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HomeMy WebLinkAbout04 April JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, Apri120, 2000 Board Members.' Dan Harpole, Member - County Commissioner District #1 Glen Huntingjord, Member - County CommÌJJÌoner DÌJtrid #2 &chard J,fí'qjt, Member - County Commissioner District #3 Geriffrry Ma.rà, Member - Port Town.rend City Coumil Jill Buhlel~ Vice-Chairman - Hospital Commissioner District #2 Sheila We.rterman, Citizen at Large (City) Roberta Fris.rell, Chairman, Citizen at Large (County) Staff Members: Jean Baldwin, Nursing Service.r Director Larry Fcry, Environmental Health Director Thoma.r Locke, MD, Health O.flìcer Chairman Frissell called the meeting to order at 1:30 p.m. All Board and staff members were present with the exception of Commissioners Wojt and Harpole who arrived after the meeting began. Chairman Frissell announced this month's joint meeting with the hospital commission was canceled because Dr. Locke was unable to attend. PUBLIC COMMENTS Dr. Melanie McGrory introduced Initiative 725 -- Healthcare 2000. The purpose of the plan is not to replace good plans that exist, but to pool resources and provide coverage for people not covered. As a primary care physician, her concern is that the majority of her patients are relatively under-insured or not insured at all. Those with insurance have high deductibles of $700 to $1,000 and, from a primary care point of view, they are uninsured. Her feeling is that the system is broken and needs an overhaul and that working within the current system is a losing proposition. A petition with signatures of 230,000 Washington registered voters is required for the initiative to move forward. She admitted that while the initiative may not be the perfect solution, it will open critical dialogue. She will forward more specific information on the initiative to the Board for review. Member Masci said whether or not this is the right solution as an initiative, it is going to have more livability and put people in direct control of their health care. Member Westerman said she believes it is appropriate for the Board of Health to take a position on the initiative. She requested a discussion of Initiative 725 be added to the next Board of Health agenda and that information provided by Dr. McGrory be included in the Board's packet. OLD BUSINESS 1999 .Jefferson County Health Pro2ram End of Year Report: See report. HEALTH BOARD MINUTES - April 20, 2000 Page: 2 Local Board of Health Leadership Workshop: Chairman Frissell and Commissioner Wojt are expected to attend the May 4-5 workshop in Seattle. A report of the workshop will be reviewed at the next Board of Health meeting. NEW BUSINESS Syrim!e Exchan2e Program - Public Comment and Draft Resolution: Lianne Perron, representing the Prosecutor's Office, expressed full support of the Syringe Exchange Program (SEP), saying it has been well thought out and well planned. Suzanne Schmidt, Chair of the Substances Abuse Advisory Board, said they voted and wrote a letter of support of the SEP. They feel it will give them better access, knowledge and accountability as to the size of the problem. She introduced Dick Gunderson as the new coordinator working on many of these issues. Jean Baldwin distributed and read a letter from Dr. Tom Locke urging the Board of Health to vote in favor of disease prevention through the SEP initiative. (See attached letter that was read into minutes.) Milt Morris spoke in opposition to the planned program. Programs across the country and in Europe have failed to reduce the transmission of infectious diseases. The drug problem has grown as a result, and these programs are a taxpayer's nightmare. If an SEP is instituted, he believes the community will regret having created a network of needle users. Both the Chief of Police in Port Townsend and the Jefferson County Sheriff personally oppose the program. They do not believe it will prevent or protect their officers from being stuck by a needle in a pat down or decrease the number of discarded needles. There are no documented cases in this County of any infectious diseases being spread through the use of dirty needles. He does not understand what is to be gained by an SEP. Discussion and a decision on the resolution was postponed until Commissioners Huntingford and Wojt are present. Board of Health Retreat / .Joint Meetings with .Jefferson General Hospital: Chairman Frissell said she and Dr. Tom Locke discussed ideas for providing more direction in joint meetings with the Hospital Board of Commissioners on the health access process. Chairman Frissell proposed a half-day Board of Health retreat to discuss health access or other objectives and what role each agency should play. Also, she asked if there is support for a facilitated all-day meeting with the Joint Boards with possible subcommittee work? Commissioners Harpole and Wojt joined the meeting. There was agreement to intersperse the monthly joint Board meetings with some longer meetings. Jean Baldwin recommended key reports be presented by Dr. Locke, Jill Buhler, and Vic Dirksen at the next Joint meeting. Dr. Locke has agreed