Harm Reduction Strategies in Dubuque County Assessing Community Need and Readiness September 2019 Background A National Epidemic Impact on Iowa Dubuque County: Crisis and Vulnerability About the Assessment
2 A National Epidemic In 2017, there were more than 70,200 overdose deaths in the United States. 47,600 of those deaths involved opioids. 130 people die per day from opioid-related overdoses. The rate of drug overdose deaths in rural areas has surpassed rates in urban areas and has become a huge public health concern. Drug overdoses are the leading cause of injury-related death in the United States, surpassing motor vehicle crashes.
Increase in injection drug use has also contributed to the spread of infectious diseases, including HIV and hepatitis C. 3 Impact on Iowa Rates of prescription opioid deaths since 1999 have quadrupled, making Iowa only one of four states to see such a dramatic increase. In 2017, there were 206 overdose deaths involving opioids in Iowa a rate of 6.9 deaths per 100,000 persons compared to the national average of 14.6. Greatest increase occurred among heroin-involved deaths: 14 in 2012 to 61 in 2017.
Between 2009 and 2016, diagnoses of HCV virus in Iowa among persons under 30 increased by 325%. 4 Dubuque County: Crisis and Vulnerability In 2015, Dubuque County was designated a High Intensity Drug Trafficking Area (HIDTA) by the White House Office of National Drug Policy. 5
Dubuque County: Crisis and Vulnerability Iowa Department of Public Health (IDPH) reported that Dubuque was one of the highest ranking counties for opioid-related hospitalizations between 2013 and 2016. Between 2014 and 2017 Dubuque County recorded 315 patients admitted into an opioid use disorder treatment program. From 2014 through August 2019 there have been a total of 60 overdose deaths in Dubuque County, 33 were due to opioids 55%. 6
About the Assessment In March, the Dubuque County Board of Supervisors commissioned MercyOne Dubuque Medical Center to determine if there is a need in our community to enhance existing harm reduction initiatives with a syringe service program (SSP). Scope was designed to: Assemble an advisory group consisting of representatives from agencies throughout the county (Opioid Response Team) Assess the community need for further harm reduction strategies Assess the community readiness for additional harm reduction strategies
Report findings to the Dubuque County Board of Health. 7 Framing the Issue Defining Harm Reduction Public Health Concerns Among People Who Inject Drugs Cost of HIV and HCV Treatment History of Syringe Service Programs Current State of Syringe Service Programs Scott County, Indiana
8 Defining Harm Reduction A strategy directed toward individuals or groups that aims to reduce the harms associated with certain behaviors. When applied to substance use disorder, harm reduction accepts that a continuing level of drug use is inevitable and defines objectives as reducing adverse consequences. Despite extensive major national reports affirming the benefits of syringe service programs in preventing the spread of diseases, they remain controversial. Advocates define the issue as an empirical scientific matter related to disease prevention.
Opponents assert that free distribution of needles encourages illegal drug use. 9 Public Health Concerns Among People Who Inject Drugs (PWID) PWID have multiple health needs that need to be addressed to support their health and wellbeing: Substance Use Disorder - Substance use disorder describes a problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress. 10
Public Health Concerns Among People Who Inject Drugs (PWID) Human Immunodeficiency Virus (HIV) Attacks the cells of the bodys immune system. There is no cure, but can be managed with treatment. Transmitted through direct contact with bodily fluids from someone who has HIV: Sharing needles, syringes or other equipment to inject drugs Blood Semen or pre-seminal fluid Vaginal fluids
Breast milk 11 Public Health Concerns Among People Who Inject Drugs (PWID) Hepatitis C Virus (HCV) An infection of the liver caused by hepatitis C and is the most common blood-borne virus in the United States. Approximately 3.2 million persons are chronically infected. Can cause serious health problems, including liver damage, cirrhosis, liver cancer and death.
