On the Road
Cincinnati Exchange Project Dispenses Needles & Hope for Harm Reduction
by Larry Buhl
[dropcap]A[/dropcap]s I was speaking with Judith Feinberg, MD, about her mobile needle exchange program in Cincinnati, President Obama was next door in West Virginia, announcing steps to fight drug abuse, especially cheap, injectable drugs that are growing exponentially throughout Appalachia.
Feinberg hoped his speech would be a turning point to bring more compassionate and reality-based solutions to addiction and its companion dangers of overdosing and HIV and hepatitis C infection. Because for the past ten years, she feels like she’s been fighting the growing IV drug use epidemic in Cincinnati alone.
By day, Dr. Feinberg is a professor of medicine at the University of Cincinnati College of Medicine and, also by day, she runs a needle exchange and harm reduction program called the Cincinnati Exchange Project (CEP).
Since February 2014, CEP—it’s just Feinberg and one paid staff member—has provided nearly 50,000 clean needles to addicts. They’ve also offered on-the-spot testing for hepatitis C, HIV, and, for those who test positive for either infection, pregnancy screening.
In addition to clean needles, Feinberg and her program manager, Libby Harrison, offer “cookers” and cotton used to heat and filter the drug, and teach clients how to safely use them. This is important because hepatitis C lives on surfaces for weeks and increases the risk of infection.
They do all this in a donated 1997 motor home that they drive throughout the Cincinnati area three days a week, three hours a day.
A harm-reduction bargain
CEP had a start-up budget of $50,000, a grant from Interact for Health, a local foundation. The project received an additional $48,000 two-year grant in 2014 from the Ohio Department of Health that let them provide nasal naloxone (trademarked as Narcan) to prevent fatal overdoses.
Of more than 500 IV drug users they have helped, Feinberg says around ten percent have sought treatment and gotten clean. Harrison has even accompanied more than a dozen clients to treatment. Usually clients are in groaning and puking throes of withdrawal, because most treatment centers require addicts to be clean at least twenty-four hours before arriving.
Dr. Feinberg says that, compared to the more than $100,000 it costs to cure a person of hepatitis C, and far, far more if they develop advanced liver diseases, the money spent so far on CEP is a bargain.
When asked if the program has enough money to meet the need in Cincinnati, she replies in her fiery native New Yorker accent with at least ten no’s, “and five exclamation points, write that down.”
With the exception of Governor Kasich’s “Start Talking” program that began last year, no statewide money has been allocated to combat drug abuse and promote harm reduction. Feinberg says “Start Talking,” which focuses on encouraging Ohio youth to resist drugs by talking with peers and adults is “a nice, politically acceptable PR campaign that makes the state look like it cares,” but does nothing to help those who are already addicted.
Simply put, the political will is not there to fund needle exchange and other harm reduction efforts. And despite the success the CEP has had in its limited area on a shoestring budget, politicians are still, in Feinberg’s words “not interested in treating addicts as human beings.”
What’s the matter with Indiana? And Kentucky? And Ohio?
The Centers for Disease Control and Prevention shows that heroin-related deaths tripled from 2010 to 2013, with the highest rate in the Midwest and Appalachia. Earlier this year, the rural IV drug crisis reached national attention as Indiana reversed its ban of syringe exchanges in the wake of a spike in new cases of HIV among drug users in one southern county.
The epidemic in the tristate area took off when government efforts to shut down illegal “pill mills” like the infamous clinic in nearby Portsmouth, Ohio, made opioid painkillers harder to obtain. Trouble was, the users were addicted and went searching for a cheap fix. For many, the new drug of choice, or necessity, became black tar heroin from Mexico, costing about $10 on the street.
In Scott County, Indiana, the problem is Opana, also known as Oxymorphone, which produces a heroin-like high that’s more potent than Oxycontin, the prescription drug users originally got hooked on. The communal way these drugs are used has helped spread HIV and HCV rapidly through social networks.
Feinberg has seen the problem coming since 2005, when she noticed injection of opioids as the common denominator in heart patients. As an infectious disease expert she knew the risk of contracting hepatitis C and HIV from sharing unclean needles and injection paraphernalia, and she suspected that the area would soon face a massive health crisis.
She was correct. The rate of hepatitis C cases in Cincinnati’s Hamilton County increased fifty-eight percent from 2009 to 2013. But politics delayed funding for her proposed needle exchange project for years.
“If I had been able to do this back in 2006, think of how many lives I could have saved.”
What’s the matter with politicians?
Even now, though Feinberg operates the clinic out of private funding, public officials still find ways of shutting her down, thanks to NIMBYism and a crazy-quilt of overlapping jurisdictions in the Cincinnati area. In Hamilton county, you need the approval of each of five health departments, plus buy-in from the mayors, prosecutors and sheriffs, all who must answer to constituents who don’t want “those people” accessing needles in their town.
“I had a county commissioner here tell me that needle exchange is the third rail of politics,” Feinberg tells me. “Basically, politicians are cowards.”
Federal funding is just as difficult to obtain thanks to Congress, which reinstated a needle exchange funding ban in 2011. The irony is, an organization can apply for federal funding for harm reduction programs like syringe exchanges, but can use the money for everything except the syringes.
Despite outdated public perceptions that heroin addiction is based in poor inner city areas, the twenty-first century heroin epidemic is largely white, small town, suburban, rural, and middle class. “Over ninety percent who come to us are white, and some are from well-off families,” Feinberg says. “More than half are employed.”
Not that it should matter what groups are afflicted by addiction, but it’s the old perception that it’s “the other” who shoots opioids at the basis of the bias that’s kept needle exchange programs so controversial.
It’s not Feinberg’s first uphill battle in public health. In fact, she says the reactions to today’s IV drug epidemic and subsequent spike in HIV and HCV mirror the early years of the AIDS epidemic where patients were stigmatized and ostracized and told they deserved what they got.
“Addiction is criminalized in the country,” Feinberg says. “But it’s a disease. It’s a chronic, relapsing brain disease and not a moral failing. People’s brains are rewired after taking (opioids) for the first time. And we’re going to be seeing this epidemic all over, not just in Ohio, Indiana, and Kentucky.”
Feinberg is upbeat, even passionate when talking about her duty. But she admits that she’s tired of fighting against the system to save lives. In addition to her day job and her other day job, Feinberg has spent hundreds of hours getting buy-in from mayors, supervisors, and local boards of health to let her CEP mobile van park in their suburbs.
“The city is letting me, one citizen, take on the burden of what is a public health crisis, and that’s just wrong.”
Click here for more information about the Cincinnati Exchange Project.
Larry Buhl writes the monthly Hep Talk column for A&U.