Current best practices for harm reduction programs include a couple provisions: No retractable needles should be distributed, patients should get as many needles as possible regardless of how many they bring back, and barriers to accessing needles should be as low as possible. But sometimes those recommendations are at odds with community acceptance for the practices.
In late March, shortly after the Kanawha-Charleston Health Department closed its harm reduction program, Mayor Danny Jones wrote a letter to Rahul Gupta, then state commissioner for public health, asking that the West Virginia Bureau for Public Health audit the program.
“The review provided very specific recommendations that needed to be met in order to restart the program,” Gupta said.
These included improving data collection and analysis about exactly how many people were using the program and what services they were using; putting in place a plan to deal with needle litter; improving communication with community stakeholders and requiring that people pick up needles they need in person.
After the audit came out, the Kanawha-Charleston Health Department requested a review of the audit from seven harm reduction experts around the country, including Dr. Peter Davidson from the University of California San Diego. All seven letters were critical of the audit.
“I think the best way to describe it was that the people who wrote the audit had a very particular idea in mind about what a syringe distribution program should look like,” said Davidson.
In his letter Davidson wrote that “almost all of the recommendations in the audit represent severe, and in some cases unconscionable, barriers to effective, evidence-based, primary prevention of blood borne virus transmission.”
“You know one of the reasons syringe distribution programs exist in the way they exist at all is because is because the sort of traditional public health clinic model hasn’t served people who use drugs very well at all,” Davidson said. “And it hasn’t been very good at providing them with the basic tools they need in order to prevent the transmission of infectious disease and prevent overdose.”
Davidson said ideally, harm reduction programs have as low a barrier of entry as possible so the maximum amount of people will participate. And the recommendations made in the audit would raise the threshold of how easy it was to access resources, but he also says there’s room to adjust programs to fit the communities they serve.
“I wouldn’t expect a needle exchange in rural Appalachia to look the same as a needle exchange in San Francisco for example,” he said. “That would likely lead to a program that didn’t serve the population very well at all.”
And in Charleston, there were actually two harm reduction programs being held simultaneously: the one at the health department and a much smaller, clinic-based program operated by Health Right, the biggest free clinic in the state.
“Back in 2011 we noticed an increase in patients that were coming in with various stories, histories of being diabetic, they would pick up the needles for the program but not the insulin,” said executive director Angie Settle.
She said they began to suspect an increase in IV drug use among their patient population.
“So we kind of quietly started the program with the needle exchange it was mainly internal not something we broadcasted, but those patients that needed it knew of the service and as they came in we were screening every patient for IV drug use,” Settle said.
Because Health Right is a clinic working with a limited number of patients with whom they already have close relationships, they could run their program differently than the health department, which was trying to do a mass public health push, serving the whole city.
Health Right is also a one for one exchange—you bring a needle back, you get a fresh one—which for most harm reduction experts is not considered best practice. But since patients can come as many times a week as they want, Settle said it seemed to be the best choice for her program.
They also require every patient to meet with a counselor when they come in for needles. Basically, participation in Health Right’s program requires a lot more effort from patients, which means not everyone will use it, but Settle said that running a conservative program is preferable to not having a program available at all.
“You know the reality here is you’ve got a drug-using population that, in fact, is going to keep using drugs whether or not you have a syringe exchange program or not,” said Dr. Artis Hoven, an infectious disease specialist with the Kentucky Department of Health.
But without a program, she said, the community is just opening itself up to the easier spread of communicable diseases.
“There is something called the art and science, if you will, of risk or harm reduction,” said Hoven. “And for many of us we are still learning what that art is and what that science is. We’re trying to make it better and to make it something that is effective.”
But if Charleston were to consider harm reduction again, a lot of community healing, conversations, and compromise would likely have to occur. And the biggest barrier may be one of the most intangible ones -- addressing stigma.
Appalachia Health News is a project of West Virginia Public Broadcasting, with support from the Marshall Health, Charleston Area Medical Center and WVU Medicine.