3/14/18. Why Would We Give Needles to People Who Inject Drugs? 0-30 days = 60% more Kentuckian is diagnosed with. >365 days = 17% days = 10%

Transcription

1 Why Would We Give Needles to People Who Inject Drugs? Greg Lee HIV/AIDS Continuing Education Director Kentucky Department for Public Health Every DAY, more Kentuckian is diagnosed with 1. Background: HIV in Kentucky 2. Background: Hepatitis C Virus in Kentucky 3. Background: Opioid Abuse in Kentucky 4. HIV Outbreak Just Across The Indiana Border 5. Kentucky: Most Vulnerable Counties in US 6. Ky Heroin Bill & Syringe Exchange Programs >365 days = 17% days = 10% days = 5% days = 8% 0-30 days = 60% 1

2 Statewide Total Diagnoses Jefferson 2,669 2,821 Known to be Living with HIV = 6,505 Fayette 947 Oldham 87 Bullitt 68 Daviess 85 Hardin 133 Warren 117 Kenton 285 Campbell 115 Boone 95 McCracken 102 Boyd 53 Lawrence 4 Madison 80 Christian 96 Shelby 58 Franklin 66 Jessamine 54 Scott 45 COURTESY - Kentucky HIV/AIDS Surveillance Report, June 2016 Hepatitis C Virus (HCV) Transmission v Sharing syringes to injecting drugs (60%) v From infected mother to child during birth v Hemodialysis (long-term) v Blood transfusion and/or organ transplant before 1992 v Occupational exposure to blood - mostly needlesticks v Baby Boomers v Sexual or household exposures (very rare) 2

3 Reported cases of acute, Hepatitis C United States, # states No data (KY) Rates of acute, Hepatitis C per 100,000 population United States, 2013 # states No data (KY) Hepatitis C Cases in Kentucky Hospitals 16,481 12,931 HOSPITALIZED CASES 10,184 11,332 3

4 Hepatitis C Discharge Billing in Kentucky Hospitals $371,408,959 COST $277,203,862 $229,028,153 $191,664,905 Rates of acute, Hepatitis C per 100,000 population United States, Trend Kentucky Rates per 100,000 population Indiana West Virginia Massachusetts Tennessee HCV increases among Young Injecting Drug Users in Kentucky, Tennessee, Virginia, and West Virginia Incidence of acute hepatitis C among persons aged 30 years, by urbanicity and year Kentucky, Tennessee, Virginia, and West Virginia, Nonurban Urban 4

5 Substance abuse admissions among y.o. in Kentucky, Tennessee, Virginia, and West Virginia Virtually a trade-off from prescriptions to heroin * Any opioids include heroin and prescription opioids. Prescription opioids includes buprenorphine, codeine, hydrocodone, hydromorphone, meperidine, morphine, opium, oxycodone, pentazocine, propoxyphene, tramadol, illicitly obtained methadone, and any other drug with morphine-like effects. Kentucky Resident Drug Overdose Emergency Department Visit Rates, Rate (number of visits/100,000 population) Kentucky Injury Prevention and Research Center 5

6 Kentucky Injury Prevention and Research Center, June Data source: Kentucky inpatient hospitalization discharge data, Office of Health Policy. Data for are provisional and subject to change. 3/14/18 Understanding HCV Transmission among Social Network of Injecting Drug Users, Hazard Area, 24 months IDU connections HCV positive Incidence HCV HCV negative networks unidentified: J Havens, NIDA R01-DA and R01-DA Kentucky Resident Neonatal Abstinence Syndrome Hospitalizations, Total Number Kentucky NAS Hospitalizations ,939% INCREASE OVER 15 YEARS Video from YouTube Age-Adjusted Rate for Drug Overdose Deaths Involving Heroin, Mortality Rate (# Deaths/100,000 Population) Kentucky Injury Prevention and Research Center, February Data source: Centers for Disease Control and Prevention, National Center for Health Statistics Multiple Cause of Death on CDC WONDER Online Database, released All images from Google 6

