Health departments and their employees making tough choices now that the General Assembly has passed Bevin's pension bill

Bevin at bill signing (Lexington Herald-Leader photo by Alex Slitz)

Kentucky's health departments and their employees face some difficult decisions in the wake of the pension legislation passed in the recent special session of the General Assembly.

The law written and signed by Gov. Matt Bevin freezes the pension costs of health departments for another year, at 49 percent of payroll, avoiding an increase to 83 percent, which would have forced layoffs and program cuts, and could have put some of them out of business.

But now the health departments must choose whether to stay in the Kentucky Retirement System "at full cost, leave the retirement system by paying a lump sum equal to future projected benefits payments, or buy their way out in installment payments over 30 years," writes David Zoeller of The Paducah Sun.

Marshall County (Wikipedia map)

Zoeller notes that the Marshall County Health Department "has already been making tough decisions," such as ending its school-nurse program and cutting its staff by almost 30 percent.

John Cheves of the Lexington Herald-Leader notes, "Public employers that quit KRS will be encouraged through financial incentives to freeze their employees’ pensions so they accrue no further benefits. Instead of a pension, employees will be transferred into a riskier defined-contribution retirement plan, such as a 401(k), with a balance that rises and falls with the stock market, and that retirees can outlive if their money runs dry. . . . Some could lose hundreds of thousands of dollars in anticipated retirement benefits if their pensions are frozen."

Cheves's object example is the Garrard County Health Department, which has seven employees, some of whom are less than 10 years from retirement. "Under the state pension formula, the final decade on the job is crucial to maximizing their monthly retirement checks," he notes, and gives a specific example:

"Cathy Stapleton, a nurse at the health department, is 55 with plans to retire at 62. She doesn’t want her pension to be frozen and replaced with a 401(k) account that would have seven years — not the usual 30 to 40 — to build wealth through compound interest. One ill-timed market crash could sink her." She told Cheves, "It means a lot when you come into a pension. It means you have a retirement where you can count on having that income every month." Getting a new 401(k) plan at age 55 "would be a lot different."

Garrard County (Wikipedia map)

Department Director J Smith told Cheves he will recommend to the Garrard County Board of Health that it stick with KRS and pay the 83 percent. "Telling middle-aged people who devoted their lives to public service that they’re suddenly going to risk financial insecurity in their senior years is not a viable choice, he said," Cheves reports, quoting him directly: “We’re not going to opt out. If we opt out, to me, we’re screwing our employees here. Some of my people have got just a few years left. We expect to get what we were promised. We were promised a pension.”

The department has already eliminated family-planning services, cut health education, "laid off its emergency-preparedness coordinator and a front-desk clerk, and officially eliminated a third position, Smith’s old job, which he still does in addition to being director," Cheves reports. "That means he splits his time between inspecting schools, businesses, septic tanks and the like for safety and cleanliness, and managing the department."

“I’ll admit, our response time is slower now because of it,” Smith told Cheves. “When people used to call in for a site evaluation, we usually could get out there the same day. Now it might take us a week. It’s just — I’m sorry, we don’t have the people we used to. . . . I told our Board of Health that if we want to keep the services we have left, we’re going to have to have a tax increase.”

Kentucky River District Health Department
service area: Wolfe, Lee, Owsley, Leslie,
Perry, Knott and Letcher counties (KRDHD map)

Using local tax dollars to fund public health would result in huge inequities, said Scott Lockard, director of the Kentucky River District Health Department, which covers some of the state's poorest and unhealthiest counties. "Communities that need public-health services the most, that have the highest poverty rate, that have the poorest health outcomes, also have the least ability to raise local revenue," Lockard told Kentucky Health News in June.

Ky. has 59 operating syringe exchanges and six in the wait; state drug-policy director credits public-health advocates for increase

By Melissa Patrick
Kentucky Health News

Kentucky is lauded nationwide for its embrace of syringe exchanges to thwart the spread of HIV and hepatitis C among intravenous drug users, but getting them approved locally continues to be a challenge and generally only happens after months, or even years, of educating the public.

Van Ingram, executive director of the Kentucky Office of Drug Control Policy, attributed the success of Kentucky's syringe exchanges to the ongoing efforts of the state's public health workers, who promote the exchanges as "harm reduction programs."

"It's just great public health advocacy at the local level, who just wouldn't give up," Ingram said July 11 at a health-related forum in Covington.

He was speaking broadly about the state's many efforts to battle the opioid epidemic, including a 2015 law that allows syringe exchanges with approval of the county health board and fiscal court and the legislative body of the city where the exchange is to be located.

Kentucky has 59 operating syringe exchange locations in 52 of its 120 counties, with six more approved but not operational. Since mid-February, when Kentucky Health News did its last syringe exchange roundup, 11 additional counties have been marked on the state health cabinet's map of exchanges.

Since February, Henderson, Hopkins, Taylor and Owen counties have been added to the map and are identified as operational locations. Magoffin County was also recently added, even though it opened last June, Hazard's WYMT-TV reports.

Among the 54 Kentucky counties the federal Centers for Disease Control and Prevention has identified as being the most vulnerable to outbreaks of HIV and hepatitis C among IV drug users, 33 have approved an exchange, with 29 of them operational.

The vulnerable counties that have not approved an exchange are Allen, Bell, Breckinridge, Carroll, Casey, Clinton, Cumberland, Edmonson, Gallatin, Grayson, Green, Harlan, Hickman, Johnson, Lawrence, Lewis, Martin, Menifee, Monroe, Rockcastle and Wayne.

Bath, Estill, Knott, and Leslie counties, which are included on the list of 54, were recently added to the exchange map, as have Todd County in Western Kentucky and Scott County in the Bluegrass region. These exchanges are marked as not yet operational.

State Sen. Whitney Westerfield of Hopkinsville "still thinks some of his colleagues are uneasy" about syringe exchanges, Max Blau reports for Stateline. "But he’s still hopeful that the results will mirror that of the CDC’s research, which shows that injection drug users who have access to syringe exchanges are five times more likely to get treatment than those who don’t.

“There’s not universal support, but we’ve moved in that direction,” Westerfield said. “I don’t see the people who hated [syringe exchanges] filing bills to reverse it. With harm reduction, there’s more general acceptance of it.”

Western Kentucky

Western Kentucky has been slow to adopt such programs, but that could be changing; three of the eight syringe exchanges west of Louisville are among the newest.

Henderson County's exchange offers an example of the importance of persistent public health advocacy and education when it comes to getting these exchanges approved.

Douglas White details in his article for The Gleaner the many evidence-based arguments that Green River Health District Health Department officials presented at a January meeting of the Henderson City Commission meeting in support of a syringe exchange. He noted that the issue had been discussed on and off for several years and the exchange had been approved by the Fiscal Court, but needed the approval of the city, which finally happened in February.

Clayton Horton, the health department's director, told Charles Taylor of the National Association of Counties about the importance of getting buy-in from the community.

“That required us to do a lot of education and do some advocacy with local governmental bodies,” he said. “We weren’t asking for resources; we’re weren’t asking them to pay for it. But we were asking them to consent and agree and to trust us and to trust the evidence-based practice to set these up and run them.”

Todd County's exchange was approved June 14, Adam May reports for WHOP in Hopkinsville, and his story also spoke to the importance of public health' leaders' role in educating the community.

