On Tuesday July 23, a city police chief, a researcher working in rural Appalachia, and a health department director spoke to a packed room in the Capitol building about the opioid addiction epidemic currently raging across America and why ending the U.S. Congressional ban on federally funding syringe services programs (SSPs) is essential to combating it. The panelists testified that SSPs not only reduce the spread of blood-borne diseases like HIV and hepatitis C, but also help link drug users to addiction treatment, improve community safety, and save millions in taxpayer dollars. “We have a big public health challenge with injection drug use in America,” says Chris Collins, amfAR’s vice president and director of public policy. “We need to base our response on the evidence of what works, and not undermine our efforts with policies divorced from science.”
(Left to right) Chief Jim Pugel, Jennifer Havens, Ph.D., M.P.H, and Kristen Dubay-Horton, M.P.H., speak about the benefits of SSPs at amfAR’s Capitol Hill briefing.
amfAR co-sponsored this Capitol Hill briefing— titled Prescription Opioids, Heroin and Disease Prevention: Law Enforcement, Research and Community Perspectives—as part of an effort to educate Congressional staffers and others in D.C. about the urgent need to assure that SSPs are both available and well-funded. It was co-sponsored by twelve other organizations working on prescription and nonprescription drug use issues and presented in cooperation with the offices of Senator Richard Blumenthal, Senator Martin Heinrich, and Senator Elizabeth Warren.
In 2009, bolstered by the advocacy efforts of a coalition of organizations including amfAR, Congress voted to end the then 21 year-old ban on funding SSPs. However, in 2011 they reinstated it. The timing couldn’t have been worse. The number of heroin users in the U.S. has nearly doubled since 2007, and prescription opioid injection has also spiked, causing incidence of overdoses and infections of diseases transmitted through syringe sharing to rise accordingly.
The U.S. Senate Appropriations Committee has passed a bill that would again allow states to use federal money they already receive to fund SSPs, unless local law enforcement or public health agencies object. This effectively allows local decision-making on this issue at no added expense to the federal government. However, this language could easily not be included in any final spending bill passed by Congress this year. “It is definitely possible to overturn the ban. It took real leadership on Capitol Hill, but we did it before,” says Collins. “This time it will again take key elected officials having the courage to insist on local autonomy and evidence-based policy to address HIV and other diseases in our country.” Currently, 186 cities in 34 states are funding their own syringe exchanges, showing that many localities have already decided it is the right decision for them.
“This time it will again take key elected officials having the courage to insist on local autonomy and evidence-based policy to address HIV and other diseases in our country.”When the ban was first imposed in 1988, evidence on the effectiveness of SSPs was less complete than today. “The belief back then was that if you gave needles, people would start using drugs. That was so far from the truth,” said panelist Jim Pugel, Chief of Police in Seattle, a city that has offered SSPs since the late 1980s. A study by the Institute of Medicine shows that SSPs neither encourage the initiation of drug use nor increase the frequency of drug use among current users. And study after study shows that they do prevent HIV and hepatitis C infection by reducing the sharing of possibly infected needles. Leading public health and medical organizations including the American Medical Association, the National Academy of Sciences, the World Health Organization, and The World Bank have endorsed them—as have the American Bar Association and the U.S. Conference of Mayors.
During the two years that the ban was lifted, 12 states employed over $5.5 million in federal dollars from their own budgets for SSPs, resulting in over $38 million in estimated HIV treatment cost savings by preventing infections. Because many injection drug users (IDUs) do not have private insurance and rely on government health services, much of that savings goes directly to the American tax payer.
Some areas most in need of a SSP cannot afford to employ this programming without using the federal dollars already coming into their community. Panelist Jennifer Havens, Ph.D., M.P.H., an assistant professor on Drug and Alcohol Research at the University of Kentucky, is conducting research in Kentucky’s Appalachia region, which, like many rural and suburban areas, has seen a sharp increase in injection drug use in recent years. “This is one of the most economically depressed areas of the country, so their priority at a local level is on keeping the lights on in schools and other very basic subsistence level needs,” she said. “But if the ban were lifted, it would enable them to at least explore the option.”
