizman, but his heart was in the right place.
Ms Teplinskaya, who is still a heroin user, travelled to Moscow last week to meet Navi Pillay, the UN High Commissioner for Human Rights, and ask her to press the Russian government on substation therapy. „I think I could have done a lot of good things for my country,“ she said. „But instead, I’ve lost my home, my health and my family. Methadone could have helped me lead a normal life.“

But her opponents are confident their views will prevail. Mr Roizman says: „They can shout as much as they want with their Western money. Methadone will never be legal in Russia.“


Russia has one of the fastest spreading HIV epidemics in the world, driven largely by the government’s refusal to institute measures to treat the country’s drug addicts — measures that have dramatically reduced HIV infections in drug addicts in other countries, including the U.S.

The New York Times reported yesterday that 60,000 new cases of HIV were seen in Russia in 2009, up 8% from the prior year. At least 60% of those new cases were spread by intravenous drug use, according to the Times, and a good portion of the rest of the new cases were likely the result of sex with drug addicts. (More on Time.com: Drug Policy Backfires: Controlling Meth Ingredients Fails to Cut Drug Supply)

Writes the Times‘ Michael Schwirtz:

Officials estimate that well over a million people abuse drugs intravenously in Russia, often sharing and infecting one another with tainted needles. They are among Russian society’s most marginalized people, more likely to face a few weeks handcuffed to a clinic bed than to receive basic treatment to break their addictions. Meanwhile, officials have treated sex education and other preventative programs with open hostility.

“Which are the main infected groups? Injecting-drug users and sex workers,” said Lev Zohrabyan, the Europe and Central Asia adviser for Unaids. “It turns out that these are the groups where the money must be directed to change the picture. But if you open the budget, you will see that for prevention work among these groups for the next two years there is nothing.”

According to Schwirtz, Russia blames America’s failure to eradicate Afghanistan’s opium crops for the IV drug problem in Russia. But if the U.K.’s current shortage of heroin, due to Afghan crop failures this year, are any indication, the international heroin supply has actually been significantly reduced. Regardless, changes in the supply side have never had any impact on the HIV epidemic.

So, what’s really driving Russia’s problem? Politics. The country has a long-standing ideological opposition to the use of “substitute” maintenance drugs like methadone and buprenorphine to treat IV drug addicts. Yet methadone is the best known treatment for heroin addiction: according to numerous reviews of the voluminous international data, it reduces relapse and death rates better than any other treatment, including all therapies based on abstinence. The effectiveness of buprenorphine treatment for heroin addiction is also well-supported by research. (More on Time.com: Salvia, a Mexican Hallucinogen Piques Scientists‘ and Regulators‘ Interest)

In all countries that have successfully reduced HIV infection rates among intravenous drug users, health officials have instituted maintenance treatment programs. But they have all also simultaneously increased clean-needle availability — the other public-health measure that undergirds many effective AIDS-prevention programs. In that respect, Russia has not been entirely remiss: it does offer some needle-exchange programs that provide addicts with clean syringes and educate them not to share.

Alone, methadone maintenance programs and legal needle-and-syringe exchanges cannot stop an epidemic. But the evidence is pretty clear that together, they can. Case in point: New York City.

In the not too distant past, New York was the epicenter of the AIDS epidemic among America’s drug addicts. In the early 1990s, at least half of all intravenous drug users in the city were HIV-positive. But a recent study of HIV infection rates among injected-drug users in New York found that while 21% of addicts tested positive for HIV between 1984 and 1994, that figure dropped to just 6% in people who used IV drugs between 1995 and 2008.

What changed? The two groups are distinguished by the prevention measures most available to them. In the 1980s and early ’90s, New York City had a large methadone treatment system, but awareness of the spread of HIV among drug addicts was initially low; at the time, syringe exchange programs were also either illegal or just getting started, and needle possession was illegal. (More on Time.com: The Most Dangerous Drugs? Alcohol, Heroin and Crack — in That Order)

In 1992, needle exchanges were legalized in New York City, and massively expanded by 1995. Over-the-counter sales of syringes in New York became legal in 2001.

Nationally, the AIDS epidemic in addicts has subsided too, with only 12% of new cases linked to IV drug use, down from more than 1 in 3.

Given that the data overwhelmingly show that maintenance programs and needle exchanges, together, can significantly reduce the spread of HIV, Russia’s refusal to treat the country’s million-plus drug users is putting millions more of its citizens — including nonusers who may be partners of drug users or of infected former partners — at deadly risk.

Objective: To present a summary of the existing literature on syringe exchange programs (SEPs) and to discuss the potential role of pharmacists in providing support for injection drug users (IDUs) and such programs.
Data sources: To identify relevant articles published since 2000, a search of PubMed and Medline was conducted using syringe exchange programs and needle exchange programs as search terms. A manual review of each article’s citation list was also conducted.
Data extraction: By the authors.
Data synthesis: Information is presented in four categories: state and federal support of SEPs, characteristics of SEP users, epidemiological studies, and social reluctance for SEP support. The information summarized in these sections is then used as a foundation for a review of the potential role of the pharmacist.
Conclusion: SEPs have demonstrated a clear effect in improving the health outcomes of IDUs by decreasing the transmission of blood-borne disease and lowering high-risk injecting behaviors. Despite conflicting support for SEPs at both the federal and local levels, pharmacists can play a pivotal role in the health of IDUs by providing sound medical advice and, in some states, acting as an alternative channel for obtaining clean syringes. Efforts should continue to focus on educating pharmacists about this role and how their individual actions can benefit the health of the entire population.


