Health advocates offer tips for getting reluctant local governments to approve syringe exchanges, or 'harm reduction programs'

By Melissa Patrick
Kentucky Health News

Kentucky leads the nation in syringe exchanges for drug users, as a way to prevent the spread of disease, but local officials in some counties at risk of disease outbreaks from intravenous drug use have resisted pleas from experts to allow exchanges.

At a public-health panel discussion, advocates of the exchanges shared some advice on how to overcome the opposition: persistence, partners, new terminology, realizing that politicians want to get re-elected, and having plenty of arguments at hand,

"Also remember that logic and rationality doesn't always win out, passion and persistence does," said Sheila Schuster, executive director of Advocacy Action Network, an umbrella organization of lobbies, who has lobbied the state legislature for more than 40 years.

The importance of early prevention, and access to care for mental health and substance-use disorders, were other topics of the panel, hosted by the University of Kentucky College of Public Health during National Public Health Week, which falls during the first week of April.

Dr. Ardis Hoven, an infectious disease specialist and consultant with the state Department for Public Health, called Kentucky's syringe exchanges a "bright spot" when it comes to tackling the issue of substance abuse and addiction, adding that she was "exalted" that they had taken off as they had.

Kentucky lawmakers approved such programs in 2015 in an anti-heroin bill, as a way to decrease the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among intravenous drug users. They require both local approval and funding. Since, local governments have approved 52 syringe exchanges, with all but four operational.

Hoven said she preferred to call the exchanges "harm reduction programs," saying that the term more accurately describes what they do. She said they not only pass out clean needles and syringes, but also provide health screenings and vaccines, access to treatment in real time, and a place to build trusting relationships between clients and workers.

Former Gov. Steve Beshear, who was governor when the anti-heroin bill passed, told the group that while it's important to recognize that politicians are always working toward re-election and don't want to deal with controversial issues, they often "answer to the squeaky wheel." He added that "persistence and leadership" are key to any advocacy work, adding that it often takes several tries to get something done.

Dr. Hatim Omar, a pediatrics professor at UK, advised the group to make sure they put a human face to the problem, because that makes it real, and to present their case in a way that would benefit the local official, reiterating that their main concern is to get re-elected.

Schuster, who has worked with the legislature since 1978, said she learned early on that you have to show up with a better argument than "It's the right thing to do."

Schuster, who largely advocates for mental-health and disability issues, told advocates that they needed to find unlikely partners, like the faith community; get to know the members of local governments and health boards; learn from other communities that have succeeded; have multiple arguments at the ready; and, most importantly, just show up.

"You've got to stir the pot," Hoven said. In addition to being armed with data and information, she encouraged building coalitions that truly understand the issue and are able to articulate it and to work with their local health departments. She also encouraged them to make sure they bring the police to the table.

"The other thing that you need to be ready to do at any given moment is to defend what a syringe service program or exchange program is and what it is not," she said. "And you ought to be able to do that in your sleep. That's crucial."

Opponents of syringe exchanges often base their criticisms on belief, not fact, and that's sometimes true of policymakers, Schuster said. For example, she said some legislators tell her that they think the programs enable drug use, which they don't, according to research; or that they need to be a strict one-for-one exchange, which undermines the goal of thwarting infection.

"We need to be educating our policymakers, because they are operating on wrong information," said Schuster.

On another front, Omar said the best way to treat addiction is to prevent it.

He pointed to the National Longitudinal Study on Adolescent to Adult Health, which found that teens who have a solid support systems, like having an adult to talk to and living in a safe environment, along with having something useful to do, are more likely to be successful in school and are protected against many things, including addictions, suicide and early sexual activity.

"This is I think where we are failing our young people," he said. "We are not providing adequate support systems."

He stressed that we also have to be honest when we talk to children about these topics, adding that the U.S. has to get over the "repetitive myth" that providing factual information to young people about drugs, sex and suicide will prompt them to do it.

"All the science in the world shows it's exactly the opposite," he said. "Knowledge is power, it improves things. . . . People do it because they don't know any better."

Beshear, who expanded Medicaid to Kentuckians who earn up to 138 percent of the federal poverty level, spoke to the importance of having access to health insurance as a way to combat substance-use disorders. He said that since the expansion in 2014, Kentucky's uninsured rate has dropped from over 20 percent to 7.5 percent.

He pointed out that the Patient Protection and Affordable Care Act is also the reason health insurance plans now cover mental health and substance-use disorders, including the Medicaid expansion population. He added this coverage to the traditional Medicaid population. Schuster added that in the first three years after the state expanded Medicaid, there was a 700 percent increase in the utilization of substance-use-disorder treatment.

Everyone on the panel agreed that until Kentucky addresses its social determinants of health, which are things like housing, education, employment, and environmental exposures that are known to affect health and well-being, it's unlikely that the state will truly improvements in its health outcomes.

"For us to ultimately get somewhere we've got to address all of those things," said Beshear.

Hoven, who called this issue "the elephant in the room,"  said that when it comes to social determinants, "We can flap our gums all day long," but until Kentucky dedicates policies that are completely funded and that empower the leaders of communities to deal with these issues, the state won't make much progress.

Schuster reminded the group that we also have to overcome the stigma that continues to exist around mental health and substance use disorders: "Stigma is alive and well."