Isn't it ironic, don't you think?

 Perusing today's Charleston Gazette-Mail, I came across this brief item announcing that WV will get $393K from the federal government to detect the spread of hepatitis. Of course, there wouldn't be much of a problem with that if the city of Charleston hadn't ended its needle exchange program. Or if the state legislature hadn't passed its own "harm production" bill this session that seems designed to promote the spread of HIV and hepatitis among people who use intravenous drugs.

As this study from the WV Center on Budget and Policy argues, these steps away from public health best practices will cost a lot in terms of both dollars and humanity

Maybe just a bit of economics might shed some light here. There are two main kinds of economic demand: elastic and inelastic. Elastic means what it sounds like, as in the demand for some good expands and contracts due to cost and other factors. For a purely hypothetical example, I might drink more IPAs if the price of cruddy box wine goes up to high. Maybe. Other kinds of demand are inelastic, like buying gas when you have to drive a car to get to work.

For people with Substance Use Disorder, demand is inelastic. That means most people who inject drugs won't stop doing so when the supply of clean needles dries up. Which is to say that more needles will be used repeatedly and some will be shared, with predictable health outcomes.

According to an April 5 Associated Press article,

As recently as 2014, only 12.5% of HIV cases in West Virginia were the result of intravenous drug use. By 2019, 64.2% were, according to state health department data. The increase was due primarily to clusters in Kanawha and Cabell counties.

Kanawha County, which includes Charleston and has 178,000 residents, had two intravenous drug-related HIV cases in 2018. The number grew to 15 in 2019 and at least 35 last year, said Shannon McBee, a state epidemiologist.

By comparison, New York City, with a population of more than 8 million, recorded 36 HIV cases tied to intravenous drug use in 2019, according to the CDC. Counties in other states with populations similar to Kanawha had an average of less than one HIV diagnosis among people who inject drugs...

In terms of human costs, the WV policy center brief linked above finds that 

To treat the 35 new HIV cases reportedly related to intravenous drug use (IDU) in 2020 will cost nearly $17 million.

To provide curative treatment for the 635 cases of chronic hepatitis C (HCV) associated with IDU in 2019 is likely as much as $44.5 million.

The estimated cost of treating the chronic hepatitis B (HBV) cases likely caused by IDU in 2018 is $196,000. While this is a relatively small cost, it would be virtually avoidable with regular HBV screening and vaccinations for drug users at a cost of about $62 per adult.

Another disease increasingly tied to IDU is infective endocarditis (IE), an infection of the lining of the heart. The 77 IDU-related cases treated at the Charleston Area Medical Center in 2019 cost nearly $4.2 million.

This is a classic example of what can happen when public health is politicized. 

 

Harm reduction done right

In case you missed it, there was an interesting NY Times article about how Dayton Ohio and its county of Montgomery dramatically reduced opioid overdose deaths from last year to this.

Lots of things seemed to come together to make this possible. The most obvious of these was Gov. Kasich's decision to expand Medicaid under the Affordable Care Act. Dayton mayor Nan Whaley claimed it was the basis for everything they've been able to accomplish, saying

“If you’re a state that does not have Medicaid expansion, you can’t build a system for addressing this disease.”

That's sad but really true. Some of the states that need it most haven't done it year, although that number is fortunately diminishing.

Other factors were harm reduction programs, support groups, a strong program to distribute Naloxone to reverse the effects of overdoses, and, importantly, the growing cooperation between Dayton police and public health workers.

Unfortunately, Charleston WV has been going in the opposite direction, as this WV Public Broadcasting story relates. 

The Times article quotes Sam Quinones, author of “Dreamland: The True Tale of America’s Opiate Epidemic,”who told a congressional hearing that "the more cops and public health nurses go out for a beer, bridge that cultural chasm between them," the better the US will be able to deal with the problem.

Harm reduction

A hot topic in WV's capitol city these days is the needle exchange program offered by the Kanawha-Charleston Health Department. Charleston's city council earlier this week essentially voted to delay a vote on eliminating the program.

Charleston's mayor Danny Jones, many of the city's law enforcement officers and others support ending the program because they believe it leaves a lot of dirty needles in public places in its wake.

As I understand it, however, the evidence suggests that ending the program won't end the problem. It could, however increase the number of people using dirty needles. Further, the Centers for Disease Control reports that addicted people who used needle exchange programs are five times more likely to eventually seek treatment than those who don't.

Obviously, it would be great to make the opioid crisis go away. And people are working on that. One huge step forward has been WV's Medicaid expansion as authorized by then Governor Tomblin back in 2013. But while we're working on a long term solution, there's no substitute for harm reduction measures like these programs.