Injection drug users (IDUs) represent a population that is disproportionately affected by the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), hepatitis B virus (HBV), and hepatitis C virus (HCV). In 2006, approximately 19% of all people living with HIV/AIDS acquired the virus through injection drug use. In that same year, 54% of people with confirmed HBV and approximately 50% of those with acute HCV reported injection drug use.[1] Because sharing of contaminated syringes is a major route of transmission for diseases such as these, providing access to and encouraging the use of sterile injection equipment is believed to be a central strategy in the effort to reduce the transmission of HIV and other blood-borne pathogens.[2] Based on the philosophy of harm reduction, syringe exchange programs (SEPs) allow IDUs to obtain sterile syringes and other injection equipment at little to no cost and to safely dispose of used injection equipment. Many of the programs require participants to exchange used syringes for sterile ones, which results in the safe disposal of used equipment and a reduction in the number of syringes disposed of improperly in the community. With the primary goal of reducing the spread of infectious disease among IDUs, their sexual partners and children, and the public at large, many national organizations and government bodies support the establishment of SEPs.[2,3] Specifically, the Centers for Disease Control and Prevention recommends that IDUs use a sterile syringe for each injection.[2] Another means to increasing access to clean equipment is the sale of syringes by pharmacists. Accordingly, pharmacists are presented with the opportunity to provide patient counseling or referrals to other health-related services and to help expand access to care and supplement the work of SEPs, particularly in areas in which SEPs have not been established.[4]

In the early 1980s, HBV and HCV rates among IDUs sparked concern among health care providers. The need for supplying sterile syringes to this patient population was first recognized during this period. However, it was not until the HIV/AIDS pandemic that the importance of these programs was accepted worldwide and the rapid establishment of SEPs began.[5] In the United States, the first SEPs were established in New York City (NYC), Oregon, San Francisco, and Washington in the late 1980s.[6] By 2005, 28 states had operating SEPs, for a total of 166 programs nationwide.[7] According to the North American Syringe Exchange Network (NASEN), at least 211 SEPs currently exist in 36 states and territories.[8] Table 1 shows the states with SEPs as publicly listed on the NASEN website.

Table 1. States with active syringe exchange programs[8]

Alaska District of Columbia Illinois Maine North Carolina Oregon Washington
Arizona Delaware Indiana Michigan New Jersey Pennsylvania Wisconsin
California Florida Louisiana Minnesota New Mexico Rhode Island
Colorado Georgia Massachusetts Missouri New York Texas
Connecticut Hawaii Maryland Montana Ohio Vermont

These states allowed the North American Syringe Exchange Network to list their contact information on its website.

The benefits of SEPs extend to both IDUs and other members of the community. Most importantly, SEPs protect the health of the public by reducing the spread of blood-borne infections, directly through decreased sharing of syringes or accidental contact with contaminated syringes by individuals in the community and indirectly through sexual contact. However, in addition to the exchange and safe disposal of used syringes and injection equipment, SEPs also offer a greater public health benefit by providing a range of additional services, including but not limited to health education and counseling; free sharps containers and condoms; on-site HIV testing and screening for HBV, HCV, and tuberculosis; referrals to substance abuse treatment; and other medical and social services.[3,6] These additional services are invaluable, especially in rural communities and for individuals with limited access to health care. Much debate and controversy surrounds the social policy of SEPs. Perceptions of the effectiveness, importance, and appropriateness of these programs vary among IDUs, health care professionals, and policy makers. In the United States, a ban preventing federal funding for SEPs was lifted in December 2009. This change may result in greater overall acceptance and support of the establishment of SEPs nationwide; however, this change may develop slowly and/or be met with resistance because of deep-rooted controversy and lack of awareness and education. Therefore, as health care professionals, pharmacists must remain aware of the evidence surrounding the effectiveness of SEPs. Evidence has demonstrated that SEPs are associated with declines in the incidence and prevalence of HIV, HBV, and HCV and of high-risk injecting behaviors (e.g., needle sharing between HIV-negative and -positive IDUs).[3,9]


The goal of the current work is to present a summary of the existing literature surrounding SEPs in the United States. This summary will address the outcomes of SEPs in the IDU population, including rates of disease transmission and injection risk behaviors. High-risk injection behaviors can include injecting with a used syringe, giving used syringes to other IDUs, sharing injection paraphernalia such as cotton or cookers, reusing a syringe more than once, or not bleaching a used syringe before injecting. We also address the potential role of pharmacists and how their support and work can further the public health benefits of SEPs. Because the success of SEPs depends in part on the sale of syringes by pharmacists—a considerable change in the practice of pharmacy—data addressing the personal beliefs of pharmacists regarding this policy are discussed. A review of past and current U.S. regulations and funding issues is also presented.

Search Strategy

PubMed and Medline were searched using the terms syringe exchange programs and needle exchange programs. The selection was restricted to English-language articles outlining the outcomes of SEPs in the United States after 2000. A total of 657 studies were identified. Articles were excluded if they focused on data from outside the United States, were restricted to SEPs in correctional facility populations, and did not specifically address the impact of SEPs or the role of pharmacists. All articles considered potentially applicable were reviewed by the authors independently before being included in the final review. As a result, 33 articles were identified for inclusion. A manual review of each article’s citation list was conducted to identify any other applicable articles. Additional articles were used to supplement these findings as appropriate.

