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 is 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.