The Health Services Agency (HSA) requests that your Board accept and file the Biennial Report of the Syringe Services Program (SSP) for the time period of March 2015 through February 2017. On June 23, 2015, HSA presented to your Board a report for the time period of March 2014 through February 2015, and was directed to return with the next program status report biennially, as delineated by California Assembly Bill (AB) 604.
This report provides information pertaining to the SSP, relevant statistics on blood-borne infections associated with using unclean syringes (needle sharing), the annual cost of the program, and proposed program improvements. In addition, as a relevant topic, this report provides a briefing to your Board regarding the current national public health crisis of opioid addiction, our local action to address the problem, and the most recent HIV outbreak associated with injection drug users sharing needles in another state.
Summary of Statutory Requirements and Board Direction
On January 1, 2006, AB547 became law and legalized services for services for health care providers to exchange used intravenous syringes for new clean ones (syringe exchanges) in California without the need for a declaration of a state of local emergency due to a significant risk of the spread of Human Immunodeficiency Virus (HIV) infection by injection drug users. Subsequent State laws AB110 (2007) and AB604 (2011) require:
“(a) The health officer of the participating jurisdiction shall present biennially at an open meeting of the board of supervisors a report detailing the status of clean needle and syringe exchange programs, including, but not limited to, relevant statistics on blood borne infections associated with needle sharing activity and the use of public funds for these programs. Law enforcement, administrators of alcohol and drug treatment programs, other stakeholders, and the public shall be afforded ample opportunity to comment at this biennial meeting. The notice to the public shall be sufficient to ensure adequate participation in the meeting by the public. This meeting shall be noticed in accordance with all state and local open meeting laws and ordinances, and as local officials deem appropriate.”
On June 18, 2014, your Board approved HSA’s recommendations for the SSP program and provided clear direction which HSA has closely followed. (Attachment A). On May 16, 2017, your Board directed staff to communicate with the Needle Solutions Team and other stakeholders about the plan to present the 2015-2017 biennial SSP report at the June 6, 2017 Board meeting. This direction has been followed by staff. In addition, HSA has met with the SSP Advisory Group to review the report’s data and recommendations. This biennial report has been noticed in accordance with all state and local laws and ordinances for open public meetings.
Program Updates and Progress
SSP – Phase 1:
· Program Administration: On April 30, 2013, in response to increasing community concern regarding the accountability of syringe exchange services and a high prevalence of discarded syringes in public places, with your Board’s approval, HSA began directly administering the SSP without additional funding for operations or staffing. SSP home delivery and mobile exchange services that were previously provided by a volunteer group, Street Outreach Services (SOS), were discontinued after HSA assumed program responsibility. In addition to the program’s core component of exchanging syringes, the SSP also provides education and referrals for substance abuse treatment.
· Advisory Group: Since inception of the SSP, HSA has periodically convened the SSP Advisory Group, which is comprised of community representatives including City and County law enforcement, County Probation, City of Santa Cruz executive management, community pharmacy representatives, CDPH, physicians, community-based organizations serving intravenous drug users, and other subject matter experts. The Advisory Group has met periodically to review SSP utilization and demographics data, and will continue to review data and provide guidance to HSA on an as-needed basis.
SSP- Phase 2:
· Disposal Kiosks: The SSP provides services to reduce the impact of improperly discarded syringes of any kind. Between April 2013 and August 2014, three self-service kiosks for disposal of used syringes were installed within Santa Cruz County and are located outside each of the two HSA health clinics in north and south county, and near the Water Street entrance of the 701 Ocean Street Government Center. The kiosks’ operation has been a tremendous success in collecting used syringes and providing for their safe disposal. Approximately 366,000 used syringes were collected from the three kiosks since 2013.
· Continued the Advisory Group: The SSP Advisory Group has met periodically to review SSP utilization and demographics data, and will continue to review data and provide guidance to HSA on an as-needed basis.
· Overdose Antidote Delivery: Since HSA’s last report to your Board in 2015, and with the help of State funding, HSA has partnered with Janus of Santa Cruz, one of the primary local substance use disorder treatment programs, to provide emergency administration of naloxone (Narcan) as an antidote for SSP clients experiencing overdose of opiates such as heroin. HSA is also providing Narcan and related training to local law enforcement personnel and health care providers in the community. From June 2014 to current day, 1,200 overdose reversal kits have been distributed in Santa Cruz County, resulting in 209 overdose reversals.
· Internet Data Posting: Beginning in June 2016, monthly SSP data has been posted on HSA’s SSP webpage. This website also includes features for optional electronic submittal of public comments and questions.
