About half of Kentucky adults support syringe exchanges, meant to decrease the risk of outbreaks of HIV and hepatitis C

By Melissa Patrick
Kentucky Health News

More Kentucky adults favor syringe exchanges than oppose them, and the more they know about them, the more likely they are to support them, according to the latest Kentucky Health Issues Poll.

Kentucky's legislature approved syringe exchanges in 2015 to decrease the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among intravenous drug users. They require local approval and funding and are often called needle exchanges; a needle is part of the syringe.

In the Sept. 11-Oct. 19 survey, 56 percent of Kentucky adults polled said they were familiar with needle-exchange programs, while 44 percent weren't familiar with them; and 49 percent favored the programs, 43 percent opposed them and 8 percent said they weren't sure.

Those who were familiar with syringe exchanges were more likely to favor them. Of the 56 percent who said they were familiar, 59 percent said they favored the programs, while 37 percent opposed them. Among the 44 percent who were not familiar, 37 percent said they favored the programs, 50 percent opposed them and 13 percent were not sure.

Last year, the Centers for Disease Control and Prevention said 54 of Kentucky's 120 counties were  among the 220 most vulnerable in the nation to a rapid spread of HIV and hepatitis C infection among those who inject drugs. Sixteen of the state's counties ranked in the nation's top 25.

But the decision to support syringe exchanges hasn't come easy for many counties, often because of beliefs that they condone drug use, concerns about safety and concerns about the costs to taxpayers, not to mention a general lack of knowledge about what they do.

"Research tells us that needle-exchange programs can help cut down on the spread of HIV and hepatitis C," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsors the poll. "Research also indicates that these programs do not increase drug use."

A great example of how local news coverage can play a role in educating its readers about needle exchanges is found in Brad Bowman's in-depth article about Franklin County's exchange in The State Journal. This story not only explains why needle exchanges are important and describes how they work, but also paints a picture of who uses them: "The clients come from all walks of life, from suit-and-tie professionals to people who are unemployed," Bowman writes.

As of March 29, according to the state Cabinet for Health and Family Services, 31 counties had approved syringe-exchange programs, with 21 of them operational. Eleven are in counties the CDC has deemed most vulnerable to HIV and hepatitis C outbreaks. Click here for more information on specific locations and hours.

Income levels didn't affect opinions about needle exchanges, but age and education did: only 42 percent of adults 65 and older approved of them, while around 50 percent of those 18 to 64 did. Support also increased as education levels increased.

Randy Gooch, director of the Jessamine County Health Department, said in a foundation news release that while the ultimate goal of the program is to reduce HIV and hepatitis C infections, they also measure success in the number of clients who get counseling and treatment services because of the interactions they have with them.

"Our greatest success to date has been realized with our first participant, a 34-year-old female who came seven weeks straight to our program and returned on the eighth week to turn in her syringes and inform us she was checking into rehab. After four weeks of rehab, she was placed on medication-assisted treatment and often comes by to visit and say she is doing well," Gooch said.

Gooch said Jessamine County's exchange, which opened in April 2016, has served 114 clients in 347 encounters, has tested 20 percent of the clients and found that 30 percent of those tested are positive for hepatitis C. They have given out 11,361 syringes and have had 8,083 returned.

"The drug epidemic will only be controlled through a multi-prong approach of education, legislation, prevention, intervention, treatment, faith and other community components," Gooch said. "I'm extremely proud of our community for being proactive in these areas as a 'Safe Community'."

The poll was conducted by the Institute for Policy Research at the University of Cincinnati and was funded by the foundation and Interact for Health. It surveyed a random sample of 1,580 Kentucky adults via landlines and cell phones and has an error margin of plus or minus 2.5 percentage points.

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."

Health commissioner leaves political correctness at the door, talks about getting governor to back anti-smoking measures

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. - State health officials didn't shy away from saying that smoking was one of Kentucky's top health issues at a recent meeting about population health, and Health Commissioner Hiram Polk went so far as to say they need to find a way to get Gov. Matt Bevin, who says smoking bans are a local issue, to adjust his policy.

Dr. Hiram Polk

"We've got to find some kind of landmark we can use there that would be acceptable to the governor and get through the legislature," Polk told the Friedell Committee for Health Oct. 25 in Frankfort.