State and Federal Support of SEPs

Despite the evidence supporting the public health benefit of SEPs, financial support for these programs varies on the federal and state levels. In 1988, a federal ban on funding for SEPs was enacted and has been subsequently restated and supported.[10] In 1998, this ban was nearly lifted by the Clinton Administration; however, the final outcome was to allow local communities to determine whether such programs should be instituted, and if so, funding had to be acquired from nonfederal sources.[10] Then, on December 13, 2009, Congress voted (57 to 35) in favor of ending the ban. The new bill, titled the Consolidated Appropriations Act of 2010, required an additional vote by the House of Representatives, which had previously passed the bill in July 2009. The updated bill, which passed the House on December 10, removed earlier provisions requiring a minimum distance of 1,000 feet between an SEP and any daycare, pool, school, playground, and youth center. With the distance requirement removed, the bill now allowed SEPs to exist in any location, as long as local public health or law enforcement authorities did not object to their placement. The act was signed into law by President Barack Obama on December 16, 2009.[12] The passing of the bill was a crucial development that will provide states and communities with the resources needed to ensure sufficient SEP coverage. Additionally, the act further supports the importance of pharmacists in taking a more active role in participating or providing education regarding syringe safety and exchange activities.[11–15]

Current Laws in Place

According to a review of 16 states, recommendations for the safe disposal of used syringes vary greatly and are derived from or regulated by a variety of agencies.[16] The review concluded that communities need to develop low-cost and easy-to-use systems by which IDUs can safely dispose of used syringes; developing SEPs was one suggestion for accomplishing this.[16]

The topic of SEPs highlights an unfortunate dichotomy in priorities for a government that seeks to curb illicit drug use but also supports the safe use of injectable drugs to prevent the spread of disease. These same issues exist on the state level, with conflicting priorities between public health departments and law enforcement agencies.[16] In 2002, 47 states had drug paraphernalia laws in place with criminal penalties for possessing or selling syringes for the purpose of injection drug use.[16,17] These laws may impose penalties for the sale, distribution, or possession of syringes and as a result may promote fear of arrest and criminal punishment among IDUs.[17] This may cause IDUs to be reluctant to store used syringes for future disposal at an SEP.[16] As of 2008, eight states had syringe prescription laws that prohibited the dispensing or possession of syringes without a valid medical prescription.[18] A total of 21 states had pharmacy regulations or practice guidelines regulating the sale of syringes.[18] The current work demonstrates the varied degrees of support for SEPs at both the state and federal levels.

Characteristics of SEP Users

Studies have indicated that participants of SEPs have higher rates of injection frequency, unemployment, jail time, homelessness, cigarette use, and alcohol use compared with IDUs who do not participate in SEPs. This suggests that IDUs who participate in SEPs represent a distinct and higher-risk sub-population of injectors.[19] Numerous studies have shown that, in general, minority men represent the largest portion of participants of SEPs.[4,9,19] Data also reveal that women are underrepresented among SEP participants, as the majority of studies of SEP clients evaluate predominantly male populations.[9,20]

As one of the largest SEPs in the United States, the Chicago Recovery Alliance (CRA) found that considerable variation existed in terms of participant demographics by geographic location and hours of operation among its multiple sites throughout the city. During a 4-year period (1994–1998), a total of 11,855 IDUs, with a median age of 41 years and the majority being men (73.5%), visited CRA at least once. One-half (50%) of the participants during this time were black, 37.6% white, 10.3% Puerto Rican, and 2.2% „other“ (Latin American or Native American). When analyzed in terms of geographic location, results revealed that younger (<30 years), white, and Puerto Rican IDUs were attracted to certain sites, whereas older participants (>30 years), who tended to be black, were attracted to others. At the time of the study, CRA had nine sites that were open only during the daytime and participants were predominately black (60.9%) and the proportion of participants 30 years or younger was less than 9.8%. In contrast, for the 10 sites that were open only at night, participants were predominately white (46.2%) and Puerto Rican (32.2%) and the proportion of participants 30 years or younger was 21.9%. Results also revealed that women tended to frequent sites that were open both during the day and at night.[9]

The findings discussed above indicate that SEPs do not attract all types of IDUs; a subset of the population might prefer not to participate in or does not have access to SEPs. For these individuals, obtaining clean syringes through other channels may be challenging. As noted previously, some states permit the sale of syringes by pharmacists without a legal prescription. Although a portion of the population will purchase syringes for medical reasons such as diabetes, we focus specifically on the impact of syringe sales by pharmacists in the IDU population. According to a small study of 62 individuals purchasing nonprescription syringes at pharmacies in NYC and Albany, NY, 74% of participants reported purchasing syringes for injection drug use and 36% for medical use. Additionally, participants who purchased for drug use were significantly more likely to be black or Hispanic than to be white (P < 0.001). Regarding injection practice, 60% of participants reported reusing the same syringe, 26% had shared syringes in their lifetime, and 10% had shared syringes in the previous month. No differences were observed in sharing or reuse of syringes by race/ethnicity, gender, or age.[4] The study showed that sharing and reuse of syringes is a common practice among all IDUs, regardless of demographics.

With varying characteristics among IDUs and, as evidence has shown, among IDUs who participate in SEPs, pharmacists have a valuable role in their communities. One-on-one and telephone interactions with IDUs and their family members provide pharmacists with opportunities to help and support both patients and SEPs. Awareness of provided services and hours of operations of local SEPs allows pharmacists to refer patients appropriately. In addition, pharmacists may be able to provide feedback and/or information regarding unmet needs of the community directly to SEPs. For pharmacists practicing in states that do not permit the sale of syringes at a pharmacy, becoming familiar with these programs and building relationships with them is equally important.

Epidemiological Studies

The main goal of SEPs is to decrease the incidence of blood-borne diseases such as HIV, HBV, and HCV. As mentioned previously, SEPs represent a method for achieving this goal by decreasing the circulation of contaminated syringes in and beyond the IDU community.[21] Numerous studies have examined the impact of SEPs on a variety of endpoints, and the most recent and clinically relevant studies are reviewed below. Specific endpoints examined include seroconversion rates of HIV, HBV, and HCV, high-risk behavior among IDUs, and how these differ between SEP and non-SEP users.