Program and Client Statistics
From March 2015 through February 2017, the SSP:
· Served 1,133 unduplicated clients (This number is not equivalent to the sum of unique ID’s from year 3 and year 4 due to overlap of unique clients over the two year period);
· Provided 8,099 duplicated client visits;
· Dispensed 597,567 new syringes;
· Collected 823,910 used syringes, including 235,275 syringes (estimated from 2,500 pounds of sharps waste) from the three kiosks, and 588,635 from onsite exchange; and
· 64% of clients were given additional education and/or referral to medical care, HIV/Hepatitis C testing or drug treatment.
The County Health Officer continues as the authorizing agent for Medical Exceptions and secondary exchange. Needles provided to first-time clients as entry to the program and replacing those confiscated by jail, hospitalization, or other authorized circumstances are currently reported as a First Encounter. Medical Exceptions were consistently less than 1% of syringes dispensed during this four-year period, while the threshold for reporting to your Board is a quarterly maximum level of 3%, per your Board’s direction on April 15, 2014. Medical Exceptions, together with First Encounters, averaged only 1.8% over the four year period. The following table compares SSP data since HSA’s program inception, from May 2013, through February 2017.
(Began April 30)
MAY 2013 -
MAR 2014 -
MAR 2015 -
MAR 2016 –
Unique ID Clients:
TOTAL Syringes Dispensed:*2
Syringes Collected by Onsite Exchange:
Syringes Collected by Kiosks:*3
46,396 (493 lbs)
84,134 (894 lbs)
83,570 (888 lbs)
TOTAL Syringes Collected:
*1 Note: Select numbers have changed slightly from previous reports due to updated data-cleaning efforts and improved unique ID tracking.
*2 Note: The portion of total syringes dispensed as both Medical Exceptions and First Encounter:
Year 1 = 1,041 (0.6%) Medical Exceptions + 2,624 (1.6%) First Encounter = 3,665 (2.2%);
Year 2 = 1,065 (0.5%) Medical Exceptions + 1,834 (0.9%) First Encounter = 2,899 (1.4%);
Year 3 = 1,913 (0.7%) Medical Exceptions + 1,809 (0.7%) First Encounter = 3,722 (1.4%); and
Year 4 = 1,913 (0.6%) Medical Exceptions + 5,975 (1.8%) First encounter = 7,888 (2.3%).
*3 Note: Ratio approximated as 1 pound (lb) sharps waste = equivalent to 94.11 syringes.
For this report’s biennial period of March 2015 through February 2017, demographic data for participating program clients is provided in two data tables (Attachment B) and is summarized as follows:
· Gender: Male (69%); Female (30%); and Other, such as Transgender or Unknown (1%).
· Age: 18 to 24 (7%); 25 to 44 (64%); 45 years or older (29%); and Not Reporting (less than 1% (5 clients).
· Ethnicity: White (76%); Latino (18%); and Multi-ethnic or Not Reporting (6%).
· Living location: North County (72%); South County (14%); and Countywide (14%).
Statistics on Blood-Borne Pathogens Associated with Injection Drug Use
The following table shows the last eight calendar years of data from 2009 through 2016 for newly identified cases reported annually within Santa Cruz County of blood-borne diseases related to intravenous drug use:
Newly Reported Cases Annually*4a,b
*4a Source: http://www.santacruzhealth.org/Portals/7/Pdfs/CDStats2013-2017.pdf
*4b Note: Hepatitis C infection often causes little or no apparent illness at the time of infection, and often goes undiagnosed. The numbers shown here do not differentiate between newly acquired infections and infections that may have occurred as long as several decades ago, when infection rates were many times higher than today. Judging by nationwide estimates of newly acquired infection rates, the numbers shown here are most likely to consist almost entirely of older, previously undiagnosed infections.
The U.S. Government has funded over seven recent studies of syringe services programs (SSPs) for persons who inject drugs. The reports are unanimous in their conclusions that clean needle programs reduce HIV transmission, and none found that clean needle programs caused rates of drug use to increase. Since that time, dozens of articles and research studies have been published in peer-reviewed publications affirming SSPs efficacy in encouraging and facilitating entry into treatment for intravenous drug users (IDUs) and thereby reducing illicit drug use. Numerous studies have also documented SSP’s effectiveness in reducing the risk of HIV infection among IDUs and their partners. The federal Department of Health and Human Services currently maintains a currently updated webpage that promotes the public health effectiveness of syringe exchange programs (http://archive.samhsa.gov/ssp/).
