Coun­ties ex­pand nee­dle-ex­change pro­grams to pro­tect pub­lic health

Some ef­forts could be up and run­ning by year’s end or early next year

The Washington Post Sunday - - LOCAL OPINIONS - MARY­LAND BY MERED­ITH COHN Pamela Wood and Phil Davis con­trib­uted to this re­port.

bal­ti­more — Nee­dle-ex­change pro­grams for drug users could be com­ing to six coun­ties across Mary­land, in­clud­ing Anne Arun­del and Bal­ti­more coun­ties, as state health of­fi­cials work with lo­cal lead­ers to stop the spread of in­fec­tious dis­eases in the face of a heroin epi­demic.

The ef­forts are be­ing led lo­cally and are at var­i­ous stages, but state of­fi­cials are en­cour­ag­ing the pro­grams, and are of­fer­ing tech­ni­cal as­sis­tance and some fund­ing, said Onyeka Anae­dozie, deputy direc­tor of the Mary­land De­part­ment of Health’s In­fec­tious Dis­ease Pre­ven­tion and Health Ser­vices Bureau.

“We’ve talked to lead­er­ship in the ju­ris­dic­tions about the im­por­tance of hav­ing a stand­ing sy­ringe ser­vices pro­gram,” she said. “We want the ef­forts led by the lo­cal ju­ris­dic­tions.”

The coun­ties in some stage of plan­ning or con­sid­er­a­tion in­clude Anne Arun­del and Bal­ti­more in the metro area, Fred­er­ick and Wash­ing­ton in West­ern Mary­land, Dorch­ester on the East­ern Shore and Prince Ge­orge’s near Wash­ing­ton. Bal­ti­more City has the state’s only op­er­at­ing pro­gram, be­gun in 1994. It re­lies largely on mo­bile units, which pro­vide ser­vices in 16 lo­ca­tions around the city 26 times a week.

The grow­ing ac­cep­tance of nee­dle ex­change re­flects changing at­ti­tudes to­ward the of­ten con­tro­ver­sial pro­grams, which crit­ics say use tax­payer money to pro­mote drug use and cause drug users to con­gre­gate at ex­change sites. Although the Bal­ti­more pro­gram has been around for years, the state passed leg­is­la­tion only in 2016 al­low­ing the pro­grams to be es­tab­lished else­where around the state. The Repub­li­can-con­trolled Congress also passed leg­is­la­tion in early 2016 that al­lows fed­eral fund­ing for nee­dle-ex­change ef­forts.

Anae­dozie said the state’s push be­gan in 2015 af­ter ru­ral Scott County in In­di­ana be­gan re­port­ing a spike in HIV and hepati­tis C in­fec­tions re­lated to the opi­oid cri­sis there.

Mary­land has not seen a re­lated in­crease in in­fec­tions; fed­eral data shows HIV cases have been trend­ing down in the state in re­cent years, es­pe­cially among IV drug users. But of­fi­cials rec­og­nize drug use poses risks, and lead­ers in the state have pur­sued pre­ven­tion, treat­ment and “harm re­duc­tion” mea­sures that can be folded into nee­dle pro­grams.

Over­dose deaths con­tinue to climb statewide, with more than 2,000 in 2016, up 66 per­cent from 2015. Most deaths were linked to heroin and fen­tanyl, opi­oids that can be in­jected.

Nee­dle pro­grams in some Mary­land coun­ties could be up and run­ning by year’s end or early next year, and are ex­pected to of­fer clean sy­ringes, dis­ease test­ing and coun­sel­ing, and re­fer­ral for treat­ment for in­fec­tions and sub­stance abuse, Anae­dozie said.

Some drug users not yet ready for treat­ment could still get nee­dles and per­haps nalox­one, a drug that re­verses the ef­fects of opi­oid over­dose.

The coun­ties have been work­ing to get back­ing from lo­cal law en­force­ment agen­cies and elected of­fi­cials, as well as neigh­bor­hoods and treat­ment com­mu­ni­ties — a re­quire­ment by health of­fi­cials in the state, which passed a law in 2016 that al­lows the ex­pan­sion of nee­dle ex­changes around Mary­land.

“It won’t work un­less there is buy-in from all the groups,” Anae­dozie said.

Get­ting such sup­port is time con­sum­ing, she added. The coun­ties need to de­ter­mine how to pro­vide test­ing for HIV and hepati­tis, and how to link peo­ple to care. Some health de­part­ments will do the work in house and oth­ers will rely on fed­er­ally sup­ported health cen­ters that al­ready of­fer ser­vices. Some coun- ties will open phys­i­cal lo­ca­tions and oth­ers will op­er­ate mo­bile vans.

In Anne Arun­del, County Ex­ec­u­tive Steve Schuh di­rected health of­fi­cials to con­sider such a pro­gram be­cause the trans­mis­sion of HIV “re­mains a pub­lic health con­cern in the county.”