Impact of SEPs on HIV, HBV, and HCV Transmission Rates

A large number of studies have examined the correlation between HIV and, to a lesser extent, HBV and HCV infection rates and SEPs. Although some of these studies have found a lower risk of infection transmission in SEP participants, results from other studies have reported either a negative effect or no effect. A 1995 study by Hagan et al.[22] found that not participating in an SEP led to a five times greater risk of HBV infection and a seven times greater risk of HCV infection. In a literature review article, Gibson et al.[23] examined 42 studies from 1989 to 1999 that evaluated the effectiveness of SEPs. Although the focus of their review was the United States, it also contained data from Canada, the United Kingdom, and the Netherlands. Of these 42 studies, 28 found a positive effect of SEPs on HIV risk behavior and seroconversion, 2 found a negative association, and 14 found either no difference or a mix of positive and negative effects. It has been hypothesized that these 14 studies failed to find an association as a result of dilution or selection bias.[23] These two types of bias are a common occurrence in SEP studies. Dilution bias arises when both the SEP and non-SEP IDU population have equivalent access to sterile syringes. This bias has been seen in studies conducted in cities where non-SEP IDUs had access to sterile syringes through the legal sale by a pharmacist or as a result of IDUs participating in an SEP that provides them with sterile syringes.

Conversely, selection bias relates to the observed phenomenon that SEP IDUs tend to be less socially integrated and more prone to excessively high baseline risk behaviors, therefore creating a disproportionate concentration of high-risk IDUs among SEP users.[24] This bias was reported in a study by Riley et al.[25] that compared the characteristics of IDUs using standalone SEPs with those using pharmacy-based SEPs. Standalone SEPs attracted a greater majority of high-frequency injection users. Hagan et al.[26] also explored this phenomenon of selection bias by examining the characteristics of an IDU cohort (n = 2,027) that began or stopped participating in a Seattle SEP during a 12-month period. The study reported that IDUs with certain high-risk characteristics such as daily injection (risk ratio 1.6 [95% CI 1.1–2.1]), injecting with heroin (1.8 [1.2–2.7]), syringe sharing (1.5 [1.1–2.1]), and backloading (i.e., practice of squirting drug solution from one syringe to another; 1.6 [1.1–2.1]) were more likely to initiate SEP use and that these same characteristics also made it more likely to continue the use of SEP services. The authors concluded that the SEP examined tended to attract IDUs who had a much higher baseline risk for blood-borne infections and that IDUs who stopped frequenting the SEP included a large number who were at low risk. Fischer et al.[27] further examined selection bias in a study that assigned IDUs (n = 600) to either an Alaskan SEP or a pharmacy for syringe purchase. The results demonstrated that IDUs who were assigned to and used the SEP tended to have a higher injection frequency and were also more likely to have shared injection paraphernalia. Both of these characteristics placed the SEP IDUs at higher risk for blood-borne infections.

If either or both of these biases are present, the study results will tend to be skewed away from supporting an association between SEP use and a decrease in transmission rates. An example of this is a study by Holtzman et al.[28] that examined the effect of SEP participation on high-risk injection behavior and HCV infection rates. Data were collected from two observational cohort studies and one randomized behavioral intervention trial from 1993 to 2004. The study reported that of the entire population (n = 4,663), approximately 46% reported SEP participation. When HCV infection rates were examined, no significant associations between SEP participation and infection rates were found. From the pool of patients who tested negative for HCV at baseline (n = 1,288), 12% became positive at the 3-, 6-, or 12-month follow-up period. The authors attributed the lack of an association between SEP use and a decrease in the HCV infection rates to both dilution and selection bias.[28]

In contrast, Neaigus et al.[29] reported a positive benefit of SEPs and pharmacy syringe sales on HIV, HBV, and HCV rates. The study examined the effect of legal SEPs and syringe pharmacy sales in NYC compared with Newark, NJ, where, during the study period, distributing syringes for drug injection was illegal. The rates of HIV (26.1% vs. 5.2%; adjusted odds ratio [AOR] 3.2 [95% CI 1.6–6.1], P = 0.0007), HBV (69.6% vs. 27.1%; 4.4 [2.8–6.9], P < 0.0001), and HVC (82.4% vs. 53.4%; 3.0 [1.8–4.9], P < 0.0001) were significantly higher in the New Jersey (n = 214) than in the NYC (n = 312) population. Additionally, only 4.7% of New Jersey participants reported obtaining syringes from a legal source compared with 92.6% of NYC IDUs. This trend continued, as New Jersey residents were also twice as likely to inject with a used syringe (19.2% vs. 8%; 2.32 [1.07–5.04]) and three times as likely to reuse their own syringe (37.9% vs. 13.5%; 2.99 [1.63–5.50]). New Jersey IDUs also were more than five times as likely to inject multiple times with the same syringe if it was new and sealed (5.43 [2.86–10.30]). The study demonstrated the positive health implications that legal SEPs and legal pharmacy syringe sales can have on transmission rates of HIV, HBV, and HCV and on syringe-sharing behaviors.

Effect of SEPs on IDU Behavior

The impact of SEP participation on IDU behavior has also been examined. Reducing high-risk behaviors is often thought to lead to the SEP’s protective effect rather than the SEP participation itself.[28] As demonstrated previously, the majority of IDUs who participate in SEPs tend to have a higher number of injections per day and higher baseline risk behaviors than IDUs who do not use SEPs. This is thought to be partly a result of SEP participants being less socially integrated than their non-SEP counterparts.[28] However, the results of these studies have shown that SEP participants share syringes and other drug paraphernalia less frequently than their non-SEP counterparts. The study by Gibson et al.[23] reinforces this viewpoint, as the review also found that not only were SEPs associated with a decrease in transmission rates but also in preventing behaviors associated with a higher risk of HIV transmission. Results from a study conducted by Longshore et al.[30] among IDUs in Providence, RI, who attended an SEP (n = 248) also reinforce a decreased risk in the sharing of syringes and other injection equipment with an increased frequency of visits to an SEP. The study demonstrated that lower frequency of SEP attendance was associated with a greater likelihood of syringe sharing, as indicated by the AOR for IDUs attending two to four times per month (2.04, P = 0.02) and for those attending no more than once per month (3.20, P = 0.01). Regarding the sharing of injection equipment, the results demonstrated that lower frequency of SEP attendance was associated with a greater likelihood of sharing cookers (IDUs attending two to four times per month: AOR 2.00, P = 0.02; IDUs attending no more than once per month: AOR 2.55, P = 0.04).[30]

In addition to examining HCV rates, Holtzman et al.[28] examined the effect of SEP participation on high-risk injection behavior. The study reported a significant correlation between more recent SEP participation and daily injection drug use among IDUs. However, this same IDU population, despite injecting more frequently, was significantly less likely to share syringes (AOR 0.77 [95% CI 0.67–0.88]) compared with non-SEP IDUs.

