• Notes on syringe exchange programs, part I

    Fully developed posts on syringe exchange programs (SEPs) are here and here. A couple more are forthcoming. Here are the notes I took as I read the literature in this area. This is Part I. Part II is here. Part III is here.

    (1) Lessons from Indiana: the case for broader implementation of syringe exchange programs, by Monica Ruiz, Sean Allen, and Allison O’Rourke (Harvard Health Policy Review, 2015)

    • The first HIV outbreak in the US in three decades occurred in 2015 in rural Indiana. The source of the spread: injection drug use (IDU).
    • Syringe exchange programs, which are effective in reducing the spread of blood borne disease, are restricted by policy at federal, state, and local levels.
    • The first SEPs in the U.S. opened in the 1980s. Today there are 133. “Since the implementation of SEPs, IDU-attributable HIV incidence in the US has declined by approximately 80%; this is the only category of adult HIV infection to show declines of this magnitude.”
    • Most laws governing injection equipment are “rooted in the perception of addiction as a criminal rather than public health issue.” Over the years, states and municipalities passed laws that restricted the sale and distribution of sterile injection equipment, though some have been reformed in response to public health crises.
    • From 1988 to 2009, a federal law banned the use of federal funds for SEPs. The ban was lifted between 2009 and 2012, during which time three SEPs received federal funding. The ban remains in effect today.
    • Until 2007, Washington DC is the only U.S. city prohibited by Congress to use municipal funds for SEPs.
    • Bowen [argues] that US drug policy [] is ‘a charged issue, largely driven by values and morals, instead of logic, economics, and principles of public health.’ This irrationality extends to community-level policy decisions, manifested through ‘not in my backyard’ ideologies that marginalize already disenfranchised groups, such as PWID, the homeless, and the mentally ill.”
    • “In Baltimore and Philadelphia, research guided policy discussions and helped change policymakers’ and constituents’ conceptualizations about substance use and the utility of SEPs. In DC, the unwillingness of Congressional SEP opponents to consider research evidence proved to be a significant impediment. Several stakeholders described Congress as an ‘evidence-free zone’ where SEP opponents misinterpreted research findings or took evidence out of context to support their opinions. One person commented, ‘…Whether you quoted from scientific journals…and…statistical evidence, from what was happening across the United States, none of it mattered.'”
    • “Research evidence overwhelmingly demonstrates that SEPs successfully reduce HIV incidence as well as injection-related practices that increase HIV and HCV risk [Ksobiech, Hurley, Palmateer, Tilson, Wodak,* Hagan [also examines hepatitis B], Kaplan]. Data from the earliest SEPs are the most impressive: in Tacoma, SEPs were associated with an over 80% reduction in the incidence of hepatitis B and C infections. Similarly, SEPs were associated with a 33% reduction in HIV infection in New Haven, CT, and a 70% reduction in New York, NY.”
    • “Numerous modeling studies show that widespread clean syringe access results in substantial financial savings compared to costs associated with lifetime HIV treatment [LurieHoltgrave, Laufner]. Lurie and Drucker* estimated that between 4,394 (15% incidence reduction) and 9,666 (33% incidence reduction) HIV infections could be averted as a result of implementing SEPs nationally, resulting in a $244 to $538 million (in 1997 USD) costs savings to the US healthcare system. Extrapolating to 2015 USD, the savings are approximately $361 to $796.5 million. Our research found similarly impressive cost-savings. In the two years following the DC Ban’s removal, we estimated 120 averted HIV infections.* The Centers for Disease Control and Prevention (CDC) estimated the average lifetime cost of treating HIV at $380,000 USD per person. Subtracting SEP operational costs, averting 120 cases of HIV translates to an approximate cost savings of $44.3 million USD. Given that the clinical care (including prescriptions) of many HIV-positive DC residents is covered by the city’s publicly funded health plan, costs saved in treatment are direct savings to DC taxpayers.”
    • “Given recent law enforcement crackdowns on prescription drug misuse, the transition from prescription opiates to cheaper, more easily accessible illicit drugs is inevitable. A recent Substance Abuse and Mental Health Services Administration (SAMHSA) report found that the number of people ages 12 and older who reported using heroin in the past year rose from 373,000 in 2007 to 681,000 in 2013, an 83% increase.”
    • “Acting on the Executive Order 15-05 issued by Governor Mike Pence, State Health Department officials were able to act quickly to establish a SEP in Scott County in less than 2 months since the initial news of the outbreak, overriding existing legislation declaring such programs to be illegal in the state. Through this Executive Order, Governor Pence showed that he could suspend his own views about needle exchange (he has previously voiced opposition to SEPs), focus on the research evidence supporting this intervention, and respond quickly to the public health need that mandated it.” The Indiana legislature also acted.