A spokesman for Schuh said the ex­ec­u­tive con­tin­ues to have reser­va­tions that such pro­grams would en­cour­age peo­ple’s drug habits but that he wants to have an open mind and see if the pro­grams could be ef­fec­tive.

Coun­cil­man John Grasso (RGlen Burnie) said he would sup­port the pro­gram.

“I would rather give some­one a clean nee­dle and pre­vent them from the pos­si­bil­ity of get­ting AIDS,” he said, adding “a nee­dle is a hell of a lot cheaper.”

Beilen­son, a for­mer Bal­ti­more health com­mis­sioner who be­gan the city’s pro­gram, said more pub­lic of­fi­cials seem to be over­com­ing their con­cerns and reach­ing that con­clu­sion.

He said there is a wealth of sci­en­tific ev­i­dence sup­port­ing the ef­fec­tive­ness of such pro­grams at pre­vent­ing dis­ease and none that show an in­crease in drug use. And most op­po­si­tion is po­lit­i­cal rather than com­mu­nity based. In fact, the Bal­ti­more pro­gram ini­tially went only to neigh­bor­hoods that re­quested such ser­vices, said Beilen­son, now chief ex­ec­u­tive of the Bal­ti­more health in­surer Ever­green Health.

“In the first five years of the pro­gram, I had seven peo­ple call­ing me about nee­dle ex­change: five pos­i­tive and two neg­a­tive,” he said. “There were no prob­lems what­so­ever with NIMBY,” or not in my back yard.

He said op­po­si­tion gen­er­ally comes from politi­cians who fear the pro­grams sug­gest their ar­eas have a drug prob­lem, pos­si­bly ham­per­ing eco­nomic de­vel­op­ment.

State of­fi­cials say sup­port is cru­cial to be­gin the pro­grams. Coun­ties must seek the state health de­part­ment’s per­mis­sion for the pro­grams, demon­strat­ing in their ap­pli­ca­tions that they’ve re­ceived lo­cal sup­port and that they have a spe­cific plan. How­ever, the state’s sign-off is a for­mal­ity if those con­di­tions are met.

Coun­ties also can ap­ply for fund­ing for spe­cific needs, although the de­part­ment could not say how much money would be avail­able.

It’s not clear how each proPeter gram will take shape, and all are likely to look a lit­tle dif­fer­ent. In Bal­ti­more County, for ex­am­ple, health of­fi­cials have pro­posed adding nee­dle ex­change to the ser­vices pro­vided to peo­ple with HIV and hepati­tis C, said Monique Lyle, a county spokes­woman.

Pa­tients who are treated for those dis­eases at county health cen­ters would be of­fered the abil­ity to ex­change their nee­dles, Lyle said. Those pa­tients also would be of­fered ed­u­ca­tion on us­ing clean nee­dles, wound care, pre­ven­tion of sex­u­ally trans­mit­ted in­fec­tions and im­mu­niza­tions. The pa­tients and their fam­ily mem­bers also will be trained to use nalox­one, the opi­oid over­dose drug.

Leana Wen, Bal­ti­more’s health com­mis­sioner, said she has worked to make all her county coun­ter­parts aware of how the city pro­gram works and has pro­vided more spe­cific as­sis­tance to those who have re­quested it.

The city’s pro­gram costs about $800,000 an­nu­ally and dis­penses about half a mil­lion clean nee­dles a year, in ad­di­tion to pro­vid­ing other ser­vices.

Wen said a lot of stigma re­mains as­so­ci­ated with drug use in gen­eral, but she hopes to clear mis­con­cep­tions about nee­dle pro­grams that she said can pre­vent dis­ease. She said when the city pro­gram be­gan 23 years ago, 63 per­cent of those with HIV were IV drug users. By 2014, the only 7 per­cent were IV drug users, con­tribut­ing to one of the na­tion’s largest drops in new HIV cases.

She called nee­dle-ex­change pro­grams “a pow­er­ful tool” to pre­vent harm, although she has seen re­sis­tance na­tion­wide.

“It’s not about con­don­ing or sup­port­ing drug use,” she said. “The first prin­ci­pal of pub­lic health is to pro­tect the pop­u­la­tion from harm.

“We’ve seen this re­sult . . . . That is why it’s im­por­tant for us to share our ex­pe­ri­ence.”

“We’ve seen this re­sult . . . . That is why it’s im­por­tant for us to share our ex­pe­ri­ence.” Leana Wen, Bal­ti­more’s health com­mis­sioner


Peo­ple learn to ad­min­is­ter nalox­one, an an­ti­dote for heroin and opi­ate over­doses, in a nee­dle ex­change van in Bal­ti­more. Crit­ics say the pro­grams use tax­payer money to pro­mote drug use.

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