Magistrate Brent Spurlin said "he was initially skeptical and heard from people who believe the needle exchange is only a way to enable addicts, but he changed his opinion as he learned more," May reports.

When Graves County opened its exchange in April, Mayfield Police Chief Nathan Kent told Chris Yu and Randall Barnes of Paducah's WPSD-TV that he applauded the health department for opening the program, and that he believed it would not enable drug users -- which is a common misperception.

“From our perspective, if folks come in here and take advantage of this opportunity, and they get the resources that convince them to make a change in their life, and they are able to overcome their addiction, then that’s just one more productive citizen,” Kent said.

Lauren Carr, the Graves County Health Department's harm-reduction coordinator, told WPSD that the first person who came to the exchange for clean needles told her, "No one has treated me like a person before."

“The whole goal of this program is to meet individuals where they’re at, but you can’t leave them there," she said. "You have to give them the resources, the education, and the things that they need to make better choices for themselves."

Hopkins County approved its exchange in April, Doreen Dennis reports for Surf KY News.

Cave City in Barren County was considering an exchange, but the city council voted unanimously against it, Gina Kinslow reported for the Glasgow Daily Times on Feb. 11. Barren County already has an exchange, in the county seat of Glasgow.

The middle of the state

The first sentence in Steve McClain's Georgetown News-Graphic article about Scott County finally passing its syringe exchange sums up the challenges involved in getting many of these programs passed: "After months and months of tense debate and votes, Scott County’s syringe exchange program launches Monday, July 1, from noon to 4:30 p.m."

And while there's not much posted online about Owen County's newly approved exchange, a December 2016 article in the Owenton News-Herald indicated that the Three Rivers District Health Department has been working on getting one there for years.

In another example of public-health persistence, the Anderson County Health Department proposed a syringe exchange three years ago and couldn't gain the support from either the city or county -- but in June of this year, the health board approved one, which now allows it to go before the city council and fiscal court, Ben Carlson reports for The Anderson News.

Taylor County approved its exchange in April. The Lake Cumberland District Health Department offers two educational videos about syringe exchanges to educate its community, one that addresses how syringe exchanges help with the cost of Hepatitis C and the other titled, "Why in the World Would You Give a Needle to a Drug Addict?", shown below.

Exchange models vary

Ingram told the forum attendees, "When you've seen one syringe exchange program in Kentucky, you've seen one syringe exchange program in Kentucky." While they all work toward what is commonly called "harm reduction," they vary in their hours, locations and services offered.

One of the more unique set-ups is the use of mobile exchanges, which Laurel, Knox, Clay and Jackson counties will share. Whitley County, which has a stationary exchange, was supposed to join the program, but has decided to not participate, according the county health department.

WKYT-TV reported in April that Lexington's program was expanding to two days a week, and since September 2015 has served more than 2,700 people, with an average of 175 coming in every Friday.

"The thing we are most proud of is 128 people have entered rehab through this service," health department spokesman Kevin Hall told WKYT. "We have on-site counselors available to offer referrals into programs and so that is 128 people who get a second chance."

Another evolution of these programs is that many of them now regularly distribute naloxone, a drug that can reverse an opioid overdose.

Terry DiMio reports for the Cincinnati Enquirer that at least 92 lives have been saved with naloxone that was handed out at two Northern Kentucky syringe exchanges. Since opening the two exchanges have handed out 1,358 naloxone kits, she reports.

Click here to get a list of all the exchanges and their hours of operation, as well as a list of facts about syringe exchange programs.

47 Ky. counties have syringe exchange programs, but only half of the 54 at higher risk of HIV and hepatitis C outbreaks have them

By Melissa Patrick
Kentucky Health News

Kentucky leads the nation in the number of syringe exchange programs, but passing such programs continues to require great amounts of public education and perseverance.

Daviess County, home of Owensboro, the state's fourth-largest city, is the latest to launch a syringe exchange. That brings the number of exchange locations to more than 50, in 47 of the state's 120 counties. Graves County has approved a program, but it's not yet operational.

Western Kentucky has been slow to adopt such programs, which were approved by the state legislature in the 2015 anti-heroin bill as part of an effort to decrease the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles by intravenous drug users.

Daviess County's program, which will serve residents of the seven counties in the Green River health district, is the fourth syringe exchange to open west of Louisville. The others are in Muhlenberg, Warren and Barren counties.

Daviess County Judge-Executive Al Mattingly said the slow embrace of exchanges in Western Kentucky is because there has been less need for the programs in that part of the state, Katie Pickens reports for The Owensboro Times, an online newspaper.

The latest Kentucky Health Issues Poll found that the percentage of adults in Western Kentucky who knew someone who used heroin was 12 percent, compared to 36 percent in Northern Kentucky, 24 percent in Lexington and Louisville and 21 percent in Eastern Kentucky.

Daviess County is not one of the 54 Kentucky counties listed by the federal Centers for Disease Control and Prevention to be most at risk to outbreaks of HIV or hepatitis C as a result of IV drug use, but it is near three counties that are on that list that haven't approved syringe exchange programs: Breckinridge, Grayson and Edmonson. None are in the Green River health district.

Of those, Grayson County has come closest to getting one. The county health board and the Leitchfield City Council have already approved it, but the county Fiscal Court failed to get a second to a motion for it on Jan. 15, Matt Lasley reports for the Grayson County News-Gazette. (The health board, fiscal court and the legislative body of the city where the exchange is to be located must approve it.) UPDATE: The fiscal court unanimously rejected the idea on Feb. 8.

The first failed vote followed two hours of testimony, both for and against the program, Lasley reports. And it seems the course of these discussions are similar across the state.

Proponents, largely from the medical community, line up to present evidence-based research about syringe exchange programs that shows how they do not encourage people to start using IV drugs,or increase the frequency of use among current users; how they reduce the spread of infections like HIV and hepatitis C; how they do not increase community crime; how they do increase community safety by taking dirty syringes off the street; and how they are known to help connect people to treatment, with one study finding that syringe-exchange participants are five times more likely to enter a drug treatment program than non-participants.

Opponents say they believe that the programs enable addiction, increase drug use or would bring drug users from neighboring counties into their communities, which could lead to more crime. Others struggle with providing an addict with a tool to feed their addiction. And many simply say they don't believe the research.

"Commonwealth's Attorney Rick Hardin said he was hesitant to believe statistics that say needle exchange programs actually increase an individual's likelihood to attend rehabilitation, as well as whether they cut down the spread of diseases such as hepatitis and HIV," Lasley reported for the Leitchfield newspaper. Hardin also prosecutes felony cases in Breckinridge and Meade counties.

Dr. Joe M. Lee

On Jan. 22, the News-Gazette published a guest editorial by Dr. Joe M. Lee, medical director of the local health department, that tried to overcome the opposition by giving the paper's readers more information. "Part of the magistrates’ concern was that the people they represent don’t understand the program and were generally opposed to it," Lee wrote. He said there had been "huge increase in Hepatitis C and HIV/AIDS" in the county, mainly as a result of intravenous drug use.

"This is a public health emergency," he wrote in bold letters."Please encourage your magistrate to vote YES and let's help our county begin recovery from this epidemic. You may be saving the life of a child, a loved one, a neighbor or a friend." Grayson County Judge-Executive Kevin Henderson said he may call up the issue again, Lasley reports.