    (2) CDC:

    • 13 percent and five percent of HIV infections in U.S. women and men, respectively, are attributed to injection drug use (2014 data).

    (3) Global estimates of prevalence of HCV infection among injecting drug users, by Carmen Aceijas and Tim Rhodes

    We identified 10 estimates of HCV antibody prevalence among IDUs in the USA []. The lowest estimate was in Baltimore in 2002 (8% of 183 IDUs), while other estimates ranged from 28 to 88% []; the latter from Albuquerque (New Mexico) in a study of 516 IDUs recruited through treatment facilities and via a community survey in 1996. An estimate of 83% was reported among 229 IDUs, recruited in similar settings in Las Cruces (also New Mexico) []. Estimates from New York show 71% of 89 IDUs recruited in treatment services and tested in 2001 and 61% of 314 IDUs participating in a survey between 2001 and 2003, to be HCV positive.

    (4) Do no harm – Health, human rights and people who use drugs (UN AIDS, 2016)

    • “Needle–syringe programmes reduce the probability of transmission of HIV and other bloodborne diseases by lowering the rates of sharing of injecting equipment among people who inject drugs [Hunt, Gibson].”
    • “Ten years of needle–syringe programming in Australia reduced the number of cases of HIV by up to 70% and reduced the number of cases of hepatitis C by up to 43%. […] [E]ach dollar spent on Australia’s needle–syringe programme between 2000 and 2010 has an estimated lifetime return on investment of US$ 1.30–5.50 in averted health-care costs [Kwon].”
    • “Costing US$ 23–71 per person per year, needle–syringe programmes are relatively inexpensive to implement and are much more affordable than the lifetime health-care costs required to treat a person living with HIV [Wilson]. Cost-effectiveness is even higher if we consider the combined reduction of HIV and hepatitis C infections [Wright].”

    needle exchainge vs antiret

    hiv hep c-IDUs


    • “The preamble of the Single Convention on Narcotic Drugs describes dependence on narcotic drugs as a ‘serious evil for the individual’ and ‘fraught with social and economic danger to mankind’. Community advocacy organizations have denounced such language as emblematic of the demonization of people who use drugs and the stigma and discrimination they face in their daily lives [Albers].”
    • “Judgemental feelings among health-care providers have been linked to lower-quality health care and lower health outcomes [Skinner, Treloar]. Nearly one quarter of people who use drugs surveyed in the United States reported they had been prevented from obtaining medical care because of their drug use, and one third said they had been denied housing because other people knew about their drug use [Ahern].”
    • “In the United States, federal law calls for people with drug-related convictions, including for personal possession and use, to be denied housing assistance, nutritional support, cash transfers, and grants and loans for higher education [Levi]. Individuals coming out of prison for drug related crimes are thus denied social support services at a time when they may need it the most, increasing the likelihood that they will drop out of drug dependence treatment, struggle to find employment and suffer from food insecurity [The Sentencing Project]. Former prisoners who live in states that fully enforce the federal ban on nutritional support are more likely to report having gone an entire day without eating than those who live in states that do not enforce the ban. Furthermore, a study showed that people who did not eat for an entire day were more likely to engage in risky behaviour, such as using alcohol, heroin or cocaine before sex or exchanging sex for money [Wang].”
    • “The Consolidated Appropriations Act of 2016 gives states and local communities the opportunity to use federal funds to support certain components of needle-syringe programmes.” Though federal funds can used to support aspects of these programs, “they cannot be used to purchase sterile needles or syringes for illegal drug injection.”

    * See Part II or III.


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  • Syringe exchange programs work

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company). It also appeared on page A3 of the September 8, 2016 print edition.

    For decades, public health experts have known that syringe exchange programs reduce the spread of certain viral infections — like H.I.V.hepatitis B and hepatitis C — by removing contaminated syringes from circulation.