to present Board of Health governance issues. She supports having a retreat to start discussions on health care access as a public health issue. Chairman Frissell agreed to talk with Dr. Locke to place specific questions on the next Board agenda regarding HEALTH BOARD MINUTES - April 20, 2000 Page: 3 retreat topies. The Board also agreed to resume 1-1/2 hour Joint Board meetings next month with presentations from Dr. Locke and Vie Dirksen. If possible, the next Board of Health meeting will be held at the Hospital at 1:30 p.m. APPROVAL OF MINUTES Member Masci moved to approve the minutes of the March 16,2000 meeting. Commissioner Huntingford seconded the motion which carried by unanimous vote. NEW BUSINESS - CONTINUED Continuation of Svrin!!e Exchan!!e Program - Discussion: Member Buhler said given all of the information and support from governmental and independent agencies for the SEP, she has to support the SEP. There may be a public mis-perception about the SEPs but the key word is "exchange." We are not giving needles to people who do not already have them, but are exchanging dirty ones for clean ones. Chairman Frissell pointed out that the Board is looking at this program as disease prevention, not as a moral or political issue. Commissioner Wojt asked how will this program will be funded? Jean Baldwin said supplies for the program are minimal with needles costing approximately $200 a year. Funds for the SEP would come from the AIDS Omnibus HIV Prevention Program with 50% of the funds targeted to treat high-risk individuals. This is not new money, nor is any additional money being budgeted. Money and staffing time will come from HIV testing and counseling of low risk individuals, which was cut by 50%. Commissioner Huntingford asked how much of a problem is needle use in Jefferson County? Ms. Baldwin reviewed the state, national statistics. She said two local sources of needle use came from Clallam County Jail and local treatment centers. Local Hepatitis C cases are unknown. She indicated most of the staff work has already been done in preparation of the program including a referral network. The program might involve an estimated 25 needle users. Commissioner W ojt moved to adopt the Access to Sterile Syringes and Needles Resolution. Member Buhler seconded the motion for discussion. Member Westerman said one of the reasons she was excited that the legislature made it possible to expand Boards of Health is because she felt it was an opportunity at a local level to de-politicalize public health. Commissioner Huntingford commented he is disappointed that the information the Board received did not reflect opposition voiced in the media. A vote was called for on the motion. Commissioner Huntingford voted "against" the motion with the remaining six (6) Board members voting "for" the motion which carried. HEALTH BOARD MINUTES - April 20, 2000 Page: 4 Annual Food Service Awards: Seven years ago, these awards were recommended by the Food Service Advisory Committee as an opportunity to recognize efforts by food service establishments. The criteria established by the Advisory Committee are limited but can be difficult to adhere to. Establishments have to be preparing potentially hazardous food and an array of foods that potentially exhibit a high risk to the public if handled improperly. Mr. Fay reviewed the point system by which the criteria were established. This year, there was a record number of 42 establishments receiving the award. A lot of establishments received consecutive awards, representing their commitment to food safety. Susan Porto said there are just over 100 eligible facilities. With the awards, Larry Fay recognized and thanked the following establishments for their exceptional efforts in maintaining our public health standards: 6th year: PT Senior Nutrition Program Waterfront Pizza Upstairs The Valley Tavern Discovery View Retirement 3rd year: 4th year: Cheeks Bloomer's Landing Silverwater Café Lonny's Jefferson County Jail 5th year: 2nd year: Mr. Fay recognized other organizations receiving awards this year as follows: Uptown Pub and Grill, The Village Baker, Upstage, The Geoduck, Sentosa Sushi, Safeway Deli, QFC Port Townsend Deli, The Pizza Factory, Niblick, MacKenzie's Deli, Maxwell's, Khu Larb Thai, Heron Beach Inn, El Sombrero, El Sarape, The Cellar's Market, Ajax Café, Stormin Norman's, QFC Port Hadlock Deli, the Tri-Area Senior Nutrition, The Portside Deli, The Lighthouse, Lanza's, Jordini's, Hard Rain Café, Brinnon Seniors, Seabeck's Pizza, Peninsula Foods Deli, Nancy's, Fat Smitty's, Bread & Roses, Whistling Oyster, and Java Port. On-Site Sewae:e Ree:ulation -- Operation and Monitorine: Inspection Program 8.15.160: The proposed Draft #4 incorporates comments from community meetings in Chimacum, Brinnon and Quilcene as well as from designers, installers, and homeowners and results in a blending of public and private sector models for 0 and M. Linda Atkins reviewed the benefits of the proposed model utilizing the PUD as the primary monitoring entity: · consistency of inspection and knowledge that inspections are being completed significantly lower cost for