State governments are expanding access to harm reduction and other innovative strategies to attack the infectious disease consequences of the opioid crisis, and the arguably unlikely role model for many in this effort has been Kentucky, which just four years ago became the first Southern state to adopt comprehensive harm reduction legislation.
The National Governors Association (NGA) last month issued two briefs outlining how states can mitigate the public health effects of injection drug use. The NGA last year convened multidisciplinary teams from seven states seeking to develop strategic plans in this area and learn from the Kentucky experience. The group included some states that have housed syringe services programs and other harm reduction services considerably longer than Kentucky has.
“States that wanted to learn from Kentucky included those that have had well-established programs,” Hemi Tewarson, who heads the NGA's health division, tells Behavioral Healthcare Executive. But while Washington, for example, has seen a longstanding commitment to harm reduction in Seattle/King County, the state's rural communities have continued to struggle to build the political support for syringe exchange and related services.
Catalyst for change
The event that precipitated change in Kentucky was the 2014 outbreak of HIV in nearby Scott County, Ind., affecting by early 2015 a total of 135 people in a community that never had seen more than five HIV cases in any year. With officials in northern Kentucky estimating that a similar outbreak there could affect more than 2,000 residents and cost over $1 billion in health care, momentum built for overcoming obstacles to allowing harm reduction approaches, including the widely held view (contradicted by research) that syringe exchange programs encourage drug use.
By March 2015, Kentucky state legislators had authorized the establishment of harm reduction programs subject to city and county approval in each community. As of this April, these programs have been approved in exactly half of the state's 120 counties.
An NGA brief titled Addressing the Rise of Infectious Disease Related to Injection Drug Use: Lessons Learned from Kentucky cited three key insights from the Kentucky experience, with the information gained from extensive interviews with state and local leaders:
Gubernatorial leadership and strong interagency partnerships at the state level can build support for syringe services programs. The vehicle for this in Kentucky has been the Kentucky Opioid Response Effort Cross-Systems Advisory Council established by Gov. Matt Bevin. Among its accomplishments has been identifying an opportunity to use State Targeted Response to the Opioid Crisis funding from the federal government to support syringe services programs.
Funding, data and technical assistance are critical for local communities seeking to introduce harm reduction approaches. Data that demonstrate how syringe services programs in Kentucky have become a prominent referral source to treatment have helped to dispel the notion that these programs do little to address participants' underlying substance use disorders.
Support for comprehensive harm reduction requires engagement of groups in the community such as law enforcement, business leaders and the faith community. “Local leaders need to hear from their friends and neighbors that this is what their communities need,” Kentucky Office of Drug Control Policy director Van Ingram is quoted as saying in the report.
Other states follow suit
Last year, the NGA selected seven states in a competitive process to participate in a learning lab on addressing infectious disease associated with substance use. The states—Alabama, Arkansas, Delaware, Michigan, Utah, Virginia and Washington—convened in March to build on lessons learned from Kentucky, and the NGA worked with leaders in these states throughout the year to help them formulate plans, NGA project leader Melinda Becker tells Addiction Professional.
The numbers regarding infectious disease make a strong case for state action, as the Centers for Disease Control and Prevention says reported cases of hepatitis C increased by 350% from 2010 to 2016, with injection drug use the main driver.
Becker says an important theme emerging from the learning lab involves the need to establish multidisciplinary teams of state and local leaders to work collaboratively toward solutions. In Utah, for example, public safety officials have remarked on how their engagement with public health leaders has shifted their perception of harm reduction.
“There has been an evolution of thinking about syringe services programs,” Tevarson says. “From people who would not have talked about this 10 years ago, it's encouraging to see this level of engagement.”
The NGA brief titled State Approaches to Addressing the Infectious Disease Consequences of the Opioid Epidemic: Insights from an NGA Learning Lab cites numerous examples of progress among participating states. In Virginia, comprehensive harm reduction programs now offer direct counseling and educational materials on substance use prevention and treatment along with syringe distribution, and also provide directly or through referral an array of behavioral and general health and social services.