7 Kentucky Motor Vehicle Crash Deaths vs. Drug Overdose Deaths, Kentucky State Police, Kentucky Injury Prevention and Research Center United Health Foundation now ranks Kentucky as SECOND highest rate of drug overdose deaths for 2017 America s Health Rankings Annual Report, United Health Foundation, December 2017 JUST AS YOU WERE THINKING IT COULDN T GET WORSE IT GOT WORSE Much of the pills & heroin in Kentucky now cut with the more deadly drug FENTANYL 7

8 Cumulative HIV infections associated with injection of Opana ER, by date of diagnosis, SE Indiana (N=188, Jan 2016) Public health emergency declared > 77,000 syringes dispensed Incident command > 35,000 syringes established dispensed Cluster identified Syringe exchange started Initial diagnosis > 160,000 syringes dispensed 20 0 HIV testing staff & DIS deployed 1-Nov-14 1-Dec-14 1-Jan-15 1-Feb-15 1-Mar-15 1-Apr-15 1-May-15 1-Jun-15 1-Jul-15 1-Aug-15 1-Sep-15 1-Oct-15 1-Nov-15 1-Dec-15 1-Jan-16 HIV Diagnoses Credit: Philip Peters, MD; NCHHSTP/DHAP/Epidemiology Branch; CDC Top 220 U.S. Counties with Increased Vulnerability to Rapid Dissemination of HIV/HCV Infections Among People who Inject Drugs County-level Vulnerability to Rapid Dissemination of HIV/HCV Infection Among Persons who Inject Drugs CDC, September 23, 2015 Vulnerable Counties Syringe Exchanges (June 2014) 8

9 Top 220 U.S. Counties with Increased Vulnerability to Rapid Dissemination of HIV/HCV Infections Among People who Inject Drugs (26 states have 1 vulnerable county. KY has 54 vulnerable counties, more than any other state) County-level Vulnerability to Rapid Dissemination of HIV/HCV Infection Among Persons who Inject Drugs CDC, September 23, 2015 Specific concerns regarding Kentucky Counties: 1. Dense drug user networks similar to Scott County Indiana 2. Lack of syringe exchange programs Vulnerable Counties NOTE: CDC stresses that this is a REGION-WIDE problem, not just a county-specific problem. Kentucky s 54 Counties with Increased Vulnerability to Rapid Dissemination of HIV/HCV Infections Among People who Inject Drugs (26 states have 1 vulnerable county. KY has 54 vulnerable counties, more than any other state) National Ranking by County 1 Wolfe 34 Martin 108 Gallatin 3 Breathitt 35 Boyle 125 Bath 4 Perry 39 Lawrence 126 Grayson 5 Clay 40 Rockcastle 129 Greenup 6 Bell 45 Harlan 132 Green 8 Leslie 48 McCreary 153 Casey 9 Knox 50 Letcher 154 Carter 10 Floyd 53 Johnson 163 Monroe 11 Clinton 54 Russell 167 Garrard 12 Owsley 56 Elliott 175 Robertson 14 Whitley 65 Laurel 178 Lewis 15 Powell 67 Carroll 179 Edmonson 17 Knott 75 Taylor 180 Allen 21 Pike 77 Grant 187 Boyd 23 Magoffin 93 Adair 191 Hickman 25 Estill 97 Lincoln 202 Breckinridge 30 Lee 99 Wayne 212 Campbell 31 Menifee 101 Cumberland 214 Mercer Vulnerable KY Specific concerns regarding Kentucky Counties: Counties 1. Dense drug user networks similar to Scott County Indiana 2. Lack of syringe exchange programs NOTE: CDC stresses that this is a REGION-WIDE problem, not just a county-specific problem. courtesy WDRB TV Louisville 9

10 DISEASE & OVERDOSE Sharing needles is an easy way to get HIV & Hepatitis C Virus. If you shoot drugs please do not share needles