monitoring and maintenance versus private contractor model. The PUD will be inspecting more components of the system than they currently perform better control, with oversight of information owner retains the right to choose the maintenance person there is no vested interest or incentive to find problems provides ability to tie PUD data into existing database (for permitting and tracking) decision and relationship with the PUD. The County does not have to start from the ground up · · · · · · Commissioner Huntingford asked for an update on the County's communications with the PUD. Larry Fay indicated the PUD's main concern is conducting the initial inspection for an existing system. The County has agreed to design a program which places responsibility for the initial inspection and the establishment of future inspection schedules with the County. After the data is in the system, the PUD will begin to pick up future inspections. As outlined in the ordinance, at the time of building permit or sale of the property an inspection would be performed by Health Department personnel and the information would then be passed on to the PUD. HEALTH BOARD MINUTES - April 20, 2000 Page: 5 Commissioner Huntingford asked what mechanism will be used by the County to hold up the sale of a house in order to have the septic system inspected? Linda Atkins responded the inspection would be a requirement of the sale of property. This would be communicated to all real estate agents and financial institutions in the County. It is conceivable that a property could change hands independently, between a buyer and seller without a real estate agent. If it is a cash sale, notification of the requirement would come at the time the sale is recorded with the auditor's office. To protect itself, the lending institution is not going to close until the requirements have been met. David Alvarez said although the vast majority of houses go through a mortgage process, he does not believe a "notice to title" can be legally enforced since the term is not referred to in the statute. Linda Atkins referred to the addition of Section (6) that specifically outlines reporting requirements and who can conduct an inspection. This addition should address the ongoing complaint that Environmental Health does not act fast enough when there is a property transaction taking place. Commissioner Huntingford questioned the specific reference to the Growth Management Act under (c) of 8.15.170. Larry Fay said this may need to be revisited, but the language came from On-Site Sewage WAC 246- 272. Larry Fay reviewed the Areas of Special Concern regarding the extra level of treatment for the Tri-Area. Appeals of Critical Area issues are done through the process of the Critical Areas Ordinance, not through the Board of Health. Member Masci moved that the Board of Health support staff recommendation relative to operations and monitoring and accept the PUD as the primary contractor. Commissioner Harpole seconded the motion which carried by unanimous vote. On-Site Sewal!e Regulation -- Vestinl!: Linda Atkins reviewed the State WAC 246-272 as it applies to additions, remodels, replacement, and expansions. When the Department is dealing with an expansion, the on- site sewage system has to be compliant with current code. Member Masci believes that staff should establish reserve areas based on a review of the plot plan as well as a drive-by and/or visit inspection. He agrees that some record needs to be established on unknown sites for any building permit. Linda Atkins said under the current procedures, staff requires an evaluation of the existing system if there is no record of the site on file. Although it is staff's desire to continue this policy, the issue is that the site change may not have anything to do with the septic system. Staff claims that it may reduce the ability to repair the system or assure that the system is not currently failing. Larry Fay noted that as recently as six or seven years ago, staff did not even look at building permits if they were not associated with the residential septic system. When the state updated their regulations in 1995, staff, HEALTH BOARD MINUTES - April 20, 2000 Page: 6 without changing policy, moved more aggressively into complying with the WAC onjnspections. Staff is fairly confident, assuming the system is working and within capacity, that anything permitted since 1992 - or even post-198?, in most cases - is going to be considered compliant. Staff recommends keeping the language in the regulation as compatible with the State regulation as possible. You have to be in compliance with the on-site sewage code as of the time you apply for the building permit. In policy, staff will try to anticipate, define and list some of the variables to ensure the system is compliant with current code. In older systems, records will need to be updated as to whether the system is compliant. Based on the code at the time, staff will say the system was permitted for a certain use and determine if the system is still functioning and require establishment of a reserve area. Although the system may not be fully compliant with vertical