Ky. study shows syringe exchange programs decrease infections associated with IV drug use, could result in 'big money saved'

By Melissa Patrick
Kentucky Health News

A new analysis of Medicaid claims data suggests that Kentucky counties with syringe-service programs have slightly lower rates of diseases associated with intravenous drug use, such as HIV and hepatitis C.

The analysis estimated a progressive reduction of 0.5 percent per month, adding up to a 6% increase over a year. That can add up to savings, not only in lives, but money. So said Dr. Connie White, deputy commissioner of clinical affairs for the Kentucky Department for Public Health, at the Kentucky Harm Reduction Summit Aug. 20. 

White said, "As a public-health person, I think of all the emotional tragedy for the patient and for the family with one of these co-morbidities," diseases and conditions that occur together. "But if you're trying to sell this program to a bunch of politicians and legislators, you're talking about money saved, we're talking big money saved."

Kentucky has more syringe-service programs than any other state in the nation, but 56 of the state's 120 counties still don't have one -- and 20 of those are considered highly vulnerable to an HIV or hepatitis C outbreak among IV drug users, according to the Centers for Disease Control and Prevention. Thirty-four of the state's most vulnerable counties have operational syringe exchanges. 

The vulnerable counties without an exchange include Bell and Clinton, which rank sixth and 11th on the national list of 220; Cumberland, Casey, Edmonson, Harlan, Johnson, Lawrence, Lewis, Menifee, Monroe, Rockcastle and Wayne, also in Appalachian Kentucky; and eight in the rest of the state: Carroll, Gallatin, Green, Breckinridge, Grayson, Green, Allen and Hickman. 

Kentucky has 74 operational syringe-service programs in 63 counties, with one more in Christian County approved but not operational. Bracken County's exchange is marked on the state's map as not yet operational, but it started operating July 8. 

Syringe-service programs are more broadly referred to as harm-reduction programs and are designed to prevent outbreaks of HIV and hepatitis C, which are commonly spread by needle sharing among IV drug users. They also provide health screenings and vaccines, and connect drug users to treatment. 

They are allowed by a 2015 state law that requires approval by the county health board, the fiscal court and the city where the exchange is to be located.

Syringe exchanges reduce disease

The Kentucky Office of Health Data and Analytics did the analysis at the request of the Department for Public Health.

One reason the study is so important is that it helps to root the debate about such programs in empirical data, said Mathew Walton, a researcher with the office. 

Walton pointed to a national study that shows a person's political affiliation, income, and amount of stigma they feel about addiction and syringe-service programs are significant predictors of whether or not someone supports these programs -- not the facts.

The study looked at Medicaid claims from January 2015 through June 2019 in any county that had implemented a syringe-service program during that time.

It looked for six infections largely connected to IV drug use and minimally associated with other activities: HIV, hepatitis C, endocarditis, osteomyelitis, and, in people diagnosed with opioid-use disorder, skin and soft-tissue infections. The researchers only included new infections in their analysis. 

The study looked at infection rates before and after the syringe exchange was established in 42 counties. Recognizing that results might not be seen immediately, included lag times of one month, three months and six months. It also adjusted for a list of variables, many related to demographics.

Cameron Bushling, a statistician with the office, said each of the lag-time scenarios showed a decrease in infections after the syringe exchange was established. 

"The infection rate in your county will go down by roughly half a percent each month after you implement a syringe service program," he said. "So some, some may think this is a small number, but it's important to keep in mind that our infection rates were very low. . . . So half a percent is still a pretty big find."

In conclusion, Walton pointed out that most of the counties in the study were rural, outside metro areas. 

"There's an evidence of an association that they were successful in reducing infection, new infections," Walton said. "These do seem to be an effective use of resources for preventing costly and harmful infectious disease." 

He said the savings would come with even small reductions in infections caused by IV drug use.

"While this analysis revealed that this set of infectious-disease diagnoses was rare, even preventing a small percentage of them can have a significant effect on the Medicaid program," he said. "A single course of treatment for hepatitis C can be as much as $85,000 or more, so even a small outbreak prevention can be both a sort of economic benefit as well as a humanitarian and medical population health benefit."

Advice for resistant counties

Van Ingram, executive director of the Kentucky Office of Drug Control Policy, after a separate presentation, was asked what advice he would give counties that have been resistant to syringe exchanges. 

"I realize these can be controversial in some communities," said Ingram, who was Maysville's police chief before taking the drug-control job, and back then opposed syringe exchanges. Many law-enforcement officers do, believing, that they encourage drug use, despite research to the contrary.