Meanwhile, the Twin Lakes Regional Medical Center in Leitchfield will soon offer an opioid medical stabilization program for expectant mothers. CEO Wayne Meriwether said he started the program because one of the hospital's OB-GYNs said he cares for a large number of mothers who are addicted to drugs, Amy Lindsey reports for the News-Gazette.

Farther east, in the Bluegrass region, Scott County is one step closer to adopting a syringe exchange. After the fiscal court voted it down in December, with two magistrates absent, it was called back up for a vote in January and passed 5-3. The program already has the approval of the county's board of health and now must be approved by the Georgetown City Council, Paul Watson reports for the Georgetown News-Graphic. Scott County has been debating the issue for about two years.

Other localities that are actively considering a syringe exchange program are Henderson and Todd counties and Cave City in Barren County.

State Rep. Kim Moser

The chair of the House Health and Family Services Committee, Rep. Kim Moser, R-Taylor Mill, told Kentucky Health News that she would like to see the law changed to let the local health board and health department start syringe exchange programs on their own.

"This is the only issue that the legislature gets involved with in telling the health department what to do," said Moser, who once ran the Northern Kentucky branch of the state Office of Drug Control Policy.

Needs-based vs. one-for-one syringe exchanges

Another point of contention is whether these programs should be based on the weekly injection needs of the client – called needs-based – or whether they should require a one-for-one exchange of syringes.

Health officials say that if the goal of the program is to stop the spread of infectious diseases such as HIV and hepatitis C, Kentucky must allow intravenous drug users to have as many needles as they need in order to have a clean one for every injection, and that a one-for-one requirement defeats that purpose.

A one-for-one model is also listed on the Cabinet for Health and Family Services' website as one of the "practices to avoid" because it "results in sharing of needles."

Senate Majority Floor Leader Damon Thayer, R-Georgetown, a critic of the program since its inception, has filed Senate Bill 69 that would require syringe exchanges to dispense only one clean needle for each used needle.

Sen. Damon Thayer

"I would love to get rid of the needle exchange altogether," Thayer told Lawrence Smith at WDRB, "but I don't think I could get that passed." He added, "I respect the public health argument. I just am philosophically opposed to taxpayers paying for a needle for someone to do an act that is illegal."

Moser said she doesn't support Thayer's bill and hopes it doesn't get out of the Senate Health and Welfare Committee. "I oppose it," she said. "I do not think that removing programs that are working, that are getting people into treatment is the way to go."

Moser pointed out that health departments are statutorily required to reduce communicable diseases, and that's what a syringe exchange program does. Further, she said Kentucky can't afford to pay $80,000 per hepatitis C treatment for its Medicaid patients, when a "very simple, cost effective" solution to prevent hepatitis C is a six-cent needle.

Dr. Lynne Saddler, Northern Kentucky Health Department's district director, also opposes Thayer's bill. She told Terry DeMio of the Cincinnati Enquirer, "The science is clear that a 1:1 [one-for-one syringe] policy is not effective in stopping the spread of HIV through injection drug use."

The Louisville and Fayette County programs use a needs-based model, as do some others. But many of them start off by giving out a set number of needles on an as-needed basis, and then move to a one-for-one model. Counties that use any grant money from the Kentucky Agency for Substance Abuse for their syringe exchange programs are required to use a one-for-one model.

Ky. making great strides in treating patients with hepatitis C, with harm-reduction programs and fewer restrictions on treatment

By Melissa Patrick
Kentucky Health News

Eliminating hepatitis C in Kentucky and the rest of the nation will require universal screening and non-restricted access to treatment, and because new cases of the disease are largely driven by intravenous drug use, states must also commit to increasing harm-reduction programs like syringe exchanges and medication assisted therapies.

Those were the overarching messages to more than 300 people who attended the fifth annual Viral Hepatitis Conference in Lexington on July 31. The good news was that Kentucky has made great strides on all of these fronts since last year's conference, which had a similar message.

Access to harm reduction is one of the areas in which Kentucky has excelled.

Cincinnati Enquirer photo

Dr. Allen Brenzel, medical director for the Department of Behavioral Health and Developmental Disabilities, told the crowd that one of the things he was most proud of was the state's syringe exchanges, which are mainly intended to decrease the spread of infectious diseases, such as hepatitis C and HIV.

Kentucky leads the nation in the number of counties with local syringe exchanges. As of July, 45 of the state's 120 counties have approved such programs at more than 50 sites. That's a lot more than Brenzel expected under a 2015 law that requires approval by the local health board, the county fiscal court and governing body of the city where the exchange is to be located.

"I travel a lot, and the fact that Kentucky has harm-reduction syringe exchange is one of the things I'm most proud of . . . It's an incredible thing," Brenzel said. "We all thought we'd have four or five of them in our urban areas, but what I think is exciting is that our rural counties stood up and said, 'We're tired of this. We're tired of our neighbors dying; we're tired of our friends [dying]. We know this is a health risk.'"

Only about 10 percent of syringe-exchange participants agree to be tested for hepatitis, and critics of the programs claim they enable drug use. On the recent KET program "Disrupting the Opioid Epidemic," host Renee Shaw asked Jennifer Hancock, president and CEO of Volunteers of America Mid-States, about that.

"It is enabling people to take that first courageous step toward a path of recovery," Hancock replied. Earlier, she said, "They are absolutely saving people’s lives."

Hancock, Brenzel and Dr. Ardis Dee Hoven, an infectious disease specialist with the state Department of Public Health, said the exchange specialists strive to build long-term relationships with their clients, making it easier to eventually steer them toward treatment.

"This is not about a supply of needles,” Brenzel said. “This is about the first step in the road to recovery."

At the conference, Brenzel also talked about the state's many different programs that are set up to distribute naloxone, the life-saving drug that can reverse the effects of an opioid overdose. Brenzel added that the U.S. surgeon general has said that having access to naloxone and learning how to use it is "as important as learning CPR."

Jon Zibbell, senior public health scientist at RTI International, an independent nonprofit research institute, told conference attendees that the nation has both a health-care crisis and a public-health crisis.

He said that while it's important to treat the 4 million people who are chronically infected, especially because we know that between 8,000 and 10,000 of them will die annually from a liver-related illness, it is the IV drug users with hepatitis C who are creating the public health crisis.

"The only real way to address the public health crisis for hepatitis C and hepatitis B is to address the people who are still injecting, to protect those downstream transmissions," Zibbell said.

On top of treating people who are actively using drugs, he said, the best way to treat these individuals may be to create a "one-stop-shop" for related services, including hepatitis C treatment, medication-assisted therapies, syringe exchange and access to naloxone.

"We need a way to make it so infected people don't transmit the virus and uninfected people don't acquire the virus, and then naloxone to keep them alive," he said.

Kentucky no longer requires people getting hepatitis C treatment to stay off illicit drugs, only that they be screened and counseled for any illicit drug use. The state has also removed the requirement that only allowed treatment during advanced stages of the disease; now anyone can be treated for it.

The state still requires the disease be treated by or in consultation with a specialist, which is a challenge because there aren't enough specialists to meet Kentuckians' needs.

Dr. Jens Rosenau, an associate professor of medicine at the University of Kentucky and a hepatologist and gastroenterologist at the Kentucky Clinic, said that between July 2014 and December 2016, before the restrictions were removed, only 22 percent of his patients started treatment for the disease, largely because of the restrictions.