separation, instead of a three- year inspection, staff could set up a one-year inspection frequency. If there are operational problems because of the differences between code and design standards, they will be found through the inspection process. Member Masci moved that the Board support stafrs recommendation to retain revised Section 8.15.060 Adequate Sewage Disposal Required. Staff will continue developing a policy that states that on sites larger than 5 acres, establish reserve/repair area based on review of the plot plan and drive-by and/or visit inspection plan. For building permits on completely unknown sites, the establishment of a record is needed. Commissioner Harpole seconded the motion, which carried by unanimous vote. Larry Fay said that staff will prepare a clean, final draft and set up hearing dates and a process for adoption. AGENDA CALENDAR / ADJOURN Meeting adjourned at 3:45 p.m. The next meeting will be held on Thursday, May 18 at 1:30 p.m. at the Jefferson General Hospital Conference Room. JEFFERSON COUNTY BOARD OF HEALTH y.>' ~' L~ILUt::C~DT~rz Roberta Frissell, Chairman ~[0v~ ..\ ey MJ.scf, Me;nbe~... '¿ ___./~i ) II' _ill-i6 ." - '.-0_... / / .' ,- '\ ..... . · ....--.-lit-.. L25~vZ'l-'~-øt . - ",/L ""Richard Wojt, Member :)~~ uJ~ht^fM~ Sheila Westerman, Member NOTICE HEALTH BOARD MEETING CHANGE . The Jefferson County Board of Health has changed their regular monthly meeting schE;QU\e. Board of Health meetings will now be held on the third Thurs- day of each month from 1 :30 p.m. to 3:30 p.m. at the Health and Hu- man Services Department. Castle Hill Center, 614 Sheridan Ave- nue. Port Townsend, WA 98368. Next meeting: April 20; 2000. Roberta Frissell, Chairman . Jefferson County Board of Health 1175m 4-19 Affidavit of publication STAïE OF WASHINGTON) SS cOUNTY OF JEFFERSON) SCOTT WILSON, being sworn, says he is the publisher of the Port Townsend Jefferson County Leader, a weekly newspaper which has been established, published in the English language and circulated continuously as a weekly newspaper in the town of Port Townsend in said County and State, and for general circulation in said county for more than six (6) months prior to the date of the first publication of the Notice hereto attached and that the said Port Townsend Jefferson County Leader was on the 27th day of June 1941 approved as a legal newspaper by the Superior Court of said Jefferson County and that annexed is a true copy of the Health Board meeting change - 3rd Thursdays as it appeared in the regular and entire issue of said paper itself not in a supplement thereof for a period of 2 consecutive weeks. beginning on the 12th day of April &endingonthe~&yof April . 2CXlD-. 20 00 '-' and that said newspaper was regularly distributed to its subscribers during all of this period. That the full amount of $ 45.00 has been paid in full, at the rate of $9.50 ($9.00 for legal notices re- ceived electr tion. publisher Subscribed and sworn to before me this 19thay of April 20.QQ... Notary Public in and for the State of Washington residing at Port Hadlock NOTICE HEALTH BOARD MEETING CHANGE The Jefferson County Board of Health has changed their regular monthly meeting schedule. Board of Health meetings will now be held on the third Thursday of each month from 1 :30 p.m. to 3:30 p.m. at the Health and Human Services Department, Castle Hill Center, 614 Sheridan A venue, Port Townsend, W A 98368. Next meeting: April 20, 2000. /J~ r ,t:&-t1. ~ Roberta Frissell, Chairman Jefferson County Board of Health Erin Lundgren BOCC Office PO Box 1220 Port Townsend, WA 98368 & Human :)erVlces To: Jefferson Connty Board of Health fÎO'---'¡ i ë) i;::,\ r.::::J.. / jr') !¡ _ I=:; < ,--- i-.!' . n' . ..~ ,..I ,--. I -- I., u ;¡ ~/7 u v r_~· Ii r"'.,,\ ! J! Ii, : -~::/ April 13, 2000 Subject: APR 1. 4 2nOfJ Tom Locke, MD, MPH, Jefferson County Health Officer -rt~L-- .. 1 . JCc:r:c::')(, -', ". 80 . L. ; LI,~.Ui\¡ CUi ¡¡'''Tv 'ARD ('F ...i V. 1 . " t ) COMMISSI(}i\iEi?S From: Board of Health Meeting - Thursday, April 20, 2000 The next meeting of the Board of Health will be held on: Thursday, April 20, 2000 1 :30 - 3:30 PM JCHHS Conference Room Enclosed are a tentative agenda for this month's meeting, draft minutes of the last Board of Health meeting, agenda materials and the department's monthly media report. · Follow-up Reports/Informationalltems: 1999 Jefferson County Health Program End-of-year Report: A copy of the program summary report that will be presented at the next Joint Board meeting is included for Board of Health review. Local Board of Health Leadership Workshop: An agenda and registration for this event has been sent out under separate cover to aU Board members. Anyone who wishes to attend and has not registered should let JCHHS staff know as soon as possible so that arrangements can be made. · Health Officer Apology: I am very sorry that I am unable to attend the Jefferson County Board of Health's April meeting. There are several important issues on the agenda that I was looking forward to taking part in. An unfortunate scheduling conflict developed with my ClaUam County responsibilities. April 20th was chosen as the