By Kate Goertzen and Michal McDowell
Across the country, lawmakers are working to curb prescription drug abuse. From North Carolina to Kentucky, to New York and West Virginia, political leaders have acknowledged the surge in the illicit use of prescription drugs, noting that “we cannot ignore the resulting devastating effects that are sweeping across the nation.”1
While the connection of prescription drug abuse to the rise in heroin use has been made by some lawmakers, what few will acknowledge publicly is the inherent link to harm reduction through syringe services programs (SSPs) for those who inject drugs. We should celebrate efforts to reduce the availability of prescription drugs for illicit use, but we must also remember that this reduction in supply, without a ramping up of available harm reduction interventions and pathways to addiction treatment (through SSPs, for example) may have disastrous effects.
The FDA recently blocked new generic formulations of the popular OxyContin (crushable formulations that are also easier to melt), stating that “the development of abuse-deterrent opioid analgesics is a public health priority for the FDA.”2 Representative Fred Upton and Senator Tom Coburn commended the FDA for this decision, noting that it “will help mitigate the harmful effects of the nation’s prescription drug abuse crisis, including the suffering it causes in families across our country.”3 They urged the FDA to enact similar regulations for new generic formulations of other drugs in the future.
The intention here is a noble one—especially in the face of a four-fold increase in overdoses from prescription opioids over ten years.4 But while it’s easy for lawmakers to get behind the messaging around curbing prescription drug abuse, it seems unlikely that such restrictions will have the intended impact on a larger scale. Though the FDA decision could deter some new illicit use of prescription drugs, it could inadvertently cause a great deal more people to inject heroin. As the FDA states in its report, after developing a level of tolerance individuals using prescription drugs illicitly often shift from taking pills orally to injecting the crushed, melted down pills for a quicker, more intense high. In eastern Kentucky, for example, over one-third of individuals abusing prescription drugs inject the drug.5
Even without the new FDA restrictions, the transition to more economical heroin is a logical one. Studies have documented that prescription opioid use may lead to heroin use, especially in southern states and Appalachia. Price is an important factor: while one dose of OxyContin costs roughly $80 outside of a pharmacy setting, heroin runs an average of $20 per dose.6 In the wake of the new restrictions, individuals will not have the option of injecting prescription opioids and thus may more readily make the transition to heroin. In the absence of evidence-based drug addiction treatment options like SSPs, making prescription drugs harder to obtain or use illicitly inevitably means more heroin use—and without access to harm reduction programs, increased rates of blood-borne diseases such as HIV and hepatitis C.
Regardless of the drug of choice, there is a very real danger associated with unavailability of sterile syringes for injecting drug users. By the end of 2009, more than 130,000 HIV-positive people living in the United States had contracted the virus through injecting drug use. In 2010, 7% and 14% of new HIV infections were attributable to injection drug use for men and women, respectively, a considerable decrease compared to the 1990s.7 This downward trend may be short-lived, however, as some experts predict a sharp uptick in new infections given the recent younger average age of first injection, and the shift to greater injection drug use among upper- and middle-class Americans.8, 9
The ban on the use of federal funds for SSPs in the U.S., enduring for the last 20 years (except when the ban was lifted in 2009–2010) has severely restricted the freedom of states to execute their right to allocate dollars. Under the current ban, states are prohibited from using federal funds to support lifesaving SSPs, and thus from effectively addressing the particular needs of their communities.
Harm reduction through SSPs enjoys wide support. Many law enforcement professionals, first responders, firefighters, and other emergency personnel embrace syringe exchange as a practical public safety measure that can significantly reduce exposure to HIV as an occupational hazard.10, 11 In addition, syringe exchanges provide public health benefits such as entry into drug treatment programs for people who inject drugs; in fact, SSP participants are five times more likely than those not utilizing services to enter and sustain drug treatment.12 Cynthia Sullivan of the Winston-Salem, NC, police department put it this way: “SEPs are good in that they help reduce risk for police officers [who may accidentally get stuck by needles disposed of improperly] when they go out on calls. I personally do not believe that SEPs increase drug use, but make officers safer. These programs are important to our communities.” 13
Faith leaders have also spoken up in support of this issue, terming SSPs “common sense”14 while often taking personal legal risks to help others stay safe. In North Carolina, for example, where syringe exchange is not legally authorized, a pastor operates an SSP out of his personal vehicle, often making house calls late at night. He is one of many faith leaders across the country finding a way to, as he puts it, make it known that “[w]hile [the] statistics should frighten anyone, it is those same statistics that should force us to expand syringe access programs or at least change the way we think about them.”15
Nowhere are the effects of the federal funding ban felt more deeply than in communities of color, where the impact of HIV/AIDS has been devastating. While they have similar rates of drug use as whites, African Americans are eleven times as likely and Latinos five times as likely to contract HIV from injecting drugs compared to Caucasians.16 And, once infected, both groups are less likely to get tested for HIV, become engaged in care, and be retained in that care.17
While a variety of interventions are needed to address heroin and prescription drug abuse trends, relaxing restrictions on how states can use their own money is imperative. Allowing this financial flexibility does not cost the U.S. taxpayer a cent. Moreover, studies show that for every dollar spent on SSPs in the U.S., three to seven dollars associated with HIV treatment costs are saved.18 In the brief period in which the ban on the use of federal funds was lifted for most of fiscal years 2010 and 2011, about $5.5 million in federal funds across 12 states 19 was utilized for harm reduction programs. This modest investment resulted in an estimated $16.5–$38.9 million in savings. Just imagine what progress could have been made by now had states been able to continue allocating prevention funds in a manner appropriate for their communities.