But after the majority of the state's managed-care organizations lifted the restrictions in April, allowing Medicaid to pay for treatment, he said his treatment uptake rates have doubled. "This month we actually started 150 patients on treatment," he said. "It is probably our record now."

Rosenau also noted that the UK Healthcare emergency department started doing universal screening for hepatitis C in July and that in just two weeks had identified more than 70 patients with the disease who didn't know they had it: "That is overwhelming." The disease is common, but latent, among the Baby Boom generation.

Kentucky is also the first state in the nation to pass a law that requires all pregnant women to be tested for hepatitis C, and for their babies to be tested at 24 months if the mother tested positive. One in 56 Kentucky births are to mothers who have hepatitis C.

Barbara Cave and Danielle Revert, family nurse practitioners in Louisville, said the state needs universal screening for hepatitis C.

Revert noted a study found that using the current guidelines for screening, 25 percent of people who would test positive for the disease would be missed. "If we're going to talk about eradicating this disease, I really think we're going to have to shift our screening focus more toward this universal screening idea," she said.

Cave added that the prevalence of hepatitis C is likely far greater than the 3.5 million that is normally reported because this number doesn't include any people who are institutionalized, incarcerated, hospitalized, homeless or are military veterans. She said the U.S. estimate should be closer to 5.2 million.

Corinna Dan, viral hepatitis policy adviser for the U.S. Department of Health and Human Services,  said it's challenging to get people to pay attention to a specific health issue like hepatitis, and that it simply doesn't have the kind of support that you see for many other health conditions, like HIV, which has a "huge advocacy base."

"We haven't done that yet effectively for hepatitis," she said. "We do need champions at the ground level, at the local level . . . because that's where people are served, that's where people have the need."

Health boards support legislative agenda to change how public health is delivered and paid for, to make Kentucky healthier

By Melissa Patrick
Kentucky Health News

At their first-ever statewide meeting, Kentucky's local boards of health voted for their state association to adopt a legislative platform aimed at modernizing the state's public health systems in order to improve Kentucky's overall health.

The "Kentucky's Public Health 3.0" plan calls for local health departments to demonstrate measurable outcomes, a supportive framework of state laws, and secure funding for all the services the law requires them to provide. The goals match the recently launched national Public Health 3.0 initiative.

During the online meeting Jan. 12, former Pendleton County judge-executive Henry Bertram, the president of the Kentucky Association of Local Boards of Health, implored board members to support the plan as a way to improve the health of Kentuckians and to better use taxpayer dollars: "We’re not spending our money correctly.”

"It's a call to action," said Bertram, who has been a member of his local health board for 16 years. He added, “The biggest voice in Kentucky for public health is the board members. . . . And I say that because many of you are elected officials that sit on those boards of health. You're county judges, you're magistrates," and medical professionals. "You've got a voice in your community.”

Bertram went on to say that while Kentucky has some excellent local health directors, "Many of us who sit on local boards of health don’t know what our responsibilities are." He said that when he became judge-executive, he didn’t even know that he was on the health board by virtue of his office.

He said it is the responsibility of health board members to fully understand why Kentucky's health is so poor and be able to explain why change is necessary.

“We’ve got to step up; we’ve got a challenge in front of us and we’ve got to hit it head-on," he said.

The plan has also been endorsed by the Kentucky Public Health Association and the Kentucky Health Department Association.

What exactly is Public Health 3.0?

Georgia Heise, health director for the Three Rivers District Health Department in Northern Kentucky, opened the meeting by stressing that Public Health 3.0 is a "grass-roots initiative" meant to improve the health of Kentuckians, not part of "Obamacare." She said in a telephone interview that such a false perception could cause some people, including legislators, to not even listen to the proposal.

“We have to separate population health, the health of our citizens, from politics. We have to. We cannot continue to do the same old, same old thing and expect different results," said Heise, who is also the president of the National Association of County and City Health Officials.

Graphic from Kentucky Health Departments Association presentation

Heise said people must first realize that "public health is not clinical, medical care," but is grounded in prevention through population-health initiatives.

"The work that has already been done with this initiative can be explained and it can be defended and that is what we need you board of health members to help us do with our legislators," she said.

Dr. Karen DeSalvo, acting secretary for health in the U.S. Department of Health and Human Services, appeared via video recording and commended Kentucky for leading the way with this initiative. She focused her comments on the plans call for health departments to join forces with community stakeholders to address the social determinants of health, because "We know that health is more than health care. . . . Our goal is to change the conversation in this country and get every sector involved in improving health and well-being."

For example, health department officials should be included in planning and zoning meetings to make sure newly developed properties include sidewalks, said Allison Adams, director of the Buffalo Trace District Health Department and the KHDA president. Health officials should advocate for "health in all policies," she said.

Adams noted that social and economic factors, such as education, employment, income, family and social supports, and community safety, contribute to 40 percent of a typical person's health, and "none of those things happen inside the walls of the health department. . . . But it's our job to be conveners of bringing these groups that affect these health factors together and letting them know . . . decisions they make and the things they do, how that influences health and the opportunity to be healthy."

The plan also calls for public-health leaders to be the chief health strategists in their communities; encourages health departments to work toward national accreditation; and calls for increased county-level health data so they can make more informed decisions.

What state law requires each Kentucky health department to do
(Click on image to view a larger version)

At the state level, the plan calls for "enhanced and substantially modified funding" for public health. Adams said it is largely funded programmatically, but departments get "very little funding" for their statutory requirements, the things that state law requires them to do. She estimated a $40 million gap between funding and what it costs to meet the requirements.

"There’s no doubt about it, our funding needs to be modified," Adams said. "We need to figure out a way to spend $1 that affects 10 people, instead of $1 that only affects one person." But she acknowledged, "Change is never easy. There will be difficult decisions to make."

But as she described Kentucky's dismal health statistics, noting that the state ranks 45th for health, she said it's time to do something differently, because what we've been doing isn't working.

"My goal is for us across the state of Kentucky to get as angry about the fact that we are 45th in the nation as we would when our basketball teams fall out of the top 25," Adams said. "I think if we could all get angry about that, we could move mountains here in the state of Kentucky."

Ky. has 25 approved syringe exchanges to reduce risk of HIV and hepatitis C outbreaks; other counties debate proposals

By Melissa Patrick
Kentucky Health News

A minister, a nurse and a physician assistant joined forces in Powell County to educate its citizens about a syringe-exchange program, which should open up this month -- but the decision to support an exchange didn't come easily for any of them, Mary Meehan reports for Ohio Valley ReSource, a regional journalism collaborative of public broadcasters.

Van Ingram, executive director of the Kentucky Office of Drug Control Policy, told Meehan that rural counties like Powell are leading the way in changing the perception of how addiction is perceived in the state, shifting the focus toward treatment and public health initiatives and away from the criminal justice system. So far, syringe exchanges have been approved in 25 of the state's 120 counties; several others are having debates like the one that went on in Powell County.

Pastor Brad Epperson of the Clay City First Church of God, who also drives a school bus, told Meehan that the many funerals he has officiated for people too young to die, and the stories he hears from the children on his bus, made him realize that something had to change. He now considers syringe exchanges the first place for addicts to get the help they need.