only feasible day for ClaUam County to conduct interviews for a new Director of Health and Human Services. I am on the interview committee for that position. Four highly qualified applicants have been selected for an aU day interview process. I was forced to make the decision between two very important competing obligations. I strongly feel that the choice of ClaUam's new Health Director affects the whole Olympic Peninsula. An exceptional individual could make a major difference in our ability to advance the public health interests of this region. I send my regrets and leave this meeting in the able hands of Jean and Larry. I will be at JCHHS on Wednesday, April 19 and would be happy to discuss any agenda items with Board Members that day, at your convenience. · Syringe Exchange Program - Public Comment and Draft Resolution: The issue of syringe exchange has come before the Board on several occasions. Time has been scheduled for additional public comment and Board discussion of this issue. Letters of support from the Jefferson County Substance Abuse Programs Advisory Board and Jefferson Mental Health Services are enclosed. A number of additional infonnational items are included. My recommendations on this important issue are summarized in my enclosed memo to the Board. · Annual Food Service Awards: Each year the Board has acknowledged the food service establishments in Jefferson County that have shown outstanding achievement in maintaining food safety standards. This is a popular award and is proudly and prominently displayed in the establishments so honored. HEALTH DEPARTMENT 360/385-9400 ENVIRONMENTAL HEALTH 360/385-9444 DEVELOPMENTAL DISABILITIES 360/385-9400 ALCOHOL/DRUG ABUSE 360/385-9400 FAX 360/385-9401 · Legislative Update, Year 2000 Session: The legislatures special session ended without adoption of a supplemental budget. Transportation funding is the major stumbling block. The fate of local public health and tobacco prevention funding remains uncertain. Legislators have returned home, I am told, "to get their summer clothes". · Draft # 4 - Onsite Sewage Regulations: The current draft of Jefferson County's proposed onsite sewage regulations was distributed during the March meeting. Please bring your copy to the April meeting or give Dianne a call to have a replacement copy sent to you. Two policy issues have been identified for Board decision: The first concerns who should perform onsite monitoring functions and the second involves environmental health review of building permit applications. A policy discussion paper is enclosed that details these issues. · Discussion Items: Board of Health retreat and schedule for Joint Board meetings. The Board's chair has scheduled time for the Board members to discuss the desirability of holding a 4-6 hour Board retreat sometime in the near future. A second discussion item involves alternatives to the current strategy of holding Joint Board meetings with the Hospital Commissioners immediately following monthly Board of Health meetings. A separate meeting time may offer greater flexibility and lower stress levels. If you have any questions regarding the enclosed agenda, or anv additions to the agenda. please call me at 385-9448. County Health & Human Services April 13, 2000 To: Jefferson County Board of Health From: Thomas Locke, MD, MPH, Jefferson County Health Officer Re: Implementation of a Syringe Exchange Program (SEP) in Jefferson County At the April 20th Board meeting, a draft resolution will be presented for consideration. This resolution will authorize the Jefferson County's public health officials to proceed with implementation of a modest needle/syringe exchange program. Public testimony will once again be taken. The scientific evidence supporting syringe exchange as an effective strategy for reducing transmission ofHIV and other deadly bloodborne infections is voluminous. The leading scientific organizations in this country (National Academy of Sciences, National Commission on AIDS, University of California, SF, Centers for Disease Control, among others) have performed exhaustive reviews of national and international research and have all come to the same conclusions: 1) SEPs lower the rate of new HIV infections among injection drug users (IDU's) 2) SEPs decrease the unsafe disposal of contaminated needles 3) SEPs do not increase drug use or crime rates 4) SEPs reduce high risk behaviors in addition to needle sharing and lead to increased referrals to treatment programs Despite this overwhelming scientific support, needle exchange programs remain controversial. A congressional ban on the use of federal funds for needle exchange has been in effect since 1988. Substance abuse is an epidemic problem in the United States and it is no surprise that a highly polarized debate has developed over strategies for dealing with this worsening problem. Infectious disease epidemics are also of great concern and fall squarely within the jurisdiction oflocal boards of heath and health officers. Over the past century, the conquest of disease epidemics has been characterized by spectacular successes and alarming failures. The successes have come :ITom the aggressive use of effective, evidence-based strategies to reduce disease transmission. Failures have resulted when effective control strategies have been ignored in favor of ideological posturing or persistent denial of the seriousness of the threat. Regrettably, HEALTH DEPARTMENT 360/385-9400 ENVIRONMENTAL HEALTH 360/385-9444 DEVELOPMENTAL DISABILITIES 360/385-9400 ALCOHOL/DRUG ABUSE 360/385-9400 FAX 360/385-9401 IllV, Hepatitis C, and many sexually transmitted diseast.s fall in this latter category of controllable epidemics which have been allowed to spread because of the lack of political will to take effective action. In their landmark 1992 decision, the Washington State Supreme Court clearly affirmed the broad authority and responsibility delegated to local boards of health and health officers and concluded that syringe exchange programs were a lawful and proper method of communicable disease control. Since this time, a steady series of local boards have taken up the issue of SEPs, often facing strident opposition and organized disinformation campaigns. Each of these boards, when confÌ"onted with the brutal realities of drug addiction and infectious disease transmission, have found the courage to take effective action. Implementation ofSEPs in rural Washington is an important step in the public health effort to seriously confÌ"ont the problem of disease transmission among mus and the subsequent spread of these deadly infections to sexual partners and children. The cost of inaction is high. Estimates ofIllV cases among mus that could be prevented ifSEPs were implemented nationally range rrom 4,000 to 22,000 per year. These estimates are based on very conservative assumptions and the true number is probably much higher. IV drug use is a known problem in Jefferson County. With the increased availability of methamphetamine and heroin, it is likely to increase in the near future. Transmission of my, Hepatitis C, and Hepatitis B rrom infected to non-infected mus in preventable through programs that reduce needle sharing. Preventing these infections in mus protects sexual partners and children fÌ"om secondary infections and saves scarce health care dollars for other important uses. Needle exchange programs are not a comprehensive solution to either the mv or substance abuse epidemics. It is one effective strategy. Many others are necessary. Decisions of this type are often not comfortable ones for board of health members. Some community members may feel that mus "deserve" the diseases they acquire and a healthy dose of personal responsibility is all that is really needed to end these infectious disease epidemics. From a public health perspective, such beliefs are wishful at best, dangerously misguided at worst. It is not the role of public health officials or boards of health to pass judgement over who deserves and who does not deserve to be infected with deadly diseases. Even if such a position could be ethically defended, it cannot be sanctioned on scientific grounds. The viral pathogens which cause these diseases are entirely indifferent to these human judgements. Epidemics are successfully controlled by strategies that target all preventable transmissions. To do less is to invite failure. \ I strongly urge each member of the Jefferson County Board of Health to cast a vote in favor of disease prevention through your support of this important program initiative. Syringe exchange programs reduce disease transmission, increase public safety, and lead to increased treatment program referrals. Failure to take effective action does just the opposite. The choice is yours. An Invitation to a Community Forum that will be an exciting opportunity to have an impact on the future of transportation in Jefferson County. The people of Jefferson County invest significant resources in programs aimed at assisting children, the elderly, the poor and persons with disabilities. Many of those people cannot take full advantage of such programs, however, because of lack of coordinated transportation efforts. In an effort to help local communities improve specialized transportation services, the Washington State Legislature in cooperation with the Department of Transportation has created the Washington State Agency Council on Coordinated Transportation (ACCT). This new agency has awarded grants to Washington State Communities in order to identify local barriers affecting specialized transportation coordination efforts and in effect to design new methods of coordinated efforts. The local ACCT grant has been awarded to Jefferson County Health and Human Services. As the lead agency for this grant they will begin to use the seed money to begin planning, designing and implementing a coordinated transportation system for all of Jefferson County. To begin that process the Jefferson County Commissioners would like to invite organizations that transport people or which need public transportation in order for their clients to access goods, services, jobs and education to attend a community forum. This Coordinated Transportation Forum will bring together City government and representatives from human