1

SAFE SYRINGE TENNESSEE

THE EPIDEMIC

There are an estimated three

million people living in the
United States with a
Hepatitis C Virus (HCV)
infection, more than any
other blood-borne infection
in this country. More than
1.2 million people in the
U.S. are living with the
Human Immunodeficiency
Virus (HIV), with the
highest percentage rate (16.8
per 100,000 people) being
located in the Southern part (https://www.cdc.gov/hiv/statistics/overview/geographicdistributi

of the country (aids.gov). According to the Centers for Disease Control and Prevention (CDC),
about 25% of HIV-infected individuals in the U.S. are also infected with HCV. Among Injection
Drug Users (IDUs), the coinfection rate is estimated to be anywhere from 50-90% (CDC, 2016).
Surveillance reports provided by the states revealed that reported cases of the virus increased by
almost 400% during the reported 7 year time period, among the central Appalachian states of
Kentucky, Tennessee, Virginia and West Virginia (Centers for Disease Control and Prevention,
2015).

CONSEQUENCES OF INJECTION DRUG USE

Injection drug use remains the most common risk factor for acquiring HCV in the United
States. This risk factor accounts for more than 50% of the cases of HCV. According to the CDC,
an estimated 20 to 30% of people who use injection drugs become infected with HCV within two
years of starting to inject drugs. Demographic and behavioral data accompanying these reports
show young persons (aged 30 or under) from non-urban areas contributed to the majority of
cases, with about 73% citing injection drug use as a principal risk factor (CDC, 2015).

WHAT ARE WE DOING NOW?

Injection drug use, in particular, opioid drug use, is an increasing issue in the state of
Tennessee. This particular addiction often begins with the over prescription of legal opioids for
pain management. The CDC lists Tennessee as one of the top prescribing states for prescribing
opioids, stating that the state has 142 opiate prescription per 100 people (CDC, Prescribing
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Data). According to a study by Lankenau, Kecojevic, and Silva (2015), HCV positive individuals
are three times more likely to have a history of opioid injection drug use than HCV negative
individuals. The fourfold increase of HCV in the central Appalachian states in the Morbidity and
Weekly Report by the CDC (2015) occurred during a rise in treatment admission for opioid
dependency with significantly more patients reporting injection drug use than ever before.

The direct cause of the spread of bloodborne disease among the IDU population is the
contamination of shared IDU supplies such as needles, syringes and works. The lack of access to
clean supplies directly correlates to the spread of these diseases. Tennessee Comp.R.Regulations
1140-03-.12 (3) prohibits instruments or devices intended to administer the injection of any
substance through the skin cannot be accessible to the public and can only be sold if there is the
proof if a medical need under the supervision of a pharmacist. This severely limits access to
clean syringes and needles. Currently, there is no law in Tennessee that allows explicitly for
needle exchange programs.

WHAT COULD WE BE DOING?

DO NOTHING What are the options?

Heroin use stemming from Do Nothing: let the epidemic manifest
a graduation of opioid use has Syringe Exchange Programs: provide clean, sterile syringes an
Methadone Maintenance: prescribe a drug to suspend heroin a
increased in the state of Tennessee,
Sterilized Injection Facilities: create a safe environment for ID
with a number of 1.18
Harm Reduction: prevention of the physical, social, and econom
prescriptions for every 6.5 million
Tennesseans (Fletcher, 2016). This
drug is more potent, more
accessible, less expensive than
opioids, and in most cases it is
injected if not completely pure.
The scarcity of clean needles and
syringes for those who suffer from
addiction leads them to sharing
this equipment and thus exposes
them to an increasingly high risk
for HCV and HIV.

The contraction of HCV

and HIV is a public health problem
and without access to clean
supplies for those who use
injectable drugs, the threat of an
outbreak is daunting. As the usage
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rate of opioids and heroin increase so does the risk for HCV and HIV affecting communities
across the state, many of those rural and without basic treatment services and resources.

SYRINGE EXCHANGE PROGRAM

Syringe Exchange Programs (SEPs) have developed across the country in response to the
HIV/HCV epidemic. Studies show that some injection drug users would use the same needle up
to three hundred times (Johnson, 2015). However, people can reduce the risk of HIV/HCV
transmission by using a sterile needle and syringe for every injection. Syringe exchange
programs provide free, sterile needles, syringes, and needle disposal options for injection drug
users (Centers for Disease Control and Prevention, 2016). They also supply other prevention
materials such as: alcohol swabs, sterile water, and condoms. Studies have shown that programs
advocating only behavior change without complementary attention to the social and
environmental factors that may counter behavior
change, have had marginal success (Crawford, Amest,
Rivera, Harripersaud, Turner, & Fuller, 2014).
Therefore, these programs include other services such
as: education on safer injection practices, wound care,
overdose prevention, referrals to treatment centers,
medication assisted programs, counseling, links to
HIV care, treatment, and testing, hepatitis A and B
vaccinations, screenings for sexually transmitted
diseases and tuberculosis, and prevention of mother-
to-child transmission. Needle/Syringe Exchange
Programs have shown reduction in HIV seroconversion rates, less harm to injection drug users,
decreased needle sharing, and fewer contaminated needles in rotation (Ksobiech, 2003).

