» Moving the needle on syringe exchanges in Appalachian Kentucky

This is part of a series of stories from the field for the “Understanding Communities of Deep Disadvantage” project.

By Lanora Johnson

CLAY COUNTY, Ky. — There are no sidewalks on either side of the narrow road that leads toward Angel’s house, tucked away in a shallow holler in Clay County, Kentucky. The faded asphalt gives way to Angel’s yard — large and hilly, home to a bleating goat, chickens and at least three dogs.

Angel was born here and has lived here for nearly the entirety of her 45 years. Her grandchildren play in her yard and the road, and she worries for their safety.

“I literally have to walk up and down this road, because … there might be a needle down there,” Angel said.

She worries her grandchildren might inadvertently step on contaminated needles that she says are left scattered along the lush green hills where the children play.

“Why in the world did they come up with free needles?” she said. “They don’t give them to diabetic patients, but they sure give it to somebody that wants [drugs]. It just makes me mad. Because these people that are diabetic, they’re not abusing nothing. And they have to pay a lot for their stuff.”

Angel’s frustrations are with the Clay County Health Department’s Harm Reduction Syringe Exchange Program. Syringe service programs (SSPs), also known as syringe exchange programs (SEPs), allow community members who inject substances to exchange used syringes for clean syringes.

In the Central Appalachian county where 38.6% of residents live beneath the poverty line and great inequities in health care access exist, it is unsurprising needle exchanges challenge peoples’ moral calculus.

Needle exchanges promote public health

About 1 in every 4 Clay County households receive disability income, and 1 in 3 get food stamps. Nearly half of the households include someone drawing Social Security. Almost everyone is white.

Complicating these economic challenges are a high prevalence of health problems, like cancer and diabetes, an enduring local drug crisis and a lack of intergenerational mobility.

Sixty-three syringe service programs operate in Kentucky, aiming to mitigate the spread of infections through shared syringe usage. Syringe exchange services are overwhelmingly supported by public health science. They are considered a best practice by the Centers for Disease Control for addressing the spread of human immunodeficiency virus (HIV), Hepatitis C (HCV) and other blood-borne infections.

Syringe exchange programs are critically important in Kentucky, where the rate of HCV infections is seven times the national average and 54 counties are considered particularly vulnerable to HIV and HCV infections. In 2018, the CDC identified Clay County as the fifth most vulnerable county to an HIV/HCV outbreak in the United States.

Addressing stigma around substance use

Clay County’s SEP has operated since 2017, six years after coroner Danny Finley identified half the deaths in the county in 2011 to be drug-related and raised the alarm about the local opioid epidemic.

In addition to guarding against the spread of disease, the program also provides a critical point of contact between substance users and much needed health services.

Christie Green, the director of the Cumberland Valley District Health Department, has found success in operating their syringe exchange program within an integrated model, which allows people participating in the SEP to come to the health department’s walk-in clinic during regular hours.

Doing so reduces the stigma associated with participating in SEPs and ensures people who inject substances can access other health care services as well, such as wound treatment. Additionally, those who use needle exchanges have a greater chance of entering treatment for substance use.

Green tries to keep the communities she serves engaged and aware of the health department’s programs, and sometimes, there is pushback.

“Even when we give away Narcan, when we promoted on social media, there’s a handful of individuals who will come back with the cost of EpiPens,” Green said. “Or the cost of diabetic needles. ‘You’re not paying for diabetic needles, but you’re giving free needles to people who are doing something illegal.'”

Addiction as a disease vs. choice

Green admits it is difficult to keep the conversation going when syringe exchange programs are compared to EpiPens and diabetic needles.

The stigma surrounding people who inject drugs is palpable. Ashley White, a case manager at Clay County’s drug court, believes the local community in Clay County is still divided between those who believe addiction is a choice and those who believe addiction is a disease — though the disease stance is starting to gain more acceptance.

Still, community members and leaders draw sharp lines between those who deserve treatment because their illnesses were not “their own fault” and those who don’t.

Though SEPs play a critical role in public health and there is no controversy on the science of needle exchanges, they are politically controversial programs.

In March of last year, the largest syringe exchange program in Charleston, West Virginia, closed down due to public pressure and prohibitive regulations from Charleston’s mayor and police chief.

Green has faced similar resistance in the counties served by the Cumberland Valley Health Department. To operate an SEP, Green needs approval from their district’s Board of Health and from the county and city governments in which the SEP will operate. Green received Clay County and Jackson County approvals in 2016, but the health department still has not been able to operate a SEP in Rockcastle County, the third county the department serves. There, she was met with concern from the county sheriff, who believed needle exchanges promote drug use.

For many law enforcement officers, substance use is not a public health issue – it is a crime.

Collaborative solutions

Though Green’s model has worked in two of three counties, the difficulty she faces in the third is a somber reminder of how SEPs are vulnerable to local officials’ political will and resistance. The stigma associated with substance use and prevailing criminal-legal logics create challenges for even larger, better-resourced public health departments.

But Green does not let this stop her work. According to Green, law enforcement officers are “key partners” in harm reduction. A healthy relationship with law enforcement ensures Green and the Cumberland Valley Health Department receive crucial information about “bad batches” of substances and other potential health hazards. This is critical, as some combinations have made already dangerous drugs even more lethal.

In Clay County and other communities, community leaders shared with us that the willingness to build personal relationships with other organizations, even when their perspectives differ, is pivotal to addressing tough challenges. Small towns have to make the most of their available resources, and their friends and neighbors are key.

“A lot of times if I don’t feel like I’m getting good engagement, I stop thinking about what I want and think about what I have that [law enforcement] may want,” said Green.

Kentucky’s Office of Drug Control Policy operates local Agency for Substance Abuse Policy (ASAP) boards, who coordinate substance use prevention efforts between state and local agencies. Green approached her local ASAP boards to share extra financial resources from her harm reduction budgets with local police departments.

Green’s work shows the value of thoughtful collaboration in small communities facing the challenges of drug use. While the national audience might have broad agreement on the effectiveness of syringe exchange programs, we need to consider culturally relevant solutions. In Clay and Jackson counties, this was possible because Green spends the time to build relationships and show value in her public health solution. She fights stigma surrounding substance use and syringe exchange programs through strategic partnerships in the community, public outreach, and a deep commitment to compassionate harm reduction. Her advocacy in Clay County literally saves lives.

Lanora Johnson is a fifth-year Ph.D. student in sociology at the University of Michigan. Her research areas include gender inequality, power-based violence and rural poverty. This summer, Johnson collected data in Marion County, South Carolina, and Clay County, Kentucky. She completed her undergraduate degree in government and sociology at Morehead State University in Morehead, Kentucky.