Current Public Health Crises
National Opiate Epidemic Problem:
The federal Centers for Disease Control and Prevention (CDC) reports that use of the injected opioid, heroin, has increased across the United States among men and women, most age groups, and all income levels. Some of the greatest increases have occurred in demographic groups with historically low rates of heroin use, including women, the privately insured, and people with higher incomes. Not only are people using heroin, they are also abusing multiple other substances, especially cocaine and prescription opioid painkillers. Heroin use more than doubled among youth aged 18 to 25 in the past decade; Heroin is an illegal, highly addictive opiate that is typically injected, subjecting such people to risk of serious, long-term, viral infections such as HIV, Hepatitis C, and Hepatitis B, as well as bacterial infections of the skin, bloodstream, and heart. The CDC data reports that 45% of people who used heroin were also addicted to prescription opioid painkillers, and that 46 people die daily from an overdose of prescription painkillers in the United States. In 2014, 18,983 Americans died from prescription opioid overdoses- more deaths than any previous year, and more than quadruple the number of deaths in 1999. Some overdose deaths also involved interaction with another drug substance, such as alcohol.
In recent years, the Health Improvement Partnership of Santa Cruz County (HIP) has established the ‘Safe Rx Santa Cruz Coalition’ (Coalition), with HSA’s participation, as a cooperative of social service, government, and healthcare organizations dedicated to aligning and accelerating existing efforts around safety, awareness, and best practices for prescription pain medication. A Coalition summary report dated April 2017 provides an overview of the opioid epidemic nationwide and specific data for Santa Cruz County (Attachment C).
This report additionally documents that in Santa Cruz County, enough opioids are prescribed by physicians for every man, woman and child to be medicated around the clock for six weeks each year. The Coalition published a Santa Cruz County Report Card for opioid abuse dated January 2017 (Attachment D) which shows that Santa Cruz County’s opioid prescription rate has slowly decreased over the last five years. However, the local prescription rate for opioids remains much higher than the state average. A fifteen-year summary of local opioid data is provided by HIP (Attachment E). HIP reports that in 2014, there were 58 overdose deaths in Santa Cruz County, 54% of which were due to prescription drugs. In 2015, Santa Cruz County ranked 9th among 58 California counties for its high opioid overdose death rate. High opioid prescription rates are correlated with high rates of drug overdose deaths.
The HIP Coalition was established to address the three current federal priority areas for opioid medications that are: 1) supporting safe prescribing practices; 2) expanding access to medication-assisted substance use disorder treatment; and 3) increasing the availability of drug overdose treatment medication (Naloxone). The Coalition has established three main workgroups to implement programs to address the three priority areas. Provided is Coalition information regarding local efforts to combat the opioid epidemic problem, including: the latest Coalition Update Report dated January 2017 (Attachment F); an organization chart that lists members for the Coalition workgroups (Attachment G); and a ‘Primary Care Guidelines Flowchart’ (Attachment H).
The County SSP is an integral part of the solution to combat the national opioid epidemic that includes injected opiates. The SSP’s four-year utilization data demonstrates tremendous success in safely collecting and disposing used opioid injection needles and providing sterile needles to intravenous drug users to prevent the spread of deadly communicable diseases. In addition, the SSP is part of the strategy to build trust and rapport with this population and engage them into services and treatment.
Public Health Emergency Declaration- HIV Outbreak
In 2015, Indianapolis State Health Commissioner announced a devastating public health emergency due to an outbreak of HIV in Scott County where 191 people tested positive for HIV. The outbreak was tied to sharing of needles among injection drug users. In May 2016, the State Health Commissioner announced his extension of the public health emergency declaration for Scott County until May 2017 to continue the successful operation of a syringe exchange program as part of a comprehensive effort to stop the spread of HIV and Hepatitis C. The Health Commissioner stated that the Scott County’s SSP has significantly reduced potential harm to their community, dramatically decreased new cases of HIV and Hepatitis C, and given their health care providers better and regular access to their citizens, who desperately need medical services.
Nationwide, there are more than 203 syringe exchanges programs, and in California, there are currently more than 40 syringes exchange programs in operation.
The CDPH Center for Infectious Disease, Office of AIDS, has established a Syringe Exchange Supply Clearinghouse, a collaboration with the North American Syringe Exchange Network (NASEN). The Supply Clearinghouse will provide a baseline level of supplies to authorized California syringe exchange programs (SEPs) for the purpose of enhancing the health and wellness of people who inject drugs and to increase the stability of California SEPs. Funds for the program, which were authorized by Section No. 14 of California Senate Bill 75 (2015) are ongoing and total $3 million annually statewide, administered by CDPH. Under this program, Santa Cruz County has been approved for syringe supplies equivalent to $110,876 annually. As of September 2016, the SSP began receiving supply shipments directly from NASEN. This augmentation is reflected in the reduced supply cost in the last year and will significantly reduce the supply costs of the Santa Cruz County SSP in future years. No funding reductions are anticipated from the new federal administration.