Nurse Mandy Watson
(Photo by Mary Meehan)

Mandy Watson, a nurse for the Powell County Board of Health, told Meehan that she changed her mind about syringe exchanges after realizing what an HIV or hepatitis C outbreak could do to the community.

The federal Centers for Disease Control and Prevention ranks Powell County 15th in the U.S. for risk of an HIV or hepatitis C outbreak from IV drug use, and the county borders Wolfe County, which is ranked No. 1 in the nation.

"Almost anybody you ask has some kind of family member who does use or (has) some type of trouble with addiction," Watson said of the county, where 13,000 people live.

Physician assistant Troy Brooks, who is on the county health board, initially opposed a syringe exchange. "He said it seemed like a way to let addicts keep using their drug of choice without consequence," Meehan reports. But then local police showed him how bad the problems is by taking him to the Clay City playground, where they collected 41 dirty needles, and he saw the need to protect children and first responders.

Tosha Baker of the Clay City Times did a story June 2 about needles in the park and elsewhere, and the discussion of a syringe exchange.

The state legislature authorized syringe exchanges in the 2015 anti-heroin bill, but in an effort to decrease the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among intravenous drug users. They require both local approval and funding.

Six of the 25 syringe exchanges approved so far aren't operational yet. Thirteen are in counties deemed most vulnerable counties by the CDC, which identified 54 Kentucky counties as among the 220 most vulnerable in the nation to a rapid spread of HIV and hepatitis C infection among persons who inject drugs. Sixteen of the state's counties ranked in the nation's top 25.

Cabinet for Health and Family Services map; updates at http://chfs.ky.gov/dph/epi/HIVAIDS/prevention.htm

The Madison County Board of Health supports a syringe exchange, but was met with "mixed feelings" about the program at the August fiscal court meeting, with some members concerned that the program condoned intravenous drug use, Ricki Barker reports for The Richmond Register.

The county will host several forums to educate local citizens about the cost and benefits of the program and answer any questions that the public may have about it. Health officials told Barker that the department sees about eight to 10 patients a day with hepatitis C.

Woodford County has received a $6,860 grant from the Kentucky Agency for Substance Abuse Policy that will be used to seed a syringe exchange program if approved by the local governments.

Securing a needle exchange in Northern Kentucky continues to depend on what Campbell County decides to do, Chris Mayhew reports for Cincinnati.com.

The Northern Kentucky Health Department wants to put a needle exchange program in the Campbell County Health Center in Newport, but Newport hasn't yet approved an exchange, despite a strong push from health officials since 2015 to do so. Mayor Jerry Rex Peluso, who supports an exchange, told Mayhew that the four city commissioners remain divided on this issue.

Intravenous drug use is so bad in Northern Kentucky that the health department created a "story map" to utilize "big data" to help combat the heroin epidemic in the area, noting that one person in Northern Kentucky died from a drug overdose every 40 hours last year. The map shows the areas with the highest number of opioid-related arrests since 2011, opioid related medical runs and where naloxone was administered; where you can get naloxone, among other things, Jay Warren reports for WCPO-TV in Cincinnati.

Several exchanges are newly approved or just getting started

Boyle and Whitley counties started their syringe exchanges Jan. 13.

Boyle County's program is open 1 to 3 p.m. Fridays in the basement of the health department in Danville, Kerry Steinhofer reports for The Advocate-Messenger. The program is initially being funded by a $20,000 ASAP grant, which will pay for supplies, but not salaries. Health officials said the hope is that the city and county will eventually fund the program.

Whitley County's exchange is open from 2 to 4 p.m. Fridays at the health department's main office in Williamsburg. Whitley County is ranked the 14th most vulnerable county in the nation for a rapid outbreak of HIV or hepatitis C infections, Mark White reports for the News Journal, the local weekly newspaper.

“Needle exchanges are the only thing they have shown that truly decreases hepatitis. Hepatitis C has become the number one killer in the state,” Public Health Director Martha Steele told White.

Mike James of The Daily Independent in Ashland reports that Greenup County recently approved a syringe exchange. The program will cost about $8,000 per year, including materials and will be funded by the local health department and a grant from Pathways Inc., a behavioral-health nonprofit. The program will be operated out of the health department one day a week for three hours a day. James reports that "users also will get counseling from a Pathways Inc. professional."

Floyd County will also begin offering its program in January as well, Andrea Saddler reports for The Floyd County Times. The county health department is conducting a survey to determine the best day to operate its exchange.

Nelson County approved its program in December, but it's not operating yet, Jim Brooks reports for the Nelson County Gazette. This exchange will be one-for-one and will be funded by the health department.

Warren County's excahnge opened in September and reports that it is off to a good start, seeing about a dozen people each week, Alyssa Harvey reports for the Bowling Green Daily News. It is open Thursdays from noon to 4 p.m. at the Barren River District Health Department.

Brad Stacy of The Morehead News reports that "the city, county and board of health approved a harm-reduction program that focuses on limiting the risks and harms associated with unsafe drug use, including needle exchange" after a standing-room-only crowd at a community forum discussed the heroin problem in the county.

Click here for a list of operating needle exchanges and their hours of operation.

Louisville's program grows, make case against one-for-one rule

The Louisville syringe exchange opened its fourth location in December at the Redeemer Lutheran Church in the Shawnee neighborhood. It will be open every Tuesday from 9 a.m. to noon, Joe Sonka reports for Insider Louisville.

"Statistics provided to Insider Louisville by the city health department show that from the program’s inception through the end of this October, a total of 5,347 individual clients have received 454,989 free syringes, with 267,746 used syringes returned," Sonka reports. He also notes that 295 clients in the exchange have been referred to drug treatment programs, two have tested positive for HIV and 182 have tested positive for hepatitis C.

Sonka reports that Louisville's exchange is the only one in Kentucky that uses a needs-based model, which is considered best practice by leading health experts to prevent the spread of disease. Other programs in the state place some limits or follow a one-for-one policy, as the state is requiring for exchanges that get state grants.

Stat, the science-and-medicine supplement to The Boston Globe, reports, "Needle exchanges, once met with fierce resistance, are working" and notes that public-health experts say that one of the challenges in decreasing infections is "that exchanges do not provide as many clean syringes as people who use drugs need."

Woodford County explores a syringe exchange; county attorney says local heroin problem is 'only going to get worse'

By Melissa Patrick
Kentucky Health News

VERSAILLES -- The Woodford County Board of Health is educating itself about syringe-exchange programs, with plans to begin the process of creating a plan for one in the county.

"We do have a horrible, insidious heroin problem," County Attorney Alan George said at the board's Aug. 18 meeting. "We are no different than any other county, but we are no worse. . . . It's only going to get worse."

George encouraged the board to take some time to learn more about how syringe exchanges work in other counties and then, if they wanted to proceed, to format a detailed plan to present to the Versailles City Council and and the Woodford County Fiscal Court, because they too must approve the program.

Syringe exchanges were authorized by the state's 2015 anti-heroin law, in an effort to thwart the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among intravenous drug users.

So far, 15 counties have approved syringe exchanges, according to a presentation by Greg Lee, who serves as the state Department of Public Health's point person for syringe exchanges.

Lee told the board that such programs have been around for 30 years, and are proven effective to discourage the spread of HIV and hepatitis C. Kentucky leads the nation in percentage of the population infected with acute hepatitis C.

