Programs allowing intravenous drug users to exchange dirty syringes for clean ones are spreading in Kentucky as communities confront growing heroin abuse and concerns over the potential for disease outbreaks caused by addicts sharing needles.
So far, health departments and local governments in 13 counties have approved needle exchanges, and 11 are in operation, according to the state Cabinet for Health and Family Services and local officials.
The Clark County Health Department held its first exchange Friday, the third department in the state to begin providing syringes to addicts since July 1, along with Boyd and Pike counties.
Mercer County is set to begin a needle exchange Aug. 1, and training is underway to begin a program in Harrison County, officials said.
Health officials in some other counties are working to get approval for exchange programs.
The goal is to prevent drug users from getting infected with hepatitis C and the human immunodeficiency virus (HIV).
Kentucky had the highest rate of acute hepatitis C cases in the nation from 2010 through 2013, according to information from the federal Centers for Disease Control and Prevention.
Since then, the problem of people using hypodermic needles to shoot up heroin, fentanyl and prescription drugs has gotten worse, authorities said, driving up the potential for bloodborne diseases to spread among people sharing needles.
“If we do nothing, if we look the other way, we are going to see a huge public health crisis in Kentucky,” said Scott Lockard, director of the Clark County Health Department and president of the state association of health departments. “We’re sitting on a ticking time bomb.”
Proponents of exchange programs are driven by the specter of Scott County, Ind., where addicts sharing needles to inject a painkiller called oxymorphone caused a staggering outbreak of HIV cases.
CDC researchers said in one report that 181 people in the county were diagnosed with HIV between November 2014 and October 2015. In the preceding 10 years, the county of 24,000 had reported only five new HIV infections, the report said.
Drug users in the county reported injecting themselves up to 15 times a day and sharing needles with up to six people, according to the CDC.
‘That easily could have been us’
After the spike in HIV cases in the rural, relatively poor county, the CDC analyzed statistics such as numbers of overdose deaths, per capita income, unemployment and sales of painkillers to figure out which counties in the nation were most at risk for a similar outbreak among IV drug users.
It was sobering news for Kentucky.
Of the 220 most vulnerable counties in the nation, 54 were in Kentucky, mostly in the southern and eastern parts of the state. Many of the others were clustered in nearby parts of West Virginia, Virginia, Tennessee and Ohio.
Kentucky had 18 counties that the CDC calculated to be more vulnerable than Scott County, Ind., to a disease outbreak among IV drug users, with Wolfe County considered at greatest risk in the nation.
Officials studying the disease outbreak in Indiana pointed to a number of factors that contribute to drug abuse there, including high unemployment and poverty, relatively low educational attainment and limited access to health care.
Many counties in Kentucky share those challenges.
“I think a lot of health departments in Eastern Kentucky looked at it and said, ‘That easily could have been us,’” said Kristy Bolen, an epidemiologist at the Ashland-Boyd County Health Department.
Needle exchanges started in Europe and some U.S. states three decades ago in response to an explosion of HIV/AIDS cases, but were illegal in Kentucky until last year, when lawmakers cleared the way for health departments to set up exchanges with the approval of city and county governments.
The change was part of a larger bill aimed at tackling growing heroin abuse in Kentucky.
Louisville started the state’s first needle-exchange program in June 2015, followed by Lexington in September.
A total of 682 people have since taken part in Lexington’s program, with new clients coming each month, according to Dr. Kraig Humbaugh, director of the Lexington-Fayette County Health Department.
Health officials in some counties said they’ve faced concerns that giving needles to drug users enables or condones illegal drug activity, or will make the local drug problem worse.
Carter County Judge-Executive Mike Malone, a Republican who is on the local health board, said he shared those concerns when officials from the health department brought up the idea.
Malone said he changed his mind because of the potential for the program to head off disease and get addicts into treatment.