People can become infected in the following ways: Sharing needles, syringes or other equipment to inject drugs Receiving needle sticks in health care settings Being born to a mother who has HCV Tainted blood supply before testing began Less commonly: Blood contact, unsterilized tattoo equipment, razors or sexual contact 12 Cost of HIV and HCV Treatment $90,000 Average cost of treating one HCV infection. In 2018, Iowa Medicaid Enterprise paid for 49 liver transplants at the cost of
$2 million each. $450,000 Average cost of HIV treatment over a patients lifetime. 75% of HIV treatment costs in the United States fall to the public sector. In 2018, there were 116 new diagnoses of HIV in Iowa. Those cases could potentially cost the state up to $39 million. 13 History of Syringe Service Programs (SSP) SSPs began in Europe in the 1980s as part of an effort to reduce rates of bloodborne diseases like HPV, HIV and HCV. Urban areas in the United States followed shortly after.
Boston, Massachusetts and Tacoma, Washington were among the first in the country. SSPs have been controversial since their inception because of their association with people who inject drugs and disenfranchised populations. Federal funds are available to support syringe service programs with the exception that funds may not be used to purchase needles. 14 Current State of SSPs 41 states have legalized SSPs. 320 programs are currently in operation throughout the country.
The North American Syringe Exchange Network (NASEN) lists two syringe exchange programs on their website as being active in Iowa: Dubuque Harm Reduction Iowa Harm Reduction Coalition NASEN is a national organization that supports and encourages the expansion of SSPs. 15 Current State of Syringe Service Programs
16 Scott County, Indiana HIV outbreak in rural Scott County, Indiana in 2014-2015. County population 23,744 17 Scott County, Indiana Update: June 19, 2019 18,000 syringes distributed per month
90% exchange rate Viral suppression rate is 77% 500 clients in treatment Statistics show the epidemic is over 88% reduction in syringe sharing 18 Literature Review What the scientific community says about SSPs
19 Literature Review Topic: Reducing HCV and HIV Topic: Negative Effects of Needle Exchange Effectiveness of Structural-Level Needle/Syringe Programs to Reduce HCV and HIV Infection Among People Who Inject Drugs: A Systematic Review, AIDS and Behavior Journal - August 22, 2013
- Abu S. Abdul-Quader, Jonathan Feelemyer, Shilpa Modi, llen S. Stein, Alya Briceno, Salaam Semaan, Tara Horvath, Gail E. Kennedy, Don C. Des Jarlais Evaluating needle exchange: Are there negative effects? Center for AIDS Prevention Studies March 1, 1993 - Authors: Joseph Guydish, Jesus Bucardo, Martin Young, William Woods, Olga Grinstead and Wayne Clark Conclusion: The findings highlight the fact that significant public health benefits can be obtained even when at least 50 percent of
the injecting population in a community receive at least 10 or more sterile syringes per year. The findings also indicate the importance of establishing structural-level large-scale syringe access programs for HIV prevention, especially early in an epidemic among PWID. Conclusion: After two years of continuous needle exchange activities in San Francisco, aggregate county drug-treatment admission data do not demonstrate negative effects on variables available for study. Cross-sectional data indicate that needle exchange is not associated with proportional increases in injection drug use, or increases in needle-sharing behavior. The cohort analysis for
individuals repeating treatment either before or after the implementation of needle exchange does not show that the exchange encourages drug users who do not inject to begin injecting. 20 Literature Review Topic: Number of Discarded Needles Topic: Sharing Needles and Getting Help
The Effect of a Needle Exchange Program on Numbers of Discarded Needles: A 2-Year Follow-Up American Journal of Public Health June 2000 - Meg Doherty, Benjamin Junge, Paul Rathouz, Richard S. Garfein, Elise Riley, and David Vlahov Evaluating Needle Exchange: A Description of Client Characteristics, Health Status, Program Utilization and HIV Risk Behavior Substance Use and Misuse Journal July 3, 2009 - Joseph Guydish, Jesus Bucardo, George Clark and Susannah Bernheim
Conclusion: The major finding of this study was that the establishment of a needle exchange program in Baltimore was not associated with an increase in the overall quantity or geographic distribution of discarded syringes in public locations over a two-year period. While consistent with earlier reports, this study is the first to report surveillance data for an extended follow-up period of two years. Conclusion: In cross-sectional analysis, clients who
reported receiving more of their needles from the needle exchange program were less likely to share needles or rinse water. In addition, a higher frequency of needle exchange visits was associated with a higher likelihood of skin cleaning and with fewer uses of a single needle. Consequently, needle exchange programs can serve as a platform from which to provide services such as HIV counseling and testing, medical triage and referral, drug-user treatment referral, and harm reduction education.
