Number of Ohio Syringe Services programs triple since 2016

Updated May, 2019 to include Lorain & Clark CountiesIn 2016 The Center for Community Solutions released a report on syringes services programs (SSPs) in Ohio, which provided information on the programs that existed at that time, including those developed in response to the state’s 2015 change in regulations authorizing the programs.[1] Syringe services programs prevent the spread of HIV and hepatitis C by providing sterile equipment to people who inject drugs, as well as safe disposal for used injection supplies. The programs also frequently offer HIV and hepatitis C screening, wound care, fentanyl testing strips for overdose prevention and naloxone for overdose reversal, and connections to other programs and services for clients. In 2016, only six Ohio cities or counties operated SSPs: Cleveland (1995), Columbus (2016), Cincinnati (2014), Dayton (2015), Portsmouth (2011) and Gallia County (2016).

Syringe services programs prevent the spread of HIV and hepatitis C by providing sterile equipment to people who inject drugs, as well as safe disposal for used injection supplies.

Over the last two years, Ohio has made progress in improving the availability of syringe services programs. In response to rising HIV and Hepatitis C rates, communities have created 12 additional programs.[2],[3],[4] The Ohio Department of Health (ODH) filed a Determination of Need with The Centers for Disease Control and Prevention, which allows federal Health and Human Services dollars to be used to support SSPs.[5],[6] The Determination of Need became effective in July 2018 and ODH promptly released the first state request for proposals (RFP) inclusive of SSP sites ― in this case for HIV prevention services. Considering health policies impacting SSPs, the Ohio Addiction Policy Inventory and Scorecard: Overdose Reversal and Other Forms of Harm Reduction was released, which identified opportunities to improve SSP access.[7] At the community level, multiple conferences have been held to raise awareness about harm reduction services and share best practice models among Ohio program planners as syringe services programs continue to develop.

At the community level, multiple conferences have been held to raise awareness about harm reduction services and share best practice models among Ohio program planners as syringe services programs continue to develop.

Profiles of New Programs in Ohio

There are currently 18 established SSPs in Ohio and another program is in development. The following section of this report provides basic information about each of the 12 programs developed since our 2016 report. This information was gathered from interviews and surveys, and in the case of Darke County, a program website. An overview of the 12 profiled programs is included in Appendix A. The report concludes with recommendations.

Athens[8]

Under the leadership of Health Commissioner James Gaskell, the Athens City-County Health Department (ACCHD) began operating its SSP in February 2017 after six months of preparation. The program operates from 1-3 p.m. on Wednesdays at the ACCHD building. Syringes were solicited from local pharmacies for the first few months of the program’s existence. This changed when the program received a $7,000 grant from the Athens County Foundation, which allowed the SSP to purchase syringes. A total of six people operate the program, including the Health Commissioner, four nurses and an addiction coach. The addiction coach is an employee from Health Recovery Services, another area nonprofit. In 2018, the SSP saw an average of 32 clients per week, and exchanged a total of 36,881 needles.

In 2018, the SSP saw an average of 32 clients per week, and exchanged a total of 36,881 needles.

The majority of clients at the SSP are from Athens County, between the ages of 20 and 40, and 53 percent are male. ACCHD’s program has a one-to-one exchange rate with a cap of 30 syringes per person per exchange. There is not much geographic diversity of participants. One person exchanging needles for multiple individuals is discouraged, however, it is allowed if the other person has visited the program in the past and has a known relationship with the person exchanging for them (i.e. a spouse). In Athens County, the number of new hepatitis C cases rose from 40 in 2008 to 180 in 2015, but after the implementation of the SSP, the county saw its first decline in years, down to 150 new cases in 2017. Hepatitis B cases also declined after the program was implemented, going from 47 cases in 2016 to 39 in 2017.

A number of other services are also provided by the exchange: naloxone training and distribution, hepatitis A and B vaccination, and testing for HIV and hepatitis A, B and C.

A number of other services are also provided by the exchange: naloxone training and distribution, hepatitis A and B vaccination, and testing for HIV and hepatitis A, B and C. Additionally, the addiction coach makes referrals to treatment at Health Recovery Services or Hopewell (a local health center) if clients wish to seek treatment. Since the SSP opened in 2017, 12 people have been referred to treatment by the coach. Naloxone is offered to participants who do not already have it, and employees inform participants with Medicaid that they can access it at pharmacies for no cost. ACCHD also tracks mental health issues among clients, estimating approximately 20 percent have a diagnosed mental health condition.Individuals in the community have shown occasional resistance to the program, but the overall response has largely been positive. Law enforcement and the local prosecutor support the program. For example, law enforcement has agreed not to monitor the SSP, unless they are contacted by the exchange.While a number of important services are provided, Health Commissioner Gaskell has stated that, if more funding were available, the health department would like to provide a navigator to assist clients with finding work and accessing adequate food and housing.