“It’s not about enabling them to take drugs. It’s about stopping the spread of disease,” Malone said. “The more you learn about it, the more you’ll understand it’s the right thing to do.”
The county’s hepatitis C numbers show the need for the program, said Trena Greene, nursing supervisor for the health department.
There were 68 cases of hepatitis C reported in the first six months of 2016, compared to 87 for all of 2015, Greene said.
The World Health Organization said in a 2004 report that numerous studies, both in the U.S. and elsewhere, had shown no evidence that needle-exchange programs cause drug abusers to increase their drug use, or that they cause more people to begin using drugs.
“It has been shown over and over and over that this program does not increase drug usage,” said Dr. Rafael Rangel, director of the Pike County Health Department.
‘It does pay for itself’
Officials in several counties said their exchanges started with a handful of participants.
Participation has grown, however, and officials expect that trend to continue as people spread the word that the programs are truly confidential and that people can get clean needles without the danger of being arrested.
Under last year’s change in state law, people won’t be charged with possessing drug paraphernalia if they disclose to police before a search that they have needles, and the needles have no more than trace amounts of drugs.
That would apply, for instance, if a drug user was stopped on the way to a needle exchange.
Police in several towns told the Herald-Leader they have not gotten reports of participants causing problems at needle exchanges.
Health officials said they understand some people don’t like the idea of providing drug users with needles at public expense, but they argue the potential cost to taxpayers of not doing so is far worse.
Jennifer Hunter, director of clinical services at Northern Kentucky District Health Department, said it costs $86,000 to treat a single case of hepatitis C, which doesn’t count costs such as physician fees.
Many people have no symptoms with hepatitis C but eventually develop liver problems that require expensive treatment.
And the lifetime cost of treating someone infected with HIV can be hundreds of thousands of dollars, Hunter said.
In comparison, many rural Kentucky health departments have budgeted $10,000 or less for their first year of needle exchanges.
“It does pay for itself,” Hunter said of a needle-exchange program. “Look at what you’ve saved in the long run.”
Dirty needles a threat to children
Research has confirmed that needle exchange programs can cut the spread of diseases.
The numbers in Scott County, Ind., bear that out. Health officials credited an emergency needle-exchange program with blunting the spike in HIV cases.
There had been 184 new HIV cases identified in the county by early December. By early May, only seven more cases had been confirmed, according to the Indiana State Department of Health.
Supporters say the programs provide other benefits as well, including giving health workers a chance to educate drug users not to put dirty needles in the trash or throw them away on the street, in the landscaping at businesses and in playgrounds, where they create the risk of accidental sticks to police, firefighters, maintenance workers and children.
Bolen said there was an incident in Ashland this year in which a 3-year-old child put his hand in the trash can at a convenience store bathroom and got stuck by a needle.
In Carter County, a 2-year-old girl stepped on a needle someone had thrown in the playground at a church, Malone said.
At the needle exchanges, health workers take in dirty needles for proper disposal and give drug users clean, sterile needles and a container to store used needles until their next visit.
“If we get them to bring them back, then they won’t be in our playgrounds, they won’t be in our streets,” Bolen said.
The exchanges also allow health workers to tell people about sexually transmitted diseases and figure out if they have other needs, such as housing help.
Health workers also get a chance to talk to addicts about getting into treatment.
“The ultimate goal is to get them out of the lifestyle,” Lockard said.
Health officials in several counties said they’d already seen cases of people going into treatment after having a needle-exchange program for a short time.
In Grant County, for instance, 23 people have taken part in the exchange program since it started in March, and four have sought treatment, Hunter said.
In Pike County, one person came on the first day — a quiet man who said he was grateful for the program and took a treatment referral.
“That was very positive,” Rangel said.
Van Ingram, executive director of the Kentucky Office of Drug Control Policy, said research has shown that IV drug users taking part in needle exchanges are five times more likely to go into treatment.
“The evidence is pretty overwhelming that they work,” Ingram said.