21 Literature Review Topic: Paraphernalia Laws Topic: Getting Help Qualitative case study of needle exchange programs in the Central Appalachian region of the United States PLOS One October 12, 2018 Stephen Davis,
Danielle Davidov, Alfgeir Kristjansson, Keith Zullig, Adam Baus, Melanie Fisher Motivation to Change and Treatment Participation Among Syringe Service Program Utilizers in Rural Kentucky The Journal of Rural Health, National Rural Health Association 2019 Hilary Surratt, Janet Otachi, Timothy Williams, Jennifer Gulley, A. Scott Lockard, Rebecca Rains Conclusion: Paraphernalia laws create a legal
conundrum in the form of criminal sanctions for the possession of needles, which may inadvertently promote needle sharing and disease transmission. Conclusion: Rurally located SSPs may play an important role in supporting confidence and motivation to change substance use behaviors among PWID. SSPs may be critical venues for integration and expansion of prevention, health promotion, and treatment linkage services for this underserved population. SSPs also appear well-positioned and viable as effective sites to deliver
motivational enhancement and treatment linkage interventions. 22 Literature Review Topic: Needle Sharing Among IDUs and Police Officer Needlesticks Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers Connecticut, 1992-1993, Journal of Acquired Immune Deficiency
Syndromes and Human Retrovirology, 1995 p 82-89. Conclusion: Reports of needlestick injuries among Hartford police officers were reviewed before and after the new laws. Among IDUs who reported ever sharing a syringe, syringe-sharing decreased after the new laws - 52% before vs. 31% after. Fewer IDUs reported purchasing syringes on the street after the new laws 74% before vs. 28% after. Needlestick injury rates among Hartford police officers were lower after the new laws (six injuries in 1,007 drugrelated arrests for 6-month period before new laws vs. two in 1,032 arrests for 6-month period after new laws). The changes in Connecticut laws were associated with decreases in
self-reported syringe-sharing and increases in purchasing by IDUs of sterile syringes from reliable sources, suggesting that the simultaneous repeal of both prescription and paraphernalia laws is an important HIV prevention strategy. Topic: Getting PWID Into Treatment Reduced injection frequency and increased entry and retention in drug treatment associated with needleexchange participation in Seattle drug injectors. Journal of Substance Abuse Treatment. 2000; 19, 247-252. Conclusion: The association between needle exchange, change in drug use frequency and enrollment and
retention in methadone drug treatment was studied in a cohort of Seattle injection drug users. New users of the exchange were five times more likely to enter drug treatment than never-exchangers. We conclude that reduced drug use and increased drug treatment enrollment associated with needle exchange participation may have many public health benefits, including prevention of bloodborne viral transmission. 23 Literature Review
Topic: Study of Studies Do Needle Syringe Programs Reduce HIV Infection Among Injecting Drug Users: A Comprehensive Review of the International Evidence Substance Use and Misuse 2006 Alex Wodak and Annie Cooney Conclusions: 1. There is compelling evidence that increasing the availability, accessibility, and both the awareness of the imperative to avoid HIV and utilization of sterile injecting equipment by IDUs reduces HIV infection substantially. Overall, there is convincing evidence that
needle and syringe programs (NSPs), assessed conservatively, fulfill six of the nine Bradford Hill criteria and all of the five additional criteria. Measured against any objective standards, the evidence to support the effectiveness of NSPs in substantially reducing HIV must be regarded as overwhelming. 2. There is no convincing evidence of any major unintended negative consequences. Specifically and after almost two decades of extensive research, there is still no persuasive evidence that NSPs increase the initiation, duration, or frequency of illicit drug use or drug injecting.
