Ethical Analysis of the Needle Exchange Program Policy in Ohio



Ethical Analysis of the Needle Exchange Program Policy in OhioConcordia University NebraskaAndrea Eden Shingleton10/18/2015IntroductionA needle exchange program (NEP) is a public health preventive measure that has been questioned from a moral and policy perspective since its inception CITATION OGu10 \l 1033 (O'Gurek & Kirchner, 2010). As the major proposed intervention for the prevention of blood-borne pathogen transmission among intravenous (IV) drug users in the United States and worldwide; NEP is defined as the provision of sterile syringes to, and collection of contaminated syringes from, persons who inject drugs (PWID) CITATION OHA15 \l 1033 (OHAIDP, 2015). Protecting PWID from being infected with deadly viruses like human immunodeficiency virus (HIV) and hepatitis B (HBV) and C (HCV) is the short-term goal of a NEP. The long-term goal is to direct individuals to a recovery program, leading to life-long abstinence CITATION OGu10 \p 60 \l 1033 (O'Gurek & Kirchner, 2010, p. 60). This paper will discuss the epidemiological and biostatistical data, the medical and economic cost, the history of NEP policy and the ethical analysis of NEP policy in Ohio.Epidemiology and BiostatisticsIn the U.S and regionally, there is a growing trend of IV drug use. In 2007, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that approximately 424,000 people inject drugs in the U.S. annually. The widespread use of injectable heroin has infected young PWID with preventable viral blood-borne infections. A known risk factor for the acquisition of HBV, HCV and HIV infection, IV drug use is epidemic in Ohio. In Figure 1, there are eight areas of Ohio identified as ‘heroin hot spots’ CITATION Dra15 \l 1033 (Drabold, 2015). Heroin is highly available in all regions of the Ohio CITATION ADA12 \l 1033 (ODADAS, 2012). In recent years, a surge of HCV and HIV infections has been detected among young PWID in the U.S and locally. Rising rates of HCV and HIV infections are primarily among young, Caucasian, both male and female, from suburban and rural settings, who inject drugs, and who started misusing prescription opioids (e.g., oxycodone) before transitioning to heroin injection CITATION OHA15 \l 1033 (OHAIDP, 2015). Figure SEQ Figure \* ARABIC 1- The 2012 Heroin Clusters in Ohio CITATION Dra15 \l 1033 (Drabold, 2015)According to the CDC new HCV infections in young adults more than quadrupled in four neighboring states; Kentucky, Tennessee, Virginia and West Virginia (see Figure2) from 2006 to 2012, with many cases linked to injection-drug use CITATION Cam15 \l 1033 (Campos-Flores, 2015). New HCV cases in the U.S. remained constant until there was a significant increase of 151.5% from 2010 to 2013 with the largest increases in rural areas CITATION CDC131 \l 1033 (CDC, 2013). The Institute of Medicine reported that the incidence of acute HBV infection is declining in the United States, due to the availability of hepatitis B vaccines, but there are still about 43,000 new acute HBV infections each year CITATION IOM10 \l 1033 (IOM, 2010). But for the first time since 1990, in 2013, the number of reported cases of acute HBV infection increased to 3,050 cases, which represented a 5.4% increase from 2012 CITATION CDC131 \l 1033 (CDC, 2013). No vaccine is available for HCV or HIV. Chronic HBV and HCV account for more than 50% of new cases of chronic liver disease, a leading cause of death CITATION CDC131 \l 1033 (CDC, 2013). Since 1981, the human immunodeficiency virus (HIV) has killed more than half a million people in the United States CITATION OGu10 \p 59 \l 1033 (O'Gurek & Kirchner, 2010, p. 59). Thirteen percent of the new cases of HIV were attributed to injection drug use and 25 % of HIV infections progressing to Acquired Immune Deficiency Syndrome (AIDS) from 2004 through 2007 CITATION OGu10 \p 59 \l 1033 (O'Gurek & Kirchner, 2010, p. 59). The CDC ranked Ohio 13th among the 50 states in the number of HIV diagnoses in 2011 with an estimated 1,218 adults and adolescents. Figure SEQ Figure \* ARABIC 2 New Cases of hepatitis C in 2013 CITATION Cam15 \l 1033 (Campos-Flores, 2015)Abuse of opioid painkillers and heroin in rural areas and small cities, as reported by Campos-Flores (2015) is triggering the escalation