Pubdate: Sat, 20 Jun 2015
Source: Wall Street Journal (US)
Copyright: 2015 Dow Jones & Company, Inc.
Contact:  http://www.wsj.com/
Details: http://www.mapinc.org/media/487
Authors: Jeanne Whalen and Arian Campo-Flores

RURAL U.S. STRUGGLES TO COMBAT IV DRUG ABUSE

Hepatitis C and HIV Outbreaks Test Public-Health Resources in Midwestern States

Every Friday afternoon, dozens of drug addicts carrying bags and 
coffee cans filled with dirty needles stream into a makeshift clinic 
in downtrodden Portsmouth, Ohio. As the only such facility in a 
region blighted by heroin and painkiller abuse, it attracts addicts 
from as far away as Kentucky and West Virginia.

City health workers run the clinic on a shoestring, handing out clean 
needles and encouraging addicts to get tested for hepatitis C and 
HIV/AIDS, and to seek addiction treatment. But the best treatment 
options are at least an hour away.

"We have hundreds and hundreds of injection-drug users,"  says nurse 
Lisa Roberts. "It's like the plague of the heartland. And rural areas 
are not prepared to handle that."

A wide swath of middle America, particularly Appalachia and 
Midwestern communities east of the Mississippi River, is finding 
itself ill-prepared to cope with a problem that many big cities 
tackled long ago: injection-drug abuse and the blood-borne infections 
that accompany it. As drug users with no memory of the AIDS crisis 
decades ago put themselves in harm's way, public-health officials are 
bracing for the huge expense of treating a wave of chronic disease.

Abuse of opioid painkillers and heroin in rural areas and small 
cities is causing hepatitis C and HIV to spread in regions where they 
were uncommon two decades ago. New hepatitis C infections nationwide 
rose 150% between 2010 and 2013, with the largest increases in rural 
areas, according to the Centers for Disease Control and Prevention. 
Last month, the CDC said new hepatitis C infections in young adults 
more than quadrupled in four states - Kentucky, Tennessee, Virginia 
and West Virginia - from 2006 to 2012, with many cases linked to 
injection-drug use. Infections in Ohio have grown by 50% over the 
past five years.

An HIV outbreak in March in the small town of Austin, Ind. - the 
first in the U.S. in years tied to injection of prescription pain 
pills - brought national attention to the crisis. An estimated 450 
people in the economically struggling town of 4,200 are addicted to 
prescription painkillers. Austin has only one doctor, no 
drug-treatment facilities and no substance-abuse counselors. So far, 
170 in the area have tested positive for HIV.

Eric Hodge lives in a gritty neighborhood at the center of the 
epidemic, where emaciated users, some of them prostitutes, wander the 
streets. He says he has injected prescription painkillers as many as 
12 times a day over the eight years he has been hooked, often reusing 
needles more than 100 times and sharing them with two or three people 
each round.

In April, he learned he was infected with HIV. "It's just 
shocking,"  said Mr. Hodge, 28 years old. "I wish I never picked that 
needle up."

Hidden pockets

What worries public officials, given the scope of the drug-abuse 
problem and the relative scarcity of testing, is that there likely 
are other HIV pockets out there like Scott County, where Austin is located.

"Nobody should be saying it's only in Scott County,"  says Beth 
Meyerson, co-director of Indiana University's Rural Center for 
AIDS/STD Prevention. "We're not screening elsewhere. We don't know.

Nor does anyone know how high the public-health costs could climb. 
Left untreated, hepatitis C can lead to cirrhosis or cancer of the 
liver, and ultimately to the need for a liver transplant. New drugs 
have high cure rates, but can cost more than $80,000 per patient. 
Lifetime treatment of HIV can run as much as $400,000.

"The cost of this epidemic is spectacular,"  says Judith Feinberg, a 
University of Cincinnati doctor who treats intravenous-drug users for 
hepatitis and other problems.

The injection of prescription painkillers such as OxyContin and Opana 
climbed more rapidly in rural areas than in urban ones between 2008 
and 2012, the most recent year for which data are available, 
according to the Substance Abuse and Mental Health Services 
Administration. Addicts liquefy and inject the pills for a stronger high.