3. NSPs are cost-effective. It is more difficult to generalize from studies of cost-effectiveness of NSPs in one country to other similar countries, let alone from developed countries to resource-poor settings. However, a number of careful studies in several developed countries and some transitional countries have demonstrated convincingly that NSPs are cost-effective. 4. NSPs have additional and worthwhile benefits apart from reducing HIV infection among IDUs. There is reasonable evidence that NSPs can increase recruitment
into drug user treatment and possibly also into primary health care. 5. NSPs on their own are not enough to control HIV infection among IDUs. There is no evidence of a protective effect for single interventions strong enough to guarantee HIV control, but the aggregate effect of several harm reduction interventions appears to be generally successful in maintaining HIV control. Sterile needle and syringe availability needs to be considered as a system and has to be supported by a range of complementary measures if communities wish to
control HIV infection among and from IDUs. 24 Unfavorable News Stories Those needles littering the streets? The city gave them out Phillip Matier and Andrew Ross May 19, 2018 For all of City Halls tough talk of late about getting needles off the streets, the
city itself is responsible for helping fuel the problemhanding out millions of syringes a year with little or no controls over their return. No doubt that goal is well-intentioned, but what wasnt mentioned is that the health department is the biggest source of the needlesit hands out an estimated 400,000 syringes a month through various programs aimed at reducing HIV and other health risks for drug users. Health department statistics show the program appears to be working, at least on one level: The number of new HIV infections among people who inject drugs in San Francisco dropped from 106 in 2010 to 38 in 2016. 25
Unfavorable News Stories Afraid of enabling drug use, Washington cities push back against needle exchanges Scott Greenstone July 28, 2019 Syringe exchanges, once seen as an answer to the public health crisis of AIDS, are coming under criticism from elected officials in parts of Washington who believe they are making a new public health crisisopioidsworse.
The pushback to syringe exchanges in Washington spotlights a divide between the keep them alive philosophy of public health officials, and the longstanding public conceptions that making drug use safer enables users and makes it harder to quit. Syringe exchanges have been shown to decrease infections and help people get into treatment. Seattle and King County found new users of syringe exchanges were five times as likely to enter drug treatment as those who dont use exchanges, and those who use exchanges regularly were three times as likely to inject less. 26
The scientific literature supporting the implementation of syringe service programs to stop the spread of infectious disease is irrefutable. Key Finding 27
Assessing Community Need Understanding the Issues Determining the Need Estimating the Number of PWID in Dubuque County PWID Survey 28 Understanding the Issues Meetings with Subject Experts:
Opioid Response Team We presented the scope of work for the needs assessment to the Opioid Response Team on June 14, 2019. Feedback led to the development of the PWID survey. Dubuque Harm Reduction We reached out to Dubuque Harm Reduction (DHR) to learn about their organization and their outreach activities. Willing to share their data: 59 individual program participants; distributed 11,855; collected and disposed of over 1,600.
PERF Police Executive Research Forum sent a panel to Dubuque for a day of meetings on August 14. Over 50 attendees from agencies across the state. Topics ranged from syringe service programs to Law Enforcement Arrest Diversion (LEAD). Iowa Harm Reduction Organization has been leading harm reduction efforts in Iowa.