11 People fear that discarded needles will increase after the opening of syringe exchange programs to the contrary, SEPs help to keep dirty syringes off the streets, playgrounds, etc. Syringe exchange programs take dirty needles off the streets and increase the safety of our police officers. Indeed, these programs have decreased needle stick injuries to police by 66 percent. Bob Scott, former Captain, Sheriff s Office, Macon County, N.C., February 2011 Dr. Dr. C. Dr. Regina Everett Joycelyn David Vivek Satcher Benjamin Koop Murthy Elders ( ) ( ) ( ) ( ) ( ) if Silence Syringe clean needles about Syringe exchanges will the exchange programs do importance anything and harm is are an to of widely reduction contain needle effective considered a part of to exchange the public helps be epidemic, health break effective programs intervention we down way should is the causing of stigma reducing not that have deaths HIV any of foolish transmission thousands reduces associated inhibitions the of transmission among with our about bright addiction individuals doing young of HIV and so. black who and drug inject and illicit Latino does use. drugs not In men turn, encourage and more there women. the people is ample use are of evidence illegal likely that drugs. to SEPs seek also help. promote entry and retention into treatment. 11

12 Community residents may worry that SEP locations will increase theft, sex trades, assaults, and an increase of contaminated needles on the street. However, studies have shown that SEP s actually decrease crime in the area they are located. on syringe exchange, another in health-care costs for people who may rely on Medicaid and Medicare. A clean syringe costs 20 or less, while the lifetime cost of treating someone with HIV is estimated to be about $380,000. Curing Hepatitis C costs about $85,000 per case. Untreated cases will cost MORE. on syringe exchange, another in health-care costs for people who may rely on Medicaid and Medicare. A clean syringe costs 97 or less, while the lifetime cost of treating someone with HIV is estimated to be about $380,000. Treating Hepatitis C costs about $85,000 per case. 12

13 Charles Aughenbaugh, Jr., President, New Jersey Deputy Fire Chiefs Association, Retired Deputy Fire Chief, March 2011 Studies show that HRSEPs do not encourage drug use among HRSEP participants or the recruitment of first-time drug users. Through their referrals to substance abuse Based upon the literature Cpl/Deputy Sheriff D. A. Jackson, treatment, that s been HRSEPs presented often to me, help People Who Inject Drugs syringe to exchange stop using programs drugs. do not appear to increase crime and/or drug abuse but rather greatly enhance officer and public safety. Background Investigator, Guilford County Sheriff s Office, Greensboro, NC, March 2011 Most Comprehensive Bill in US to date Kentucky Senate Bill 192 (2015) provides for the establishment of Syringe Exchange Programs in KY Local option for for People Who Inject Drugs to be run by county public health departments; " " language that protects drug users from criminal charges if they report an overdose to the authorities; Expanded access to, a drug that can reverse the effects of a heroin overdose; More state funding and Medicaid support for. 13

14 Kentucky Senate Bill 192 (2015) provides for the establishment of Syringe Exchange Programs in KY Local option for for People Who Inject Drugs to be run by county public health departments; " " language that protects drug users from criminal charges if they report an overdose to the authorities; Expanded access to, a drug that can reverse the effects of a heroin overdose; More state funding and Medicaid support for. Kentucky Senate Bill 192 (2015) provides for the A person establishment shall not be charged of Syringe with or prosecuted Exchange for Programs a criminal offense in KY prohibiting the possession of a controlled substance or the possession of drug paraphernalia if: Local option for syringe exchange programs for a) In good faith, medical assistance with a drug overdose is sought from a public People safety answering Who Inject point, Drugs emergency to be medical run by services, county a law enforcement public health officer, or departments; a health practitioner because the person: 1) Requests emergency medical assistance for himself or herself or " " language that protects drug another person; or 2) users Acts in concert from criminal with another charges person who if they requests report emergency an medical overdose assistance; or to the authorities; 3) Appears to be in need of emergency medical assistance and is the Expanded access to naloxone, a drug that can individual for whom the request was made; b) The reverse person remains the effects with, or is, of the a individual heroin overdose; who appears to be experiencing More state a drug funding overdose and until the Medicaid requested support assistance for is provided; and addiction treatment programs. c) The evidence for the charge or prosecution is obtained as a result of the drug overdose and the need for medical assistance. This measure " " language that protects drug peace users from criminal charges officers if they report from an getting overdose to the authorities; stuck with needles. (6) (a) Prior to searching a person, a person's premises, or a person's vehicle, a peace officer may inquire as to the presence of needles or other sharp objects in the areas to be searched that may cut or puncture the officer and offer to not charge a person with possession of drug paraphernalia if the person declares to the officer the presence of the needle or other sharp object. If, in response to the offer, the person admits to the presence of the needle or other sharp object prior to the search, the person shall not be charged with or prosecuted for possession of drug paraphernalia for the needle or sharp object or for possession of a controlled substance for residual or trace drug amounts present on the needle or sharp object. 14

