The opioid epidemic that now disproportionately affects rural and suburban communities requires decisive action by local government and public health officials. It’s laudable that Assemblymember Susan Eggman, D-Stockton, has initiated a conversation about solutions, particularly her proposal for safe consumption facilities.
But as some who oppose Eggman’s Assembly Bill 186 rightly point out, syringe-access programs (SAPs) are, for now, more appropriate in dense, urban settings. With limited resources, Fresno County would be wise to improve its existing harm-reduction programs that have potential to reach the masses, rather than focus on more complicated services that only a few can access.
Nationwide, it’s estimated that only 29 percent of SAPs are found in suburban or rural areas. People in sparsely populated areas generally have trouble reaching SAPs that are far away, making it less likely that they will use them. A 2015 HIV outbreak in rural Indiana that was linked to injection drug use highlighted the feasibility concerns that attend implementing some of these programs in rural settings.
As was noted at the time by then-Indiana Health Commissioner Dr. Jerome Adams, who was confirmed earlier this month as the 20th U.S. Surgeon General, “health officials must function within the culture and laws of their environment.”
Mobile and outreach programs can alleviate some of these issues, but there is only one semi-mobile SAP currently operating in Fresno County. Simply put, for geographical and political reasons, Fresno County isn’t there yet.
However, Fresno County does have an opportunity to improve its harm-reduction services vastly, including through improved distribution of clean syringes and the drug naloxone to reverse overdoses.
Injection-drug use in Fresno County is three times higher than the national average, due largely to the prevalence of methamphetamine production within the county. Therefore, it is imperative that harm-reduction services are targeted toward these unique needs.
The Fresno Needle Exchange is currently the only standalone harm-reduction services program in Fresno. With a budget that only covers supplies and an all-volunteer staff, it is the sole program to distribute nearly 1 million syringes and thousands of naloxone prescriptions per year. While 1 million syringes might seem a mind-blowing number, it is hardly enough to keep up with demand.
For effective prevention of disease transmission, the Joint United Nations Program on HIV and AIDS recommends 200 sterile syringes per injection drug user per-year. With approximately 16,000 injection drug users in Fresno County, only 25 percent of those who should be getting sterile syringes are covered.
Allocating municipal funds to support SAPs is cost-effective. On average, it costs an SAP between $4,000 and $12,000 to prevent one HIV seroconversion – far below the estimated $385,000 it costs to treat one diagnosis of HIV. In 2008, Washington, D.C., allocated $650,000 of municipal revenue to fund SAPs; within two years, it’s estimated that policy change averted 120 new cases of HIV and produced a cost savings of $44 million.
Naloxone distribution by community programs costs approximately $15 per distributed dose, with estimates that approximately 10 percent of distributed doses are used to prevent overdose. A cost analysis predicts that naloxone distribution results in a cost of $2,500 for each year of health gained. That’s far below the $50,000 threshold traditionally considered to be cost-effective by public health professionals.
Opponents of harm-reduction programs often suggest that treating addiction would be a better long-term goal. But analysis of SAPs and other harm-reduction programs conclude that they actually correlate with greater entry into treatment programs.
In Baltimore, people who visited SAPs were more likely to enter treatment that those who did not; in Seattle, people who use SAP services are more likely to remain on methadone treatment. This makes sense. SAPs and other harm-reduction programs allow a person who uses drugs to interact with volunteers, a nurse or counselor who has the person’s best interests in mind.
They can aid both in the short term, by providing clean syringes, and over the long term, by providing options for treatment programs and facilities.
Before suggesting that Fresno County ought to allow safe injection facilities to prevent disease transmission and overdose, county officials need to be encouraged to authorize harm-reduction services to operate at a level that can reach people who need them all across this 6,000-square-mile county.
Dr. Carrie Wade is the harm-reduction policy manager for the R Street Institute. Connect with her on Twitter @CarrieWade.