Chicago Recovery Alliance One of the oldest syringe service programs in the country operating in Chicago for nearly 30 years. More than a dozen Other meetings with key subject experts including law enforcement. 29 If you have people injecting drugs
in your community, you already have needle exchange going on in your community. Were here to make it safe for everyone. Maya Doe-Simkins Chicago Recovery Alliance 30 Determining the Need Centers for Disease Control and Prevention Criteria
State and local health departments should consult with the CDC by providing evidence that their jurisdiction is: 1. Experiencing, or 2. At risk for a significant increase in viral hepatitis infections or an HIV outbreak due to injection drug use 31 Determining the Need CDC Criteria: The Iowa Department of Public Health submitted data
on behalf of the entire state in 2017. The CDC replied: Based on the data presented, CDC concurs with IDPH that there is a statewide need for SSPs. The State is strongly encouraged to discuss plans to direct funds for SSPs with your federal funding agencies. 32 The Centers for Disease
Control and Prevention has identified the entire state of Iowa, including Dubuque County, as being at risk for HIV and HCV outbreak. Key Finding 33 Determining the Need
HIV Dubuque County 34 Determining the Need HCV in Dubuque County 200% Increase in 5 Years 35
HCV diagnoses of people under age 40 in Dubuque County have increased by 200% in the last five years. Key Finding 36 Estimating the Number of People Who Inject Drugs (PWID) in Dubuque County
IDPH Recommendation Use the total number of people under 40 who have been diagnosed with HCV and multiply that number by 2. 75 people diagnosed = 150. Dubuque Harm Reduction Reports that the organization has served 59 individual program participants. Each participant reports that they share supplies with three additional people. 59 x 3 = 177. Substance Abuse and Mental Health Services Administration (SAMHSA) 652,000 people age 12 and over in 2017 had heroin use disorder which represents 0.2 percent of people 12 and older. Applying 0.2 percent times the total population of Dubuque County in 2017: 0.2 x 97,041 = 194. Average = 174
37 Significant barriers exist to collecting all the pertinent data related to the issues addressed in this assessment. Key Finding 38
Assessing Community Need Survey of People Who Inject Drugs 39 Survey of People Who Inject Drugs in Dubuque County Demographics 02/10/2020 40
Survey of People Who Inject Drugs in Dubuque County Demographics 41 Survey of People Who Inject Drugs in Dubuque County Drug Use 42
Survey of People Who Inject Drugs in Dubuque County Drug Use 43 71% of people responding to the survey indicate that they have shared a needle. Key Finding
44 Survey of People Who Inject Drugs in Dubuque County Drug Use 45 Survey of People Who Inject Drugs in Dubuque County Drug Use 46
Survey of People Who Inject Drugs in Dubuque County HIV and HCV 47 Survey of People Who Inject Drugs in Dubuque County HIV and HCV 48
73% of individuals who have been diagnosed with either HCV or HIV are not being treated for their conditions. Key Finding 49 Survey of People Who Inject Drugs in Dubuque County Attitudes Toward Syringe Service Programs
50 Survey of People Who Inject Drugs in Dubuque County Narcan/Naloxone Use 51 Survey of People Who Inject Drugs in Dubuque County Narcan/Naloxone Use
52 Survey of People Who Inject Drugs in Dubuque County Sexual Activity 53 92% have engaged in unprotected sexual activity in the last 30 days.
Key Finding 54 Assessing Community Readiness Harm Reduction Strategies in Dubuque County Community Readiness Survey 55 Harm Reduction Strategies in Dubuque County
Drug Checking (Fentanyl Test Strips) Drug checking allows people who use drugs to identify the substance they intend on taking and helps prevent harm by unknowingly consuming substance adulterated with a contaminant like fentanyl. Good Samaritan Law Encourages those who witness a drug overdose to stay and call 911. Medication-Assisted Treatment MAT is the use of FDA-approved medications, in combination with counseling and behavioral therapies to provide a whole-person approach to the treatment of substance use disorders. Naloxone/Narcan Naloxone is an inexpensive, FDA-approved drug that works to reverse an opioid overdose without any potential for abuse.
56 Community Readiness Survey Designed and implemented a community assessment survey modeled from similar surveys used in other communities. Electronic link sent to Opioid Response Team, clerks of the 21 municipalities in Dubuque County, EMS and first responder teams. Similar approach used to distribute the Dubuque County CHNA survey. Purpose was to gain a baseline understanding of public knowledge of harm reduction strategies including syringe service programs. Survey was open for one month and garnered 186 responses representing 13
zip codes in the county. 57 My community is committed to promoting health and wellbeing. 58 Harm Reduction Definition Harm reduction is a term used to
describe the practice of spreading techniques and information with the purpose of improving the quality of life and reducing the chance of injury. The main goal of harm reduction services is to lower risk levels for current drug users. 59 Do you feel your community is ready to implement harm
reduction strategies that would include a syringe service program? 60 To what extent are each of the following a problem in your community? 61 To what extent are each of the following a problem in your
community? 62 To what extent are each of the following a problem in your community? 63 Individuals responding to the community
survey ranked: alcohol, meth, prescription drugs and heroin as a problem in the community. Key Finding 64 In your community, how often do you see the following? 65
To what extent does drug use contribute to the following in your community? (A great deal and quite a bit) 66 To what extent do you believe the following infectious diseases are a problem in your community? 67
To what extent do you personally favor or oppose a syringe service program in your community if lawful to execute? 27% - Strongly Favor 34% - Strongly Oppose 39% Somewhat/Neither 68 Only 34% of people
responding to the survey indicated they strongly oppose syringe service programs. Key Finding 69 Should harm reduction supplies be available for people who use drugs in your community?