With prescription drug users across the U.S. shifting to injection—and to heroin, we are sacrificing public health, public safety, and public money at the altar of ideology and petty politics. Letting states spend their life-saving prevention dollars as they—backed by the evidence—deem most effective, should be an easy call.
1 Rogers supports bill to reschedule most abused prescription painkillers. Floyd County Times (March 2013). Available at: http://www.floydcountytimes.com/
2 FDA blocks generic version of crushable OxyContin. USA Today (April 16, 2013). Available at: http://www.usatoday.com/story/news
3 Letter from Rep. Fred Upton and Sen. Tom Coburn to FDA Commissioner Margaret Hamburg (May 3, 2013). Available at: http://energycommerce.house.gov/
4 Calcaterra S, Glanz J, Binswanger I. National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009. Drug and Alcohol Dependence 131 (2013): 263-270. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23294765
5 Havens J, Walker R, Leukefeld C. Prevalence of opioid analgesic injection among rural nonmedical opioid analgesic users. Drug and Alcohol Dependence 87 (2007) 98-102. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16959437
6 Drug Free Newsroom, Kentucky Finds Heroin on the Rise as Prescription Drug Abuse Declines. Available at: http://www.drugfree.org/join-together/community-related/
7 Centers for Disease Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention. HIV Surveillance in Injection Drug Users. Available at: http://www.cdc.gov/hiv/idu/resources/slides
8 Horyniak D. Understanding health and harm among young people who inject drugs. Centre for Research Excellence into Injecting Drug Use. Available at: http://creidu.edu.au/projects/1
9 Lankenau SE, et al. Patterns of prescription drug misuse among young injection drug users. J Urban Health 2012 89(6): 1004-16. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22684424
10 NCHRC. NC Study Reveals that Law Enforcement Want to Reform Paraphernalia Laws. January 2013. Available at: http://www.nchrc.org/law-enforcement/north-carolina-law-enforcement-attitudes-towards-syringe-decriminalization/
11 amfAR. Public Safety, Law Enforcement, and Syringe Exchange. March 2013. Available at: http://www.amfar.org/
12 Hagan H, et al. 2000. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. Journal of Substance Abuse Treatment 19(3): 247-252.
13 Cynthia Sullivan, Victim Assistance Coordinator, Police Department, Winston-Salem, N.C., March 2011. From personal communication and as cited in: amfAR, The Foundation for AIDS Research. Fact Sheet: Public Safety, Law Enforcement, and Syringe Exchange. March 2013. Available at: http://www.amfar.org/uploadedFiles/
14 Sister Maureen Joyce, CEO of Catholic Charities in Achieve: A quarterly journal on HIV prevention, treatment, and politics (Winter 2010). Available at http://www.gmhc.org/files/editor/file/r_a_winter10.pdf
15 Pastor James Sizemore. A Life-Saving Yet Illegal Syringe Program. The Fayetteville News Observer (July 2, 2013). Available at http://www.newsobserver.com/2013/
16 CDC. HIV Infection Among Injection-Drug Users—34 States, 2004-2007. Available at: http://www.cdc.gov/mmwr/
17 Centers for Disease Control and Prevention. HIV in the United States: The Stages of Care. Available at: http://www.cdc.gov/nchhstp/
18 Nguyen TQ. Increasing investment in syringe exchange is cost-saving HIV prevention: modeling hypothetical syringe coverage levels in the United States. Nineteenth International AIDS Conference, Washington DC, abstract MOAE0204, 2012. Available at: http://www.iasociety.org
19 Personal communication with state health departments, February-March 2012.