15 KRS 218A.500/510 Kentucky Syringe Exchange Programs Kentucky pharmacists can now be licensed to Kentucky Senate Bill 192 (2015) provides for the provide naloxone (Narcan establishment of Syringe Exchange ) to anyone: People who use narcotics Programs in KY Family members or friends of people who use Local narcotics option for syringe exchange programs for People First Who responders Inject Drugs to be run by county public See health departments; for Naloxone Training "Good Samaritan" language that protects drug users from criminal charges if they report an overdose to the authorities; Expanded access to naloxone,, a drug that can reverse the effects of a heroin overdose; More state funding and Medicaid support for addiction treatment programs. Expanded, a drug that can reverse the effects of a heroin overdose; The Office of Drug Control Policy provides a Naloxone Locator online at odcp.ky.gov/stop-overdoses Expanded, a drug that can reverse the effects of a heroin overdose; Kentucky Public Health and the Kentucky Pharmacists Association distribute naloxone in communities (also providing HIV and HCV testing) To date (01/23/18) 1,515 naloxone kits dispensed 1,576 people received training on naloxone 82 tested for HIV 64 tested for HCV 15

16 Hickman Muhlenberg Kenton Campbell Gallatin Pendleton Carroll Grant Mason Greenup Robertson Lewis Harrison Boyd Carter Rowan Jefferson Franklin Bath Elliott Lawrence Fayette Woodford Clark Menifee Jessamine Johnson Nelson Mercer Powell Martin Breckinridge Wolfe Madison Magoffin Boyle Garrard Estill Lee Breathitt Floyd Pike Grayson Lincoln Jackson Owsley Taylor Knott Casey Rockcastle Perry Green Edmonson Pulaski Clay Letcher Adair Laurel Leslie Warren Russell Knox Harlan Cumberland Wayne Allen Clinton Whitley Monroe Bell McCreary 3/14/18 Indiana needle-sharing drops from 18% to 5% within first few months. Outbreak levels off due to SEP (although approved intermittently by Indiana) KRS 218A.500/510 Kentucky Syringe Exchange Programs The Department for Behavioral Health, Developmental and Intellectual Kentucky Senate Bill 192 (2015) provides for the Disabilities provides a Treatment Provider Locator online at establishment of Syringe Exchange Programs in KY dbhdid.ky.gov/providerdirectory Local option for syringe exchange programs for People Who Inject Drugs to be run by county public health departments; "Good Samaritan" language that protects drug users from criminal charges if they report an overdose to the authorities; Expanded access to naloxone, a drug that can reverse the effects of a heroin overdose; More state funding and Medicaid support for 54 Kentucky Counties with Increased Vulnerability to Rapid Dissemination of HIV/HCV Infections Among People who Inject Drugs 220 U.S. Counties at Risk National Ranking by County 1 Wolfe 34 Martin 108 Gallatin 3 Breathitt 35 Boyle 125 Bath 4 Perry 39 Lawrence 126 Grayson 5 Clay 40 Rockcastle 129 Greenup 6 Bell 45 Harlan 132 Green 8 Leslie 48 McCreary 153 Casey 9 Knox 50 Letcher 154 Carter 10 Floyd 53 Johnson 163 Monroe 11 Clinton 54 Russell 167 Garrard 12 Owsley 56 Elliott 175 Robertson 14 Whitley 65 Laurel 178 Lewis 15 Powell 67 Carroll 179 Edmonson 17 Knott 75 Taylor 180 Allen 21 Pike 77 Grant 187 Boyd 23 Magoffin 93 Adair 191 Hickman 25 Estill 97 Lincoln 202 Breckinridge 30 Lee 99 Wayne 212 Campbell 31 Menifee 101 Cumberland 214 Mercer Vulnerable Specific concerns regarding Kentucky Counties: Counties 1. Dense drug user networks similar to Scott County Indiana Operating Syringe Exchanges as of 01/02/ Lack of syringe exchange programs Approved but not Operational yet NOTE: CDC stresses that this is a REGION-WIDE problem, not just a county-specific problem. 16

