Association for Public Policy Analysis & Management

Background. Syringe Exchange Programs (SEPs) are underutilized, effective, and cost-effective evidence-based policies employed by state and local governments. Currently, only 17 states (CA, CO, CT, DE, HI, KY, ME, MD, MA, NV, NJ, NM, NY, NC, RI, VT, WA) and DC explicitly authorize SEPs by state law. SEPs are designed to reduce risky injection drug use behaviors such as needle-sharing and are shown to reduce Hep-C and HIV transmission and to increase substance use disorder treatment referrals. SEPs reduce medical costs associated with injection drug use such Hep-C, HIV, and endocarditis treatment. Syringes on average cost $0.17 and injection drug users inject an estimated 1,000 times annually, totaling an annual syringe cost of $170 per injection drug user. Alternatively, the cost of lifetime treatment for Hep-C ranges from $100,000-$300,000 and HIV costs up to $618,000. In 2016, a federal ban prohibiting states from using federal funds for SEPs was lifted. In 2015, Scott County, Indiana experienced a large outbreak of Hep-C attributed to needle-sharing behaviors and the Appalachian region remains at high risk for Hep-C and HIV outbreaks. Kentucky law SB192 authorized county health departments to implement harm reduction syringe exchange programs as of 2015 given that the county receives approval from all governing authorities including the local and/or district boards of health, the county government, and the city government in the jurisdiction in which the exchange is intended to operate. As of April 2018, 33 counties have approved SEPs and 24 are operational.

Objective. This study examines whether disease transmission rates and rates of endocarditis have decreased as a result of operational SEPs within the state of Kentucky by region within the state.

Methods. I conducted qualitative interviews with key stakeholders early in the implementation process in 2015 to determine the facilitators and barriers of needle exchange program implementation and policy diffusion at the local level. Data for this analysis were drawn from local health departments and key stakeholders, the CDC, the Kentucky Injury Research and Prevention Center, and the Kentucky Public Health Department. I employed a differences-in-differences model to analyze disease rates and SEP utilization rates in the years prior to policy implementation in Kentucky regions with operational SEPs compared to disease rates in the years post-implementation.

Conclusions. Despite climbing disease rates, I find that SEPs are an effective use of resources with high returns as the counterfactual of disease rates is most likely to be greater had SEPs not been operational within Kentucky. Between 2016-2017, disease rates appear to plateau and trend downward in areas with operational SEPs whereas disease rates in regions without SEPs continue to rise. These findings suggest that SEPs are an efficient and effective policy that reduce public health threats and increase treatment enrollment, avoiding future medical costs associated with injection drug use behaviors. Policymakers should consider adding SEPs to strategic plans for combatting the opioid epidemic in the US.