    They have known that programs using sterile injection equipment are both safe and save money.

    And yet they are rarely seen in the United States.

    Evidence abounds that they work. A study of the first American program — started in the Tacoma, Wash., area in 1988 — found that use of the exchange was associated with a greater than 60 percent reduction in the risk of contracting hepatitis B or C. Another study of over 1,600 injection drug users in New York found that those who didn’t use a syringe exchange in the early 1990s were more than three times as likely to contract H.I.V.

    Syringe exchange programs do more than improve health. Because they are so effective and far cheaper than the lifetime cost of treating H.I.V., hepatitis B or hepatitis C, they save taxpayers money. A cost-effectiveness analysis published in 2014 replicated the findings of others that came before it: A dollar invested in syringe exchange programs saves at least six dollars in avoided costs associated with H.I.V. alone.

    The most frequently expressed concerns about the programs are that they promote drug use and raise crime levels. But according to many studiesthat isn’t so. Instead, they are associated with increased participation in treatment programs.

    Syringe exchange programs “reduce not only infectious disease but also create an opportunity for people to get the care and provide a transition into treatment for people in the community,” said Michael Botticelli, director of the federal Office of National Drug Control Policy, at an event sponsored by the Chamber of Commerce of northern Kentucky, a region hit hard by illegal drug use.

    In the 1990s and early 2000s, seven evidence reviews for federal government agencies reaffirmed that syringe exchanges were effective, safe and cost-effective. Since then, numerous other studies of programs have replicated these results, including a systematic review by the World Health Organization and another by the United Nations. These include examination of exchange programs outside the United States, such as those in Canada and Australia.

    Syringe exchanges are endorsed by the 2015 National H.I.V./AIDS Strategy for the United States and the 2012 President’s Emergency Plan for AIDS Relief Blueprint. The American Medical Association says they work.

    With all this evidence and the official endorsements, you’d think the government would generously fund syringe exchanges. But just as the first program opened in 1988, Congress prohibited federal funding for any such programs. With the exception of a few years, that moratorium held until this year. Though federal funds may now be used to support syringe exchanges, they still may not be used to buy injection equipment.

    Although most states and local governments limit or prohibit syringe exchange programs, some restrictions have been lifted, offering additional opportunities to study their effects. For example, in 2008, the District of Columbia’s syringe exchange funding ban was lifted, and several programs began offering harm reduction and exchange services. One study found that the funding ban’s lift was associated with a 70 percent drop in new H.I.V. cases tied to injection drug use.

    “Policies that limit syringe access are not in the best interest of public health,” said Sean Allen, an infectious disease and public health researcher at Johns Hopkins University and a co-author of the study. “Syringe services programs can prevent new H.I.V. infections, but they need to be accessible to work.”

    Today, injection drug use — notably, of heroin — is on the rise and has led to outbreaks of H.I.V. in some communities. In response, some leaders, like Gov. Mike Pence of Indiana, the Republican vice-presidential nominee, have reversed course and embraced the programs.

    Today, only about 200 syringe exchange programs are operating in 33 states. In many areas where they could do a lot of good, resistance to them remains strong.


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  • AcademyHealth: Effectiveness and cost-effectiveness of syringe exchange programs

    There’s one intervention for injection drug use that we rarely consider in the U.S. — syringe exchange programs. Do they work? Yes, and on multiple levels. I round up the evidence in my AcademyHealth post.


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  • The golden tweet

    Via Justice Don Willett:

    golden tweet


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  • Response to reviewer

    Via Academia Obscura (click to enlarge … a little):

    peer review


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  • How to keep up

    Here’s what I told the USC Annenberg School of Journalism, and its newsletter included it today:

    Politico Pulse is very useful for the inside-the-beltway perspective. Pulse Check, Politico’s health policy podcast is also very good. It’s my favorite podcast in this area.

    Modern Healthcare’s A.M. is a roundup of stories from that source only. I think Modern Healthcare does an excellent job in general. It’s a rare day I don’t read at least one of their pieces in full.

    RealClearHealth’s Morning Scan catches things from all sources, but just a few, so it’s a reasonable load.

    Institute for Clinical and Economic Review’s (ICER’s) Morning View has a comparative- and cost-effectiveness angle, and largely focuses on prescription drugs. It also includes a few other, high profile stories.

