It was something of a shock when Indiana Governor Mike Pence declared a public health emergency last March—Scott County, in the southern part of the state near the Kentucky border, isn't the kind of place that comes to mind when you think of drug abuse and HIV outbreaks. But by that March, 79 people in the county had tested positive for HIV, a consequence of rampant intravenous drug use in southern Indiana. But it didn't have to be that way, according to a new perspective published today in the New England Journal of Medicine. The real culprits, the authors argue, are counterproductive drug policies such as Indiana's ban on needle-exchange programs, and the overuse of prescription painkillers.
"Many observers were surprised" by Pence's declaration, according to authors Steffanie Strathdee and Chris Beyrer. "Other observers, however, had seen it coming." A growing number of people in Scott County, as well as neighboring counties and states, had been using drugs such as the painkiller oxymorphone. But as new policies made those drugs harder to acquire, addicts increasingly turned to alternative injectable drugs, including heroin. And because Indiana makes it hard to get clean needles—using a needle for non-medical purposes is a felony punishable by up to three years in prison—more and more people had to either share or go without a fix.
By June 10th of this year, 169 people had tested positive for HIV in southeast Indiana.
This was a recipe for disaster when it came to HIV and other blood-borne viruses, like hepatitis C. By June 10th of this year, 169 people had tested positive for HIV in southeast Indiana, where Scott County is located, compared with the typical five per year. Eighty percent of those with HIV also tested positive for the hepatitis C virus.
All of this points to the need for an overhaul of some of Indiana's—and the nation's—drug policies, Strathdee and Beyrer argue. First, needle-exchange programs should be the norm. While Pence's order lifted the effective ban on such programs, the reprieve is temporary and only applies to counties undergoing declared public health emergencies, "a requirement that ensures they can only respond to, rather than prevent, new outbreaks." the authors write. That goes for other states—needle-exchange programs are effectively illegal in 24 other states—as well as the federal government. Congress should permanently lift the federal ban prohibiting funding to needle-exchange programs, Strathdee and Beyrer argue.
Providing better support for needle exchanges isn't enough, however. Officials need to offer better treatment programs to address addiction and the infections associated with it. Indiana and other states also need to address inappropriate prescriptions for opiate-based painkillers, Strathdee and Beyrer write.
Beyond that, realistic improvements may require an entirely new perspective on illegal drugs, according to Strathdee and Beyrer. "States need to adapt prescription drug-monitoring programs so they are secure, enable searches in real time, and are used as clinical and public health tools rather than law-enforcement weapons," the authors write.
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