Portsmouth, Ohio is a bucolic vision of small-town Ohio — predominantly rural, mostly conservative and home to a whopping 20,000 people. It’s also home to an epidemic of injection drug use and a treatment program that locals here are attempting to emulate.
Bobbi Brachett of the Portsmouth City Health Department says nearly everyone in the city has had their lives touched somehow by drug use, with the most tragic instances involving children (the youngest of whom was 4 years old) who have contracted Hepatitis C from playing with tainted syringes found in public. The town has experienced a dramatic spike in heroin use, along with ongoing abuse of methadone and oxycodone.
To address these problems head on, Portsmouth in March 2011 established a syringe exchange program called “Prevention NOT Permission.” The title is a response to opponents of needle exchange programs who view the process of offering drug addicts clean needles in exchange for used syringes as an endorsement of using illegal drugs.
Brachett says those who look unfavorably on injection drug users simply need to hear some of the stories from parents who have lost their children due to addiction and disease.
“Their stories are heart wrenching,” Brachett says. “Those injecting are also our loved ones — they’re our brothers and sisters, our friends and neighbors, our children — it’s our responsibility as a community to help them. We have to get them back.”
The “Prevention NOT Permission” program reported 22,000 syringes exchanged during its first year, which not only helped stop cases of infections exchanged via shared needles, but made streets, parks and playgrounds safer for kids by virtually eliminating discarded syringes.
In Cincinnati, two local advocates are in the process of securing private funding to operate a syringe exchange program called the Cincinnati Exchange Project. Adam Reilly, Planned Parenthood HIV program coordinator, and Dr. Judith Feinberg, of the University of Cincinnati’s Infectious Diseases Center, are moving forward with an effort to medically outfit a recreational vehicle (RV) to be used as a mobile syringe exchange unit. The RV will offer staff members educated in drug counseling along with supporting materials and medically safe syringe exchange disposal equipment. Reilly says being mobile will make syringe exchange viable for areas in the city with the highest rate of HIV, Hepatitis C and incidents of heroin-related overdoses and arrests, including Over-the-Rhine, lower Price Hill and Westwood.
The program was only made possible when the city of Cincinnati Health Department on March 1 issued an emergency ordinance condoning syringe exchange in response to Reilly and Dr. Feinberg presenting a surfeit of data identifying an HIV/Hepatitis C epidemic among injection drug users in the city.
But even though the program is approved, Reilly says it still faces one major stumbling block — Ohio’s laws regarding drug paraphernalia possession. Despite the Health Department’s emergency ordinance, city police can still arrest — and the prosecutor can still charge — individuals possessing used syringes, even if they’re attempting to exchange them for clean ones. Reilly says without the cooperation of law enforcement the program has little chance of succeeding, as users will never feel safe enough to openly offer syringes. At this point, the city’s official stance on the issue remains unknown.
Reilly says he’s received conflicting information on whether the program’s confines fall under Hamilton County or the city of Cincinnati prosecutor’s jurisdiction. Charles Rubenstein, acting Cincinnati prosecutor, confirmed to CityBeat that the issue is within his jurisdiction but verbally declined to comment on whether or not his office planned to pursue such cases. Police Chief James Craig failed to respond to numerous calls and emails by CityBeat, and public relations officials in the mayor’s office attempted to get a statement from Mayor Mark Mallory but also failed to respond prior to publication.
Reilly says his group isn’t expecting law enforcement to overlook crimes involving drug use, only to respect the proven methods approved by the Health Department.
“We’re not saying don’t arrest them if they do something illegal,” Reilly says. “We’re just saying, ‘Let them do the exchange, and if they only have the syringe on them and it’s obvious that they’re exchanging that syringe, then just allow them to do it.’ ”
A cry for help
Twenty-seven-year-old Janice (preferred first name only), admits she started injecting because of a “guy.” While her relationship with the “guy” ended, her relationship with drugs continued. Her addiction eventually led her downtown, where she says she began living on the streets and prostituting to pay for drugs. During this time, she became involved with yet another “guy” — this one she says shared not only his needles, but also his HIV infection. After being picked up for soliciting and facing jail time or rehab, Janice says she finally felt ready to confront her addiction.
