BEDFORD — Providing clean needles to drug users as a means of reducing the spread of infectious disease is what's known as a harm reduction technique. So is providing a clean vessel to draw the drug into the needle.
Both are part of harm reduction strategies included in the Lawrence County Health Department's proposal for a syringe exchange program that was first presented to the county commissioners for approval in February. Earlier this month, the health department returned to the commissioners to get approval of the SEP contract with Indiana Recovery Alliance, a Bloomington nonprofit that offers harm reduction services. The commissioners approved the health department's SEP plan in February, but tabled a decision on the contract with IRA last week over concerns about one of IRA's harm reduction techniques.
Sterile bottle caps, also known as cookers, are given to injection drug users who visit needle exchange programs, as are clean needles.
"I can give you a clean needle, but if you still have an old cooker that is a contaminated cooker, and what you draw out of this is contaminated with hep C, you are still going to get hep C," said Sherry Lawson, Lawrence County public health nurse. "You need to keep the entire process as clean as possible."
But the dispensing of those bottle caps was a point of contention for commissioners Dave Flinn, Chris May and Bill Spreen who had reservations about issuing an item they felt promotes the "cooking" of an illegal drug. The commissioners tabled the matter at the June 14 meeting and asked the health board to meet with the county's judicial board for further discussion on the proposal.
Lawrence County's hepatitis C infection rate is among the 15 highest in the state, which prompted the health department to declare a state of emergency in January. The county's rate increased 112 percent from 2010-14, according to the health department.
The county's plan calls for its SEP to be handled by Indiana Recovery Alliance, which also runs Monroe County's needle exchange program.
'Not an easy process'
Carrie Ann Lawrence, Ph.D., is director of Project Cultivate with the Rural Center for AIDS/STD Prevention at the Indiana University School of Public Health. Lawrence works with county health departments that are drafting plans for syringe exchange programs. She helped the Lawrence County Health Department with its needle exchange proposal and spoke at the meeting of the Lawrence County Commissioners in February when Dr. Alan Smith, county health officer, and Sherry Lawson, county health nurse, first presented the plan. She spoke then about how crucial it is for counties that have declared a health emergency to implement a syringe exchange program.
She did not attend the June commissioners meeting, but was aware of the request being tabled.
"We know this is a hard thing to do, it's not an easy process," she said. "Getting support of the local community can be hard, I hope we can have a further conversation."
Commissioner Bill Spreen took issue with the dispensing of "cookers," which is slang for clean bottle caps or other vessel used.
"The problem I have is when I look down this list and see 20,000 cookers," he said during the June 7 meeting. "I assume that's for them to make their drugs. I have a huge problem with providing people, at the taxpayers' expense, the products to do this. They're going to have to bend some of the rules for me to go along with this."
Lawson said she plans to present the syringe exchange plan again at a commissioners meeting in late July.
"At this point, no changes will be made," said Lawson. "That plan is written with the best practices in mind, which means we are doing what has been scientifically proven to be the best way to do a program and our board of health voted unanimously to keep it like it was for that very reason."
Lawrence said the bottle caps are another safeguard is preventing the spread of hep C.
"Even if you are giving out clean needles, you're not helping if the person is using a dirty spoon or dirty piece of cotton," she explained. "This is the best way to do it. You need to have all these working parts. "And Lawrence County being close to the epicenter of where it started in Austin, you really need to have all the safeguards in place."
Lawson has looked into other counties with exchange programs to see what services they include.
"Every program has harm reduction materials and cookers are included in those and they all have them," she said. "Harm reduction includes a lot of things, education is part of that and the importance of clean techniques."
Lawson and Lawrence were surprised the commissioners raised objections after hearing from several health officials about the need for a syringe exchange plan and giving the health department the OK to submit its plan to the state in February.
"I thought after the initial meeting, they felt they had the knowledge they needed," Lawrence said. "I was shocked, nobody was expecting it."
Lawson said the health board — Dr. George Sorrells, Dr. Jim Mount, Judge Michael Robbins, deputy coroner John Sherrill, retired school superintendent Dennis Turner, pharmacist Steve Anderson, veterinarian Karen Rusch and Smith — voted unanimously for the county plan.
"They covered every base and thoroughly read the plan," she said.
Indiana Recovery Alliance
Chris Abert, project director with Indiana Recovery Alliance, said the organization does not give out utensils to manufacture drugs.
"The State Department of Health has issued guidelines for needle exchange programs and we follow those," he said. "We need to address all points where hepatitis C or HIV can be transmitted, so we give out bottle caps as educational pieces about infection of transmission of infectious disease."
Those guidelines are based on 25 years of research into the effectiveness of needle exchange, he said.
"But the best practices for public health are sometimes opposed for political reasons," said Abert.
Abert said he hopes the county leaders reconsider their objections.
For one, he said the cost of treating a person with hep C is about $83,000 for 12 weeks. For another, hep C is a strong predictor of HIV-positive status. And lastly, no county wants to be the next Scott County, where a hep C/HIV outbreak in Austin in 2015 has reached more than $58 million in costs to Indiana's Medicaid program.
"When there's harm reduction, the infection rate goes down by 80 percent," said Abert. "People are five times more likely to go into treatment than if you don't have that program. People come for clean syringes, and when they are ready to get clean, they can get help."
Growing opioid epidemic
Despite the staggering costs to treat hep C, there is no money going to county health departments to slow the spread of infection, said Lawrence.
In 2015, Gov. Mike Pence lifted a ban on needle exchange programs, but the state does not allow any state funds be used for such programs.
The Indiana Recovery Alliance is funded with grants and private donations, said Abert, and receives no state or county funding. The proposed contract to offer needle exchange here is for one year and would require no local funding.
Opioid addiction is a growing problem in rural areas. Indiana ranks 15th in the nation for drug overdoses. In 2013, Lawrence County's rate of non-fatal emergency room visits for opioid overdoses was nearly twice the state rate, per 100,000 people.
"The heroin epidemic is not going away anytime soon," said Lawrence. "As a state, we're just learning to do this and everyone is watching Indiana."
For communities to have an effective response to the epidemic, action and education are vital.
"We need to think through these decisions, if there are questions, if you're not sure about syringe exchange as a harm reduction, ask," she said.
From her work with counties, she understands the confusion and controversy of syringe exchange programs and how the idea of handing out clean needles to illegal drug users seems like bad public policy.
"I know where I was when I first heard about this and I was hesitant, but once I recognized it was the best thing to do to keep our communities safe, I was more comfortable with it," she said.
The commissioners requested the health board meet with the local judicial committee to discuss the merits of the SEP contract. Lawson said that meeting is being scheduled.
Currently 19 Indiana counties are either in the process of planning or seeking approval of a syringe exchange. Five additional counties — Scott, Monroe, Madison, Fayette and Wayne — have received state approval to run an SEP. Scott County, where 191 people have tested positive for HIV since the 2015 outbreak tied to sharing of dirty needles, recently received state approval to extend its SEP another year.
Depending on the decision of the commissioners, Lawrence County could be the sixth. Lawson pointed to a recent report from Positive Link, a testing service, that tested inmates for hep C at the Lawrence County jail. Eight of nine inmates were positive. In 2014, 33 percent of inmates tested positive for hep C. With numbers like that, Lawson said the county can't afford to do nothing.
"I don't know what will happen, but we will stand our ground," Lawson said. "Hopefully, people who don't understand will get further education and learn about things."