The overarching objective of Safe Syringe is to reduce the incidence of infectious diseases, primarily viral hepatitis and HIV, related to IDU in Marion County, thus preventing an outbreak of HIV related to IDU. This objective thus far has been successful, though infectious disease data is effected by the COVID-19 pandemic in that (1) decreased community testing was practiced in 2020 and (2) public health investigative efforts were diverted to COVID-19 and diseases with high morbidity and/or public interference (i.e., viral hepatitis was not a priority for investigation in 2020-2021; roughly 40% of cases were investigated by medical record review during this time). From 2017 to 2021, the incidence of acute hepatitis B decreased from 4.7 to 1.6 cases per 100,000 population; acute hepatitis C decreased from 7.6 to 3.3 cases per 100,000; and HIV/AIDS new diagnoses decreased from 25.1 to 23.8 cases per 100,000. While medical record review noted 50% of acute hepatitis C cases were associated with IDU, 93% were associated with substance use of any type.[1]
Additional objectives include: enhancing access to substance use disorder treatment services, providing on-site testing for HIV and HCV, and reducing the number of opioid-related overdose deaths in Marion County through the provision of naloxone and overdose education, reducing emergency department visits related to bacterial infections secondary to IDU, and removing hazardous needle waste from the community.
Syringe services programs are often inappropriately identified as recovery-based initiatives in the public arena in order to gain political and justice system favor. To emphasize the singular goal of preventing infectious diseases, no specific outcome measures were provided for the above-listed additional objectives, such as entry into treatment programs. Any utilization of wraparound services is celebrated by Safe Syringe.
Two hundred and forty-eight clients have been connected to SUD treatment through Safe Syringe. In addition to peer recovery coaches operating the program, Safe Syringe partners with Indiana Addiction Issues Coalition to provide additional recovery support by (1) reducing the workload of Peers during outreach to focus entirely on harm reduction; (2) providing more time for clients to discuss treatment options and needs; (3) increasing the diversity of staff to represent all populations utilizing Safe Syringe; and (4) providing management support and back up for a position with historically high turnover.
Until the COVID-19 pandemic, Safe Syringe utilized MCPHD's Community-Based Care public health nursing staff to support immunizations and testing through the program. However, diversion of public health activities beginning in March 2020 crippled Safe Syringe's ability to provide these interventions with internal support. Eskenazi Health Emergency Department's Public Health team provided a tester/counselor to Safe Syringe from 2019 through 2021 to support point-of-care testing. In February 2022, this service was replaced by Bell Flower Clinic, MCPHD's sexually transmitted infection program, and now includes comprehensive STI testing in addition to HIV and HCV. Since the program's start, testers have performed: 365 HIV (1% reactivity), 143 HCV (43% reactivity), 182 syphilis, 167 chlamydia, and 181 gonorrhea tests. Approximately 150 clients have received 240 immunizations through Safe Syringe, including influenza, hepatitis A, hepatitis B, human papillomavirus, tetanus-diphtheria-pertussis, and COVID-19 (data for COVID-19 immunizations is not readily available through MCPHD's database).
Marion County emergency departments treated 7,204 overdoses in 2021. Moreover, overdose deaths doubled during the pandemic with 806 reported overdose fatalities in 2021. The increase in opioid-induced overdose driven in part by the shift from predominantly heroin use to fentanyl; 23% of overdose fatalities in 2016 were caused by fentanyl, compared to 79% in 2020.[2] Safe Syringe has distributed over 33,000 doses of naloxone to clients since 2019 with at least 1,899 overdoses reversed by laypeople. An ongoing, external cost-effectiveness analysis has so far demonstrated significant reductions in the number of Indianapolis Emergency Medical Services ambulance runs related to overdoses. By counterfactual approach, the study estimates that the number of runs in the last quarter of 2020 through 2021 would have been 20 to 30 percent higher in the absence of Safe Syringe.[3]
Data for Safe Syringe is collected through MCPHD's Safe Syringe database and analyzed using Viya. Additional data and reporting is collected from Indiana Department of Health's Syringe Exchange Database. MCPHD records health-related data, such as testing and immunizations, through Insight and analyzes using Viya. Lastly, MCPHD Epidemiology utilizes ESSENCE syndromic surveillance data for Emergency Department utilization.
A primary source of start-up and personnel funding for this program was the US Department of Justice Comprehensive Opioid-Abuse Programs award from 2018-2021. This award included evaluation by Dr. Bradley Ray, former Director of the Center for Criminal Justice Research under the Indiana University Public Policy Institute. Dr. Ray and his team examined the interactions of Safe Syringe with local law enforcement, including performing a survey of officer attitudes following a presentation on harm reduction by Safe Syringe staff and surveys of clients covering their interactions with law enforcement.