Regarding younger IDUs, Bailey et al.[31] surveyed 700 IDUs aged 18 to 30 years from 1997 to 1999. The majority of participants were younger than 26 years (64%), and almost two-thirds (65%) had not used an SEP in the 6 months before baseline. Additionally, on average, only 13% had used an SEP more than once per month. The study assessed risk factors based on the frequency of SEP visits (no visits, one to six visits, or seven or more visits). Participants who had visited SEPs seven times or more had the highest injection frequency rate (AOR 2.88 [95% CI 1.69–4.91], P < 0.001) but also the highest percent of not sharing syringes (0.32 [0.19–0.54], P < 0.001). This high–SEP use group was also the most likely to inject only once per syringe (0.25 [0.13–0.45], P < 0.001) and the least likely to share various injection paraphernalia such as cookers and cotton (0.51 [0.30–0.85], P = 0.013) and to backload (0.39 [0.19–0.81], P = 0.21). Finally, IDUs with the highest SEP use were also the most likely to use condoms with both regular and casual sex partners; however, only the regular partners comparison was significant (2.95 [1.56–5.56], P = 0.001). This study further reinforces the trend that although SEP users have a tendency to inject more frequently than those with less SEP frequency, overall they exhibit less high-risk drug behavior. However, the study also exposed a particular subgroup of IDUs who did not appear to use SEPs to a great extent (i.e., those aged 18–30 years).

Huo and Ouellet[32] also reported an observed decrease in injection risk behaviors for SEP users in a Chicago IDU population (n = 901). Compared with non-SEP users, IDUs who frequented SEPs injected drugs more frequently and were more likely to be HIV positive; however, this was expected because the SEP was located in an area with the highest HIV prevalence. However, the results of the study demonstrated that relative to non-SEP users, SEP-using IDUs were less likely to share syringes (odds ratio [OR] 0.33 [95% CI 0.23–0.46]), lend a used syringe (0.55 [0.41–0.75]), share other drug paraphernalia like cotton filters and cookers (0.70 [0.52–0.95]), and reuse their own syringes (0.18 [0.10–0.30]) and more likely to bleach syringes used by others before injecting (2.28 [1.37–3.80]). Additional evidence from a cohort study by Hagan and Thiede[33] and a meta-analysis by Ksobiech[34] also reported that IDUs who used an SEP were less likely to inject with a used syringe than non–SEP-using IDUs.

Gibson et al.[35] followed 338 IDUs and examined the effect of SEP participation on HIV risk behavior. Follow-up interview time from baseline was 10.7 months. At baseline, 31% and 33% of all participants reported using SEPs and having a high risk, respectively. IDUs were determined to be low risk if they only used unsterilized syringes with a regular sex partner they believed was HIV negative or if they bleached used syringes before injecting with them. High-risk IDUs were those who shared syringes with nonregular sex partners or with a regular partner whose HIV status was unknown or positive. The study evaluated whether SEP participation provided any protective benefit against HIV risk behavior. The results of the study showed that no significant difference existed in frequency of injections per month between IDUs who used and did not use SEPs. However, borrowing sterile (27% vs. 50%) or unsterile (17% vs. 35%) syringes occurred significantly less frequently in SEP users. Additionally, the rate of high-risk behavior was also significantly higher in the non-SEP group (12% vs. 24%). It was also shown that SEP use provided a more than twofold protective effect on HIV risk behavior (OR 0.45 [95% CI 0.21–0.92]). When access to other sources of syringes was evaluated along with SEP access, the odds of HIV risk behavior decreased sixfold if IDUs did not have syringe access beyond SEPs. The study once again demonstrated the evident protective effect of SEPs on HIV infection prevention.

Bluthenthal et al.[36] examined the effect of SEPs on 340 high-risk IDUs from 1992 to 1996. All patients reported sharing syringes at baseline. The study then followed these participants after the opening of an SEP in their community, and the results were based on two follow-up interviews 6 months apart. Overall, 60% (204 of 340) of the participants at follow-up reported that they had quit sharing syringes. Starting and continuing SEP participation was associated with syringe-sharing cessation. Patients who had steady sex partners who were also IDUs were found to be less likely to stop sharing syringes compared with those who did not have steady sex partners (52.1% vs. 67.2%). Furthermore, to determine whether SEP participation was independently associated with syringe-sharing cessation, the authors conducted a multivariate analysis that controlled for a number of variables (e.g., total number of interviews, age, presence of a steady sex partner). The results of the study demonstrated that IDUs who started SEP use (AOR 2.68 [95% CI 1.35–5.33], P = 0.005) and IDUs who continued SEP use (1.98 [1.05–3.75], P = 0.003) were both associated with ceasing syringe sharing, but independently of each other. The study further highlights the positive benefit of SEPs on syringe sharing.