of co-infections of HCV and HIV in these unusual regions. Co-infections in Ohio have grown by 50% over the past five years CITATION Cam15 \l 1033 (Campos-Flores, 2015). In March 2015, an outbreak of HIV in a rural southeastern county of Indiana was detected. In this small rural area of 4,200 people, 135 people were HIV infected by May; by June the number had grown to 169 and by August it was 181 (CDC, 2015; Campos-Flores, 2015; ISDH, 2015). Commencing after the sharing syringes to inject the painkiller, Opana, the Indiana HIV epidemic has lead community leaders and policymakers to reconsider the traditionally controversial prevention strategy of NEP CITATION Cam15 \l 1033 (Campos-Flores, 2015). In this outbreak, 84.4% of the patients were co-infected with HCV CITATION CDC154 \l 1033 (CDC, 2015).Medical and Economic CostWithout diagnosis or treatment blood-borne viruses can lead to death. Untreated HCV and HBV can lead to cirrhosis or cancer of the liver, chronic liver failure, liver transplant or death CITATION CDC131 \l 1033 (CDC, 2013). Promising new HCV drugs have high cure rates, but can cost more than $80,000 per patient CITATION Cam15 \l 1033 (Campos-Flores, 2015). As indicated by the U.S. Department of Health and Human Services (DHHS, 2015), untreated HIV leads to AIDS; these individuals typically survive about 1-3 years and die from an opportunistic infection. HIV medications or antiretroviral therapy (ART) maintains a low viral load giving the individual a normal life span. The lifetime cost of HIV treatment is estimated at $400,000 CITATION Cam15 \l 1033 (Campos-Flores, 2015). Studies from the late 1990s found that the cost of a NEP to prevent one HIV infection ranges from $4,000-12,000 as compared to the estimated $190,000 lifetime medical costs of treating a person with HIV at that time CITATION Bow12 \l 1033 (Bowen, 2012). In California, Pacific Pride Foundation’s NEP recently substantiated that the percentage of new HIV infections attributable to IV drug use decreased from 18% of the total in 2006, to 15% in 2007, and then dropped to only 3.7% in 2008 CITATION OGu10 \p 60 \l 1033 (O'Gurek & Kirchner, 2010, p. 60). A study in the Journal of Managed Care Pharmacy estimates that the medical expenses of a person who is abusing opioids is eight times as high as those who do not abuse opioids CITATION ADA12 \l 1033 (ODADAS, 2012).The societal costs of infections from blood-borne pathogens are enormous. In addition to the loss of human lives, increases in avoidable infections paired with Ohio’s opiate epidemic have severely strained law enforcement, criminal justice, and health care resources CITATION ADA12 \l 1033 (ODADAS, 2012). The Ohio Department of Alcohol and Drug Addition Services (2012) attests that the capacity of the state’s publicly-funded addiction treatment services have been stretched to the limit and are currently inadequate to accommodate the need. Nationally, the CDC (2015) reported that heroin overdose deaths nearly quadrupled between 2002 and 2013. The ODADAS (2012) confirm that 65 percent of drug overdoses in Ohio were due to prescription opiates or heroin, and there was a 440 percent increase in unintentional drug overdoses from1999 to 2011. History of NEP policyStarting in 1984, the first NEP opened in Amsterdam with the goal of reducing the transmission of hepatitis B CITATION Dav09 \p S70 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009, p. S70). In 1988, the newly identified HIV/AIDS epidemic spawned NEPs in United Kingdom and Australia CITATION Dav09 \p S70 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009, p. S70). Following the trend, the Canadian Federal Minister of Health openly supported needle exchange, and launched NEPs in Vancouver, Montreal, and Toronto in 1988 and 1989 CITATION Dav09 \p S70 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009, p. S70). In contrast, the U.S., on November 4, 1988, enacted a federal ban on funding of needle exchange program services and research CITATION Dav09 \p S71 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009, p. S71). The United States Comprehensive Alcohol Abuse, Drug Abuse, and Mental Health Amendments Act of 1988 (H.R. 4907) states that no funding could be spent ‘to carry out any program of distributing sterile needles for the hypodermic