METHADONE MAINTENANCE

Methadone maintenance is another policy alternative that has the potential to lower the
rate of HIV and HCV in IDUs. Due to strict regulations that prohibited medical heroin to treat
heroin addiction, the U.S. Food and Drug Administration (FDA) approved methadone
maintenance treatment for heroin addiction in 1972 after numerous studies testing the efficacy of
the treatment, but was not allowed for treatment until reviews of the treatment by the Institute of
Medicine (Rettig & Yarmolinsky, 1995). Over the years Federal regulations were revised
allowing treatment providers more latitude in planning treatments regimens, but they have to
document the outcomes and shortcomings for the treatment (Marion, 2005). Methadone is a
well-studied medication to treat opioid addiction as it blocks the craving for opioids, suppresses
the withdrawal symptoms for 24 to 36 hours, blocks the effects of administered heroin, and does
not cause euphoria or intoxication (Joseph, Stancliff, & Langrod, 2000). Studies show that
spending time in a methadone maintenance clinic can affect many aspects of the participants
life in a positive way, including reduction of HIV risk, (Corsi, Lehman, & Booth, 2009).
BuildingBetterLives 4

Currently, Tennessee has 12 locations that are opioid treatment clinics with methadone
maintenance. The use of methadone allows users to have a way to beat their cravings, but at the
same time limit their potential exposure to HIV and HCV. While methadone maintenance is used
as a secondary form of HIV/HCV prevention, Bruce suggests it needs to be a primary form of
prevention in order to reduce the likelihood that HIV and HCV are not transmitted to other drug
injecting users. The reasoning behind this is by the time a drug injecting user gets into treatment,
they will have accumulated medical health and mental health problems from the delayed
treatment (Bruce, 2010).

STERILIZED INJECTION FACILITIES

Sterilized injection facilities (SIF) have been regarded as something that could be one of
many paths to public health of intravenous drug users and specifically the transfer of HCV and
HIV through public shared injecting. The sites offer supervised opportunities for drug users to
consume independently secured substances in a safe and preventative environment. According to
Davies (2007), reducing incidents of infectious diseases, is among the general objectives for
SIFs around the world; however, there is little longitudinal research that concludes that the
facilities create a decrease in the rate of HIV, HCV or other infectious diseases. This is primarily
due to the lack of feasibility in measuring the traces of infectious diseases that present in
substance users (Davies 2007). Despite this, what these sites can foster is service uptake amongst
its visitors. When attendees have access and knowledge of treatment programs for substance
abuse, they can get to HIV and HCV harm reduction (Wright, 2004).

As of 2017, there is only one SIF nationwide that is in its beginning stages in Seattle,
Washington. Leaders in this city express their concerns for a lack of change in past decades of
ineffective tactics and that something new needs to be done (Aleccia, 2016). This approach
primarily is looked at as preventing overdoses and taking an indirect approach to helping people
live sober or consume drugs in a safer environment thus leading to safe drug use.

HARM REDUCTION

Harm reduction is another path that can be taken in attempt to reduce HCV and HIV
contractions. It focuses on the prevention of the physical, social, and economic problems of drug
abuse that does not require the actual decrease in drug consumption (Brown, Luna, Ramirez,
Vail, Williams, 2005). It integrates the concept of human rights, social justice, and health of
communities that serve as the focus of measurement instead of drug users. This strategys main
purpose is to empower the consumer of health services. One of the basic fundamentals of this
philosophy is that drug users are at times not able or willing to end drug use, and that substance
use, either legal or illegal, is inevitable. Therefore, abstinence is unachievable and treatment
programs that only offer abstinence-based curricula are excluding many people who use drugs
and increasing the risk of HCV/HIV contraction. Common risk reduction programs include fact-
BuildingBetterLives 5

based drug education, drug use related illness and injury prevention, and appropriate drug
treatment (Harm Reduction, 2017). In Tennessee, there are four known programs rendering risk
reduction services and they exist in Memphis, Nashville, and Chattanooga (Tennessee - Connect
Locally, n.d.). There are no services like these in rural or less urban environments in the state of
Tennessee.

THE SOLUTION

The growing success and research of SEPs has prevented the contraction and spread of
HIV and HCV (Center for Disease Control, 2016). The effectiveness of these programs relies on
the availability of safe, preventative materials and outreach involvement. States that have
adopted laws that allow needle purchases in pharmacies without prescriptions have seen an even
larger decrease in HIV/HCV infections as well as increased disposal of needles. Nearly two
million needles have been kept out of San Francisco waste with this expanded program.
(Medscape, 2017). California laws allow adults over eighteen to purchase an unlimited amount
of needles and syringes. Pharmacies in these programs must provide safe disposal of needles,
provide written information or verbal counseling on drug treatment, access testing and treatment
for HIV/HCV, and information about how to safely dispose of sharps waste, and store needles
and syringes behind the counter (State of California, 2016).

In 2015, the South accounted for 52% of all AIDS diagnoses (Center for Disease Control,
2016). In Tennessee, one person out of one hundred and three, is experiencing lifelong risk of
HIV. Allowing needle sales in
pharmacies would decrease https://www.cdc.gov/hiv/statistics/overview/geographicdistr

the spread of HIV in

Tennessee. The counseling,
preventative materials, and
social support also show a
reduction in risky behaviors
from injection drug users
leading to their choice to get
clean. This decreases the
likelihood of contraction and
contamination through intravenous drug use, sexual intercourse, and needle sharing (Coyle,
Needle, & Normand, 2016). The proposed policy change is to create syringe exchange programs
in Tennessee while also allowing the sale of needles at pharmacies without prescriptions.
BuildingBetterLives 6

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. . Hadian, M. (2013). Effectiveness of Methadone Maintenance Treatment in Prevention

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BuildingBetterLives 7

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