Summit County[9]

Summit County Public Health (SCPH) began its SSP in June of 2016. While the program received a small amount of funding from the local United Way, its primary funding source is the surplus from its addiction counseling department. There are typically six to eight employees onsite for program, including front desk staff, counselors and peer support. SCPH currently operates the program at three locations, where they see a total of 90 clients per week ― a number surpassing the program’s initial projections. In total, 674 unique clients have used the program. To ensure anonymity while allowing the program to track users, each client who comes in is given a unique ID code. Information is then collected on the client’s age, sex, ZIP code, drug usage, employment and education. The program also tracks the services provided to each client, who (if anybody) the client came with and if they signed up for an assessment.

Six hundred and seventy-for unique clients have used the program.

The services are limited to Summit County residents. The SSP is not one-to-one, and clients generally receive the number of needles they would use in one week. Participants are not allowed to receive needles for people who are not present. SCPH tracks local rates of HIV and hepatitis A, B and C.

Each new client receives a welcome packet that includes informational brochures about counseling, dental, HIV and emergency services.

The program also provides several additional services. Clients can receive naloxone and fentanyl test strips. The SSP also provides HIV and hepatitis C testing, and vaccinations for hepatitis A and B. Additionally, each new client receives a welcome packet that includes informational brochures about counseling, dental, HIV and emergency services. While counseling is available immediately and onsite, dental services, though provided by SCPH, require scheduling an appointment in advance. All of the services clients can be connected to onsite are provided directly by SCPH. The department does not contract with outside organizations to operate the SSPs, however, SCPH does house one of the SSPs at Akron Say No to Dope Inc.The community response at all three locations has been positive. The relationship with law enforcement is also positive, Community Solutions was told that people who are pulled over going to or from the exchange are less likely to be charged for possession of drug paraphernalia if they show the officer their SSP ID card.

Summit County’s goal is to increase the number of SSP locations to five, one to cover every day of the work week. Any expansion, however, would be contingent upon receiving additional funding.

Jefferson County[10]

The SSP in Jefferson County is operated by the Family Recovery Center (FRC), a local organization that provides services to address chemical addiction, mental health disorders and other health care needs in order to promote community wellness. FRC opened the SSP in November 2017 after it was approved and resourced through the combined efforts of their board of directors and the Health Departments of Jefferson County and neighboring Brooke County in West Virginia. It took a couple months for the program to be established, as the groups required time to procure the equipment, syringes and grant funding. The program in Jefferson County is operated on the first and third Fridays of each month and is run by Katherine Hawthorne, a case manager and certified peer supporter with FRC, as well as one or two volunteers from the Jefferson County Health Department (JCHD). From January through August of 2018, the program saw 108 unique clients who received 1,724 clean syringes. In an attempt to ensure the anonymity of the participants, demographic information is not generally tracked, however, it is believed that the participants range in age from 20 to 65.

From January through August of 2018, the program saw 108 unique clients who received 1,724 clean syringes.

The program is generally a one-to-one exchange, although new clients who do not have needles to exchange receive a start-up kit of 20 needles. The SSP does not place a cap on the number of needles a client can exchange per visit. FRC plans to track the impact the exchange has had on the population’s health. JCHD integrated hepatitis B and C testing into the program in the last quarter of the year, and plans to integrate HIV testing this year.

The SSP is operated at an FRC clinic that offers medication-assisted treatment (MAT), including Suboxone and Vivitrol, and outpatient addiction and mental health counseling.

The SSP is operated at an FRC clinic that offers medication-assisted treatment (MAT), including Suboxone and Vivitrol, and outpatient addiction and mental health counseling. These services require an advance assessment, however, the clinic has established walk-in hours during the time the SSP operates. During this time, an assessment can be performed. FRC also offers intensive outpatient services for non-medicated clients, anger management, parenting, job skill services and both individual and family counseling. Additionally, onsite testing for hepatitis B and C, as well as other sexually transmitted infections is provided by JCHD. The exchange does have to refer clients elsewhere for inpatient services, detox and HIV testing. Naloxone and fentanyl testing are provided for free by FRC, however, clients must attend a separate training to receive naloxone.

FRC has a strong relationship with the community, and program staff report very little pushback in response to the SSP. The relationship the program has with law enforcement is also positive.

Program leaders noted that their top priority for any new funding would be to support onsite HIV testing efforts. However, they emphasized the positive impact the program as a whole has had on Jefferson County. Since recovery is an individual process, program staff say having the ability to meet people at their level of willingness, as the SSP does, is crucial. The program helps connect clients to services they might not otherwise have access to that improve quality of life, and provide them resources when they do decide to seek treatment.

Canton[11]

After a year of preparation, Canton City Public Health (CCPH) began operating its SSP in June 2017. The driving forces behind its establishment were Diane Thompson, director of nursing, and epidemiologist Amanda Archer. Both have roles in the county’s opiate taskforce. The exchange has a budget of $90,000 per year, mostly comprised of in-kind donations. These donations include the staff time of a nurse navigator from CommQuest―a local mental health, addiction and social services organization―and food and drinks, including hot sandwiches and water, provided by OhioCan, another local organization dedicated to assisting those impacted by substance abuse. CCPH’s HIV prevention funds ($20,000) support harm reduction supplies; when the program started syringes were funded by the AIDS Healthcare Foundation ($24,000). To date, this has been the only funding available for the SSP to purchase syringes. The SSP operates every Friday, and about six or seven people run the program each week. This includes Thompson and three other employees of CCPH, the nurse navigator from CommQuest and one or two volunteers from OhioCan who provide food and drinks to clients. Since its inception a year and a half ago, 310 distinct clients have attended the SSP. These clients returned a total of 62,533 used needles and have received 76,693 new ones. The program saw a total of 166 people, including returning clients, in September and 191 in August. The program sees between 37 and 54 clients per week and exceeded its initial goal of 200 clients in the first year, seeing 240 unique clients in that time frame. The program tracks limited demographic information, including gender, age and ZIP code. Fifty-seven percent of clients are men, the median client age is 33 (clients range from 18 to 69-years-old) and clients representing 50 different ZIP codes use the exchange.

These clients returned a total of 62,533 used needles and have received 76,693 new ones.

The first time clients come in, if they have no needles to exchange, they are given 10. When they bring those 10 back, they receive 20. This continues until clients receive a number of needles in line with how many they use per week. At that point, the exchange becomes one-to-one. There is no set cap on how many needles a person can exchange, however the exchange does generally limit it to the number of needles one person could conceivably use in a week. One of the program’s long-term goals is to reduce the rates of hepatitis and HIV in the county, though it is too early in the program for data to fully reflect any impact on those rates. However, the number of new hepatitis C diagnoses in Stark County did decrease in 2017, after increasing by more than 37 percent from 2010 to 2016. This increase from 2010-2016 included a 303 percent increase in new diagnoses amongst those between the ages of 25 and 34.

This increase from 2010-2016 included a 303 percent increase in new diagnoses amongst those between the ages of 25 and 34.

The program provides a number of additional services along with the needle exchange. The nurse navigator from CommQuest distributes naloxone kits and is able to refer clients to mental health care, detox and treatment. Clients can be tested for HIV and hepatitis C, and also receive a vaccination for hepatitis A, onsite. The exchange provides information for clients to access food, housing and clothing. The program also provides harm reduction tools, such as condoms and gauze. CCPH prides itself on the hospitality of its exchange. The anonymity of the program makes it difficult to track exactly how many people have sought treatment as a result of going to the exchange, but anecdotally the sense is that a very small number of clients utilize these additional services. However, program officials are aware of at least one former client who has been in recovery for seven months.

Though program leaders maintain strong relationships with the community, law enforcement and the mayor’s office, they report lack of funding as the SSP’s most significant challenge.

Though program leaders maintain strong relationships with the community, law enforcement and the mayor’s office, they report lack of funding as the SSP’s most significant challenge. The program is still operating with the initial batch of needles purchased in June 2017, but currently does not have resources to purchase additional syringes once those are depleted. Lack of resources also limit the number of services the exchange can provide. For example, the SSP was able to give out fentanyl test strips only when it received a donation of 25 strips. However, the program is not seeking additional fentanyl strips because staff are hesitant to expand a program they would be unable to sustain if they run out of needles for the SSP. The program is currently applying for grants to support the purchase of additional syringes.

However, the program is not seeking additional fentanyl strips because staff are hesitant to expand a program they would be unable to sustain if they run out of needles for the SSP.

Greene County[12]

Greene County Public Health (GCPH) began its SSP in November 2017. Development of the program was spearheaded by health educator supervisor Kirsten Bean. The program has an annual budget of $15,000, with funding coming both from the district’s general health fund and a grant from the AIDS United Syringe Access Fund. When the program first started, health educator Jessica Warner ran it. The SSP occurs every Friday. As the program has grown, Warner is now joined by two other health educators at every exchange, as well as interns from nearby Cedarville University, who provide blood pressure and glucose screenings on the last Friday of each month. The exchange is one-to-one. Between January and October 2018, the SSP saw a total of 117 exchanges of more than 1,300 syringes, involving at least 30 unique clients. The clients are asked to fill out a new visitor form the first time they attend the exchange, and through these forms certain data is tracked. This includes gender (63 percent are male), living situation (alone, with parents, with spouse, etc.), and employment status (69 percent are unemployed). The forms also include several other questions to help exchange staff understand the situations clients face. Nearly all of the clients are from the city of Fairborn, where the exchange is located. GCPH plans to track the effect this exchange will have on public health levels, including HIV and hepatitis C rates in the county.

The GCPH exchange offers a number of additional services onsite, including HIV and hepatitis C testing, fentanyl test strips, hepatitis A vaccines, blood pressure and blood glucose testing.

The GCPH exchange offers a number of additional services onsite, including HIV and hepatitis C testing, fentanyl test strips, hepatitis A vaccines, blood pressure and blood glucose testing. Additionally, pamphlets that provide information on how to find food banks, shelter and showers are given to clients. While clients have requested more robust food and clothing services, currently the program only has funding to provide snacks and a few used clothing items kept in a closet on site. The program tends to refer those seeking treatment to TCN Behavioral Health (TCN), a local behavioral health clinic. TCN also operates the area’s Project DAWN[13] site, which provides naloxone to clients. Bridges of Hope homeless shelter provides donations of toiletries and basic hygiene packs for the SSP to give out.

Bridges of Hope homeless shelter provides donations of toiletries and basic hygiene packs for the SSP to give out.

Program leaders report that the community response to the SSP has been somewhat mixed, primarily because of resistance from some local government officials. However, they note that sharing research on the public health benefits of SSPs has been an effective tool for gaining support among such officials. The board of health has been supportive throughout the process and Community Solutions was told that law enforcement is providing clients with a 1,000-foot buffer around the program in which they will not be arrested for possession of drug paraphernalia. There have been no significant concerns from local citizens, however, some of this may be due to lack of awareness of the program.

The biggest challenge currently for the Greene County SSP is lack of space and publicity.

The biggest challenge currently for the Greene County SSP is lack of space and publicity. Program leaders have stated that, with more funding, they would try to expand to a larger space and increase the amount of promotional materials available in order to reach more potential clients. They also want to provide more food and potentially have showers onsite that clients could use.

Marion[14]

Marion Public Health (MPH) began its SSP in 2017. It is funded by a grant received from Marion General Hospital. The exchange operates every Tuesday at the Public Health Department and is administered by Rachel Hill, director of nursing, and two other public health nurses. There is also an epidemiologist on-site who tracks demographic data and gathers information from new clients pertaining to their behaviors and risk factors for communicable diseases. Over the course of its existence, the exchange has served 20 unique clients, several of whom come in on a monthly basis. Not all of the clients are local, some travel from as far as Bucyrus and Galion to visit the exchange. They also represent a wide range of ages, with participants spanning from their 20s to their early 60s. The vast majority of participants are white. Fifteen of the SSP’s 20 clients began attending in the past six months, something MPH views as a sign its clientele is expanding.

Not all of the clients are local, some travel from as far as Bucyrus and Galion to visit the exchange.

The exchange rate is one-to-one, and a client cannot receive clean needles unless they bring in an equivalent number of used needles. There is a cap of 30 syringes per month. While MPH tracks data on population health such as HIV and hepatitis rates, officials have not yet studied how these rates have changed since the exchange began.Several other services are available to MPH’s needle exchange clients, including free HIV and hepatitis C testing. Additionally, because MPH is a Project DAWN site, naloxone training and kits are provided, something nearly all of the clients have chosen to participate in. Clients also have access to sexual health services at the department’s clinic. Marion Area Counseling Center (MACC) also provides a recovery coach, when scheduling permits, and materials about recovery with MACC are also provided to clients. In addition to MACC, the exchange also partners with the local Alcohol, Drug and Mental Health Services (ADAMH) Board, which helps run the Project DAWN site, and Marion General Hospital, the agency that provided the initial funding.Community response to the SSP has been largely positive. Before the program began, about 50 area residents attended a community conversation where attendees were largely supportive. Community Solutions was told law enforcement has complied with a 1,000 foot buffer zone around the exchange in which, during operating hours, users of the exchange will not be arrested on drug paraphernalia charges.Misinformation within the community about the exchange highlights the fact that many people don’t know a lot, if anything, about it. Word-of-mouth has not resulted in the number of clients program leaders hoped for, so more advertising for the program would be beneficial. Other items MPH would like to spend additional funding on are snacks and other amenities that would make those who use the exchange feel more safe and comfortable. The program location was also changed to the MPH building, for staff efficiencies and to better serve clients – helping them feel more welcome and less stigmatized.

Lucas County[15]

The Toledo-Lucas County Health Department (TLCHD) began operating its SSP, known as Northwest Ohio Syringe Services (NOSS), in August 2017. It operates twice a week, from 1-4 p.m. on Tuesdays and 1-4 p.m. on Thursdays. Its development was spearheaded by the HIV/STD Prevention Coordinator at the Toledo-Lucas County Health Department, along with community stakeholders from the HIV Prevention Community Planning Group. Currently, a licensed social worker and registered nurse are employed full-time to coordinate the program. Nursing students and fourth-year medical students from the University of Toledo Medical College assist during clinic hours as part of their clinical rotations or elective public health coursework. Data, including demographic data, is collected for both new and returning clients. Upon arrival at the exchange, new clients receive a personalized NOSS ID card.

Nursing students and fourth-year medical students from the University of Toledo Medical College assist during clinic hours as part of their clinical rotations or elective public health coursework.

NOSS is not a one-to-one exchange; instead it provides syringes based on reported need. NOSS also employs secondary exchange, allowing clients to exchange on behalf of others. Through the first year of its existence (August 2017 to July 2018), the program saw 191 clients, collected more than 10,000 used syringes and distributed nearly 20,000 new ones. These 191 clients include participants from seven counties and three states. The clients are predominantly white males between the ages of 30 and 40-years-old. While the program’s long-term goals include reducing HIV, hepatitis C and overdose death rates, the program is still too new to evaluate trends based on its impact.

Along with the clean needles, clients are given fentanyl test strips, safe sex supplies, safe injection education and overdose prevention education.

Along with the clean needles, clients are given fentanyl test strips, safe sex supplies, safe injection education and overdose prevention education. Additionally, medical care is available in the form of injection site wound evaluation, rapid HIV and hepatitis C testing, and pregnancy testing. Clients can also receive hepatitis A and flu vaccines and be referred to a doctor for additional medical care. Naloxone training is also available onsite and participants receive two doses of naloxone nasal spray. NOSS also screens for human trafficking and food insecurity. Program funding comes through a partnership with University of Toledo Medical Center’s Ryan White Program, which provides HIV prevention and health care services, and the Mental Health and Recovery Services Board of Lucas County (MRS Board). During its first year, the exchange referred 64 people to substance abuse treatment. They have also had clients request, but have been unable to provide, numerous other services, including STD testing, wound care, prescription antibiotics and physician services. They previously provided benefits enrollment (including Medicaid, the Supplemental Nutrition Assistance Program and Cash Assistance), which ended due to Health Department layoffs. Clients looking for these services are now referred to other organizations.

They previously provided benefits enrollment (including Medicaid, the Supplemental Nutrition Assistance Program and Cash Assistance), which ended due to Health Department layoffs.

The response from law enforcement to the program has not been as positive as other SSPs have reported, as clients have stated that officers confiscate supplies, including naloxone, fentanyl test strips and biohazard containers. NOSS is currently working on developing an online form for people to anonymously report these occurrences, so that they can better target their community harm reduction education going forward. This education will be used to work with substance abuse treatment agencies, law enforcement, and pharmacists, among others.NOSS partners with a large number of organizations to provide additional services to clients, including Toledo City Council, the Lucas County MRS Board, Lucas County Opiate Coalition, Lucas County Human Trafficking Coalition, Reentry Coalition of Northwest Ohio, University of Toledo Opiate Task Force, HIV Prevention Community Planning Group and the Drug Abuse Response Team Collaborative. Additionally, the exchange is housed by Talbot Clinical Services and St. Paul’s Methodist Church. These two organizations also allow the program to hold outreach events at these locations outside of exchange hours. With additional funding, NOSS leaders would expand hours of the exchange, add locations and increase staff.

Darke County[16]

Family Health Services of Darke County (Family Health) opened its SSP, called Xchange, in October 2018. The program operates the second and fourth Fridays of each month.[17] Funding for the program comes from a $100,000 grant Family Health received from the Cardinal Health Foundation in Columbus. It is currently too early in the process to gather useful data on who is using the exchange or to judge the public health impact of the program, however, program leaders say it was created due to a “slow uptick” in hepatitis C cases and an increase in deaths from opioid overdoses in the county.[18]

Funding for the program comes from a $100,000 grant Family Health received from the Cardinal Health Foundation in Columbus.

The program is a one-to-one exchange.[19]There is no hard cap on the number of needles a single person can exchange, though quantities may be limited based on calculated need from frequency of intravenous drug use. Clients will also have access to education, additional health screenings and referrals to substance abuse treatment.[20]Darke County’s program has received the support of local law enforcement, including the Darke County Sheriff’s Department and the Greenville Police Department. The Darke County Sheriff’s Department has complied with the 1,000 foot buffer zone around the exchange where clients will not be arrested for drug paraphernalia, although possession of the drugs themselves in this area is still illegal. Program officials say there has been a mixed response within the community. Some individuals have expressed concerns over the program, via comments on social media and directly to the leadership of Family Health.[21]

Zanesville-Muskingum County[22]

The Zanesville-Muskingum County Health Department (ZMCHD) began operating its SSP, known as Safe Point, in February 2018. It runs every Thursday from 12:30 to 3:30 p.m. ZMCHD spent two years educating local elected officials and community leaders so that they would understand that the program is about more than just distributing needles. The needles come from donations and all other supplies are purchased by ZMCHD. The program is run by a three person staff and tracks data on the number of clients served and client demographic information. To date, the most common drug used by clients is heroin and the majority of clients are white.

To date, the most common drug used by clients is heroin and the majority of clients are white.

The program is a one-to-one exchange, and ZMCHD recently increased the maximum number of needles a client could exchange per week from 20 to 30. They have had clients from both within and outside of Muskingum County and some clients have opted to exchange for both themselves and others in a single visit. ZMCHD offers immunizations, HIV and hepatitis C testing, naloxone kits, condoms and resources for treatment and referrals to medical or mental health providers.Community Solutions was told law enforcement has complied with a 1,000 foot buffer zone around the exchange on the program day where clients will not be arrested for possession of drug paraphernalia.

Brown County[23]

The Brown County Health Department (BCHD) SSP, called Prevention Point, began in March 2018 and operates every Thursday. It took six months to set up under the leadership of the health department’s director of nursing, Pamela Williams, and Kathy Wright, LPN. Program funding comes from the Brown County Board of Mental Health and Addiction Services, as well as a recently awarded grant from Interact for Health in Cincinnati. Prevention Point is operated by two nurses from BCHD and a social worker from Talbert House, a local organization which provides recovery services. Program data is collected on number of clients served and client demographic information. BCHD is not currently studying the effect this program has had on population health, but plans to do so in the future as the program grows.

BCHD is not currently studying the effect this program has had on population health, but plans to do so in the future as the program grows.

Prevention Point is a one-to-one exchange. Along with the needle exchange, clients of Prevention Point have access to treatment information, pregnancy testing, HIV and hepatitis C testing, naloxone training, condoms and sessions with the social worker from Talbert House. Clients are also offered information about where to receive other services such as housing, food and clothing and are also offered referrals for substance abuse treatment.The community response to Prevention Point has been mixed; it has not received support from the Sheriff’s Department. Despite this, the exchange has not encountered any issues with law enforcement from an operational standpoint. The SSP is limited financially in terms of its ability to advertise and its number of locations, although Prevention Point aims to expand to new locations in 2019.

Clark County[24]

Clark County Combined Health District (CCCHD) began operating its SSP, One2One, in September 2018 out of a local soup kitchen. The exchange was co-founded by CCCHD and McKinley Hall, a local nonprofit that provides addiction services. The program grew out of a recommendation from the Clark County Substance Abuse, Prevention and Treatment Coalition and required about one year to plan.

The program grew out of a recommendation from the Clark County Substance Abuse, Prevention and Treatment Coalition and required about one year to plan.

Most of the resources for the program are contributed in-kind, with staff supported from McKinley Hall and CCCHD providing supplies. Four staff members, two from each sponsoring organization, operate the exchange, which runs from 1 to 3 p.m. on Wednesdays. The program’s reach is slowly growing as word-of-mouth spreads, which is in line with projections, and the SSP sees a dozen or more clients a week. With additional funding, the program would prioritize adding hours of service operation.

The SSP is currently run as a 1:1 exchange, with a cap of 10 syringes per visit. The program is designed to reach local clients and operates within walking distance of an area where clients congregate.

In addition to sterile injection supplies, the program also offers naloxone distribution and training; referrals to primary care, mental health and substance abuse treatment; hygiene kits; and sexually transmitted disease information packs. Testing for hepatitis C and HIV is available on the first Wednesday of each month. Along with McKinley Hall, Mercy Reach – another rehabilitation organization – also has representatives at the SSP every Wednesday. In the first month of operation, all of the services were utilized by clients.Local law enforcement, emergency medical services and the prosecutor’s office were slower to support the program, but do understand what it is trying to accomplish comply with the buffer zone. The Mental Health and Recovery Board of Clark, Greene and Madison Counties also was initially resistant to the SSP planning, although the board sanctioned the program after learning more about it.

Lorain County[25]

Lorain County’s SSP, LINC (Local Initiative to Network Compassion) of Lorain County Harm Reduction Clinic, launched in February 2019. The program is administered by the Nord Center, a local behavioral health clinic, and is open every other Friday from 1 to 4 p.m. at the First United Methodist Church, in Wellington.

The need for a harm reduction clinic in Lorain County was apparent when the Cleveland-based syringe exchange reported serving clients from Lorain County on a weekly basis.

The need for a harm reduction clinic in Lorain County was apparent when the Cleveland-based syringe exchange reported serving clients from Lorain County on a weekly basis. To begin the process of creating a program in Lorain, Lorain County Public Health (LCPH) secured a “Determination of Need” from the Centers for Disease Control and Prevention in October, 2017. Subsequently, a collaboration between LCPH, the Alcohol and Drug Addiction Services (ADAS) Board of Lorain County, philanthropic foundations, law enforcement and other local health and human services organizations met to create a county-wide harm reduction clinic.The clinic was set up in conjunction with the existing LINC program in Wellington. LINC was created by the Wellington Police Department and funded by the Alcohol and Drug Addiction Services Board of Lorain County in conjunction with local government, the Wellington School District, local churches and other volunteers to provide outreach to people with substance use disorders and their families. Through LINC, those seeking assistance with substance use disorders are treated with compassion and are connected with the help they need by walking into any of partner locations and requesting it.The LINC of Lorain County Harm Reduction Clinic is primarily sustained through in-kind employee time and materials from collaborative members. Syringes and safe disposal are also provided through in-kind donations of member organizations. The NORD Family Foundation supported the program with a $65,000 grant.

LCHD provides HIV and Hepatitis C testing, immunizations and naloxone to clients Medworks is available to help clients enroll in Medicaid and connects them to other needed resources.

The clinic provides clean needles, 20 per exchange, and fentanyl test strips to clients, along with a number of support services. LCHD provides HIV and Hepatitis C testing, immunizations and naloxone to clients Medworks is available to help clients enroll in Medicaid and connects them to other needed resources. Lorain County Family Planning is on-site to provide sexually transmitted disease testing and a link for reproductive health needs. Southern Lorain County Ambulance District emergency medical technicians provide wound care. LCADA Way, a local nonprofit that provides drug and alcohol abuse treatment, is available to connect clients to treatment and recovery services. Let’s Get Real, a nonprofit recovery community organization, provides peer support and transportation to the harm reduction clinic. Firelands Counseling Service provides a counselor that clinic clients can talk to on-site, as well as referrals for more counseling at their center.The clinic promotes its services through the recovery community and other venues. REDCap, a secure web-based application, is used by each agency staffing the SSP to track not only the number of clients, but also the drugs injected, the services they utilized and the results of HIV and hepatitis C testing.

The response from both the community and law enforcement has thus far been largely positive. LCPH credits this to the success of the original LINC program, operated by the Wellington Police Department since 2017.

Recommendations

SSPs meet the drug safety needs of each individual client by offering sterile injection equipment and providing an opportunity to dispose of used equipment in a safe manner. While some Ohio programs provide supplies based on client use patterns and frequency, regardless of the client’s disposal of supplies, others operate as one-to-one exchanges, whereby a new sterile syringe is provided only in exchange for a used syringe. When these programs can evolve to become need-based service programs, the re-use of needles will decrease. To decrease used syringes in the community, safe disposal sites are recommended independent of syringe service sites (although they can also act as disposal sites) in more community locations. Health departments and pharmacies are common hosts.

To decrease used syringes in the community, safe disposal sites are recommended independent of syringe service sites (although they can also act as disposal sites) in more community locations. Health departments and pharmacies are common hosts.

Additional funding – private and public – is needed to meet the service need in Ohio. Several Ohio counties identified by The Centers for Disease Control and Prevention as ‘at risk’ for HIV outbreak do not operate SSPs. Lack of funding – specifically for safe injection supplies which cannot currently be funded by federal dollars – is commonly described as a barrier.Those planning SSPs should familiarize themselves with other service organizations relevant to their clients’ needs, to leverage existing local resources. Many services important for SSP clients – including HIV and hepatitis C screening, naloxone, mental health and other primary care services – are provided in communities that host SSPs. Collaborations for shared service provisions or warm referrals can maximize resources and reach clients experiencing significant unmet need.

Collaborations for shared service provisions or warm referrals can maximize resources and reach clients experiencing significant unmet need.

The rate of new HIV infections among injection drug users in Ohio has doubled since 2012. Unlike hepatitis, there are federal, state and often local funds to support HIV prevention services. Those working to start an SSP are encouraged to work with existing local HIV planning groups to prioritize syringe services programs in order to draw down state and federal HIV prevention funds. These funds can be used, at a minimum, to provide HIV screening for SSPs, and, if prioritized, could be used for program costs as well. HIV is a complex and costly disease – and it is completely preventable. For people living with HIV, early detection and linkage to clinical care will result in better health outcomes for the impacted individual and reduce the spread of the disease.

For people living with HIV, early detection and linkage to clinical care will result in better health outcomes for the impacted individual and reduce the spread of the disease.

State statute allows for local control of SSPs and compliance requires significant planning. Given common misperceptions regarding addiction and SSPs, program planning processes should prioritize community education, which can lead to fewer barriers to implementation, while potentially creating allies and collaborations, given the breadth of the opiate crisis—and response—in Ohio. Including information about addiction, including risk factors, may also serve to decrease stigma.Existing and developing SSPs are encouraged to continue sharing planning and fundraising strategies, training resources, data collection platforms and operational policies and protocols. Given the decentralization of the existing regulatory environment for SSPs, collaboration by existing programs will create efficiencies and allow for standardization of best practice. The creation of a central hub or portal for existing SSPs will aid in achieving these aims.

Conclusions

The state’s 18 SSPs offer a way for Ohioans who inject drugs to do so as safely as possible. SSPs connect with an often hard-to-reach population through client-centered service provisions. The programs offer a number of resources for clients – from overdose prevention to substance abuse treatment and primary care.

Most programs continue to rely on private donations and volunteer or in-kind staff in order to operate.

Despite the positive results of SSPs and community support for many of the exchanges, funding for most programs does not meet the need. There continues to be a lack of dedicated state funding for these preventive programs, even though if acquired, HIV and hepatitis C are often treated through state-sponsored health programs. Most programs continue to rely on private donations and volunteer or in-kind staff in order to operate.Infectious disease prevention programs programs are cost effective and ultimately protect the community at large. Given the continued increase in HIV and hepatitis C infections in Ohio, continued support for initiation and expansion of these programs is warranted.

APPENDIX A: Profiled Syringe Services Programs

[1] Britton, T. (2016). SSPs in Ohio. The Center for Community Solutions. https://www.communitysolutions.com/wp-content/uploads/2018/01/UPDATED-Syringe-Exchange-Programs-in-Ohio-03212016.pdf[2] Ohio Department of Health. New Diagnoses of HIV Infection Reported in Ohio, As of June 30, 2018. https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/hiv-aids-surveillance-program/resources/ohio-hiv-surveillance-data-tables[3] Ohio Department of Health. Hepatitis C: 4 Year Report. July 10, 2018. https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/hepatitis-surveillance-program/resources/hepatitis-c-4-year-report[4] An earlier version of this report, released March 4, 2019, reflected 10 new programs. Lorain and Clark counties, recent program additions, were added to this report.[5] Federal dollars are not permitted to be used for the purchase of syringes but may be used for staffing and other operating costs.[6]https://www.cdc.gov/hiv/risk/ssps-jurisdictions.html[7] Health Policy Institute of Ohio. Ohio Addiction Policy Inventory and Scorecard: Overdose Reversal and Other Forms of Harm Reduction. November, 2018. https://www.healthpolicyohio.org/ohio-addiction-policy-inventory-and-scorecard-overdose-reversal-and-other-forms-of-harm-reduction/[8] Information in this section based on a phone interview with James Gaskell, Health Commissioner, Athens City-County Health Department, conducted October 5, 2018.[9] Information in this section based on a phone interview with Angela Genet, Injury Prevention Coordinator, Summit County Health Department, conducted October 22, 2018.[10] Information in this section based on a phone interview with Katherine Hawthorne, Case Manager and Certified Peer Supporter, Family Recovery Center, conducted October 26, 2018.[11] Information in this section based on a phone interview with Diane Thompson, Director of Nursing, Canton City Health Department, conducted October 29, 2018.[12] Information in this section based on a phone interview with Jessica Warner, Health Educator, Greene County Public Health, conducted November 7, 2018.[13] Deaths Avoided With Naloxone. https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/violence-injury-prevention-program/projectdawn/[14] Information in this section based on a phone interview with Rachel Hill, Director of Nursing, Marion Public Health, conducted November 29, 2018.[15] Information in this section based on email communication with Courtney Stewart, Licensed Social Worker for Northwest Ohio Syringe Services, December 6, 2018.[16] Darke County felt they were too new to adequately answer the questions posed. Information in this section comes from sources available online.[17] Substance Abuse. (n.d.). Retrieved from https://www.coalitiondarkecounty.com/substance-abuse.htm[18] Hartley, S. (2018, SSPtember 6). Family Health ‘moving forward’ with XChange despite concerns. Early Bird Paper. Retrieved November 12, 2018, from https://www.earlybirdpaper.com/family-health-moving-forward-with-xchange-despite-concerns/[19] Hartley, S. (2018, August 31). Family Health to Roll out Exchange Program. Bluebag Media. Retrieved November 12, 2018, from https://www.earlybirdpaper.com/family-health-to-roll-out-xchange-program/[20] Hartley, S. (2018, SSPtember 6). Family Health ‘moving forward’ with XChange despite concerns. Early Bird Paper. Retrieved November 12, 2018, from https://www.earlybirdpaper.com/family-health-moving-forward-with-xchange-despite-concerns/[21] Ibid[22] Information in this section based on email communication with Tawny Pletcher, Public Health Nurse at Zanesville-Muskingum County Health Department, December 20, 2018.[23] Information in this section based on email communication with Pamela Williams, Director of Nursing for the Brown County Health Department, December 17, 2018.[24] Information in this section based on email communication with Charles Patterson, Health Commissioner for the Clark County Combined Health District, March 15, 2019.[25] Information in this section based on a phone interview with Cindy Modie, Director of Community Health for the Lorain County Public Health Department, March 27, 2019.