The most significant barrier to program success is the conflict between existing public health initiatives and the criminalization of syringes for illicit drug use. The legalization of syringe services programs did not negate IC 16-42-19-18 Unlawful Possession of a Syringe.” While leadership at IMPD, Marion County Prosecutor's Office, and Marion County Sheriff's Office are supportive of Safe Syringe, the only protection afforded participants exists under Section 9 of the Syringe Exchange Program Law, which specifies that attending an SSP does not constitute probable cause for law enforcement to stop, search, or seize an individual. MCPHD provided education to all IMPD patrolmen during their shift roll call; a post-presentation survey was disseminated by researchers at IU-SPEA with the following results:[4]
Despite generally positive attitudes toward Safe Syringe, over half of officers reported that harm reduction promotes drug use and that they would arrest participants for illegal possession of a syringe. Harm reduction initiatives benefit law enforcement by reducing the prevalence of HIV and HCV in the community and decreasing the risk of needle stick injury for by 66% through the provision of sharps disposals and public interaction with law enforcement.[5] The results of this survey led to collaboration between MCPHD, Indiana State Department of Health, Dr. Ray and his research team, IMPD and other law enforcement throughout Indiana to tailor an officer safety curriculum (SHIELD) developed by Northwestern University to reflect local policies, enhance law enforcement's support of harm reduction programs, and reduce the risk of needlestick injury and COVID-19 infection in our first responders.
Dr. Brad Ray and his team conducted the second part of their evaluation in 2020 and 2021 following completion of the IMPD survey study. This phase focused on 30 client interviews covering their interactions with law enforcement while enrolled in Safe Syringe. Staff included flyers for participation in client harm reduction kits for one month; clients that reported law enforcement interaction to staff were encouraged verbally to participate in the study. Study participants received a $50 gift card to compensate for their time. Findings from these qualitative interviews indicated positive client perception of Safe Syringe and its staff, as well as reduced needle sharing among participants, increased appropriate disposal of used syringes, and increased access to treatment and other resources.
Of those interviewed, seven had been stopped and searched by police since enrolling in the program. Six of the seven were able to provide law enforcement with their participant identification card, yet six of the seven were still arrested for syringe possession. Two clients reported relatively positive police interactions: one in which the officer stated he supported the program and would not arrest if no drugs were found on the person, and one in which the client was released, but the syringes were confiscated.
While syringe charges decreased overall from 2019 to 2020, some spikes were still observed immediately following the launch of Safe Syringe in 2019, and during Safe Syringe's limited operations in spring 2020. Marion County Sheriff's Office and Marion County Coroner's Office data demonstrated that every jail booking per incarcerate increased the likelihood of overdose fatality by 20%; the presence of a syringe charge at the most recent booking more than tripled the rate of overdose fatality.
Dr. Ray collaborated with Corey Davis, Deputy Director of the Network of Public Health Law, and Detected Sergeant Ronald Martin of North Carolina, to present findings from Marion County and provide insight into paraphernalia decriminalization in other jurisdictions, the negative impact of decriminalization on morbidity and mortality, and the positive impact observed in communities in which decriminalization has been implemented.
Source: Ray, B. (2021, May 26). Implementation of a Syringe Services Program and Law Enforcement Barriers. Wayne State University. Data from Marion County Sheriff's Office.
Due to confounding variables and delayed program expansion related to the COVID-19 pandemic, the cost-effectiveness analysis for Safe Syringe is still ongoing. Myers and Stauffer published an interim report for City-County Council on June 2, 2022. At the time for the report, the analysts were still awaiting 2021 hospital and infectious disease data from Indiana Department of Health. Key points included:
· When controlling for initial start-up costs, the average cost per client from October 1, 2020, through December 31, 2021, is $309.05.
· The initial goal client saturation rate of 20% estimated people who inject drugs in Marion County through 2021 was achieved. If a saturation rate of 33% was achieved through approximately 7,000 more visits, the estimated cost per client would be $99 per visit. The estimated number of people who inject drugs in Marion County was projected at 0.8 percent.
· Through December 2021, nearly 30% of clients did not have a second visit. If the following variables were positive, there was a 77% probability the client would not return for a second visit: identifies as White, injects daily, heroin as primary drug, hepatitis C positive, condom use, in some form of peer recovery or no interest in treatment. If all the listed variables were negative, the chances the client would not return was reduced to 4%. These trends will continue to be examined as client participation increases, including observed significant delays between first and second visits.
· Significant reductions in the number of IEMS runs related to overdoses by counterfactual approach, the study estimates that the number of IEMS runs in the last quarter of 2020 throughout 2021 would have been 20 to 30 percent higher in the absence of Safe Syringe.
· Substantial cost savings for inpatient care related to drug use, particularly as both the number of syringes distributed, and the amount of naloxone provided are increased.
[1] Marion County Public Health Department. Insight Patient Database. Viya Report
[2] Indiana Drug Overdose Dashboard. (2022, Feb 24). Retrieved from https://www.in.gov/health/overdose-prevention/data/indiana/
[3] Myers and Stauffer LC. (2022). Marion County Public Health Department Safe Syringe Access and Support Program Interim Report. Indianapolis, IN.
[4] Sightes, Ray, Paquet, Bailey, Huynh, & Weintraut. (2019). Police officer attitudes toward syringe services programming. Drug and Alcohol Dependence, 205. https://doi.org/10.1016/j.drugalcdep.2019.107617
[5] Groseclose, SL. (1995). Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut. Journal of Acquired Immune Deficiency Syndroms and Human Retrovirology, 10(1), 82-89.