"One of the things we know works is syringe exchange programs," Lee said. "Year after year studies show that these programs do not increase drug use, they actually decrease crime in the area, they increase community safety, they reduce spread of infection, increase first-responder safety and connect people who use drugs to drug treatment."

One Kentuckian is infected with HIV and two are infected with hepatitis C every day, mostly from intravenous drug use, Lee said.

Lee also noted several other benefits of syringe exchanges, including: Police departments in communities with the programs have seen a 66 percent drop in needle sticks; people in the programs are four times as likely to get into drug treatment; and for every dollar spent on these programs, seven dollars are saved in treatment costs.

Several Woodford County health board members asked about funding. Lee said syringe exchanges are "not an expensive program," because of the low cost of needles and because they are typically only open one day a week for a few hours.

Lee said some counties fund the programs through the state's Agency for Substance Abuse Policy program and that Operation UNITE had also helped some Appalachian counties fund their programs. He noted that while federal funds can now be used, so far no federal funding has been specifically allocated.

George wanted to know how other counties made sure participants in the program were from that county, noting that health departments are meant to only serve the people in that given county.

Lee said most programs don't ask people where they live. "One of the things that you want to be sure of is to not have any barriers to scare people from coming in to these programs," he said.

George also asked about whether programs were required to have a one-for-one exchange and if counseling was required.

Lee said that initially participants are typically given as many needles as they need to get through the week, but that as they become regular participants, the exchange rate becomes closer to one-for-one.

As for counseling and educational materials, Lee said that that is up to each individual needle exchange, but also said that the counseling aspect of the program works best after a level of trust has been developed between the staff and the participant.

Lee cautioned the board about the importance of involving local law enforcement.

"These programs will not work if you don't have local law enforcement behind it. Even though you don't need their official approval, you certainly need their understanding of what we are doing," he said.

Judge-Executive John Coyle, the board chair, said he supported a syringe exchange in Woodford County because the "health benefits outweigh any of the other concerns." And when asked if the local law enforcement would be on board, he said, "I don't think they will be opposed to it." Coyle is a former sheriff.

The next Woodford County Board of Health meeting will be Nov. 17, with plans to have another guest speaker on the topic.

Needle exchanges slowly spread as locals conclude they're better than HIV and hepatitis outbreaks, injuries from discarded syringes

Needle exchanges may be difficult for some people to accept, but they are better than outbreaks of hepatitis and HIV or accidental injury from discarded needles, officials in Kentucky counties that have established the exchanges told Bill Estep of the Lexington Herald-Leader.

"Programs allowing intravenous drug users to exchange dirty syringes for clean ones are spreading in Kentucky as communities confront growing heroin abuse and concerns over the potential for disease outbreaks caused by addicts sharing needles," Estep reports. "So far, health departments and local governments in 13 counties have approved needle exchanges, and 11 are in operation, according to the state Cabinet for Health and Family Services and local officials."

Kentucky leads the nation in hepatitis C cases and has 54 of the 220 counties that the federal Centers for Disease Control and Prevention considers most at risk for HIV or hepatitis outbreaks from shared needles, based on "statistics such as numbers of overdose deaths, per capita income, unemployment and sales of painkillers," Estep notes. "Kentucky had 18 counties that the CDC calculated to be more vulnerable than Scott County, Indiana, to a disease outbreak among IV drug users, with Wolfe County considered at greatest risk in the nation."

A version of this map appeared on Kentucky Health News May 5. This one adds needle-exchange sites.

Some local officials "said they’ve faced concerns that giving needles to drug users enables or condones illegal drug activity, or will make the local drug problem worse," Estep reports. Republican Judge-Executive Mike Malone of Carter County "said he shared those concerns when officials from the health department brought up the idea. Malone said he changed his mind because of the potential for the program to head off disease and get addicts into treatment.

“It’s not about enabling them to take drugs. It’s about stopping the spread of disease,” Malone said. “The more you learn about it, the more you’ll understand it’s the right thing to do.”

Estep reports, "Health officials said they understand some people don’t like the idea of providing drug users with needles at public expense, but they argue the potential cost to taxpayers of not doing so is far worse."

Needle exchanges are operated by local health departments with approval of the county health board, the fiscal court and the city where the exchange is located, under a law passed by the 2015 General Assembly.

UPDATE, July 22: "Clark County’s needle exchange opened a week ago with one client." Fred Petke reports for The Winchester Sun. "Local officials are good with that." Clark County Health Department director Scott Lockard told Petke in an email, “Some of the health departments had their exchanges open several weeks before having their first client.”

Kenton County's approval of a needle exchange inches Northern Kentucky, hit the hardest by heroin, toward getting one

The Kenton County Fiscal Court unanimously approved a mobile needle exchange program March 29, which moves the City of Covington's needle exchange program one step closer to fruition, Terry DeMio reports for the Cincinnati Enquirer.

The Fiscal Court's approval was one of several conditions required by the City of Covington to allow its exchange to move forward. Covington's plan also requires two other counties in the Northern Kentucky Health District to adopt exchanges (only Grant County has); limits access to only resident's of the district's four counties; and would move the exchange to St. Elizabeth Healthcare hospital.

In addition, it requires a one-for-one needle exchange and a mandate that all participants must be tested for hepatitis C, hepatitis B, HIV, and, where applicable, pregnancy. This condition is likely not legal and is being investigated by the Northern Kentucky's Health Board's legal counsel, DeMio reports.

Kenton County's plan differs from Covington's in that it mandates only the offering of these tests, DeMio reports.

Both plans will require the Kenton County Board of Health's approval.

Needle-exchange programs were authorized by the state anti-heroin law passed in 2015, and require both local approval and funding. They are meant to slow the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among intravenous drug users. Northern Kentucky has been hit the hardest in the state by heroin and its hepatitis C rates have been reported at 19 times the national rate.

The needle exchange would be funded by $250,000 from the R.C. Durr Foundation, and the health department would use its staff and already available testing to further pay for the exchange, DeMio reports.

The Fiscal Court also approved exploring the idea of building a community-wide addiction treatment center on the county jail grounds; putting $25,000 toward a heroin helpline; and approved a resolution to encourage the Northern Kentucky Board of Health to create a high-quality prevention and education program for the community.

The Northern Kentucky Area Development District has already put out proposals for the heroin helpline, DeMio notes. And County Judge-Executive Kris Knochelmann told him that Boone and Campbell counties were willing to consider putting $25,000 each toward it, and that St. Elizabeth had promised $75,000 toward its operation.

The other needle exchanges in the state that are either operating or have been approved are in Louisville and Lexington and in the counties of Pendleton, Carter, Elliott, Franklin, Grant and Jessamine.

Boyd, Clark counties approve needle exchanges; Boyd's is a limited, one-for one; Covington's proposed limits draw objections

By Melissa Patrick
Kentucky Health News

Clark and Boyd counties are the ninth and 10th Kentucky counties to approve a needle-exchange program, and Madison and Anderson counties are talking about it. Meanwhile, the city of Covington has approved an exchange with conditions that don't match its health department's plan, and one of the conditions might not even be legal.

Needle exchanges were approved under the state's anti-heroin law passed in 2015, and require both local approval and funding. They are meant to slow the spread of HIV and the hepatitis C virus (HCV), which are commonly spread by the sharing of needles among intravenous drug users.