Huo and Ouellet[37] studied the positive effect of SEPs on injection behavior and high-risk sexual behavior. Their study examined the impact of SEPs on IDU sexual risk behaviors in 889 IDUs in Chicago between 1997 and 2000. Of participants, 717 used SEPs. The study examined three aspects of sexual risk behaviors: number of partners, frequency of condom use, and number of unprotected sex acts. Patients were interviewed at baseline with three additional annual follow-up visits. The results of the study showed that no difference occurred in the number of sexual partners between the two study groups across time (P = 0.40). The number of unprotected sex acts also was not different between the two groups at baseline; however, the number decreased by 26% per year in the SEP group and only 10% in the non-SEP group (P = 0.02). Additionally, SEP users were more likely to use condoms consistently with their main partners (P = 0.001). However, no difference between the two groups was reported in condom use with casual or commercial sex partners. The study concluded that use of SEPs may encourage less high-risk sexual behavior, which in turn could lead to a decrease in blood-borne viral transmission.

Results from the studies discussed above demonstrate the significant amount of evidence supporting the positive health aspects of SEPs; however, the location of an SEP and whether it affects the overall health benefits achieved has not been addressed. Hospital-based SEPs are common in countries such as Canada and the United Kingdom but are not widespread in the United States. This type of SEP would be advantageous because IDUs tend to frequent hospital emergency departments for their regular source of care, which is extremely costly. A randomized-controlled trial by Masson et al.[38] examined this specific topic. The study compared the effectiveness of hospital- and community-based SEPs on IDU health status and injection practices. The study enrolled 166 people during a 2-year period. Patients were randomly assigned to receive syringes from either hospital- or community-based SEPs, with follow-up assessments at 6 and 12 months. The study reported that SEP location had no significant effect on either injection behaviors or health status. However, both groups reported a decrease in high-risk behavior and an improvement in overall physical health. Additionally, IDUs assigned to the hospital SEP had 83% more inpatient admissions and 22% more ambulatory care visits than those in the community SEPs. The study demonstrated that the location of an SEP did not lead to a difference in reducing high-risk injection behavior; however, hospital-based SEPs had the additional advantage of providing easy access to outpatient care services for IDUs.

Sustainability of the Effects of SEPs

The current work provides considerable clinical evidence demonstrating the positive effect of SEPs on high-risk injecting behavior and transmission rates. However, little evidence exists indicating whether this positive SEP effect can be sustained over time. Braine et al.[39] interviewed IDUs at the Tacoma Syringe Exchange Program in 1997 (n = 197) and again in 2001 (n = 326). The study examined change in injection risk behavior of SEP participants over time. The authors found that in 1997, 987,000 syringes were exchanged and, by 2001, the total had increased to 1.44 million. The frequency of injections per day did not change significantly over time, with the majority of patients in both periods injecting two or more times per day (54%, 1997; 65%, 2001). Change in injection risk behaviors was also examined during the 4 study years. These behaviors included backloading with used syringes, giving a used syringe to someone else, and self-injection with a known used syringe. For all three behaviors, the frequency of backloading (18% vs. 22%), giving a used syringe (23% vs. 30%), and injecting with a used syringe (23% vs. 27%) did not significantly decrease from 1997 to 2001. Factors that affected injecting with a used syringe in both time periods included having depressive symptoms 30 days before the study interview and the combination of being younger than 35 years and coinjecting with amphetamines. Other factors that affected used syringe sharing changed from year to year. In 1997, more women shared syringes than men, but by 2001 this trend had reversed. Finally, the researchers examined the HIV incidence rate in 12 new injectors who had been IDUs for 5 years or less. They found that none of the 12 IDUs were HIV positive. Although injection risk behavior did not decrease over time, the study demonstrated that injection risk behavior among Tacoma Syringe Exchange Program participants remained stable from 1997 to 2001. Additionally, the frequency of injection did not increase significantly during the period of study. This demonstrates the sustainability of the impact of SEPs and again reinforces the benefit of SEPs in the IDU population.

Although IDUs who frequent SEPs tend to have a higher injection rate frequency, these programs also lead to a substantial decrease in high-risk drug behavior among participants. IDUs who participate in SEPs also exhibit safer sex practices. Further, some studies have shown that SEP participants have lower rates of HIV, HCV, and HBV. However, a considerable number of barriers regarding SEPs and IDUs remain. As seen in the study by Bailey et al.,[31] the percent of young IDUs who used SEPs was very low. This appears to be a segment of the IDU population in which additional education and outreach on the benefits of SEPs are needed. Additionally, the potential benefit of SEPs that are integrated in the hospital setting represents another avenue that should be further examined. It is common for IDUs to use the emergency department as their primary source of care. Given that this population tends to have a number of chronic medical conditions, having access to inpatient care, along with access to SEPs, would be beneficial in the long term as well. Finally, legal issues surrounding SEPs in the United States, as well as support at the state level, also play a major role in decreasing transmission and high-risk behavior.

Social Reluctance for SEP Support

With the relatively low number of SEPs currently operating in the United States and conflicting support at both the state and federal levels, considering available alternatives for IDUs is important. Without SEPs, IDUs could obtain syringes either through unauthorized channels or at the pharmacy, with or without a prescription depending on state regulations.[40] As previously described, state laws differ in view on the over-the-counter sale of syringes to IDUs in pharmacies.[17] Although this may not be an option in all places, pharmacies provide an ideal setting for this method of distribution for several reasons, including convenient location in the community, counseling and referral to additional resources by pharmacists when necessary, and protection of IDUs‘ privacy if they are unwilling to identify themselves through use of an SEP.[40,41]

Research on pharmacists‘ personal beliefs regarding SEPs is limited; however, reports of their personal beliefs on the sale of syringes at the pharmacy are readily available. Looking specifically at the legality of selling syringes, many pharmacists are uncertain how to interpret laws and policies. In many states, the laws and pharmacy regulations may not provide pharmacists with clear answers regarding the legality of the sale of syringes. Many of these laws and regulations allow the sale of syringes for a legitimate medical purpose, but that is another concept that is loosely defined and open to interpretation.[42] For example, some individuals may feel that distributing clean needles to prevent the spread of disease is a legitimate medical purpose, whereas others may feel that it simply furthers drug abuse. Regardless of state laws or regulations or how pharmacists interpret them, for the sale of syringes to IDUs, the final decision to sell belongs to the individual pharmacist. Although often a controversial topic, it has been shown that this decision is greatly dependent on the beliefs and perceptions of the individual pharmacist.[41,43–46]