“You can’t really make anybody stop what they’re doing — they just really need to come to their own,” she says. “And hopefully they make it there — a lot of people don’t make it. But there’s nothing that you can do to convince someone to stop. I’ve known several people that died.”
For people who feel insulated in the suburbs, Janice says the problem extends far beyond the reaches of downtown. She contends many addicts living on the street find their way there from the suburbs after transitioning from prescription painkillers to heroin or crack, as they’re cheaper and incredibly easy to buy. She says many of the prostitutes on the streets are also injection drug users.
“It affects not just the people doing the drugs who are on the streets,” she says. “There are family men that come down and pick up these girls that come back to their family in the suburbs — it reaches a lot further than people can even imagine.”
Growing up in the suburbs in Florence, Kelly (first name only preferred) says he and his friends frequently visited areas like Avondale and Over-the-Rhine to buy drugs. Kelly says at age 20 his best friend turned him on to heroin. During the next year, he shot up about 50 times with his friend, who was shooting up every day. Kelly says he never really cared about the high as much as bragging about the experience of doing it — something he says now “was a dumb reason, I suppose.” He says the idea of getting a disease or bubbles in his blood stream worried him, so his friend actually did the shooting, always with a clean syringe.
“I remember driving down the road puking out the window hours after I had shot up from the nausea that opiates give me,” he says. “I remember seeing my friend, who was a rather robust dude, wither away into a skeleton of himself in the year that he was active in addiction.”
Kelly says he had quit completely by age 21.
Now 26, he says he feels lucky to never have become addicted, but sees the faces of addiction on the street every day. Walking around Clifton he says the players change, but the glazed look and zombie walk after a good shot remain the same. He worries about kids who might be using and sharing a lifetime of disease along with their needles.
“People can make it out — it’s just, how much will they harm themselves or others before they do?” he says. “This is why I think that a needle exchange is so important and works in the right direction to preserve our youth’s future, cause you don’t know what these kids’ lives will be like in five years and they may not care at the moment. I didn’t. But when they finally open their eyes again and look in the mirror what will they find?”
About five years ago, Dr. Feinberg, while performing attending duties at University Hospital, started seeing an increase of endocarditis cases. Endocarditis is an infection of the heart valve that can ultimately lead to heart failure. The infection requires approximately eight weeks of treatment with intravenous antibiotics and, in more serious cases, surgery to replace the heart valve. Having practiced at Johns Hopkins in Baltimore, Feinberg says she recognized the problem as being as one she’d dealt with before in patients, predominately as a direct result of injection drug use. She estimates the average cost to treat endocarditis with an eight- to 12-day hospital stay with antibiotics to be around $85,000 and heart surgery combined with a hospital stay to be about $250,000.
As most injection drug users don’t possess health insurance, the financial burden defaults to taxpayers. Feinberg estimates the lifetime cost for treatment of HIV to be $600,000. Studies have found the lifetime cost to treat Hepatitis C without a liver transplant to be $100,000-$300,000 and Hepatitis C with a liver transplant to be $300,000-$500,000. Feinberg says a needle exchange program that keeps even one person from contracting a disease will save taxpayers more than the program costs per year (even though the Cincinnati proposal is privately funded).
“There are two halves to this — the first is the addicts themselves and the cost they bring to the health care system,” Dr. Feinberg says, “and the other half of this is the non-addicts who can encounter these syringes in the course of their everyday lives.”
As an internationally recognized expert on HIV, Feinberg says through syringe exchange she hopes to impact the heroin problem in Cincinnati before the two epidemics become inextricably linked.
In the United States, studies report anywhere from 70 to 90 percent of injection drug users to be infected with Hepatitis C, and 36 percent of new HIV infections are directly related to injection drug use. Feinberg says her job as a physician is to treat individuals, not to judge them. She compares injection drug use to other addictions in which users have to be ready to accept treatment, and she emphasizes that it’s a matter of good public health to keep these people from spreading disease to others in the community.
“I think what happens is people’s moral and ethical concerns get hung up in the public safety,” Feinberg says. “By supporting syringe exchange I’m not saying injection drug use is good — that’s crazy. Drug use is an awful thing, but you can’t wish it away. The problem is there and you have to deal with it.”