"We can get people to a point where they are ready to take that step—which is a very difficult step— to say, ‘Okay, I’m ready to stop.’"And in other areas, existing SSPs don’t have nearly the impact they could have with better funding. Kristin Dubay-Horton, M.P.H., Director of Health and Social Services at the Bridgeport Health Department in Connecticut, said that in her community, half of all HIV infections come from injection drug use— which is well above the national rate of 10 percent. She oversees two SSPs that are featured in amfAR’s ten minute film, The Exchange, about the positive impact the programs can have on individuals and communities. The film, which screened at the briefing, follows a Bridgeport SSP’s van as it goes out into the community to provide counseling and syringe services. “Due to cuts in state funding, there isn’t a van behind my needle exchange anymore,” said Dubay-Horton after the video concluded. “And the person you saw on the screen doing syringe exchanges doesn’t work for me anymore either.”
A recent study showed that one-third of Americans who used drugs for the first time in 2009 began by using a prescription drug recreationally. In 2011, the White House issued a Prescription Drug Abuse Prevention Plan to crack down on this non-medical prescription drug use. But reducing the supply of these pills may have the unintended consequence of increasing injection drug use without accessible bridges to addiction treatment. “We went after prescriptions mills and put them out of business,” says Pugel of the Seattle Police Department’s response, then added that their success increased the market for purchasing the drugs illegally—which forced up their price. “Heroin is now 50 cents on the dollar to what opioids run,” he says. Havens added that the regulations have caused more people to begin injecting the opioid pills, like oxycodone, that they paid high prices to obtain illegally. “People think, ‘I can get a lot more out of this if I inject it versus snorting it or taking it orally,’ ” she said. “They want to get more bang for their buck.”
Studies and recent news items have reported that other rural and suburban areas across the country in states including Colorado, Vermont, Wisconsin, Texas, New Jersey, and Oregon are seeing increases in injection drug use similar to those observed in Kentucky. HIV has yet to break into many of these often isolated areas, including Kentucky’s Appalachian communities, but Havens believes it is just a matter of time until it does. And she fears that unless an SSP has opened by then, HIV will spread rapidly. In one area where she works, 60 percent of the IDUs are living with hepatitis C, showing that needle sharing and other risk behavior for transmitting HIV is high.
SSPs also reduce crime. Chief Pugel reported that in Seattle, when police pick up low-level, non-violent drug offenders, they don’t take them to jail; they take them SSPs to get linked to housing, job counseling, or healthcare, depending on their need. “Low level crime, like car theft and shoplifting, inevitably declines once you have a stable drug user instead of one that’s on the run.” According to one study, employment increased by 44.8 percent among SSP clients within six months, and another study reports that drug users accessing SSPs are five times more likely to enter a drug treatment program than those who are not. Plus, a local SSP means that fewer police officers and firefighters run the risk of get stuck by used syringes that could transmit HIV in the line of duty. Connecticut police officers reported two-thirds fewer needle sticks after SSPs were implemented.
According to Pugel, not prosecuting low-level offenders does not mean the city’s going soft on crime. “It’s the large level dealer who is not addicted who is the business person who we will always go after—and have fun doing it,” he says. “Going after the low-level dealer is too easy and it doesn’t work. They need help,” he adds, explaining why it is time for the government to stop pursuing policies that have failed to curb drug abuse in America—and instead try focusing on those that science shows work.
“We build a relationship of trust with the user,” says Dubay-Horton of how her SSPs do more for IDUs’ health than just offer them clean needles. “They are slowly able to talk about their issues and problems and take control of their life in a way they weren’t. We can get people to a point where they are ready to take that step—which is a very difficult step— to say, ‘Okay, I’m ready to stop.’”
Read more: