The Northern Kentucky (NKY) Independent Health Department represents four different counties in Kentucky: Boone, Campbell, Grant, and Kenton. This region is often referred to as District 8 and it is made up of 381,153 Kentuckians. In 2008, a startling 18% of individuals in the region were diagnosed with depression and 9.8 % of individuals were living below the poverty level. Yet, the most pressing issue in this district is the heroin epidemic and its association with HCV. According to the NKY Drug Strike Force, three of the four counties in District 8 are the most problematic in the Northern Kentucky Area Development District.
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Boone, Kenton, and Campbell counties represent 60% of Kentucky’s heroin prosecutions for trafficking and possession. Data shows between 2008 and 2012 the heroin court cases in these three counties increased from 257 cases to 1339; an alarming 500% surge. These alarming statistics influenced the NKIHD to partner with various organizations to form the NKCRHE. Although a comprehensive community wide plan is now under development through the Response Team, there are major political, social, and economic factors to consider before reducing and stopping the epidemic.
The Heroin Impact Response Team sees stigma is the primary reason for the silence associated with heroin in NKY. Stigma is defined as a mark of disgrace with a particular circumstance, quality or person. This mark can be alienating and oppressive to individuals and can lead to prejudice and discrimination. People with a history of drug use are highly stigmatized and often become outcasts in society. Some groups argue this stigma helps reduce the drug problem in communities because it shows society’s disapproval of drug use. However, this argument is flawed because it does not consider that stigma can lead to shame and can lead people to hide their unacceptable and undesirable behaviors. Hiding and silencing drug use not only leads to delays in seeking help, but also leads to barriers in recovery and reintegration into society.
NKY is a prime example of silence resulting from stigma. Between 2010 and 2012, the number of heroin overdoses in NKY doubled from 31 to 61 and the rates of HCV were more than double Kentucky’s rate.Despite this alarming statistic, until October 2012, communities in NKY were silent about the epidemic. The map below shows NKY is rooted in a historically conservative state, and thus NKY’s social and cultural environment strongly reflect conservative ideologies. These ideologies promote the silence, because speaking out would constitute condemnation, it would depict the family-unit as inadequate, and the community as a hazardous waste land.
Finally, families in NKY are speaking out about the epidemic. They are sharing their personal stories and those of their lost loved ones. Through advocacy and education, they are working to break down the barriers associated with the stigma of drug use. Yet stigma is a powerful barrier, and education and community participation may not be enough to reduce the social barriers associated with heroin use. An additional powerful approach may be to remove certain legislative and administrative restrictions that reinforce stigmatization. The removal of these restrictions can lead to drug-user harm reduction strategies and programs, which could be considered the first steps to stop the spread of HCV and the first steps to recovery.
One of the most effective harm reduction strategies to consider is sterile Needle and Syringe Programs (NSPs). In 2004, the World Health Organization (WHO) released a report on the effectiveness NSPs in which they confirmed studies in the report presented “a compelling case that NSPs substantially and cost effectively reduce the spread of HIV (and other infectious diseases) and do so without evidence of exacerbating injective drug use at either the individual or societal level” (World Health Organization, 2004). Not surprisingly, the CDC, the National Institute of Health (NIH) and most of the medical and scientific community are advocates of NSPs because the scientific data supports the efficacy of these programs. In addition, these types of programs are seen as the first steps to recovery because they provide abusers the opportunity to seek help and obtain necessary primary health care
Although the federal government does not ban the use of NSP’s, since the late 1980’s federal funding for NSPs was prohibited in the United States. In 2009, President Barack Obama removed this ban and allowed states to use federal funds for Syringe Exchange Programs (SEPs). The ban, unfortunately, was reinstated in 2011 due to a change in the federal spending package for 2012. As a result of the political controversy, this type of harm reduction strategy will be difficult to promote in NKY because despite the scientific data, Kentucky legislation continues to prohibit the use of NSPs. The controversy arises from the common misconception that NSPs promote drug use, encourages abusers to stay addicted to drugs, and fosters criminal behavior. Others argue these types of programs are a costly waste because they do not stop addiction. Scientific data, however, shows both of these arguments are invalid. The efficacy of the programs is evident in various studies and the cost benefit analysis’ shows that “a full-coverage program that exchanges all used syringes in the United States would cost approximately $423 million but avert 1.3 billion in medical care and treatment costs”
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The development of an exchange program is not explicitly prohibited in the Kentucky statutes, however the Kentucky Revised Statute 218A.500(3) addresses the prohibition of distribution of drug paraphernalia: “ It is unlawful for any person to deliver, possess with intent to deliver, or manufacture with intent to deliver, drug paraphernalia, knowing, or under circumstances where one reasonably should know, that it will be used to plant, propagate, cultivate, grow, harvest, manufacture, compound…inject, ingest, inhale, or otherwise introduce into the human body a controlled substance…” (Kentucky Legislative Research Commission, 2010). In 1992, Dr. John Poundstone wrote a letter to the Kentucky Attorney General requesting an opinion on NSPs in the state of Kentucky. The Kentucky Attorney General advised urban-county health departments could be guilty of criminal offence and liability if they were to pursue development of a needle exchange program
If successful in changing Kentucky legislation to allow harm reduction strategies such as SNP’s, the next issue NKY will encounter is the economical component. In 2005, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported an estimated $1.9 billion was spent on mental health and substance abuse (MHSA) treatment in Kentucky which is approximately 1.5% of all the MHSA treatment in the United States (Substance Abuse and Mental Health Administration, 2012). However, the most pressing economic problem in NKY is the low federal and state funds distributed to the region for drug abuse and mental health; in fact, Northern Kentucky receives the lowest funds of the 14 regions in the state.
Since federal funding cannot be used for NSPs the NKY region would be completely dependent on state and local funds. Yet, NKY receives only 8.16% of the state’s general funds for MHSA despite making up more than 10% of Kentucky’s general population. To make matters worse, NKY Health Department continuously faces budget cuts and the reduction in funds results in an uneven distribution of monies for various programs. In 2012-2013 the health department faced a 5% decrease in revenue due to cuts in state, federal and Medicaid funding; figure 1 shows this represented approximately $739,247.
Figure 2 shows the decrease in revenue resulted in a 7% decrease in expenditures, approximately $1,050,043. These cuts make it difficult for the health department to address the heroin and communicable disease issues in a more robust manner. Notwithstanding these economic setbacks, the heroin and HCV epidemic has spiraled out of control and has become a monster that can only be tamed by organizations coming together to address the issue.
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