There are no permanent SSP staff or budget. Staff have been mobilized from HSA Clinics Division and Public Health Divisions to provide temporary personnel for SSP services. The following table lists the costs taken from other programs to support the SSP.
*5 Note: Calculation is actual salary and benefits of staff borrowed from other programs to cover SSP.
Economic studies have predicted that syringe exchange programs could prevent HIV infections among clients, their sex partners, and their offspring at a cost of approximately $13,000 per infection averted*6. This is significantly less than the lifetime cost of treating an HIV-infected person, which is estimated to be between $253,000 and $402,000 per person, depending on the stage of the disease at time of diagnosis*7.
SSP Phase 3: After almost four years of directly operating the SSP, with sufficient utilization data to review and analyze, and given the current national public health epidemic of opioid addiction, HSA proposes to launch Phase 3 of the program as follows:
1. Continue with the 1 for 1 syringe exchange policy at the two authorized SSP sites located at the County’s Emeline Clinic and Watsonville Health Center. All SSP individuals, including those requesting additional syringes, would be offered and directly linked to these two county clinic sites for immediate intake and be evaluated by a medical professional staff. This is the next phase of SSP’s mission and goal to engage and monitor SSP individuals in the Federally Qualified Health Center/clinic setting to receive ongoing primary care, specialty care, mental health and substance use disorder services. The clinics staff will follow the required documentation protocol in the approved electronic medical record (EPIC) and maintain compliance with patient confidentiality laws. Medical Exceptions and First Time Encounters categories will no longer be part of the SSP operation, effective upon your Board’s approval of the recommended action.
2. The Chief of Clinic Services and Medical Directors of the Emeline Clinic and Watsonville Health Centers will ensure that clinic medical staff and support staff are informed and trained to comply with #1 above.
3. Under the County Public Health Office’s direction, Public Health Division staff continue to work with local medical providers and the State Department of Public Health to collect, analyze and disseminate surveillance data on new cases and chronic cases of HIV, hepatitis B and C. Staff shall return to your Board timely to report and make recommendation accordingly if there is an increase in new cases of communicable diseases.
4. Work with city jurisdictions to explore options to install safe sharps-disposal containers countywide in locations where known frequent public discarding of syringes occurs.
5. Maximize capitalization of funding advantages through future Drug Medi-Cal expansion and other relevant initiatives offering potential opportunities to further enhance the SSP as a substance use disorder intervention program to support SSP clients in recovery.6. Continue to participate in statewide and local initiatives to address the opioid addiction epidemic problem.
HSA is committed to fulfilling its mandates and mission to protect and promote the public health and safety of the community. The SSP is part of the solution to this issue, and is part of a comprehensive public health services continuum necessary for injection drug users to reduce transmission of blood-borne diseases. Staff would like to further improve the SSP services and implement Phase 3 of the program.
It is, therefore, RECOMMENDED that your Board:
1. Accept and file the Health Services Agency (HSA)’s 2015 - 2017 Biennial Report for the Syringe Services Program (SSP);
2. Authorize HSA to continue with the 1 for 1 syringe exchange policy at the two designated SSP sites located at the County’s Emeline Clinic and Watsonville Health Center;
3. Authorize HSA to discontinue provision of additional syringes due to Medical or First Encounter exceptions by HSA Syringe Services Program staff and replace this practice with linking Syringe Services Program individuals, including those who request additional syringes, to County clinic sites for timely patient intake and professional medical evaluation. The individuals will become patients of the clinics for ongoing primary care, specialty care, mental health and substance use disorder services;
4. Direct staff to timely return to your Board to report and make recommendation if there is an increase in new cases of blood-borne communicable diseases;
5. Direct HSA to work with city jurisdictions to explore options to install safe sharps-disposal containers countywide in locations where known frequent public discarding of syringes occurs;
6. Direct HSA to maximize capitalization of funding advantages through future Drug Medi-Cal expansion and other relevant initiatives offering potential opportunities to further enhance the SSP as a substance use disorder intervention program to support SSP clients in recovery; and
7. Direct staff to continue participating in statewide and local initiatives to address the opioid addiction epidemic problem.