New Cases in Indiana HIV Crisis Down as States Struggle to Address Opioid Epidemic

New Cases in Indiana HIV Crisis Down as States Struggle to Address Opioid Epidemic

By Neville Elder 06/22/15

The Fix talks exclusively to Dr. Jerome Adams, Indiana's Health Commissioner, about the crisis.

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The terrifying spike in HIV infections in Scott County, Indiana seems to be slowing down. And of 170 confirmed cases, Indiana’s State Department of Health (ISDH) Commissioner Jerome Adams told The Fix that 11 people are now in treatment with viral suppressing drugs:

“And (those people) are no longer at risk to transmit HIV…When you look at when this outbreak started, to have 11 people virally suppressed...is just amazing. We’ve got 112 people who are engaged in care…and getting started on treatment. That is a number we’re proud of. We’ve still got a lot of work to do and by no means are we declaring victory but that said, I feel we’re on the right track and It’s an appropriate time to hand over to the local authorities.”

The ISDH, which still considers the crisis a "public health emergency," will now hand the reins to Scott County to continue the work started by Adams and the CDC. Going forward, the county’s "one-stop-shop" clinic for those at risk, now includes HIV and hepatitis testing, immunization and help with practical matters like insurance enrollment in Indiana’s Medicare alternative, and the Department of Workforce Development to help people get jobs. Indiana’s HIV crisis can be traced back to state government policy. There were no needle exchanges in Indiana until Governor Mike Pence declared a state of emergency (SOE). With the SOE came a temporary needle exchange program but it was too late for many residents. But Adams stressed the importance of harm reduction in its many forms.

“(A) needle exchange doesn’t get people off of drugs..they will slow the transmission…if people continue to engage in high risk activity you will still see disease transmission.”

In May, he testified in a Washington D.C., hearing entitled “What are the State Governments Doing to Combat the Opioid Abuse Epidemic?” for the Subcommittee on Oversight and Investigations (SOI) (part of the Energy and Commerce Committee (ECE)). In his testimony, Adams, a physician himself, talked about the tragedy in his home state:

“There is much we’ve learned during our response to this unprecedented HIV outbreak, but at its root is our country’s prescription opioid crisis.”

Across the country as states attempt to control the opioid abuse epidemic and crackdown on illegal prescription use (Indiana’s own attempts to introduce new drug rules have led to a 10% reduction of prescriptions) addicts are crossing state lines to Kentucky and Ohio to find friendly doctors. "Doctor shopping" as it is known, is a problem recognized by Representative Joe Kennedy from Massachusetts who, at the same hearing, said:

“Lack of communication across state lines is leaving a gap in how we tackle prescription drugs.”

Both the ISDH and other states see Prescription Drug Monitoring Programs (PDMP), a statewide electronic database collecting data on substances dispensed in the state, as vital to controlling abuse. Forty-seven states including Indiana have PDMPs, the remaining states are currently enacting legislation.

In New York City, the Department of Health treats "doctor shoppers" as patients with substance abuse disorders not criminals. On-the-spot referrals to detox and rehabs and harm reduction programs like needle exchanges distribute out naloxone (the anti-OD drug).

In his speech to the committee, Indiana’s health commissioner diplomatically left criticism of his home state’s legislature to others. After all, the policy of banning needle exchanges, and treating addicts as criminals, is not exclusive to the red state of Indiana.

But when Dr. Adams talked to The Fix this week he launched a sharp attack on Big Pharma:

“I believe if you derive a profit from any industry or sale you also share a responsibility for any negative outcomes that result as a part of that process...Pharmaceutical companies...quite honestly have profited off of something that is causing a lot of harm and misery for citizens…you don’t need a narcotic for a knee sprain.”

This touched on his speech in Washington D.C., in May:

“Targeted marketing by the pharmaceutical industry encouraged providers to use opioids more aggressively to treat chronic, non-terminal pain…Although there is no evidence to support the routine use of opioids in the management of chronic pain, the rapid subjective evaluation of pain and subsequent increase in ... prescriptions did little to solve the pain problem and resulted in an epidemic of opioid misuse.”