Polk called smoking a "political issue" and said solutions include higher cigarette taxes and enforcement of smoke-free areas. He also said he has been talking to Ben Chandler, the new director of the Foundation for a Healthy Kentucky, about ways to get the governor to adjust his stance on this issue.

"It is really rare for somebody in this position to say publicly that 'I want to try to change the governor's mind'," Al Cross, director of the Institute for Rural Journalism and Community Issues, publisher of Kentucky Health News and Friedell Committee member, told the group as he summarized the day. Cross said the 80-year-old Polk, a noted surgeon, is a "guy who speaks his mind."

Tim Feeley, deputy secretary of the Cabinet for Health and Family Services, noted that Kentucky has some of the highest smoking rates in the nation, along with obesity, cancer and opioid abuse. He called for more smoking and nutrition education.

Drug issues

Polk said since taking office his "time has been overwhelmed with the issues of IV drug abuse." And that after attending many meetings on the topic, "There are no good ideas about what to do with drug addiction."

He said the cabinet is working on three opioid initiatives: one that centers around a "healthy living" early childhood educational program, which he hopes to have set up in at least five school districts by fall 2017; a program to increase access to medication-assisted treatments; and beginning this week, a program involving the state's mobile pharmacy, which will travel around the state upon invitation and share educational literature, pass out free Narcan (naloxone), accept outdated drugs and operate a one-for-one syringe exchange.

There was some question about the state's requirement that syringe exchanges be one for one. Feeley said, "As of right now, Governor Bevin has endorsed the needle exchange on a local-option basis. He has also stated that he is in favor of a one-for-one needle exchange. . . . We want to do a needle exchange that encourages the individuals to come in and to get into treatment. . . . Some of the thought is that a one-to-one exchange is the best way to do that."

Cross said the administration's stance seems to be that only exchanges funded by state grants will have to be a one-for-one exchange. He said this strategy might work to appease the legislators who don't understand that this is a public health program designed to prevent the spread of HIV and hepatitis C. "We'll find out during the General Assembly," he said.

Polk also pointed out the increased health disparities among the state's African American population and those living in the Appalachian region, though he emphasized the problems in Appalachia.

"The situation in Appalachia is just appalling," he said. "I think again, Appalachia is more discriminated against than African Americans. If you look at anything. It needs the most help for everything."

Cross said that while Polk "is not politically correct," this is "largely a good thing" because public officials often "don't say what they believe to be fact and try to avoid confrontation. Hiram Polk is not conflict-averse, and we should be thankful for that."

And as for finding health solutions, Polk boldly reminded those in the room that many health decisions are selfishly motivated.

"We've got conflicting and selfish interests of people all over health care, many of which are represented in this room," he said. The perfect example of this, he said, is the pharmaceutical industry, which successfully lobbied to protect its "massive profits" under the Patient Protection and Affordable Care Act. He also said that the "larcenous nature" of this industry is sure to demand "$1,000 for every single treatment" of the newly developed medication assisted treatment drugs, which the state hopes to promote.

Cross said drug makers argue that their profits finance cutting-edge drug research, but also comprise a powerful lobby that knows how to influence the political system. He said the Kentucky Farm Bureau Federation is likewise a powerful lobby, "which I believe is the primary device by which Kentucky's tobacco heritage remains in control of tobacco policy in this state. . . . If you can change Farm Bureau, you can change the game."

Medicaid boss speaks

Medicaid Commissioner Steve Miller briefly reviewed the governor's proposals for the program and said the cost of the current plan is not sustainable. He said the plan "may not be all the answers . . . [but] what we have been doing, and the way we have been doing it, needs to change." After the meeting, Miller told Cross that state and federal officials have entered into negotiations about it.

Miller told the committee his agency is working to hold Medicaid managed-care organizations accountable to their contracts, but said they haven't changed their behaviors.

Providers still struggle with MCOs paying them on a timely basis, if at all. They also struggle with the administrative burden of dealing with five different MCOs. Scott Lockard, public health director in Clark County, asked if the state had considered contracting with only one MCO. Miller said the state wasn't ready to go that far, but averred, "We don't need to have five. I think we need to have more than two."

Raynor Mullins, professor emeritus at the University of Kentucky College of Dentistry, said it is clearly understood that Kentucky's financial woes are "substantial" and  asked, "When are we going to get serious and start to talk about tax reform?"