The pharmaceutical industry tried reformulating some drugs to make 
them harder to inject, but addicts came up with ways around those 
measures. In Austin and elsewhere, users cook tamper-resistant Opana 
into a viscous solution, which requires larger-gauge needles to 
inject. Public-health officials say that spreads even more blood""and disease.

Endo Pharmaceuticals Inc., the maker of Opana, says it is committed 
"to addressing opioid misuse and abuse"  and continues to research 
abuse-deterrent technology. Purdue Pharma LP, which makes OxyContin, 
says the drug's reformulation is "expected to reduce abuse," though 
abuse "is still possible."

Cheap heroin also has flooded the rural market.A spread-out rural 
population makes it harder for public-health officials to track and 
contain outbreaks, and for those in need to reach health services. 
Many areas lack substance-abuse clinics or doctors skilled at 
treating infectious disease.

Needle exchanges have been shown to curb the spread of infections, 
but federal funding for them is banned. Legal obstacles, funding woes 
and community opposition make it difficult to operate exchanges. West 
Virginia has none, although it plans to open one next month.Kentucky 
passed a law in March allowing cities and counties to open exchanges. 
In April, Indiana adopted a law allowing exchanges in counties where 
the state has declared a public-health emergency. So far, only Scott 
County has received that designation.

Big cities have been dealing with injection-drug use for decades. 
Substance-abuse facilities and needle exchanges are common, as are 
public-health campaigns warning about the risks of abuse. But in 
rural areas and smaller cities, young users have no memory of the 
1980s AIDS epidemic and typically view such risks as urban problems, 
health officials say."In many urban settings in the U.S., people who 
inject drugs have had years of preventive counseling and messaging 
and know how to protect themselves,"  said Jonathan Mermin,director 
of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and 
TB Prevention, earlier this year. In rural areas, he said, many may 
not have received counseling, "and it presents a problem."  The 
crisis has overrun cities like Portsmouth, population 20,000. Steel 
and brick mills once made the Ohio River port prosperous enough to 
have its own NFL team""the Spartans, which moved to Detroit in the 
1930s and became the Lions. But many of the town's factories have 
closed in recent decades, and today the town is dotted with empty 
storefronts and boarded-up homes.

The current drug scourge dates back to the 1990s, when 
prescription-drug "pill mills"  run by unscrupulous doctors popped up 
around town. Authorities eventually shut them down, but the addiction 
problem remained. Rampant opioid abuse and hepatitis C infection 
prompted the city's health department in 2011 to open the state's 
second needle exchange.

Shared needles Robert Morris, 45, says he got hooked on prescription 
Percocet in the mid-1990s, after a tailbone injury, then switched to 
heroin about six years ago because it was cheaper. He often shared 
needles with friends, a habit that led to hepatitis C infection.

"I've had needles I've used for two weeks,"  he says. "It's so bad. 
You try to sharpen it with fingernail files and everything." He 
started visiting the needle exchange this year.

On a recent afternoon, he emptied his used syringes into a plastic 
biohazard bucket and received a fresh supply. He tucked them into his 
belt, hiding them under a sweatshirt. "I'm embarrassed,"  he said.

Kevin Conkle, 38, says he got hooked on painkillers after falling and 
breaking his ribs, and eventually started snorting and then injecting 
OxyContin. When it became too expensive amid the pill-mill crackdown, 
he switched to heroin.

For about a dozen years he was essentially homeless, bouncing from 
sofa to sofa and even living one summer in an open-air chicken coop. 
To pay for his habit he lived what he calls a "corrupt life," 
including "oemanipulating money from friends."

He says he got hepatitis C by sharing needles, then passed it on to 
his girlfriend that way. Now he gets clean syringes at the health 
department's exchange.

Eventually, he started going to a Portsmouth addiction clinic for 
doses of Suboxone, a medication used to wean addicts off heroin. But 
that clinic closed down last year. The nearest clinics dedicated to 
opioid-addiction treatment are now 60 miles away, says Ms. Roberts, 
the nurse at the health-department facility.