services, transit, para transit, schools, community vans, ferry, taxis, carpools volunteer drivers and other concerned organizations and the community. DATE: , PLACE: April 21, 2000,10:00 a.m. -12:00 noon Pope Marine Building Port Townsend, W A I hope you'll be able to attend this important meeting. We would welcome your input on the future of coordinated transportation in Jefferson County. If you have any questions, please call Anna McEnery at (360) 385-9410. ADDITIONS, REMODELS, REPLACEMENT, EXPANSIONS State Code WAC 246-272 states that: Expansion is defined as: a change in a residence, facility, site or use that: (a) Causes an on-site sewage system to exceed its existing treatment or disposal capability, for example when a residence is increased from two to three bedrooms or a change in use from an office to a restaurant; or (b) Reduces the treatment or disposal capability of the existing on-site sewage system or the reserve area, for example, when a building is placed over a reserve area. 246-272-17501 Expansions. The local health officer or department shall require an on-site sewage system and a reserve area in full compliance with the new system construction standards specified in this chapter for an expansion of a residence or other facility. In order to comply with State Code, continue to assure adequate treatment of wastewater and maintain existing high water quality standards in our ground and surface waters 8.15.060 (3) has been revised to: (3) Anv new or replacement residence or any expansion of the square footaQe or maior remodel to an existinQ residence may be connected to an existing onsite sewage system when the existinQ system has adequate hydraulic capacity. meets vertical and horizontal separation requirements and adequate reserve area in compliance with current code can be established. JEFFERSON COUNTY BOARD OF HEALTH Thursday, April 20, 2000 1:30 - 3:30 PM JCHHS Conference Room AGENDA I. Approval of Minutes of Meeting of March 16,2000 II. Public Comments III. Old Business 1. Follow-up Reports -1999 Jefferson County Health Programs End-of- year Report Informational Items - Local Board of Health Leadership Workshop, May 4-5, 2000, West Coast SeaTac Hotel IV. New Business 1. Needle/Syringe Exchange Program - Public Comment and Draft Resolution (50 min) Jean 2. Food Service Awards (30 min) Larry/Susan 3. Draft On-site Sewage Regulations - Policy Issues (30 min) Larry 4. Board of Health Retreat - Discussion Item (5 min) 5. Joint Board Meetings - Discussion Item (5 min) V. Adjourn Next Meetin~: May 18, 2000 JWERSON COUNTY BOARD OF HEALTH DR~r , MINUTES Thursday, March 16, 2000 Board ¡VIemberf: Dan HarDoJe. AIember - Count;' Commiffioner DÙtricí #1 Glen Hunting/ord, lvlember - CO;/nf:J CommÙJ"ioner DÌJtrid #2 Richard 117qjt. iVIember - Coun!)' Commissioner DÙtrict #3 Geoffrey Ala.râ, M.ember - Port Townsend Ci!JI Counâl Jill BuhJer. Vice-Chai17Jlan - Hospital CommÙfioner Disrrict #2 Sbeila T¡;:'estermatl, Citizen at Large (City) Roberta Frisse/l, Chairman, Citizen at LArge (County) StaffMemberJ: .lean Baldwin, Nursing Services Director Lar?J' Fq,y, Environmental Health Dim10r ThomaJ Locke, MD, Health Officer DRAfT Chairman Frissell called the meeting to order at 1:40 p.m.. All Board and staff members were present with the exception of Commissioners Wojt and Huntingford. There was a discussion of the meeting starting time. The regular meeting time for the Board of Health is 2:30 to 4:30 p.m. However, with the Joint Meeting with Jefferson General Hospital scheduled to begin at 4:00 p.m., the Board of Health meetings were rescheduled to 1:30 p.m. Jean Baldwin agreed to take responsibility for ensuring the correct meeting times are communicated. PUBLIC COMMENT - None OLD BUSINESS - None NEW BUSINESS Legislative Update. Year 2000 Session: Dr. Tom Locke reported the legislature is in special session and the house budget is uncertain. From the public health perspective, the Senate budget has achieved all the major funding objectives and included a bonus of a $1.4 million emergency fund which was requested last year. It is likely that legislation will be introduced and passed that will enact some aspects of 1-695 and probably the vehicle tab fee decrease. However, it appears there may be a reversal, prohibiting boards and legislative bodies from setting fees, which affect the Board of Health. Included in the summary of the bills passed this year was a watered down Patients Bill of Rights. One of the results is an expedited process for people appealing adverse decisions to managed care plans. A bill passed that attempted to address the problems in the individual insurance market, including small businesses. The legislature sided with the industry's position to repeal the remaining reforms enacted in 1993. Insurance plans can exclude coverage on pre-existing health problems for nine months now instead of three. Insurance companies are allowed to deny up to eight percent of applicants and shift them to the State's high risk pool. The most controversial part of the bill was that insurance companies were able to get their loss ratio set at 72%, which is down from roughly 88%. This means