Besides concern for the users themselves, Feinberg again points to first responders, sanitation workers and residents who might come in contact with tainted syringes. She says through surveys and focus groups, users readily admit to discarding needles in public places, including streets, alleys, parks and playgrounds.
In addition to offering syringe exchange, Reilly hopes to also get permission to distribute Narcan, a medication that halts the effects of opiate overdose and saves the lives of users. The nasal-administered medication produces no side effects and won’t harm users who might be overdosing from a drug other than an opiate. Reilly says he hopes to not only distribute the drug to family members of users, but also other users who might be shooting with someone who overdoses. He says users often flee when someone overdoses for fear of getting arrested.
“If they are armed with this drug and they know how to administer the Narcan, they could do it and then call an ambulance,” Reilly says. “The chance of saving this person’s life goes up exponentially.”
Ideally, Reilly would like to see $125,000 per year for the Cincinnati Exchange Program to operate at maximum efficiency. Non-profit organization AIDS United has already contributed $14,000 in funding for two consecutive years. In addition, Reilly hopes to hear in August if the group will receive in excess of $60,000 in grant money from the Greater Cincinnati Health Foundation. Regardless of funds, Reilly still plans to move forward with the program, as similar programs such as the one in Portsmouth operate on shoestring budgets funded solely by donations. He hopes as the public hears more about the program additional funding will come in.
State of change
During the mid-’90s, Cleveland faced a growing epidemic, as 17 percent of hew HIV cases were related to injection drug use (IDU). To address the problem, Cleveland’s health department and city officials, including the mayor, police chief and prosecutor, worked together to set up a syringe-exchange program in 1995. Continued support for the program coupled with drug education and treatment programs helped reduce the city’s rate of new IDU-related HIV cases to 3.4 percent. Nationally, the rate is 12 percent, according to the Office of National AIDS Policy.
Chris Krueger, syringe access coordinator with the AIDS Taskforce of Greater Cleveland, says that when users establish ongoing, safe relationships with clinic staff members, they’re far more likely to ask for help with treatment when they’re ready.
“There’s actually lots of studies that have shown that across the U.S. that there’s drastic drops of drug use in cities these programs are in and people are more likely to go into recovery and stay in recovery than if they were forced into going into recovery,” Krueger says.
In addition to his efforts in Cleveland, Krueger is lobbying for legislation to make it easier to establish syringe exchange programs across Ohio without having to obtain an emergency order from a city’s health department. House Bill 182 would give a city’s board of health the power to determine if a needle exchange should exist. State Rep. Nickie Antonio (D-Lakewood), who co-sponsored the bill, says the proposed legislation requires a collaborative approach from a city’s board of health, law enforcement and community organizations and would be strictly monitored to meet safety and operational guidelines. She says cities would not be forced to establish a program — the decision would be solely a matter of choice.
“I do believe passing the bill legitimizes the program and offers a way for communities to be able to do this when they want it,” Antonio says. “And by no means does this bill put any pressure on any community to do anything that they don’t want to do.”
The bill would permit a local board of health to establish its own syringe exchange program, permit contracts with private non-profit organizations to operate the program, prohibit the criminal liability for program employees exchanging drug paraphernalia, require program operators to report annually to the department of health and require statewide standards for program participants to carry wallet certifications.
The bill was unanimously supported by the House Health and Aging Committee on Feb. 8 and is currently in limbo awaiting introduction to the floor by Ohio House Speaker William Batchelder. As the former executive director of a women’s center located in inner city Cleveland, Antonio says she understands that it might be difficult to empathize with individuals addicted to drugs but contends that people do eventually seek help, and when they do it’s our responsibility as a community to be there for them.
“You know, sometimes doing the right thing is not the most popular thing, but it’s the right thing,” Antonio says. “And this is the right thing.”
