December 2, 2015
The outbreak of HIV and hepatitis C (HCV) in a small rural community on the Indiana-Kentucky border places an unwelcome spotlight on the damage done by short-sighted leadership, an abundance of opiates but a scarcity of substance abuse treatment, and the helplessness and hopelessness of poverty on the psyche. But, mostly, it is just terribly sad.
So far, at least 170 people have been infected with HIV in this outbreak and over 80% of these also acquired HCV through needle sharing. All of those infected were white, and women accounted for almost half of the cases. Dissolved oxymorphone was the drug of choice.
A report in a Morbidity and Mortality Weekly Report describes this outbreak as erupting in an area blighted by unemployment and a thinly stretched health care system -- in a county that "consistently ranks among the lowest in the state for health indicators and life expectancy."
Scott County is not a one-off. It is faithfully representative of the changed face of opiate abuse in the U.S.: poor, rural, white, young people who started their abuse with pills and moved on to injecting. Other communities across the U.S. are mirror images of this despair and are also seeing increases in injection drug use as the cost of heroin has dropped and oral oxymorphone was re-formulated to make it harder to tamper with. According to one estimate, as of 2013 there were about 300,000 users of heroin in the U.S.
With this come blood-borne infections -- that is, unless prevention strategies like clean needles are available. Harm reduction people are getting tired of pointing out that needle exchange is an irrefutably evidence-based intervention, as this message falls on the selectively deaf ears of conservative policy makers. Lives will be saved but votes lost by doing the right thing.
A call for reasoned approach to this mess is found in an editorial by Stephanie Strathdee and Chris Beyrer in the New England Journal of Medicine, which appeals for physician and state actions to prevent future HIV outbreaks. Acknowledging that this outbreak, like all outbreaks, was made possible by a constellation of factors, their focus on physicians and government is justified.
A recent analysis demonstrating a rise in mortality due to suicide and substance abuse among whites (at the same time that these causes of death are declining in blacks and non-white Hispanics) points to a malaise among poor and poorly educated whites, which their health care providers, short on time, address too often with opiates. Patient advocates appropriately complained years ago that clinicians did not adequately address pain, especially chronic pain. Makers of painkillers seconded that motion and developed more potent oral opioids, which were then heavily marketed to health care providers, particularly those in primary care. Pain became a new enemy with sad to smiley faced assessments mandated as a sixth vital sign. Now we are witnessing an unintended consequence of our war on pain and the culture of analgesia it has spawned. As clinicians are pressured to spend less time with patients, shortchanging the opportunities to plumb their patients' complaints, many are pushed to just prescribe a pill. A flood of prescription drug abuse has followed, and many abusers -- as illustrated by the Scott County experience -- shift from pills to needles.
Punitive state laws that make needle exchange a crime and clean needles purchasable only with a prescription lead to sharing of injecting equipment -- and you know the rest of the story. To be clear, clean needles would not solve all the problems of the people in Scott County, but they would largely take HIV and HCV off their list of woes. Needle exchange, like condoms in prisons, touches deep cultural issues that have transcended objective discussions of data. To many, providing clean works is antithetical and perceived as supporting substance abuse. Plus, it acknowledges a problem most would rather not face. Poverty and substance abuse are flagrant evidence of the failure of our systems and of the mythology of our greatness as a nation; confronting this is not easy, especially for conservative policymakers. That Republican Indiana Governor Mike Pence suspended his state's needle exchange ban, albeit only for affected communities, is a testament to the evidence supporting this life-saving intervention.
That this and other measures taken to address this outbreak fall short and are likely to be short lived is undeniable. That the structural problems at the heart of this outbreak remain untouched is frustrating. For the moment, clean needles are being distributed in Scott County. Some will see this as a small victory for harm reduction and others as another defeat in the war on drugs. Either way, communities and their leaders across the country have to face reality and make decisions that will affect whether or not they will allow themselves to be the next Scott County.
What are some other top clinical developments of 2015? Read more of Dr. Wohl's picks.
David Alain Wohl, M.D., is an associate professor of medicine in the Division of Infectious Diseases at the University of North Carolina and site leader of the University of North Carolina AIDS Clinical Trials Unit at Chapel Hill.
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