70 Should harm reduction supplies be available for people who use drugs in your community? 71 Which of the following harm reduction strategies, resources or education do you believe could prevent harm in your community?
72 Which of the following harm reduction strategies, resources or education do you believe could prevent harm in your community? 73 Which of the following harm reduction strategies, resources or education do you believe could prevent harm in your community?
74 Which of the following harm reduction strategies, resources or education do you believe could prevent harm in your community? 75 Which of the following harm reduction strategies, resources or education do you believe could prevent
harm in your community? 41% Strongly Agree/Agree 39% Strongly Disagree/Disagree 20% Neither 76 Needle or syringe exchange programs include strategies to prevent the sharing of contaminated needles and provide for the safe disposal of syringes. Which of the
following do you support for your community? 77 Needle or syringe exchange programs include strategies to prevent the sharing of contaminated needles and provide for the safe disposal of syringes. Which of the following do you support for your community? 78
Needle or syringe exchange programs include strategies to prevent the sharing of contaminated needles and provide for the safe disposal of syringes. Which of the following do you support for your community? 79 Needle or syringe exchange programs include strategies to prevent the sharing of contaminated needles and provide for the safe disposal of syringes. Which of the following do you support for your community?
60% of respondents to the survey showed some degree of support in providing sterile injecting equipment, if lawful to do so. 60% 80 60% of respondents to the survey showed
some degree of support in providing sterile injecting equipment, if lawful to do so. Key Finding 81 Key Findings 12 Key Findings of the Assessment
82 Key Findings 1. The Centers for Disease Control and Prevention has identified the entire state of Iowa, including Dubuque County, as being at risk for HIV and HCV outbreak. 2. The scientific literature supporting the implementation of syringe service programs to stop the spread of infectious disease is irrefutable. 3. Significant barriers exist to collecting all the pertinent data related to the issues discussed in this assessment. It was a particularly difficult estimating the population of people who inject drugs in Dubuque County. 4. According to the CDC, the average cost of treating one HCV infection is
$90,000 and approximately $450,000 for HIV treatment over each patients lifetime. In 2018, there were 116 new diagnoses of HIV in Iowa. Potential cost to the state could be as much as $39 million. 83 Key Findings 5. HCV diagnoses in people under the age of 40 have increased by 200% in Dubuque County over the last five years. This significant increase is most likely the result of injection drug use among this age group. 6. According to the PWID survey, people who inject drugs come from all age groups, education levels and nearly 40% of them are actively employed.
7. According to the PWID survey, people who inject drugs are engaging in other risky behaviors. Over 70% reported that they have shared needles. 92% have engaged in unprotected sexual activity in the last 30 days. 8. According to the PWID survey, 73% of individuals who have been diagnosed with HCV or HIV are not getting the treatment they need. 84 Key Findings 9. Only 34% of people responding to the community readiness survey indicated that they strongly oppose syringe service programs, if they were lawful to
implement. 10. Individuals responding to the community readiness survey ranked the following as a serious to moderate problem in the community: 85% Alcohol 80% Methamphetamine 75% Prescription Drug Misuse 71% Heroin 85 Key Findings
11. There is considerable community support for additional harm reduction strategies, including: 83% Community Education Programs 83% Infectious Disease Testing 62% Mobile Harm Reduction Teams 12. 60% of respondents to the community readiness survey showed some degree of support in providing sterile injecting equipment, if lawful to do so. 86
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