Big Pharma has already bungled attempts to stop the epidemic. In 2012, when the government banned all generic oxycodone pills in an attempt to stem abuse, the manufacturers of OxyContin, Perdue, returned the favor and introduced extended-release tablets, designed to be less attractive to addicts. An extended release, makes the high harder to come by as the drug won’t "hit" in one dose upon the moment of ingestion. Although addicts quickly found ways around this trip-wire, the popularity of OxyContin did briefly dip. Unsurprisingly, the drug of choice simply changed. In the same year the first reports of overdose deaths from another more powerful opioid, Opana, were being recorded in Scott County, Indiana—ground zero for the HIV epidemic.

Opana was reformulated to thwart intravenous and snorting use, too. The pill’s new tougher shell was supposed to foil attempts at breaking it up and when it was dissolved and diluted it became a gluey gel. Even as goop, Opana can be injected using larger gauged needles. It almost certainly pushed some of those who had been snorting the drug towards injection habits in Indiana. Those behaviors were, of course, made riskier with the ban on needle exchanges.

Even worse news for IV abusers of the new look drug was around the corner. The reformulated Opana has been linked to blood-clotting disorder that has landed some addicts in the hospital. According to a MedPage Today/Milwaukee Journal Sentinel analysis of FDA reports:

“In the four years prior to reformulation, there were only two cases of blood clotting disorders with Opana as the primary suspect. But in 2012...53 cases…accounting for some 5% of all adverse event reports where Opana was the primary suspect.”

Adams told The Fix in no uncertain terms he thinks pharmaceutical companies should do more:

"I think (pharmaceutical companies) should help fund addiction and recovery. I don’t want to go as far to say they should be compelled but certainly, I would hope they would step up to the plate and say ‘OK, if a proportion of our country are addicted to drugs because of prescription opioids or addicted to prescription opioids…we’re going to help provide funding so they can enroll in and have access to recovery and treatment centers.’”

And in calling for "take-back programs" to get stray opioids off the streets, Adams is looking to pharmaceutical companies to finally take responsibility for their pill pushing.

It’s Indiana’s experience that could act as a blueprint for the rest of the nation. Start early, says Adams, and high school students could avoid the misery of addiction and the complications of HIV:

“In Scott County, we met a 23-year-old in our HIV clinic who was first prescribed opioids in high school as a result of a knee injury. Less than three years later, he was injecting opioids and he’s now HIV-positive.”

He told The Fix:

“We need to educate patients/consumers…you don’t need an opioid for everything, for even most things and that there’s a danger to it…we need to educate the prescribers. Doctors feel compelled to give a narcotic if the patient asks for it otherwise the patient will rate them poorly...They feel like they have no choice if they want to keep their license.”

Initiating hard-hitting educational campaigns, not unlike the striking posters that the ISDH put up at truck stops warning travelers of the danger of contracting HIV when using commercial sex workers on the highway through Scott County.

Adams said it plainly in his address to the committee:

“Mitigating policies should create easy access to HIV and hepatitis testing, with care coordinators on-site for immediate referral to medical and SUD treatment ... adoption of locally based harm reduction strategies, and help people obtain healthcare coverage and jobs.”

The tragedy of Scott County is that it’s taken the ruination of 170 lives to draw attention to the simply held fact that substance abuse should be addressed by doctors not judges. But it speaks well of Dr. Adams and the ISDH that he was able to rollback years of prejudice and convince Governor Pence, and the notorious hard-line sheriff of Scott County, Dan McClain, that the first step to slow HIV transmission rates was the introduction of a needle exchange program.

Neville Elder is a regular contributor to The Fix. He's also a photographer and writer. He last wrote about the end of the Silk Road and about the life and death of Charles Kennedy.

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British born Neville Elder is a writer,photographer and filmmaker. He's been sober since 2006, lived in New York since 2001 and is in no hurry to move back to a Brexited Britain. He writes the odd murder ballad with his band Thee Shambels and teaches photography at the New York Institute of photography. Find him on Linkedin and Twitter.

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