Doing Harm: Many Prime Opioid-Fighting Strategies Remain on the Shelf

A month to the day after the 2015 announcement of an IV drug use-linked HIV outbreak that put Scott County, Ind., on the world map, Indiana lawmakers held an initial hearing on proposed legislation that would authorize syringe service programs for the first time. As momentum grew during that year's session toward successful passage, one might have expected that Scott County's crisis would fuel a lasting awareness of the importance of public health approaches to fighting community drug problems statewide.

Four years later, much of that promise appears unfulfilled in Indiana—as in much of the rest of the nation. Only nine of Indiana's 92 counties have syringe services programs authorized in the 2015 legislation (Scott County is one). Lawrence County did have a program but terminated it in 2017, with one county commissioner quoting Scripture in explaining how a widely evidence-backed harm reduction strategy ran counter to his moral beliefs.

And while policy leaders in Indiana have more enthusiastically embraced naloxone distribution as a public health approach to combat opioid overdose, most of the funding support for this goes to public entities that have high administrative costs and can't distribute the overdose reversal drug as efficiently as grassroots groups that connect directly to drug-using populations.

“Paternalistic bureaucrats are not well suited to understanding bottom-up strategies,” Chris Abert, founder and director of the nonprofit Indiana Recovery Alliance, tells Addiction Professional.

Organizations such as Abert's are generally left to dream about what they could do with the millions in overdose prevention funding that they see funneled to government and health care entities. “I think about how much naloxone we could distribute with tens of millions of dollars,” he says. “We could saturate the state.”

Voices for change

Indiana Republican State Rep. Ed Clere might appear an unlikely candidate to be harm reduction advocates' closest ally in the state's legislature. His professional background is in real estate, but he says he has held an interest in health issues since reading about the raging HIV/AIDS crisis as a student in the 1990s.

Clere, whose New Albany district sits just south of Scott County, authored the Indiana syringe exchange law in 2015. He chaired the state House's Public Health Committee from 2012-2015. Clere considers it an advantage that the Indiana law embraces evidence-based approaches that, for example, do not mandate one-to-one exchange of needles. However, he laments the fact that syringe service programs must receive local approval in order to begin operations.

“It is politically difficult in many if not most cases, even when there are local health experts who see the value of syringe service programs,” Clere tells Addiction Professional. “The political process tends to involve a lot of misinformation and fear-mongering.”

Lawmakers without a knowledge base in healthcare tend to get swayed by arguments that syringe services programs encourage drug use (research evidence consistently contradicts this), or that a community's playgrounds will become littered with discarded needles if a syringe services program sets up shop. “These tend to be showstoppers,” Clere says of the familiar talking points.

As a result, he says, many Indiana communities that need syringe services programs still don't have them, four years after the authorizing law was adopted. The comparatively few that do have these services are a diverse group ranging from one of the state's poorest and most sparsely populated counties (Fayette County, on the Ohio border) to Indiana's largest county (Marion County, with county seat Indianapolis).

Within the state legislature, some four years after the Scott County HIV outbreak and the syringe services legislation, “We're not even talking about a lot of the things that we should be considering,” Clere says, citing use of fentanyl test strips as a prime example of a topic that has not yet captured attention in his state.

“Harm reduction tends to be a difficult discussion in the legislature,” he says. “Although there is growing interest and acceptance, it's still tentative.”

He believes the fiscal benefits of harm reduction strategies, compared with the costs of treating illnesses such as HIV and hepatitis C, do not receive enough attention among policy-makers.

Naloxone numbers

Abert explains that the Indiana Recovery Alliance began in 2014 as an outreach effort toward the homeless population. Its focus quickly shifted to addiction when its leaders realized that homeless individuals weren't dying because of Indiana's frigid winters, but because of a drug overdose crisis.

The alliance conducts two naloxone trainings a week across the state, trying to attract members of the drug-using community so that they will be able to help a friend or loved one in an overdose scenario. Abert says that in Monroe County (Bloomington), which houses the state's most comprehensive syringe services program and the only one fully administered by those with a drug use history, local law enforcement officials brag about distributing a mere handful of naloxone doses in the community.

“The evidence is clear that when you give out naloxone to EMS and social services agencies, they don't use it with the same frequency as people who use drugs,” Abert says.

This realization nationally gave recent rise to the Opioid Crisis Response Fund, which is operating as a subsidiary of the Harm Reduction Coalition and is launching its effort by supporting community-based organizations in distributing as much naloxone as they can in a year. The Indiana Recovery Alliance is one of the grantees under the initiative.

Abert says leaders of the alliance still spend a great deal of time combating “150 years of society having sent the message that people who use drugs are dangerous, and that we should stay away from them and not help them. To fight against that narrative is quite a fight.”

He adds, “At the state level, we continue to have advocacy days. When those don't work, we do straight-up protests.”

Clere believes communities need to look at naloxone in the same way that automated electronic defibrillators (AEDs) have become an ubiquitous presence in major public gathering places such as schools and sports arenas. He regrets that public safety officers in the largest city in his legislative district still do not carry naloxone.

“That has a lot to do with local politics, and bargaining with the local unions,” Clere says. “There are a lot of holes in the system.”