injection of any illegal drug or distributing bleach for the purpose of cleansing needles for such hypodermic injection’ CITATION gov88 \l 1033 (Govtrack.us, 1988). Additionally, the Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (S. 2240), which covered special funds for AIDS care reiterated that no funds could be used for NEPs CITATION Dav09 \p S71 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009, p. S71). By the late 1990s, successful NEPs were operating in Western Europe, Brazil, India, Canada, New Zealand and Nepal because researchers had published numerous articles defending NEP effectiveness in HIV prevention CITATION Dav09 \p S71 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009, p. S71). In 1997, studies published from the Montreal and Vancouver NEPs found increased rates of HIV infection in their needle exchange population, due to NEPs location in higher risk areas CITATION OGu10 \l 1033 (O'Gurek & Kirchner, 2010). This information was taken out of context and used to support the continuation of the ban. In 1998, the Department of Health and Human Services officially recognized the benefits of NEP in HIV prevention, but due to lack of political endorsement from President Clinton the funding ban continued. Two decades later, the U.S. Congress repealed the prohibition on federal funding for NEPs in the FY2010 Consolidated Appropriations Act CITATION Fis12 \l 1033 (Fischer, 2012) . Unfortunately, in the budget deliberations of the 112th Congress, House Republicans proposed to reinstate the ban on the use of federal funds for domestic and international NEPs and it was passed CITATION Fis12 \l 1033 (Fischer, 2012). No other country has ever had a comparable ban on funding to support NEPs CITATION Dav09 \p S72 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009, p. S72). With laws enforcement overlooking NEP activities, some local advocacy groups have distributed clean needles. Until recently, the state of Ohio policies only allowed temporary syringe exchange programs in the case of public health emergencies. As of September 29, 2015 Ohio Revised Code 3707.57 made it legal 1) to establishment of a blood-borne pathogen prevention program, 2) for workers to carry out their duties without violation of statues against distribution of hypodermic needles and 3) for program participants to possess hypodermic needles without legal recourse CITATION Ohi152 \l 1033 (, 2015). Regrettably, the state of Ohio continues to deny funding for syringe exchange programs and forces agencies to jump through various zoning hoops.Ethical analysis of NEP policyMorality Policy FrameworkTo analyze the major ethical issues raised by NEP policy, I have chosen to use the morality policy framework. This particular framework is a way to understanding the unique characteristics of policies that attempt to regulate personal morals and behaviors CITATION Bow12 \l 1033 (Bowen, 2012). Arsneault (2001) verified four key characteristics of morality policies in his analysis of abstinence-only sex education. These key points are applicable to NEP policy and they include 1) controversy and an inability to arrive at a resolution by looking at practical data alone, 2) legislation that is symbolic in nature, rather than focused on concrete policy outcomes, 3) the involvement of diverse sectors of the policy community, and 4) ongoing debate surrounding the issue, even after legislation has passed CITATION Bow12 \p 126 \l 1033 (Bowen, 2012, p. 126).Historical PresedenceIn the history of NEP policy, we find that the federal funding ban has survived for more than two decades, five presidential administrations and countless changes in congressional leadership CITATION Bow12 \l 1033 (Bowen, 2012). Scientifically, a mounting body of research has demonstrated that participation in NEP, not only reduces HIV transmission, but also did not increase drug use CITATION Bow12 \l 1033 (Bowen, 2012). Meeting the criteria for a morality policy, NEP policy is a public health dilemma that is just as much an ethical issue as a political one CITATION Rob02 \l 1033 (Roberts & Reich, 2002). In this analysis, I will feature examples in which value-based arguments have conflicted with evidence-based ones, and endorse the role of evidence-based research in policy making. Driven by morals and values, current NEP policy is not based on a logical, problem-solving approach CITATION Bow12 \l 1033 (Bowen, 2012). Political Factors of NEP PolicyDuring the HIV epidemic, the discovery of transmission via needle-sharing and the recommendations for distribution of clean needles fell on the deaf ears of policymakers already brainwashed by the zero tolerance policy. Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie (2009) shine light on the well-established moral policy called the ‘War on Drugs,’a zero tolerance strategy for illicit drug use and it’s relevance to the current NEP policy. At the time, illicit drug use was designated as a criminal and moral problem more than as a public health problem and the prevailing policy deemed NEPs as inconsistent with the ‘War on Drugs.’ In fact, the views of police, drug treatment counselors, community leaders and clergy were given greater weight than the views of epidemiologists and public health officialsCITATION Dav09 \p S72 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009, p. S72). Policymakers believed that authorizing funding for NEPs was equivalent to condoning illegal drug use. OpponentsOpponents of NEPs argue that these programs promote continued use of IV drugs, make it easier to afford drugs and send a mixed message to the public; although drugs are illegal, we provide avenues for their continued use CITATION OGu10 \l 1033 (O'Gurek & Kirchner, 2010). Joe Loconte, an expert on ethics and public policy, recommends confronting drugs abusers on moral grounds; stating the best thing for addicts is ‘tough minded treatment programs enforced by the courts’ CITATION Loc98 \p 15 \l 1033 (Loconte, 1998, p. 15). In his article, Killing Them Softly, he sums up the major reasons for not providing clean needles to PWID; 1) the harm reduction philosophy and nonjudgmental attitudes of NEPs are misguided, 2) addicts have no constraint and are enslaved to drugs, 3) neighborhood NEPs save addicts money to purchase more drugs, 4) not enough PWID die from sharing needles to justify funding it, 5) the research supporting NEPs is flawed and 6) medical interventions for social ills are not moralCITATION Loc98 \p 15-16 \l 1033 (Loconte, 1998, pp. 15-16). In the early days of the AIDS epidemic, community organizations mobilized to oppose NEPS. The most boisterous, African American churches viewed NEP as another social experiment like the Tuskegee Syphilis Studies, which needed to be stoppedCITATION Bow12 \p 132 \l 1033 (Bowen, 2012, p. 132). Crary (2008) found that with the disparate prevalence of HIV in African American communities and new evidence to support NEP, many groups changed their policy. In fact, on National Black HIV/AIDS Awareness Day in 2008, the NAACP, National Urban League, and other black advocacy groups issued a statement in support of NEP, asking Congress to overturn the federal funding ban (Crary, 2008).Typically, not seen as opponents to NEP, researchers and academics have also involved themselves in the development of needle exchange policy. An example of the academic controversy surrounding needle exchange, involved a physician and professor at the University of British Columbia named Schechter. He became entangled in public controversy when the results of his team’s study of a large Vancouver NEP showed that frequent attendees of the program had higher HIV prevalence than less frequent attendees CITATION Bow12 \p 133 \l 1033 (Bowen, 2012, p. 133). In a meeting with the U.S. Office of National Drug Control Policy and an op-ed printed in the New York Times, Schechter reiterated that in his findings HIV incidence decreased and that NEPs do not increase HIV prevalenceCITATION Dav09 \p S74 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009, p. S74). Other academics have spoken out against needle exchange, including psychiatrist Dr. James L. Curtis, an outspoken critic who authored a New York Times editorial on the topic CITATION Bow12 \l 1033 (Bowen, 2012).ProponentsEarly in the AIDS epidemic, NEPs emerged as a simple effective solution for reducing the spread of HIV and other diseases in injection drug users CITATION Fis12 \l 1033 (Fischer, 2012). Provision of clean needles for PWID is a widely accepted public health practice around the world. The most prominent ethical