Miller said he would leave tax policy to others, but added, "The revenue stream as it exist today is not adequate enough to cover the Medicaid expenditures and other things that need to be done. . . . It is not sustainable as we are doing it today."

Sept. 23 is deadline to apply for grants that can be used for syringe exchanges; 17 approved, but few in high-risk counties

By Melissa Patrick
Kentucky Health News

The state Office of Drug Control Policy is offering competitive grants to local boards of the Agency for Substance Abuse Policy for them to use toward harm-reduction programs for 2017. The deadline to apply is Sept. 23.

The grant money can be used for syringe exchanges (with some restrictions), Narcan (naloxone) programs, community education and other harm-reduction efforts. While local health, fire and police departments cannot apply directly for the grant, ASAP boards can apply on their behalf. Grant amounts will be considered up to $20,000, depending on the proposal, according to the Office of Drug Control Policy. Click here for a link to your local ASAP chairperson.

This is the second year the grants have been offered. Last year, all 37 ASAP boards that applied got some funds. Elliott and Harlan counties are the only two in the state without ASAP boards.

A 2015 federal Centers for Disease Control and Prevention analysis identified the 220 U.S. counties most vulnerable to an HIV or hepatitis C outbreak among intravenous drug users, and 54 of those counties are in Kentucky.

So far, 17 Kentucky counties have approved syringe exchange programs, according to the Cabinet for Health and Family Services. But only six (Knox, Pike, Grant, Carter, Boyd and Mercer) are in the most vulnerable group.

Stars locate syringe exchanges; green counties are deemed most at risk for HIV and hepatitis outbreaks

Syringe exchanges were authorized in Kentucky under a 2015 anti-heroin law and require local approval and funding. They are meant to slow the spread of HIV and hepatitis C, commonly spread by the sharing of syringes and needles.

"The key to needle exchange is that it is an opportunity to engage someone in treatment," Allen Brenzel, medical director of the state Department for Behavioral Health, Development and Intellectual Disabilities, said in an interview. "There is no evidence to support that they cause people to use more often or to use more drugs. What they do is they help people begin the process of engaging and trusting that people will help them. . . . They are very, very important."

Brenzel said the federal report alone is reason enough for counties to adopt syringe exchange programs. "An HIV epidemic would cost us, in addition to the human lives, millions and millions of dollars to treat and contain," he said.

Hepatitis treatment is also expensive. Dr. John Ward, director of the CDC's Division of Viral Hepatitis, said at a recent conference in Lexington that the cost of testing and treatment for hepatitis C is between $32,000 and $56,000 on most health plans.

Kerry Steinhofer of The Advocate-Messenger in Danville reports that Boyle County, which is considered the 35th most vulnerable by the CDC, is in the early stages of planning a syringe exchange. Its ASAP board plans to apply for one of the aforementioned grants and is hopeful they will be chosen.

Brent Blevins, the county health department, told Steinhofer that he did not expect any problems with the Danville City Commission or the Boyle County Fiscal Court in getting approval of a syringe exchange.

Lincoln County Judge-Executive Jim Adams told Abigail Whitehouse of The Interior Journal in Stanford that he expects some political pushback. The county is ranked 97th most vulnerable nationwide, and is in the early stages of learning about syringe exchange, Whitehouse reports.

Clark County started its exchange program about eight weeks ago and has already seen more clients than it anticipated seeing after six months, indicating a higher number of drug users in the community than expected, Health Director Scott Lockard said in a telephone interview. (On Sept. 2, the exchange saw 14 total clients, collected 199 needles and gave out 289.)

What's important is that disease is being prevented, Lockard said. "We are truly farther along and doing much better than I thought we would be at the six-month window," he said. "Obviously there is a need."

Lockard said Kentuckians are becoming more accepting of syringe exchange programs, and predicted that more counties will soon follow with their own. A Kentucky Health Department Association survey taken in December found that 75 health departments, out of 109 who answered the question, were in some phase of the education process or approval of syringe exchange programs.

"This is an example of public health at its finest," Lockard said. "I think we are going to see positive impacts on our hepatitis C rates in our communities, and hopefully prevention of any HIV outbreaks."

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.