Clark County Health Director Scott Lockard noted that the federal Centers for Disease Control and Prevention has "identified 54 counties in Kentucky as being vulnerable to rapid dissemination of HIV or HCV infection among persons who inject drugs. Of the top 25 most vulnerable counties in the nation 16 of them are in our state."

Clark County

On March 23, the Clark County Fiscal Court approved on a 4-2 vote a needle exchange that will start on or before June 1, but the program will need re-authorization in January, Greg Kocher reports for the Lexington Herald-Leader.

"Both the Fiscal Court and the [Winchester] City Commission inserted a sunset clause in the orders requiring the health department to present data on our program in January 2017 in order to get re-authorization for a longer time period," Lockard told Kentucky Health News in an e-mail.

He noted that the CDC identified nearby Wolfe County as the most vulnerable county in the nation to rapid dissemination of HIV and HCV among drug users, with adjoining Powell and Estill counties 15th and 25th, respectively.

"Residents from all three of these counties frequently come to Clark County for medical services from our provider community and the health department," he said. "More must be done in the area of prevention if we are to avoid a situation similar to what Scott County, Indiana, encountered."

That county, about 30 miles north of Louisville, has drawn national attention for its high rates of HIV and hepatitis C, mostly caused by intravenous drug users who share needles. According to published reports, "from November 2014 to mid-June 2015, the Indiana county of 24,200 reported 170 HIV cases. It reported 130 new cases of hepatitis C in 2014," noted Bill Robinson of The Richmond Register.

According to Lockard, Clark County's program will use a patient negotiation model, which does not require a one-to-one needle exchange, during the initial visit, but will try to get close to a one-for-one model on subsequent visits.

"We will educate participants that they need to return needles to get needles," he said.

Boyd County

The Boyd County Fiscal Court voted 4-1 March 15 to approve a one-to-one needle exchange for one year, Lana Bellamy reports for The Daily Independent. 

The Ashland City Commission had already given its approval for the exchange, which may begin as early as July. Bellamy reports that the program will be paid for by special taxing districts, and all of the fiscal court members voiced concerns about the sustainability of the funding.

Ashland-Boyd County Health Department Director Maria Hardy told the court that syringes typically cost about 97 cents each, but the health department will be able to buy needles from a distributor for 9 cents each, Bellamy writes.

The Boyd County program will assign tracking numbers to its participants to protect their identities and allow a maximum of 40 needles to be exchanged each week.

County Commissioner John Greer, the only member to vote against the resolution, said he was concerned the program would encourage drug abuse and Sheriff Bobby Jack Woods agreed, Bellamy reports. This is a common concern among opponents of needle exchange programs, though evidence-based studies have proven otherwise.

Covington

During the same week, the City of Covington approved a needle-exchange program, but with conditions that could kill the program, Terry DeMio reports for The Cincinnati Enquirer.

The conditions are that all participants be tested for hepatitis C, hepatitis B, HIV, and, where applicable, pregnancy. That could be illegal, DeMio reports.

A Northern Kentucky Health Board spokeswoman told DeMio that they believe that they cannot require anyone to undergo any medical procedures, but said they were checking with legal counsel. Other health and harm-reduction officials told DeMio that this requirement is not legal, and that such a condition would likely prevent a program from getting off the ground.

"The Covington commission's resolution includes other conditions that differ from the health board's model program, too, and would require passage from the Kenton County Fiscal Court and the Board of Health before it's approved," DeMio writes.

These conditions include a requirement that two other counties in the Northern Kentucky Health District also adopt a needle-exchange program (only Grant County has); restrict use of the program residents of the district's four counties; and moving the exchange to St. Elizabeth Healthcare hospital.

The city also wants a one-for-one exchange, Michael Monks reports for The River City News.

The health department says its plan is "need-based," not one-for-one, because studies show that is the best way to reduce the risk of community exposure and spread of HIV and HCV. This is the main goal of the program, although needle-exchange programs also provide HIV and HCV testing and access to drug treatment.

The health department's plan is to initially provide clients with the number of syringes they would use in a week, along with a safe container for their return with instruction to return the used needles for new ones. Participants who don't return dirty needles after three trips would not receive new syringes, DeMio reports.

The department has been trying to establish needle-exchange programs in the district since the law passed one year ago. The Kenton County Fiscal Court is expected to discuss a needle exchange plan March 29, DeMio reports.

Dr. Lynne Saddler, the health department's director, told the Enquirer "that the Covington resolution was a start and that more discussion is planned by the health department."

Other counties

Madison County Health Department officials are also worried about becoming another Scott County, Indiana, as they face an epidemic of heroin use in their county, Bill Robinson reports for The Richmond Register.

Thus they have begun the process of educating their public officials, Robinson writes. Public Health Director Nancy Crewe presented her detailed findings to support a needle exchange at a quarterly joint meeting of the county Fiscal Court, Richmond City Commission and Berea City Council, noting that they were just beginning the long process of educating the public.

A needle exchange program was also brought up at the March meeting of the Anderson County Fiscal Court meeting, and was met with some disparaging remarks, Ben Carson reports for The Anderson News.

"What jackass thought of that idea?" asked Magistrate David Montgomery. "We might as well give them the dope, too."

Despite these comments, Montgomery did volunteer to be on a committee to explore a needle exchange program along with members of the health board, Lawrenceburg City Council, law enforcement, EMS and county jailer.

Robinson also reports that the Bourbon County Fiscal Court has voted to reject an exchange.

The other needle exchanges in the state that are either operating or have been approved are in Louisville and Lexington and in the counties of Pendleton, Carter, Elliott, Franklin, Grant, and Jessamine.

Three more Kentucky counties, two of them rural, recently approved needle exchanges, making six counties with them

By Melissa Patrick
Kentucky Health News

Jessamine, Carter and Elliott counties are the latest Kentucky counties to approve needle exchange programs, joining Fayette (Lexington), Jefferson (Louisville) and Pendleton counties.

The approval of exchanges in Carter and Elliott counties, in northeastern Kentucky, creates a major rural beachhead in a state where officials have said rural officials will be slow to adopt the strategy of preventing HIV, hepatitis and other diseases transmitted by illict drug users.

The major obstacle is a widespread belief that needle exchanges enable drug users, despite studies that say otherwise. That has created another big hurdle, lack of federal funding. However, Congress removed that obstacle last month at the behest of two Kentuckians: Senate Majority Leader Mitch McConnell and U.S. Rep. Hal Rogers, chair of the House Appropriations Committee.

The two Republicans had opposed federal funding for needle exchanges, but recently led the charge to get Congress to lift a ban that was enacted in 1988, lifted in 2009 and reinstated in 2011 The latest change was included in the omnibus spending package passed in December. The measure still doesn't allow federal funds to be spent on the syringes themselves, but it can be spent on relayed costs such as staff, transportation, counseling, treatment referral and outreach.

Not only does the lifting of this ban potentially bring much needed dollars into Kentucky to help pay for the exchanges, but the support of two top Republicans and the federal government could go a long way in convincing local governments to support needle exchanges in the state, Laura Ungar reports for The Courier-Journal..

Kentucky's needle-exchange program is part of the landmark heroin bill the General Assembly passed in 2015. It is intended to prevent the spread of disease and steer drug users toward treatment. Kentucky leads the nation in hepatitis C and suffers more than 1,000 drug overdose deaths each year.