philosophy in support of NEP is to minimize harm or harm reduction. Even with the federal ban, AIDS activist and community groups recognized the critical need for NEPs. Legally, the early NEPs operated without the support of legislation putting the workers in jeopardy of jail time. Illegally distributing needles to drug users for two years before becoming partners in New York City’s first legal needle exchange in 1992, the Bronx-Harlem Needle Exchange Program and the Lower East Side Needle Exchange Program are two examples of this grassroots movement CITATION Hev92 \l 1033 (Hevesi, 1992). From the beginning of the HIV crisis, academics and researchers from around the world have published recommendations calling for expanded access to sterile needle as a part of safe effective prevention programs CITATION Dav09 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009). As a matter of fact, public health experts as well as medical organizations including the American Medical Association, the American Public Health Association, the American Bar Association, and the American Civil Liberties Union, have all endorsed needle exchange CITATION Bow12 \l 1033 (Bowen, 2012).While epidemiologists and public health officials are bound to limit their opinions to science, not religious beliefs; some objections to NEPs are not based on ‘researchable’ issues CITATION Dav09 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009). For example, the reason why politicians support funding for one group over another is not logical. Dr. Elizabeth Pisani, an AIDS epidemiologist and journalist, argues that ‘HIV prevention is cheap…the price of a condom or sterile needle today… save thousands in health system cost in caring for an AIDS patient’CITATION Bow12 \p 131 \l 1033 (Bowen, 2012, p. 131). Sighting cases of male IV drug users transmitting HIV and other sexually transmitted diseases to woman, who transfer the virus on during birth to their children, Dr. Pisani challenge lawmakers by asking ‘if the money argument is not good enough to get politicians to do nice things for junkies? How about babies then? Politicians are always happy to do nice things for innocent women and babies’CITATION Bow12 \p 131 \l 1033 (Bowen, 2012, p. 131). Opponents are concerned that NEPs lead to increased illicit drug use; researchers can addressed this with empirical research. Other fears that needle distribution will send mixed message or condone illicit drug use are not researchable CITATION Dav09 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009). The pragmatic public health position demands a balancing of risks, costs, and benefits (i.e., harm reduction) whereas the politicians’ absolutist ‘zero tolerance’ stance on illicit drug use mandates that unfounded fears be relieved. This makes it difficult, if not impossible, to resolve the tension of a morality-based policy CITATION Dav09 \l 1033 (Vlahov, Des Jarlais, Goosby, Hollinger, & Lurie, 2009). Des Jarlais (2000) states that this opposition is a facet of the ‘cultural wars’ in the United States and not a function of the scientific data on needle exchange. In fact, some opponents of NEP will now verify scientific data as accurate. A vocal opponent to NEP, Loconte (1998) acknowledges the major public health risk imposed by the fact that 30 percent of all new HIV infections are related to IV drug use. The extreme position of this cultural wars perspective on NEPs was expressed by an American television personality who said, ‘Give’em dirty needles and let them die’ CITATION Des00 \l 1033 (Des Jarlais, 2000).RecommendationPublic health officials and epidemiologists have to recognize the limitations of relying solely on evidence-based arguments in policy making and obtaining public support. Utilizing public relations experts to persuade the public to accept controversial interventions is just the start CITATION Bow12 \l 1033 (Bowen, 2012). Advocating for adequate funding for drug treatment programs and reframing drug abuse as a community problem are the fundamental needs in todays’ zero tolerance culture CITATION Des00 \l 1033 (Des Jarlais, 2000). A communitarian approach to drug abuse stops the ‘us versus them’ mentality. In public health, this approach presumes that certain behaviors and cultural patterns should be promoted in