BURLINGTON — Necessity is the mother of invention, and syringe exchange programs sprang up decades ago to address necessities borne of the HIV/AIDS epidemic.
Now that epidemic is fading, and leaders of some syringe exchange programs fear they may lose funding just when they’re needed to fight today’s public health crisis of opiate addiction.
Vermont officials say they are doing what they can for the exchanges. But a boost in state funding has yet to replace a dip in federal support for HIV/AIDS prevention work.
While federal money for HIV/AIDS prevention was intended primarily to support testing and case management services to people living with the disease, over the last five years syringe exchanges leveraged that money to take on an increasing role in the deepening opiate epidemic.
During that same period, Vermont embraced naloxone, a powerful tool for combating opiate-related deaths. Often referred to by the brand name Narcan, naloxone is a drug effective at reversing an overdose.
The Vermont Department of Health began distributing naloxone for free to drug rehab clinics, recovery centers and syringe exchanges in December 2013. It’s an innovative approach, officials said, and one that goes beyond what’s being done in most other states, which typically provide the drug only to first responders — something Vermont does as well.
Syringe exchanges have given out the bulk of that free naloxone. Decades of work helping to prevent the spread of infection and disease among injection drug users left syringe exchanges uniquely positioned to distribute naloxone.
Those existing relationships with street drug users, built around low-barrier services that encourage small steps toward improved health and well-being, have proven to be invaluable in reaching those at greatest risk to die from overdose, workers said.
Safe Recovery in Burlington, operated by the Howard Center, is Vermont’s largest syringe exchange. This year 4,700 drug users have passed through its doors, according to the Howard Center.
In the first six months of 2017, Safe Recovery gave out 71 percent of the naloxone through Vermont’s distribution program. Overall, syringe exchange programs accounted for 79 percent during that period.
Since naloxone distribution began, more than 300 people in the state have died from an opiate overdose, according to Health Department figures. Social workers, treatment providers and public health officials all say the death toll would be far greater without naloxone.
“I don’t know where we would be if Narcan hadn’t gotten here ahead of the fentanyl epidemic,” said Safe Recovery Executive Director Grace Keller.
Keller, who has worked at Safe Recovery for close to a decade, said fentanyl and other powerful synthetic opioids in the heroin supply has raised the stakes for drug users.
“I went years without losing a client to overdose. We’ve lost more clients in the last six months than my previous nine years at Safe Recovery combined,” Keller said.
In the last year and a half, more than a dozen people experiencing an overdose were taken to Safe Recovery, a converted home on Clarke Street just a block from downtown, Keller said.
“None of them were breathing when they were brought to our office. If it wasn’t for Narcan, all of those people could have died in front of our whole staff,” she said.
Survey data collected as of June at more than 20 sites when people sought naloxone refills showed that 1,125 people had used the drug to reverse an opiate overdose. Safe Recovery alone tallied 1,013 reports of overdose reversals as of mid-September. Both figures date back to the program’s inception.
The number of reversals is almost certainly higher than what the data reflect, because many people don’t return to fill out a survey, according to public health advocates.
Beyond the immediate crisis
The benefits of syringe exchanges in battling the opioid epidemic can extend even further, according to officials. “We certainly recognize it can be an opportunity to connect people with treatment and other services,” said Deputy Health Commissioner Tracy Dolan.
According to Keller, talking with someone who is shooting up about how to look after their health will naturally transition into a conversation about treatment and recovery.
“It may be the first time in months anyone has asked them how they’re doing,” added Theresa Vezina, harm reduction program manager for Vermont Cares, another of the state’s syringe exchange programs.
Safe Recovery, in particular, parlayed federal HIV/AIDS money into robust case management services for people using drugs. At the time, federal money could not go directly to syringe services, but it could be used to pay for staff. That restriction was recently lifted, but less federal money is now available for syringe exchanges.
From 2012 to 2015, the Howard Center was able to expand Safe Recovery’s staff to seven people, thanks to a large federal HIV/AIDS prevention grant. Since it ended, the Safe Recovery staff has shrunk to three.
During the four years of the federal grant, Keller and her colleagues were able to do things like drive users to treatment centers around the state as slots opened for them, or help people find housing and apply for state benefits. Now they struggle to meet the demand for the basic health and education services the program offers, she said.
Despite the effectiveness of syringe exchanges in the fight against opiate addiction and death, six Vermont counties currently have no such services: Franklin, Grand Isle, Orleans, Essex, Bennington and Orange.
At Safe Recovery, the only syringe program that keeps normal business hours, 34 percent of the clients come from outside Chittenden County, and it serves people from every county in the state, according to information collected by staff.
“The gold standard would be to have syringe exchange in every community, and to have case management available at those exchanges,” Keller said.
The Health Department would like to do more for syringe exchanges, Dolan said, but the problem is they compete with other elements of Vermont’s opiate response, including addiction treatment, prescription monitoring, recovery centers and prevention efforts.
