The COVID-19 pandemic poses unique risks to people with opioid use disorder (OUD). Overdose risk increases when using individuals are in isolation and injection drug users are at higher risk of COVID-19 mortality due to increased rates of other infectious diseases and negative health effects from substance use.
State-supported comprehensive harm reduction programs that often provide sterile syringes, naloxone to reverse opioid overdoses, and education and counseling have shown encouraging results and remain critical during the current crisis. As policymakers face tough budget decisions in the coming months, understanding the value of harm reduction services will be increasingly important.
The National Academy of State Health Policy (NASHP) recently spoke to Allan Clear, director of the New York State Department of Health’s AIDS Institute’s Office of Drug User Health to identify the effectiveness of these programs. The institute’s Office of Drug User Health operates the state’s Syringe Exchange Program, Expanded Syringe Access Program, Opioid Overdose Prevention Program, Increasing Access to Buprenorphine Program, and Drug User Health Hubs. Clear has worked with people with substance use disorders (SUD) for decades and ran one of New York’s first syringe exchanges.
Describe the history of harm reduction in New York.
We had been doing underground needle exchange in New York City. The state Department of Health had been monitoring what we were doing and recognized that syringe exchange was of value and important in terms of the HIV epidemic. When the Foundation for AIDS Research said it was going to fund programs in New York City, that’s when the AIDS Institute stepped in, developed regulations, and amended the public health law on syringes, which allowed us to move forward legally and with the blessing of the government.
You don’t see it in documents, but New York state has invested heavily in harm reduction over the years, so our overriding philosophy in the AIDS Institute and Office of Drug User Health is a harm reduction approach.
Why is there an emphasis on people who inject drugs as a distinct service population?
I personally don’t think harm reduction would be necessary if we treated people who use drugs in the way we treat people with ‘medical’ problems. We have a health care system which we call “drug treatment,” which has been developed completely outside of the health care system, which I think is fairly unusual. If you have a pain in your neck or a pain in your stomach, you go to your doctor. If you have a substance use issue, you have to completely navigate an unknown and foreign system to find help. And that help is not in any form of outreach – it’s just waiting for you to find it. And then it’s a very imprecise and inaccurate response to your medical problem. The drug treatment system has never really gotten behind efforts that embrace people who use drugs, as opposed to people who desire to stop using drugs, and people sort of dip in and dip out of the treatment system. And I commend [our] agency for saying, “we do drug user health.”
Describe the inception of the drug user health hub program.
The best health care delivery system for people who use drugs would be the existing health care system. Ideally, we would destigmatize drug use to the extent that it becomes a normal thing for people who use drugs to get a compassionate response and quality health care when they enter the health care system. However, at this moment in time, we don’t have that, so we have to develop a system that exists outside of the mainstream medical system. This is why in New York, we have 24 syringe exchange programs (SEPs), and 12 of them are designated as drug user health hubs.
What is the process for becoming a drug user health hub?
[There is no formal certification process. Selected programs are given additional funding to enhance their regular programming in order to incorporate low-threshold medical care – an approach that offers services without attempting to control a patient’s intake of drugs and provides counselling only if requested.] The office approached a SEP in Albany, that already had a Law Enforcement-Assisted Diversion (LEAD) program, so, they added on extra case management staff to work with the pre-arrest diversion from the Albany police department. The office also approached a SEP in Buffalo, which had been extremely hard hit by overdoses. They used the money to build up capacity to respond to overdoses internally and to conduct outreach and anti-stigma work within the community, as the Buffalo police department was not carrying naloxone at the time. In Ithaca, they did a great deal of work around exploring drug policy reform and decided to do low-threshold buprenorphine program at their SEP. Over time, we’ve added another nine programs.
What are some of the most important services provided by a drug user health hub?
There are also so many restrictions and problems for doctors to prescribe buprenorphine that there’s a big shortage of providers who are willing to do it. We sort of saw buprenorphine as a frontline medication that prevents death from heroin or opioid overdose, and what we have been promoting is that we provide the medication and then find out what the person wants.
[Clear and his colleagues discovered that once people are properly treated and given assistance with resume drafting and interview techniques to help them return to the workforce, they were more amenable to addressing their secondary health needs, including hepatitis C. Describing the individuals that benefit from the services the hubs provide, Clear said, “people would come back and would be interested in other health care – they want other elements of their care addressed. They now have found a venue where they are welcome and where they get the care that they need.”]
How do the efforts of the Office of Drug User Health play into addressing infectious disease?
[Using the opioid overdose reversal drug naloxone as an example, SUD and infectious disease are intertwined.] Naloxone is not really about HIV – it’s obviously about keeping people alive who consume opioids. Back in the late 80s and early 90s, people who inject drugs drove the epidemic here, and now we’re down to something like less than 2 percent a year of new infections among people who inject drugs. The other element in there now that we talk about a lot is invasive infections, so MRSA, staph infections, endocarditis, all of which are on the increase among people who use drugs. We’re doing a lot of work around supporting staff in emergency departments (EDs) to recognize signs of SUD, conduct screening in the ED to see if someone does have an OUD, or if someone shows up with a staph infection to investigate their injection practices.
How would you apply what you’ve seen over the years to the work that needs to be done systemwide?
I’ve been around since the start of the AIDS epidemic and have seen the response and know how to address serious health epidemics for people who use drugs, and here we are – two and a half decades later – still trying to integrate health services …for people who use drugs into a health system that is not receptive to them. It makes me think, “Why didn’t we learn our lesson? Emerging from the AIDS epidemic, why didn’t we make those changes that were sustainable?” I’m hoping that we can, certainly with our office and the relationships we have built with other entities. We should be able to do something that is lasting and transformative.