    The New York Times’ Morning Briefing for the rest of the news.

    I also keep up on Twitter, which is self-curated. To get started, consider Ezra Klein’s Twitter health care list.


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  • AcademyHealth: Marketplace choice architecture, 2016

    My new AcademyHealth post provides an update on how ACA Marketplaces help (or don’t help) consumers select plans. If you’ve ever tried to select a plan among many choices, you know how important certain information (like which doctors and drugs are covered) and functionality (like sorting and filtering) can be. If you haven’t, trust me, it’s very important. Go read!



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  • Hospital quality and market share

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company). It also appeared on page A3 of the August 23, 2016 print edition of The Times.

    There’s an exceedingly simple way to get better health care: Choose a better hospital. A recent study shows that many patients have already done so, driving up the market shares of higher-quality hospitals.

    A great deal of the decrease in deaths from heart attacks over the past two decades can be attributed to specific medical technologies like stents and drugs that break open arterial blood clots. But a study by health economists at Harvard, M.I.T., Columbia and the University of Chicago showed that heart attack survival gains from patients selecting better hospitals were half as large as those from breakthrough technologies.

    That’s a big improvement for nothing more than driving a bit farther to a higher-quality hospital.

    Because more Medicare patients went to higher-quality hospitals for heart attacks between 1996 and 2008, overall chances of survival increased by one percentage point, according to the study. To receive care at a hospital with a one-percentage-point gain in survival rate or a one-percentage-point decrease in readmission rate, a heart attack patient traveled 1.8 or 1.1 miles farther, respectively.

    The investigators also found survival gains for heart failure and pneumonia, but with far less of a difference, about 0.21 and 0.10 percentage points.

    Although it’s clear that more patients have sought care at better hospitals over the years, exactly how they figure out which ones are better is less clear.

    Identifying a better hospital on your own may be conceptually simple, but in practice it’s not so easy. (Obviously, this is something you’d want to consider in advance of an emergency like a heart attack.) There are several websites that convey various metrics of hospital quality.

    For example, on Medicare’s Hospital Compare site, you can learn which hospitals have lower-than-average mortality rates for five medical conditions — including heart attacks, heart failure and pneumonia — and two surgical procedures. You can also find which have higher-than-average readmission rates for the same conditions and procedures, as well as over all.

    And you can pore over statistics on 11 measures of patient satisfaction; on almost 50 ways to assess the timeliness of effective care; on nine kinds of complication rates; and on six ways to assess appropriate use of imaging, like M.R.I.s.

    Your head may already be spinning. But if you wanted even more information, you could read about deficiencies compiled during hospital inspections at HospitalInspections.org, run by the Association of Health Care Journalists. There are also state-specific websites, like New York’s or California’s.

    Perhaps because of the complexity of sifting through all this information, most patients don’t choose hospitals this way. More likely, many rely on their doctors for recommendations. Doctors are more attuned to clinical quality than patients can be, because patients lack the expertise and don’t engage with the health care system frequently enough to evaluate hospital quality.

    “Our results fit with the view that hospitals’ reputations spread through social networks of patients and doctors influencing the decision over where to seek care,” Adam Sacarny, an economist at Columbia and one of the study’s co-authors, said.

    Rather than clinical quality, which is hard to perceive, patients may be more directly attuned to how satisfied they, or their friends and family, are with care. That’s something they can more immediately experience and is more readily shared.

    Fortunately, most studies show that patient satisfaction and clinical measures of quality are aligned. For example, patient satisfaction is associated with lower rates of hospital readmissions, heart attack mortality and other heart attack outcomes, as well as better surgical quality.

    Hospitals could also improve patient experience in ways that have nothing to do with quality of care: Nicer TVs in the rooms or more opulent lobbies don’t reduce mortality rates. For this reason, we should not assume that greater satisfaction necessarily means better medical outcomes. It’s still a good idea to check the quality ratings and consult with your doctor about where you’ll get the best care — and not be put off if it means driving a bit farther. It could save your life.


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  • Science

    Via Justin Beach:



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  • AcademyHealth: The state and future of telemedicine

    I’ve written about telemedicine several times before, but some recent work nicely characterizes its state and hints at its future. That warrants and update, which you’ll find on the AcademyHealth blog. Go read it!



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