Surveys have been conducted to better identify specific barriers that would deter a pharmacist from making this type of sale. Several structural and individual barriers that prevent pharmacists from selling syringes to IDUs have been reported. A qualitative study conducted among a sample of pharmacists from Atlanta, GA, sought to identify and classify some of these barriers.[41] The analysis found that pharmacists‘ concerns and hesitations to sell syringes could be categorized into three groups: personal attitudes and beliefs about drug users and HIV/AIDS, concerns about deception, and concerns about legality. Pharmacists who viewed drug addiction as a personal choice and a matter of personal responsibility were less likely to sell syringes to an IDU. Some pharmacists were hesitant to sell syringes to IDUs because of their concern that the syringes would not be disposed of properly and might be found in the community. However, individuals who viewed access to sterile syringes as a strategy to prevent HIV were more willing to sell syringes to IDUs. For some pharmacists, the hesitation to make such a sale was based on the discomfort that comes with being lied to. Some pharmacists reported that they were more willing to sell syringes if the individual was honest about how they were going to use them. Most of the pharmacists surveyed admitted having a limited knowledge of the state laws and board of pharmacy regulations that governed the sale of syringes without a prescription. Among those that were aware of these laws and regulations, the interpretation varied greatly. This demonstrates that in addition to the conflicting levels of support among state and federal organizations, understanding of the issue on the individual level varies considerably.

Another analysis compared the opinions of pharmacists in rural versus urban locations in and between four states (Colorado, Connecticut, Kentucky, and Missouri).[43] The analysis demonstrated that individual opinions vary not just from state to state but also based on the location of the pharmacy and the population that the pharmacy serves. The results demonstrated that location can play a substantial role in pharmacists‘ decision to sell syringes to IDUs depending on the important issues in that particular region. For example, pharmacists located in areas where production and abuse of methamphetamine are common were less likely to sell syringes to IDUs. These pharmacists reported that in their community, fighting this rampant drug abuse was more important than preventing the spread of blood-borne disease.

Discussion: Roles for Pharmacists

Several barriers exist surrounding pharmacist acceptance of the value of increasing syringe access in the IDU population; however, the role of the pharmacist is an important element of combating the spread of blood-borne viruses and infections in the IDU population. Therefore, it is important to examine steps that can be taken at the pharmacy level to change these negative perceptions and encourage a proactive view for the pharmacist when dealing with IDUs seeking sterile syringes.

Pharmacists have the potential to play a key role in preventing the transmission of major blood-borne viruses in the IDU population through the provision of sterile syringes and injection equipment, patient counseling (e.g., substance abuse treatment, safe injecting practices, safe disposal practices, safe sex practices), and support of local SEPs.[47] The sale of syringes by pharmacists supplements the work of SEPs by operating in locations that lack SEPs, operating during hours during which SEPs might be closed, and appealing to a subpopulation of IDUs who may be less likely to participate in SEPs. Despite the benefits of supplemental syringe access at the pharmacy level, data from a study among IDUs in Harlem and the Bronx, NY, demonstrate that even with pharmacy-based expanded access to syringes, SEPs remained the most frequently used source of syringes.[48] This further emphasizes the importance of the support needed for SEPs from other health care professionals, including pharmacists.

Surveys of various populations of pharmacists regarding their attitudes about selling syringes without a prescription to IDUs have repeatedly highlighted that, as a result of both individual and structural barriers, pharmacists can be divided into three groups: one that strongly favors the sale of syringes, a second that strongly opposes such sales, and a third that is unsure.[41,43,44,47] Individual barriers included pharmacists‘ personal attitudes and beliefs about drug abuse and HIV/AIDS and concerns of deception. Structural barriers included state laws and regulations that addressed the sale of syringes without a prescription, as well as pharmacy regulations and practice guidelines.[41] Because pharmacies represent an important and convenient alternative to SEPs for IDUs to obtain sterile syringes, examining how some of these barriers can be addressed is necessary.

Many of the personal barriers that were identified may be related to misconceptions that can be changed by exposing pharmacists to additional education surrounding the issue. Although changing state laws and regulations regarding the sale of syringes may not be possible, current laws and regulations can be clarified and education on their proper interpretation can be provided. The ultimate decision to sell syringes without a prescription belongs to the individual pharmacist. Unfortunately, pharmacists may be reluctant to perform the sale simply because they do not truly understand the proper interpretation of laws, regulations, and policies.[49] Outreach efforts to educate pharmacists on these laws and regulations can help ensure that they have a similar understanding of the meaning of the laws and regulations for their specific state(s) and are better informed in making a decision on performing the sale of a syringe without a prescription. In addition, this also lends to a more consistent practice among pharmacists regarding the sale of syringes. Increasing educational efforts targeted at these issues could increase pharmacists‘ willingness to sell syringes to IDUs and their willingness to support and participate in SEPs.

