Four years after a law allowing local governments throughout California to legalize needle exchanges went into effect, fewer than 25% of counties have done so.
That has health officials, drug advocates and some politicians worried that HIV and hepatitis rates may be increasing among intravenous drug users.
As early as next month, state legislators are expected to reintroduce a controversial bill to address those concerns. The bill would allow over-the-counter sales of clean needles to adults at pharmacies throughout the state.
But many law enforcement agencies vehemently oppose the idea, saying the current policy of letting individual locales decide for themselves is sufficient. Opponents worry that making the sale of syringes legal would go too far toward condoning drug use and increase the number of dirty needles left in public spaces.
Allowing needles to be sold directly to the public "would lead to a unregulated, unfettered mess that we wouldn't be able to change once it starts," said John Lovell, a Sacramento lobbyist who represents the California Narcotic Officers' Assn., the California Police Chiefs Assn. and the California Peace Officers Assn.
Over the last two years, former Gov. Gray Davis vetoed two similar bills, raising concerns that the legislation did not require a one-for-one swap, meaning users must exchange a used needle for every clean one.
Opinion polls show the public generally favors access to syringes over the counter, as well as legal needle exchange programs.
Still, many communities have balked at needle exchanges for fear of raising the crime rate. Last summer, for instance, the Riverside County Board of Supervisors turned down a measure to legalize exchanges by a 3-2 vote.
Several legislators backing the pharmacy sales bill, including Sen. John Vasconcellos (D-Santa Clara), say that the system is falling short and that giving users direct access to needles is the only way to curtail the spread of HIV and other blood-borne diseases among drug users.
Supporters say they expect the measure will again pass the Legislature.
A spokesman for Gov. Arnold Schwarzenegger said he hadn't yet made a decision on whether he would sign it.
California is one of five states that does not allow needle sales, except with a prescription for insulin or epinephrine.
After years of pressure from health officials, AIDS organizations and drug advocates, Davis backed compromise legislation in 1999 between health officials and law enforcement that allows local governments in California -- either cities or counties -- to legalize exchanges as long as they declare a state of health emergency every two weeks.
At the time, both sides hailed the move. But because a majority of municipalities haven't legalized exchanges, health officials and advocates have called for further reform.
Today, the majority of Californian municipalities continue to rely on a patchwork of illegal underground exchanges that began in the late 1980s after health officials linked dirty needles to the spread of HIV and other blood-borne diseases.
In some cities, addicts have no access to clean needles, using the same needles for weeks or sharpening their syringes with matchboxes and sharing them with fellow addicts.
Most underground exchanges are run by volunteers -- many of them former addicts -- and operate out of vans, in parks late at night or by a secret pager system not unlike the ones drug dealers use.
Legal exchanges are often much larger than illegal operations and either have their own clinics or are located within other health and drug treatment centers.
According to the state Office of AIDS, there are 14 cities and counties throughout California with legal exchanges, including San Francisco, Mendocino and Marin counties.
Both the city and county of Los Angeles endorse exchanges and financially support them, but neither routinely declares a state of health emergency, which technically makes the operations illegal.
Substantial research indicates that giving users access to clean syringes lowers the transmission of disease and does not promote drug use.
According to federal health statistics, 27% of all AIDS cases across the country are the result of intravenous drug use.
There are no data, however, showing that California's patchwork system of needle exchange has led to higher rates of infection.
Ricky Blumenthal, a health researcher at the Santa Monica-based think tank RAND Corp., said higher rates of HIV and hepatitis are inevitable among users of dirty needles and their sexual partners.
"I hope we don't wait until the cow has left the barn and rates climb back up dramatically among addicts to realize that what we have now isn't working," he said.
Other critics of the 1999 law add that it is having an unintended effect on some underground exchanges.
Over the last decade, several dozen volunteers with illegal needle exchanges were arrested but few were convicted because defendants often persuaded judges and juries they had no choice but to break the law.