“In an ideal world, there would be more money for everything. It’s a resource issue,” Dolan said.
Two recent large-dollar federal grants to fight opiate addiction will go to the state’s other opiate response priorities, missing the syringe exchanges entirely.
A current two-year, $1.8 million federal grant for overdose prevention was targeted toward monitoring prescription opiates and educating doctors about safe prescribing practices. Another newly awarded $2 million federal grant will also go toward preventing the misuse of prescription opiates and bolstering treatment and recovery services.
As role grows, money slow to follow
The connection between syringe exchanges and HIV/AIDS prevention is evident in the organizations involved.
The HIV/HCV Resource Center in Lebanon, New Hampshire, which operates two syringe exchanges in Windsor County, was created 26 years ago “by volunteers as a support network for their friends who were sick and dying from AIDS related illnesses,” according to its website.
Vermont Cares and the AIDS Project of Southern Vermont share similar histories and missions. Much of their work is still focused on providing free testing for sexually transmitted diseases and case management for people living with HIV/AIDS or hepatitis.
Federal HIV/AIDS prevention funding has decreased nationwide. The most recent figures available show Vermont recorded just 11 new cases of HIV in 2015, the lowest number since 1983.
The federal HIV/AIDS prevention money coming to Vermont has dwindled from $1.56 million in 2012 to $755,000 in 2016. The state paid out much of that money in grants to organizations working on HIV/AIDS prevention, with the bulk going to syringe exchanges.
Much of that money came from a single four-year, $2 million HIV/AIDS prevention grant from the Centers for Disease Control and Prevention that ran from 2012 to 2015.
This year is the first that a change in law allowed federal money to go directly to syringe exchange services. However, combined federal syringe exchange and HIV/AIDS prevention money in 2017 is still well below what support for HIV/AIDS prevention alone was in 2012.
The state has stepped up, increasing its support for syringe exchanges from $100,000 in 2014 to $175,000 in 2015, and for the last two years the state appropriation for syringe exchanges was $250,000.
That money is making a difference. Howard Center CEO Bob Bick said it may allow the restoration of some staff lost after the CDC grant ran out in 2015, though Safe Recovery’s 2018 budget is still being finalized.
However, the combined state and federal money that syringe exchanges received in 2012 was $725,000. In 2017 that figure is $526,000.
The difference of $200,000 might not seem significant, but Vermont Cares Executive Director Peter Jacobsen estimates his organization could expand syringe exchange services to every county in the state for half that amount.
Expanding services statewide
Since Vermont Cares joined the state’s naloxone distribution program in 2015, the nonprofit has greatly expanded the geographic reach of syringe exchange services.
Vermont Cares gets naloxone to drug users through partnerships with municipalities, rehab programs and health centers as well as a retrofitted van purchased with a private grant from the Elton John AIDS Foundation.
“We have the tool, in the van, and a strategy that works for most communities where we make periodic visits at regularly scheduled times,” Jacobsen said.
That means naloxone is available to more people closer to where they live, and it’s being offered in a low-barrier venue to drug users regardless of whether they’re ready to overcome their addiction.
It’s one reason syringe exchanges are more likely to reach people who are actively using than the rehab programs or recovery centers that also hand out naloxone.
People may be reluctant to take naloxone from the rehab facility where they go for counseling and daily doses of maintenance drugs, for fear that asking for or accepting naloxone may be viewed as an admission they’re not ready to get clean, Vezina said.
Turning Point recovery centers, for example, expect recovering addicts to stay clean, and asking for naloxone may be seen as a sign that they’re still using, instead as a hedge against the possibility of relapse.
Employees and volunteers at several Turning Point centers said the majority of the naloxone they give out goes to the loved ones of drug users.
Jacobsen estimated Vermont Cares needs $100,000 to hire enough staff to expand programs to the unserved counties. Currently, the annual budget for the nonprofit is about $900,000.
Conversations are already underway to try to start services in St. Albans and Wells River. The latter town has proactively sought to bring syringe exchange services to its residents, Vezina said.
Not all municipalities are taking that approach. Newport officials have tried to block the program from coming to their city, Vezina said. Minutes from a June 2014 City Council meeting show members voted 3-2 against allowing Vezina to provide services on city property. Vermont Cares is still able to assist area residents by appointment.
“We’ve had many a battle with the Newport City Council,” she said.
Newport Mayor Paul Monette, in explaining his tie-breaking 2014 vote, said he viewed the possibility of giving clean syringes to people coming out of prison as “enabling them to start being an addict again,” according to a Newport Daily Express report.
More recently, Vezina said she thought she had found a solution with a local church willing to host the syringe exchange, but that plan was scuttled when it turned out the parking lot, where she was hoping to park the van, is city-owned.
Jacobsen and Vezina said officials’ concerns about syringe exchanges are misplaced: Drug users who decide to get clean needles or naloxone aren’t being enabled; they’re taking a small step toward a healthier life.
“If you’re addicted to drugs, that’s a really important step,” Jacobsen said.