Education of pharmacists is particularly important when laws and regulations change. After syringe sales were deregulated in four states (Minnesota, New Mexico, New York, and Washington), outreach efforts were made to inform and promote the acceptance of the new laws among both the IDU and pharmacy communities.[47] One study conducted in New Mexico found that pharmacists were generally not well informed about recent changes in pharmacy laws or about SEPs. The study concluded that an educational outreach supported by the department of health was well received and that similar programs in other states may be beneficial to help increase pharmacist knowledge and acceptance of the issues surrounding increased access to clean syringes for IDUs.[50] Sustained promotional efforts may be necessary, as the reluctance to sell syringes to IDUs and to buy them from pharmacies is rooted in decades of laws and regulations.[47]


The IDU population has a greater risk of contracting bloodborne diseases such as HIV, HCV, and HBV through the sharing and reuse of syringes. Ensuring that IDUs have access to sterile syringes can help reduce this risk and the corresponding risk of spreading diseases to others. SEPs have demonstrated a clear effect in improving the health outcomes of IDUs. Opponents of SEPs believe that such programs imply societal condoning of illicit drug use. However, many IDUs either will not stop injecting drugs or cannot get into substance abuse treatment programs; therefore, the need to provide IDUs with this support is crucial for them and for the public at large. SEPs have demonstrated a clear effect in improving the health outcomes of IDUs, which ultimately benefits overall public health. Participation in SEPs has been shown to decrease the transmission of blood-borne disease and high-risk injecting behaviors. In addition to SEPs, in some states, IDUs have the option of purchasing syringes without a prescription. Although pharmacists play a pivotal role in the health of IDUs by providing an alternative channel for obtaining clean syringes, acknowledging that they can play a pivotal role simply by being aware of and supporting active SEPs is important. Pharmacists are knowledgeable and accessible sources of health information and can counsel IDUs regarding syringe access and disposal and addiction treatment programs. Therefore, pharmacists should be aware of SEPs in their community and provide the appropriate information to IDUs when requested.

Efforts are needed to educate pharmacists about their roles in syringe access and how their actions can benefit the health of the entire population. Concerns or misconceptions that pharmacists have about IDUs, SEPs, blood-borne diseases, and the interpretation of state and federal laws regarding syringe sales must be addressed. Providing this education will help increase pharmacist participation in this crucial public health activity.


At a Glance

Synopsis: The current work provides a summary of the literature on syringe exchange programs (SEPs) and discusses roles for pharmacists in providing support for injection drug users (IDUs) and SEPs. IDUs have an increased risk of contracting blood-borne diseases such as human immunodeficiency virus, hepatitis B virus, and hepatitis C virus through the sharing and reuse of syringes. Ensuring that IDUs have access to sterile syringes can help reduce this risk and the risk of spreading diseases to others. SEPs have demonstrated a clear effect in improving the health outcomes of IDUs. Because pharmacists are knowledgeable and accessible sources of health information and can counsel IDUs regarding syringe access and disposal and addiction treatment programs, they should be aware of operating SEPs in their community and provide the appropriate information to IDUs when requested.

Analysis: Although IDUs who frequent SEPs tend to have a higher injection rate frequency, these programs also lead to a considerable decrease in the highrisk drug behavior of participants. The ultimate decision to sell syringes without a prescription belongs to the individual pharmacist; however, pharmacists may be reluctant to perform the sale because they lack a complete understanding of the proper interpretation of laws, regulations, and policies. Increasing educational efforts targeted at these issues could increase pharmacists‘ willingness to sell syringes to IDUs and their willingness to support and participate in SEPs.


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For more than 20 years, local heroin addicts have relied on a collection of needle exchanges for clean works. But in recent months, crack users too have quietly found an outlet in the city.

In a nondescript alley in the University District, users can pick up clean crack pipes, pipe filters and ascorbic acid for injecting crack. Heroin users can also pick up a drug that reverses a heroin overdose — an apparent first for a city needle exchange.

„We take a different philosophy approach than most government institutions or public health departments. They have a budget, and have to pick and choose who they’re going to help,“ said Shilo Murphy, executive director of the non-profit People’s Harm Reduction Alliance, which runs the U-District needle exchange.

„We say this is our community, this is our neighborhood, and we should decide what we have at the table.“

The exchange, which celebrated 20 years in the neighborhood this week, has come a long way from its roots — when a man named Bob walked the Ave. and dispensed sterile needles from his backpack.
These days, the largely volunteer-driven exchange, which serves 400 to 600 people a month, is better known for branching ahead of its peers in the harm reduction world.

Public health officials know of no other local program that gives out crack kits or Naloxone, the heroin-overdose reversal drug. But they see the potential benefits.

Just as sterile syringes reduce the spread of HIV and other diseases, new and unbroken glass pipes are believed to prevent lip cuts and the spread of hepatitis strains. Rubber tips and new filters ward off mouth burns. Ascorbic acid helps prevent users from using lemon juice to dissolve cocaine rocks into an injectable liquid — a common practice that can lead to fungal infections.

„Our program is primarily an HIV prevention program,“ said Michael Hanrahan, manager of education and prevention services of the HIV/STD program with Public Health — Seattle & King County. The agency, which runs four exchange programs, has watched the demand for clean needles surge from 1.8 million in 2006 to nearly 3.4 million last year.
Hanrahan said research has documented HIV transmission from dirty needles, but he wasn’t aware of rigorous studies showing disease spread via crack sores.

„But it’s certainly theoretically plausible,“ he said.
Last year, the Legislature passed a law allowing lay people to legally administer Naloxone, which counters the effects of an opioid overdose. Hanrahan said Public Health is interested in giving the drug to users, but because it is a prescription drug, the agency first needs to work on protocols with the state Board of Pharmacy.

At the People’s Harm Reduction Alliance – partially comprised of former users who run a table at Northeast 43rd Street and University Avenue Northeast – there is less need to follow protocols and studies.
The program began giving out crack kits a few months ago, after staffers felt the need to support crack users, who still make up a major local drug trend, according to a recent University of Washington study.
And the exchange began giving out Naloxone soon after the new law took effect in June.

Murphy estimated his program gives out two million needles a year and 10 pipes a day. This month, it handed out 25 vials of Naloxone.
„We don’t have clients, we just have community members. I make it clear to everyone that everyone is family here,“ Murphy said.
„We believe all drug users should have the right to not get diseases and have the ability to prevent diseases.“

Friday, August 6, 2010

source: http://www.seattlepi.com/local/42462…ml?source=mypi