However, the law requires local-government approval for needle exchanges, which has proven to be a challenge in many counties, even Northern Kentucky an urbanized area that has been hit hardest by heroin.

Jessamine County

Jessamine County Public Health Director Randy Gooch said about 20 county health boards have approved needle exchanges, but most have been thwarted by city or county governments, reports Rosalind Essig of The Jessamine Journal.

Gooch said he hoped Jessamine County's action would encourage other communities to start talking about needle exchanges and hoped that to do likewise.

“The more that smaller communities — maybe like Jessamine and Pendleton County — are able to engage the community and create these programs, the stronger that we become, from a public health perspective,” Gooch told Essig.

Jessamine County is the most recent county to get approval for a needle exchange. Its Fiscal Court voted 4-2 in favor of it Jan. 19. The Nicholasville City Commission, with a 4-1 vote, and the Jessamine County Board of Health had already given approval, Essig reports.

The county and city officials struggled with such concerns cost, efficacy, mandated counseling and whether the program enables drug use.

“I am excited, and it's been a long road," Gooch said after the final vote. "It's a difficult thing, I know, for elected officials and for the community, as well, because most people are very skeptical, because they think it's enabling the users.” Gooch told Essig that addicts will inject drugs regardless of whether they have clean or dirty needles.

As for the cost, Gooch said in the meeting that the health department would involve community partners and existing staff to do the work so that it would not incur a high cost, stating that he did not foresee a tax increase to pay for it. He noted that one of their partners is St. Joseph Jessamine, which will dispose of the needles for free. He estimated the program could grow to about 200 participants, putting the cost of the one-time-use-only syringes at about $4,300 a year.

Jessamine's program will operate one day a week at the local health department during normal business hours, and will provide a separate entrance for the participants. After initially providing addicts with clean syringes based on their level of drug use, the program will then require future needle exchanges to be one-for-one.

The Jessamine Journal recently published the first of a series of stories about heroin and its impact on the local community. The Woodford Sun has published a similar series, but its health board has not acted. Both communities are largely suburbs of Lexington.

Carter and Elliott counties

The Little Sandy District Health Department, which serves Carter and Elliott counties, has received a $3,900 grant from the Kentucky Agency for Substance Abuse Policy to help fund a needle exchange program through June. 30, at which point the district will cease to exist because Carter County is quitting it, Joe Lewis reports for the Journal-Times in Grayson. "The needle exchange program would presumably fall under the direction of the new Carter County Health Department," Lewis writes.

Carter County will have to re-evaluate whether it can maintain the program, Trena Greene, nursing supervisor for the health department, told Kentucky Health News.

Greene said the final protocol for the program was submitted Jan. 13 at the board meeting and awaits approval. She said it will be a one-for-one needle exchange, held on set days and times. It will be conducted at two offsite locations, one in Grayson and the other in Olive Hill.

Hepatitis C cases are being reported to our health department at "two or three or four a week," Greene said. It is "just phenomenal."

"When they come for the needle exchange, we can offer rapid hepatitis C and HIV testing," Greene said. "And of course, we will offer them resources and counseling at the time we make the connection," with the goal of getting the users into a treatment program.

Greene said Carter and Elliott counties and the Carter County towns of Grayson and Olive Hill gave approval for the exchange some time ago, and the state grant allowed it to move forward.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Health-board smoking bans that Supreme Court struck down are still being obeyed: 'Everybody loves it,' advocate says

By Melissa Patrick
Kentucky Health News

Three counties in Kentucky with unenforceable smoking bans continue to be smoke-free by the people’s choice.

Clark, Madison and Woodford counties have smoking bans that can’t be enforced because they are regulations of county health boards, which the Kentucky Supreme Court ruled in June do not have the power to ban smoking in public places. But officials in each county reported that most of the establishments in these counties continue to be smoke-free by choice.

“We are finding, in general, public spaces and restaurants are still complying with regulations as if it is still enforceable,” said Christie Green, public-information officer for the Madison County Health Department. “It seems as if the general public prefers this.”

In Versailles, the city council “hadn’t heard from one single tax-payer who is opposed to it,” recently resigned city council member Sonny Jones said in an interview before his resignation.

Scott Lockard, director of public health in Clark County, said likewise. “The community has remained smoke free. The public has demanded this, ” he said, and as far as he was aware “No businesses have gone backward in this.”

That doesn’t surprise Ellen Hahn, director for the Kentucky Center for Smoke-Free Policy and the state’s leading smoking-ban advocate. “When communities go smoke free, everybody loves it,” she said.

The anti-smoking regulations can’t be enforced, advocates said. “If enforced, a lawsuit might result,” Lockard said. “We have no active enforcement right now in Clark County.”

The court ruled in a case from Bullitt County, where a local judge had blocked enforcement.

Each of the other counties is handling the issue somewhat differently.

Woodford County, out of “respect for the cities” of Midway and Versailles, will let them determine whether they want to reinstate their previously enacted smoking bans before the county fiscal court makes a decision for the unincorporated area of the county, County Attorney Alan George said, “because the bulk of the affected business is in the city.”

Midway passed a new anti-smoking ordinance Aug. 18 and Versailles plans to hold its first reading on one Sept. 2.

Madison County plans second reading and passage of its smoking ordinance for Sept. 9. Berea is scheduled to do likewise Sept. 2.

Clark County has “no forward actions” or “no ordinance drafted” at this time, Lockard said. Asked if officials are waiting on the Nov. 4 election to move forward, he said that “no one had come out and said the election will play a role,” but he noted that the Winchester mayor and the county judge-executive have opponents.

The Supreme Court ruling was a great disappointment to smoke-free advocates. Betsy Janes, coordinator for Smoke Free Kentucky, said several health boards had been ready to implement smoke-free regulations, but were waiting on the Supreme Court. These plans obviously have had to change.

“It was a major blow, but the good thing is that it is very clear who has the authority to do this now,” Janes said. “Fifty-five percent of Kentuckians want to be smoke free. We are losing 1000 Kentuckians a year to second hand smoke,” based on research that has determined its effects.

While Hahn said the decision was a “step backwards for Kentucky,” she also said her center is “busier than ever” working with fiscal courts to create smoke-free laws on the local level. She said there are 35 city or county ordinances in effect, covering 31 percent of Kentuckians.

The Kentucky Chamber of Commerce supports statewide smoking ban, which has never come to a vote in either chamber of the legislature.

“Twenty-four other states have statewide smoke-free laws and we want to not be the last to join them,” said Ashli Watts, the chamber’s public-affairs manager.

While Clark County is not pursuing a smoke-free ordinance now, the health department is actively educating the public about the benefits of such laws and plans to be a strong advocate to get something passed, Lockard said.

“We are finding overwhelming positive response to smoke-free,” he said. “The Board of Health and health department will work in any way possible to get a law on the books.”

Lockard also voiced his hope that school boards will pass smoke-free policies in schools, which he said should be attainable because no legislation is needed.

“There are 174 school districts in Kentucky and less than 40 of them have smoke-free policies on their campuses,” Lockard said. “If we could have all schools smoke-free, that would have a major impact on our communities.”

Lockard reflected on what Tom Frieden, director of the federal Centers for Disease Control and Prevention, said in his recent visit to Kentucky, that the most important changes Kentuckians need to make to improve their health are to stop smoking, decrease secondhand smoke exposure, and to exercise.