all societies, regardless of local cultural norms for the good of the community CITATION OGu10 \l 1033 (O'Gurek & Kirchner, 2010). Promoting a move from coercion to coexistence, tolerance, and mutual learning, communitarianism requires social skills that scientist like epidemiologist may not feel comfortable with. Therefore, it is the job of public health professional to stop relying on evidence-based arguments, realize this is a democratic society (with all its pros and cons) and teaching the public to advocate for themselves CITATION Rob02 \l 1033 (Roberts & Reich, 2002).In Ohio, the current policy allows for NEPs, but still needs the support of the local community to permit the zoning. Federal, state, local, and community partners need to take action quickly, if we are to collaborate on an effective public health policy to stop the increased rates of HIV, HVC and HBV in our neighborhoods CITATION OHA15 \l 1033 (OHAIDP, 2015). Clinically, these efforts must include enhanced surveillance, clinical and community-based research, and the development of age-appropriate prevention and treatment services CITATION OHA15 \p 8 \l 1033 (OHAIDP, 2015, p. 8). Socially, Ohio needs to personalize the regional drug problem with television and radio public service announcements, collaboration with faith-based agencies and integrate the efforts of lobbyist to gain public support for an improved NEP policy.References BIBLIOGRAPHY \l 1033 Arsneault, S. (2001). Values and virtue: The politics of abstinence only sex education. American Review of Public Administration, 31(4), 436-454.Bowen, E. (2012). Clean needles and bad blood: Needle exchange as morality policy. Journal of Sociology & Social Welfare, 39(2), 121-141.Campos-Flores, A. (2015, June 19). Rural U.S. Struggles to Combat IV Drug Abuse:Hepatitis C and HIV outbreaks test public-health resources in Midwestern states. Retrieved October 6, 2015, from : . (2013). Surveillance for Viral Hepatitis – United States, 2013. Retrieved October 6, 2015, from . (2015, May 1). Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone — Indiana, 2015. Retrieved October 6, 2015, from : , D. (2008, February 7). Groups seek to end needle-exchange ban. Retrieved from USA Today: Jarlais, D. (2000). Research, Politics, and Needle Exchange. American Journal of Public Health, 90(9), 1392-1394.DHHS. (2015). HIV/AIDS Basics . Retrieved October 7, 2015, from : , W. (2015, February 2). Ohio lawmakers might enable more clean needle exchanges. Retrieved October 7, 2015, from : , M. (2012, February 2). A History of The Ban on Federal Funding for Syringe Exchange Programs. Retrieved October 6, 2015, from : . (1988, June 23). H.R. 4907 (100th): Comprehensive Alcohol Abuse, Drug Abuse, and Mental Health Amendments Act of 1988. Retrieved October 6, 2015, from , D. (1992, July 18). Health authorities delay AIDS needle exchange. Retrieved from The New York Times: http:1992/07/18/nyregion/health-authorities-delayIOM. (2010). Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. (H. Colvin, & A. Mitchell, Eds.) Retrieved October 6, 2015, from : . (2015, August 28). News Release. Retrieved October 7, 2015, from : , J. (1998). Killing then softly. Policy Review, July, 14-22. Retrieved October 10, 2015, from . (2012). Ohio’s Accomplishments to Reduce Opiate Addiction and Overdose. Retrieved October 8, 2015, from : 'Gurek, D., & Kirchner, J. (2010). Needle exchange for HIV/AIDS:An effective public health policy. Journal of Lancaster General Hospital, 5(2), 59-63.OHAIDP. (2015, March). Action plan for the prevention, care, & treatment of viral hepatitis 2014-2016. Retrieved October 5, 2015, from : . (2015, September 29). 3707.57 [Effective 9/29/2015] Bloodborne infectious disease prevention programs. Retrieved October 7, 2015, from , M., & Reich, M. (2002). Ethical analysis in public health. Lancet, 359, 1055-1059.SAMHSA. (2007, July 19). The NSDUH Report: Demographic and Geographic Variations in Injection Drug Use. Retrieved October 6, 2015, from : , D., Des Jarlais, D., Goosby, E., Hollinger, P., & Lurie, P. (2009). Needle exchange programs for the prevention of human immunodeficiency virus infection: Epidemiology and policy. American Journal of Epidemiology, 154(12), S70-S77. ................
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