"Well, first, just don't give up," he said. "Second, do everything you can to get the public on your side, the voters on your side. . . . and continue to keep raising this issue."  

He also suggested identifying the thought leaders in a community, those who have influence, and then educating them on why it's important to have one. His last bit of advice was to reach out to public health departments that have already fought this fight successfully and learn from their strategies.

Asked the same advice question, Frankie Haynes, the harm reduction coordinator for the Barren River District Health Department, stressed that educating the public is the key. 

"I can't tell you how many times we went into different entities and just explained to people what harm reduction was, or what needle-exchange services are, what are we doing," she said during a panel discussion about exchanges, "And once you give them a whole rundown on what it looks like to be a part of our program, what to expect within the program, you really start seeing eyes opening to the need for these programs across the state." 

The Bowling Green-based Barren River department is working to expand syringe services into Logan County, which has received approval from its Board of Health, but still needs the approval of the Russellville City Council and the county Fiscal Court. Two of the district's eight counties (Warren and Barren) have exchanges. 

Jennifer Twyman, health-education specialist with the Louisville Metro Public Health and Wellness syringe exchange program, agreed with Haynes. She said discussions with the public put a face on the program: "Talking to people in the community, so that they know what we're doing, makes just a huge difference."

'Vigilance and protective measures are essential to save lives' from overdoses in pandemic, state health secretary writes

By Eric Friedlander
Secretary, Kentucky Cabinet for Health and Family Services

"Together, we are stronger than opioids."

It’s a uniting mantra we use as part of the Kentucky Opioid Response Effort to guide our purpose, affirm our hope and call upon our greatest asset in this commonwealth: one another.

Eric Friedlander

Together, we are building a system of care to reduce harms associated with opioid use and prevent misuse, connect more people with evidence-based treatment, including medications for opioid use disorder and expand recovery programs and services.

When covid-19 hit, new norms were called for: distancing from each other, working from home or not at all; and loss of child care and at-home schooling led to some people experiencing frequent and long bouts of isolation. We were fortunate in the Commonwealth to act quickly and decisively, united as the new Team Kentucky, flattening the curve together.

While we resolved to stop the spread of a dangerous virus, the stressors and anxieties took their toll on our mental and behavioral health.

It wasn’t long before we started hearing reports nationally and locally from first responders and health departments. Emergency service calls were up. Orders for Narcan – the opioid overdose reversal drug – increased.

Treatment providers voiced concern, wanting to safely keep people in treatment. Individuals in remission and recovery started to lose vital in-person connection and support, despite recovery groups’ creativity to provide virtual meeting spaces and other recovery initiatives. Overdoses in April were the highest reported since 2017 when the opioid crisis was at its peak. These reports coalesced to confirm what service providers have been concerned about since the pandemic began.

Vigilance and protective measures are essential to save lives right now and each of us can take action. Similar to CPR training, we urge Kentuckians to be trained and to carry Narcan. The website odcp.ky.gov/Stop-Overdoses/ can help connect individuals with pharmacies and harm-reduction programs ready to supply the live-saving medication.

We also encourage everyone to become familiar with the state’s online provider locator, findhelpnowky.org, to help those in need to find treatment. Identify mutual-aid groups for family and friends who are supporting those struggling with substance use.

At the state level, we continue to advance telemedicine, and have adopted policy changes to support its use.

We suspended the requirement for prior authorizations for behavioral and substance-use services in Medicaid. We’re also committed to ensuring access to health coverage so payment will not be a barrier.

Just 12 months ago, we were encouraged by a 15 percent reduction in overdose deaths. We knew our work was far from over, but this was an indicator of progress. More people were getting access to prevention, harm-reduction services, and more treatment providers were prescribing medications for opioid use disorder and providing evidence-based practices. The stigma around substance use was beginning to change.

This point in time has created new challenges to maintaining progress. It also has reminded us our recovery as a commonwealth is a work in progress, just as an individual’s recovery, because addiction is a chronic, complex disease. Let’s use these challenges as opportunities for change and advocacy.

We have long been aware of the resilience of individuals and families affected by substance-use disorder. We have watched so many adapt to these uncertain times and access services differently, ask for assistance with accessing technology and other resources, and go to any length to participate in their treatment and recovery, many of them doing so while caring for children and working or navigating loss of employment and other financial challenges.

We owe it to our fellow Kentuckians to not give up, not be discouraged, and not stop believing change and recovery are possible. Let’s acknowledge the challenges we are facing and commit to overcoming them – together. Because that is how we are stronger than opioids.

Eric Friedlander can be reached at 502-564-7042.