As the bill’s co-sponsor, State Rep. Mike Foley (D-Cleveland) says he introduced the same legislation in 2009, but it failed to pass. This go around, he believes the bill has garnered a newfound support from both Republicans and Democrats who see the issue as a public health emergency. He says he knows firsthand that there is no stereotypical injection drug user. After spending time at Cleveland’s syringe exchange clinic, Foley witnessed people coming in with syringes from the inner city and the suburbs who varied in age, ethnicity and economic backgrounds. He says the atmosphere was not sterile and foreboding, but more of a safe haven where he observed staff members truly concerned for people’s wellbeing.
“The staff had a great relationship with people and it was kind of a safe place if people wanted to get help, they felt like they could get it,” Foley says.
Reilly hopes Cincinnati follows in the footsteps of Portsmouth and Cleveland. He believes local officials need to support a needle exchange program before people’s lives become forever affected by discarded syringes.
“I really hope it doesn’t take some headline news like — ‘Five-year-old gets stuck with syringe in park and contracts Hepatitis C’ for people to take notice,” he says. “That’s the American culture — if you look at a bunch of issues, we’re always reactionary and not proactive.”
As it stands, his group may hand out clean syringes, but Reilly says this alone loses the added benefit of getting used syringes off the street. By exchanging on a one-for-one basis, the program attaches value to each syringe, encouraging users to even pick up discarded ones they find. As users come in for exchange, staff members are able to establish trusting relationships that allow them to discuss treatment options. He says the program in no way encourages or promotes drug use.
“Somebody who is going to inject drugs is going to do that whether they have access to sterile syringes or not,” he says. “I can tell you for a fact, people aren’t waiting for the city to set up a syringe-exchange program so they can start injecting drugs.”
LOCAL ORGANIZATIONS OFFERING ADDICTION SERVICES
A number of local agencies exist to help free individuals from addiction. At the Center for Chemical Addictions Treatment in the West End, CEO Sandra Kuehn says the facility strictly acts as detox center, offering 28-day inpatient programs, outpatient programs and day treatment. She says during the last five years she’s seen a dramatic increase in the number of people coming in for opiate addiction, with this year alone reporting a 63 percent increase. Kuehn says the center provides medically monitored detox and uses the medication Suboxone for opiate addiction to ease withdrawal symptoms. Because detox is considered an emergency service, she says there’s no waiting list and people are admitted on an as-need basis. She says going through detox is the first step in recovery.
“We use medications to reduce the symptoms that withdrawal precipitates, but nothing that we can give a patient will make them as comfortable as they were on their drug,” she explains. “Once they’re clean, we can refer them treatment — because detox is not treatment, it’s just getting your body mentally and physically ready to do something different.”
At Prospect House in Price Hill, director David Logan says the facility offers a 90-day residential recovery program with a measured success rate of 68 percent over the last 10 years. He says one of the major challenges Cincinnati faces is not getting addicts to seek treatment, but instead to find treatment facilities with space to house them. He says Prospect House currently has a three-month waiting list for their program. He says while the state professes to be tough on drugs, programs to help addicts remain critically underfunded. A study by the University of Akron found that for every 10 people who need treatment in the state of Ohio, only one receives it.
“If you get people identified who are interested in treatment and there’s no place to put them, they lose interest in treatment. So it’s a kind of a cruel jest that has been perpetrated in a way,” he says.
For injection drug users who find themselves HIV positive, Caracole House in Northside offers both case management services and housing for those in need. Executive Director Linda Seiter says the goal is to help people establish medical care, obtain necessary medication and learn how to manage their illness. She says for those who are homeless or living in unstable housing, the first step in treatment is providing them with a roof over their head. Seiter fully supports syringe exchange and believes it’s senseless that people are continually infected through needle use when there’s a possible solution. She says it’s frustrating how people readily acknowledge that addiction is a disease, yet at the same time treat it as a moral issue. Seiter says Caracole House is a safe place where individuals will never be judged.
“We don’t care how people contract HIV — that’s unimportant to us,” she says. “What is important is that they have access to medical care, they have access to medication, they have the psycho-social support and access to services that help them be as healthy as possible. The rest is unimportant.”
Center for Chemical Addictions Treatment is located at 830 Ezzard Charles Drive, 381-6672; Prospect House is located at 682 Hawthorne Ave., 921-1613; Caracole House is located at 4138 Hamilton Ave., 761-1480.