Kentucky looks at needle-exchange success in Ohio city

PORTSMOUTH, Ohio — A steady stream of weary-looking addicts, many with bags of used hypodermic needles stuffed into old winter coats, walked into an alley behind the health department and joined a small line inside.

Called in one by one to a tiny room, the mix of young women, couples and older men gave only their initials, ZIP code and drug of choice to two health workers at folding tables.

"Heroin?" asked Lisa Roberts, a nurse with the Portsmouth City Health Department. "Tar, powder or both?"

"Both," replied one man, dumping a handful of used needles into an overflowing orange plastic bin before grabbing packs of clean syringes. Roberts urged him to sign up to get free naloxone, an overdose reversal drug, to get tested for disease and consider entering a drug treatment program.

"I'd love to be able to kick the habit," the man said, who declined to give his name as he walked back outside.

Faced with Ohio's highest rates of hepatitis C from a devastating heroin epidemic rooted in pain pill abuse, this former steel town on an Appalachian stretch of the Ohio River declared a public health emergency in 2011 and in 2012 began a weekly syringe exchange to reduce disease and get help to users — a controversial concept being considered in Kentucky.

Funded by donations, the Portsmouth exchange hands out an average of 5,000 clean needles every month. And while it's not popular with everyone — some believe it encourages use — public health officials say the "Prevention Not Permission" program has helped reduce hepatitis C, gotten needles out of parks and streets, and, most importantly, linked addicts to treatment, testing and counseling they might not otherwise seek.

"If you're going to do something about the heroin epidemic, you've got to engage the users," Roberts said.

It's one example of the kind of exchange programs the Kentucky General Assembly is considering as part of a broader package of legislation aimed at combating the state's growing heroin problem. A House bill includes a provision allowing local jurisdictions to adopt similar needle exchanges, where addicts swap used syringes for clean ones.

The Kentucky bill doesn't require the exchanges but allows health departments and cities to adopt them. That would let local communities decide whether they're needed and to navigate potentially thorny issues such as where to locate them, said Van Ingram, director of the Kentucky Office of Drug Control Policy, who supports the proposal. The bill provides no state funding, he said. Federal money also cannot be used for exchanges, so the exchanges would have to rely on donations or local funding.

The issue took on added urgency recently when dozens of new cases of HIV related to intravenous drug use popped up in southeast Indiana.

Meanwhile, Kentucky public health officials say hepatitis C, a chronic blood-borne disease, is growing statewide.

Kentucky Cabinet for Health and Family Services figures show a 2012 hepatitis C rate of 4.1 per 100,000 residents in 2012, compared with 0.07 in 2007. Emily Gresham Wherle, spokeswoman for the Northern Kentucky Health Department, where heroin is rampant, said the rate in her department's area reached 10.9 in 2014 based on federal reports.

"Our hepatitis C rates are dramatically increasing, and certainly intravenous drug use has played a part," Ingram said.

A 2014 Kentucky Injury Prevention and Research Centerreport found that hospitalizations involving opiate dependence and hepatitis C increased from 72 in 2000 to 1,192 in 2012.

Under Kentucky law syringe sales are kept on record and purchasers must show identification and list their intended use along with an address and phone number, according to a spokeswoman for Walgreens, which operates many pharmacies across the state.

That often leads drug abusers to re-use needles, advocates said. According to the Kaiser Family Foundation, there were about 227 syringe exchange programs in the nation in 2013, including one near Cincinnati.

Portsmouth, once a hub of manufacturing before many of its factories closed, saw opiate pain pill abuse take off in the late 1990s, fueled by "pill mill" clinics that over-prescribed medications such as Oxycontin, Roberts said.

High rates of addiction and skyrocketing hepatitis followed. The pill mills were shut down around 2011, Roberts said, but that didn't erase addiction. Cheaper and more easily accessible heroin swooped in to replace them. And treatment options in the area remain limited.

"The heroin epidemic has just mushroomed," said Roberts, who added her own daughter has struggled with heroin addiction.

Deciding enforcement and treatment alone weren't enough, city officials embraced a harm-reduction approach — opening the needle exchange, educating users and providing free naloxone nose spray kits. Administered by health department staff, the exchange costs $8,000 to $10,000 a year, officials said, funded mostly by donations from HIV-prevention groups.

Last week, Roberts and health worker Rebecca Miller laid out brochures on HIV and hepatitis, a box of condoms and a stern list of rules, including that each user can exchange no more than 30 needles. "This program is not to keep you happy but to keep you safe," it read.

Roberts said the exchange has served business professionals and high school cheerleaders — even three generations of one family.

Roberts said officials have given out 180 naloxone kits so far and are aware of 35 overdoses that were reversed as a result. She urged each person to take a free class and get the kit.

"If either of you ever overdose, it can save your life," Roberts told one couple. "Tell everybody not to share needles."

Portsmouth health Commissioner Chris Smith said the program has shown benefits, even if it hasn't been a cure-all.

Between 2011 and 2012, the hepatitis C rate fell from 309 per 100,000 in Scioto County, Ohio, where Portsmouth is located, to 171 per 100,000 — a big drop but still far above the state average of 32 per 100,000, according to state health figures.

Roberts said health workers persuade nearly half of the exchange's clients to seek addiction treatment, although many relapse over time.

Support for the program is far from universal — the most common complaint being that it facilitates use. Last week, one exchange client told Roberts that a police officer who found a needle on him told him to "go tell the health department they can have their property back." The Portsmouth city manager declined to comment.

"You either love it or hate it," said Andy Gedeon, director of environmental health in Portsmouth, "until you really dive into it, learn the stats."

Similar misgivings keep a federal ban on funding for such programs in place. While there is research showing benefits, advocates say such programs should include a comprehensive set of counseling, testing and treatment referrals.

As the Kentucky legislative session nears its end, it remains unclear whether the Kentucky General Assembly will pass the heroin bill or include the exchange provision.

If it does pass, Louisville Metro Health Department officials said they probably would study whether such a program is needed or would be effective in the city. The city had 14 confirmed cases of acute hepatitis C in 2013, according to figures state officials said were likely under-reported.

Christopher Stewart, an addiction psychiatrist who served as the medical director at Louisville's Jefferson Alcohol and Drug Abuse Center until 2014, said such a program would be a big benefit to Louisville and be one more way to get help to addicts.

"I do not agree that it encourages the addiction," he said. "If somebody has crossed the threshold of shooting up heroin with needles, making needles harder to get is not a deterrent."

Kenning also reports for The (Louisville, Ky.) Courier-Journal.