17 Suddenly and quietly in late December, 2015: Feds kept the federal funding ban on syringes themselves, but ended the ban on all other aspects of the programs staff, vehicles, gas, rent, and so on. The ban's end was spearheaded by two Kentucky Republicans, House Appropriations Chair Hal Rogers and Senate Majority Leader Mitch McConnell, in large part as a response to an HIV crisis in Indiana and a heroin epidemic nationwide. Northern Kentucky Resident HIV Cases among Injecting Drug Users Projected cost of 2017 s cases = $6,840,000 oo (Grant is the only NKY County with syringe exchange) à Grant County Boone County Kenton County Campbell County 17

18 Warren Jefferson Franklin Pendleton Grant Harrison Fayette Jessamine Mercer Boyle Clark Whitley Mason Knox Clay Carter Boyd Floyd 3/14/18 Kentucky Syringe Exchange Program Data through January 2017 AREA # of clients # of visits Syringes Syringes Received/ Distributed Returned Ratio Out/In # HCV # referrals for # referrals for # naloxone # HIV tests tests substance abuse other clinical kits provided provided treatment services distributed STATE TOTAL 7,399 28, , , Vulnerable Counties URBAN TOTAL (Fayette Co. Operating 521 Syringe 49 Exchanges as 417 6,615 26, , , and Louisville Metro) of January 2017 RURAL TOTAL (all others) 784 1,968 80,347 49, are available at chfs.ky.gov/dph/epi/hivaids/prevention Characteristics of EFFECTIVE SEPs Ensure low threshold access to services Maximize access by number of locations and available hours Ensure anonymity of participants Minimize the administrative burden of participation Promote secondary syringe distribution Train and support peer educators Do not impose limits on number of syringes (doing so promotes sharing of needles) Maximize responsiveness to characteristics of the local people who inject drugs Adapt planning activities and service modalities to subgroup needs Provide or coordinate the provision of other health and social services Include diverse community stakeholders in creating a social and legal environment supportive of SEPs SEP Practices to AVOID Supplying single-use syringes Limiting frequency of visits and number of syringes Requiring one-for-one exchange (results in sharing of needles) Imposing geographic limits Restricting syringe volume with unnecessary maximums Requiring identifying documents Requiring unnecessary data collection 18

19 Increase HIV Testing & Linkage to Care Increase HCV Testing & Linkage to Care Increase Naloxone (Narcan) Availability Increase Drug Treatment Create Harm Reduction / Syringe Exchange Programs What are we asking of you? No ordnances. Just your approval to allow the HD to try a Syringe Exchange Program. No money. The program will get grants and use money targeted for SEP. What are we offering? A syringe exchange program that will reduce the HIV and Hepatitis C Epidemic. The program will reduce medical costs for taxpayers as most of the affected individuals wind up on Medicaid/Medicare. An increased chance to get IV drug users into rehabilitation reducing jail, court, medical costs and improving the individual s and their family s lives. Reduced risks for First Responders and reduced risks for needles in public areas such as parks and playgrounds. Why Would We Give Needles to People Who Inject Drugs? Greg.Lee@ ky.gov HIV/AIDS Continuing Education Director Kentucky Department for Public Health 19

20 Lake Cumberland District Health Department Dr. Christine Weyman, Medical Director