Syringe services programs are relatively new in rural America.
A survey of syringe services conducted in 2013 found that 20% of syringe services programs were in a rural location. Injection drug use is seen by some as a problem that doesn’t affect rural areas. But rural areas are not immune to injection drug use. And unfortunately, because of the lack of treatment and syringe services programs, rural areas are more at risk than other parts of the country for outbreaks of HCV and HIV as experienced by Scott County, Indiana in 2015.
After the outbreak in Indiana, the CDC identified 220 other counties vulnerable to a similar outbreak of HIV/HCV. In its analysis, the CDC examined indicators such as the number of drug overdose deaths, access to prescription opioids, access to buprenorphine, and socio-demographic characteristics such as per capita income, race, and unemployment rates.
The CDC identified 26 states with more than 1 at-risk county. States with the most at-risk counties included West Virginia, Kentucky, Tennessee, Maine, Vermont, Pennsylvania, Indiana, Missouri, and Ohio. These states also have large rural populations and many of these states, until recently, had legal barriers to establishing syringe service programs. In addition, surveillance data from four predominantly rural states (KY, TN, VA, and WV) indicate a 364% increase in the number of acute HCV infections from 2006 to 2012. At the same time, there were few syringe services programs available in any of these states.
In 2015, Scott County, Indiana (population 24,000) saw unprecedented rates of Hepatitis C virus (HCV) and human immunodeficiency virus (HIV). These increased rates were driven by increasing rates of intravenous drug use in rural southern Indiana’s Scott County. The small town of Austin, Indiana (population 4,200) in Scott County became the center of this outbreak.
In March 2015, the Indiana State Department of Health reported nearly 80 new cases of HIV. CDC public health experts stated that some residents/persons were injecting a liquified form of the prescription opioid Opana, up to 15 times a day. At the time, Indiana banned syringe services programs in the state. However, due to the outbreak of blood borne diseases such as HIV and hepatitis C virus (HCV) infections in the county, then Governor Pence declared a public health emergency. The Executive Order declaring the emergency allowed the Scott County Board of Health to establish a “short term” syringe services program to provide new, sterile needles to community members who inject drugs. Following the issuance of the Executive Order, the Indiana state legislature passed SEA 461 in May 2015 to allow syringe services programs to be established in the state upon meeting very specific conditions. The legislation allowing syringe services programs in Indiana was set to expire in 2019. However, a bill was signed into law in 2017 that gives more authority to local governments to establish syringe services programs and extends the authorization period for syringe services programs until 2021.
Opioid Misuse and Overdose
Opioid misuse and overdose death rates have been at unprecedented levels in almost every state in the United States, however, rates are particularly high in rural counties. Lack of access to treatment and other health care services has exacerbated the opioid epidemic in many rural states. Health care providers who can prescribe medication assisted treatment using one of the three FDA approved medications for opioid use disorders, are scarce in rural areas. According to a 2012 study, only 3% of family physicians, the most common specialty in rural areas, were certified to provide buprenorphine to treat opioid use disorders.
In 2016, the Centers for Disease Control and Prevention (CDC) released a report published in Morbidity and Mortality Weekly Report (MMWR) that provided an overview of the risk for bloodborne infections (human immunodeficiency virus (HIV) and hepatitis C (HCV) and hepatitis B virus infections) among people who inject drugs. While overall rates of injection drug use are decreasing, according to the CDC, white people who inject drugs accounted for more than 50% of the new initiates of people injecting drugs in 2015. The CDC warns in the 2016 MMWR that lack of access to syringe services programs in rural areas could lead the way to future increases in blood borne diseases.
Considerations for Establishing an SSP in Rural-Frontier Communities
The definition of a rural area varies by government agency. For example, the US Census Bureau defines it differently than the Office of Management and Budget or the Federal Office of Rural Health Policy. However, if you live in a rural area, you usually define it by how far the drive is to a town center or facilities such as a health clinic or hospital. Commute time to a more densely populated area can require an hour or more drive with little to no public transit available. This poses unique challenges for syringe services programs in rural communities and an issue to consider in the siting of a facility. Below is a list of items to consider before establishing syringe services programs in rural areas.
Make it Accessible
The first rule of syringe services programs is that you must meet people where they are to build trust and encourage participants to return. Locations that are inconvenient (both in time and location) will be a disincentive to participate in the syringe services program. Keep in mind that people who inject drugs may have difficulty finding transportation to an established syringe services program, and public transportation is scarce in many rural areas. Engage the community first to find a location where most people in need of services congregate and consider what their mode of transportation is. Outreach workers can help get this type of information from people who inject drugs. In addition, find out if bus services are available in the area and whether the potential location for the syringe services program is on a bus line.
Communicate Early and Often
A concentration of community services in a specific area might spur local opposition to siting a facility. Be aware that the community may already feel burdened and not want another social service. Be sensitive to their concerns and seek to engage them in a constructive dialogue about how to mitigate these issues — before — identifying a location. Talk to people who represent the entirety of your local community. For example, include law enforcement, elected officials, business leaders, public health, medical community, people who inject drugs, individuals in recovery, the faith community, and families and friends of individuals with substance use disorders in any outreach efforts. Look for individual leaders in these sectors of the community first, try to gain their support and in turn they can be a trusted advocate for you. The Harm Reduction Action Center in Colorado may provide useful information for communities facing opposition to siting syringe services programs.
Location, Location, Location
Find a location where people will feel comfortable going. A community clinic in one at risk county is in a prime location, however, since it is near a police station, there is a concern that people who inject drugs may not feel comfortable going to that facility. Again, talking to individuals who inject drugs or who are in recovery will help identify potential issues. People in rural areas may be particularly concerned with anonymity. Be cognizant of the facility’s entry point, is there a more discreet entrance where people can feel some privacy when they enter or exit. Alternatively, they may want to enter through the front door of a facility and mix in with other visitors to the facility. Explore assorted options such as mobile vans, co-locating with another facility, or providing needles through individual outreach workers.
Identify Potential Site Challenges
Before identifying a location, understand your local zoning ordinances, or consult with a local land use attorney. Some ordinances may preclude the siting of such a facility or may have restrictions on parking or hours. If you are seeking to establish a mobile unit, find out if the van can go to the same location every week at a set time. Knowing the answers to siting questions can help keep concerns from growing into full-blown opposition. Building support with local faith communities and law enforcement may help overcome concerns about syringe services programs. In fact, they may be your strongest allies. In addition, information about the public benefit of syringe services, to include a reduction in needle stick injuries, infectious diseases, and overdose deaths has been used in some communities facing zoning restrictions.
Identify Other Community Services
Syringe services programs refer people to services such as drug treatment, birth control, enrollment in health care, housing referrals and other health care services. Before deciding on a location, determine whether these services exist in the area. To find local treatment availability, see SAMHSA ‘s treatment locator.
Some state laws require extensive record keeping to track the number of syringes that are distributed, the number of clients in the programs, etc. State law may also require that reports be provided to local governments or to the community. Determine up front how these data will be tracked, whether they will be shared.
Stay Up to Date
To learn more about other considerations and opportunities for rural areas, please visit the Rural Health Information Hub here.