Ms. Roberts and the facility's founder, Bobbi Bratchett, both have 
children who have struggled with drug addiction. When addicts show up 
with their used needles, the two women chat with them and encourage 
them to get tested for hepatitis and HIV. Ohio provides state funds 
for free HIV testing, but recently stopped providing free hepatitis C 
kits. Anyone wanting a hepatitis test now must have insurance or pay 
the $50 out of pocket.With no government funding, the Portsmouth 
exchange relies on private donations or syringe handouts from 
sympathetic hospitals. Some Portsmouth residents help out by donating 
unused insulin syringes from deceased relatives. Ms. Bratchett says 
she constantly begs for donations on Facebook.

"I think it's a shame we have to have such a program, but we have a 
need for it,"  says Portsmouth Mayor Jim Kalb.

Ohio Medical Director Mary DiOrio says the state is tracking the 
spread of hepatitis and helping local governments, which she says are 
responsible for health programs.

The hepatitis C rates in Scioto County, where Portsmouth is located, 
are among the highest in Ohio. So far, the county has recorded only a 
handful of HIV cases each year, but everyone is nervous, Ms. 
Bratchett says. A poster near the exchange's front door warns 
visitors about the Austin, Ind., outbreak.

In Austin, which is about 200 miles west of Portsmouth, the primary 
drug of abuse isn't heroin, but the prescription painkiller Opana. 
Because the high only lasts a few hours, users shoot up as many as 15 
times a day. Its street price is high, so addicts split and share the 
pills, along with needles.

Mr. Hodge, the addict who is HIV-positive, says he first started 
shooting OxyContin around 2007, then switched to Opana about three 
years ago. To support his habit, he says, he has sold his belongings, 
from vehicles to clothes, and has stolen from his mother.

He has never sought treatment, he says, but after learning of his HIV 
infection, he is reconsidering. "I'm fed up with it,"  he says.

He has started taking HIV medication and is hoping to get clean by 
enrolling in a detoxification program in Jeffersonville, about a 
half-hour away. But he worries about returning from treatment to a 
neighborhood rife with drugs.

Another Austin addict, Donnie Letner, 37, also is desperate to get 
clean. He says he has been addicted to pain pills for 10 years. He 
enrolled at a drug-treatment facility in nearby Louisville, Ky., a 
year ago, but left a day later when he was told about the cost, he says.

He has tried kicking painkillers by taking the addiction medications 
methadone and Suboxone, purchased on the black market. Each time, he 
relapsed. Living in a house with other addicts, he says, "makes it hard."

He recently tested negative for HIV.

"It's humiliating,"  he says. "I'm ashamed of myself."  But with no 
drug-treatment program in town and the one in Jeffersonville giving 
priority to those who are HIV-positive, he says, he isn't sure what to do.

The Jeffersonville detox facility, Turning Point Center, is 
struggling to meet demand with only 28 beds to serve much of southern Indiana.

William Cooke, Austin's sole doctor, says it has been difficult to 
persuade mental-health providers and others who work with addicts to 
open offices in Austin, in part because providers didn't think they 
would get reimbursed sufficiently.

A needle exchange began in April and is authorized to operate for a 
year. But users still run the risk of transmitting viruses if they 
share equipment to prepare drugs for injection.

Scores of women in town support their drug habits by engaging in 
prostitution with truckers passing through on I-65, says Jeanni 
McCarty, a nurse who works with Dr. Cooke. One told her she slept 
with more than 70 truck drivers despite learning she was 
HIV-positive, fueling concerns of far wider contagion.

The stigma attached to addiction and HIV has deterred some infected 
users from seeking services, says Ms. McCarty. "They want the help, 
but they're scared."

The HIV crisis has traumatized the town. Some church leaders have 
organized prayer walks in response. One recent evening, hundreds of 
people took to the streets near downtown, stopping every few blocks 
to pray in a large circle""some silently, others out loud.

"Heal this land, God!"  one man called out at one stop. "We are 
taking back this city, God!"

On a nearby sidewalk, someone had written in chalk, "Just say no to drugs."
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MAP posted-by: Jay Bergstrom