if insurance companies are paying out more than 72% of their premiums, they get to raise their fees and are guaranteed a 28% profit for administrative overhead costs plus profits made while holding the HEALTH BOARD MINUTES - March 16,2000 Page: 2 premiums. Insurance companies said they would not re-enter the rural markets unless they were assured of making money. If insurance companies again offer individual insurance policies in these areas, it is still not expected to fix the rural healthcare crisis. It is still the failure of the managed care model to work in rural areas. ~ Larry Fay said three of the four bills being tracked by Environmental Health failed. The one bill that passed was an amendment extending the sunset on the Department of Ecology's authority to delegate well construction inspections to local health for another six years. The three that failed were the surface water quality bill, the solid waste bill which included criminalizing illegal dumping, and the onsite- sewage bill. Next year, the water quality bilI is expected to return. Jean Baldwin reported that the County should soon know how much tobacco prevention money they will receive. Dr. Locke said the $1.4 million emergency fund was totally unexpected and no one has yet worked out what constitutes an emergency and how funds might be allocated. Commissioners Huntingford and Wojt joined the meeting. Needle/SvriD!!:e Exchamæ Pro2ram - Plannin2 Update: Jean Baldwin noted that Jefferson and ClaIlam Counties are now working in partnership on the Syringe Exchange Program (SEP). She reviewed her presentation covering SEP project goals and services, infectious diseases: mv and Hepatitis C, public concerns, cost benefit, Washington State support of SEPs, state and local data comparison, and Jefferson County data and plan. She noted that the Hepatitis C virus is raging in the needle population and is the least understood. With Hepatitis B being the most infectious and mv the least, Hepatitis C ranks in between. Member Masci asked why not address Hepatitis B? Ms. Baldwin indicated that in addition to meeting with Law and Justice and treatment providers, letters will be sent to health care providers and there will be an article in the Healthcare Publication Newsletter. The remaining part of Phase I is public comment and a Board of Health resolution on policy direction. Milt Morris spoke in opposition to the planned needle exchange program and distributed copies of articles on other such programs. He has spoken with Dr. Locke, Jean Baldwin, and Sheriff Pete Piccini. He asked how many cases in Jefferson County are directly attributable to shared needles? The answer was none. He believes an SEP would put police officers in a difficult position; suspects stopped can say they are on their way to exchange their needles. Sheriff Piccini indicated it appears to be condoning the use of drugs. In some areas with SEP programs, the methadone epidemic raged even worse. He does not believe there would be a decrease but believes the County will find a bigger problem. What is the next step, free drugs? He referenced articles from the Reader's Digest, Center for Disease Control, public polls and the General Accounting Office on selling needles. US Health and Human Services Secretary, Donna Shalala has stated there is no proof that SEP's are effective in fighting drugs or AIDS. The risks outweigh the benefits. A 1997 public poll showed 62% oppose SEPs, 60% favor abstinence, drug intervention and rehabilitation programs. He indicated the costs for SEPs steadily increase at the taxpayers' expense. He proposed that money be spent on law enforcement, tougher penalties, and making people responsible for their actions and activities. If it comes to locking them up, then do so. He has spoken with roughly 100 Jefferson County residents and they are opposed to what is being proposed. HEALTH BOARD MINUTES - March 16, 2000 Page: 3 Mark Gordon said he has been living with HIV for 15 years. While he is not a needle user, he has seen the affect when people do not have clean needles - they die. It is a moral issue. Can you sleep knowing that you could have saved someone from becoming infected with my? Commissioner Wojt said when you look at drug use in the United States, the two biggest killers are legalized drugs. More people die from smoking and alcohol than from other substances. Although, not an advocate of drug use, he recognizes that much of the associated crime is because they are illegal and expensive. Prison does not seem to be a practical solution. Member Masci cautioned the Board that this is a public health discussion, not a drug distribution discussion. When reviewing the material, he cautioned the Board to look at the way the data is presented. There are inferences that are not supported by data from the scientific perspective. You need people with experience in the drug culture. The people we are attempting to prevent from spreading incredibly infectious diseases amongst themselves are also going to infect their babies, families, or members of the community. If five people do not share their needles, then five will not spread the disease. It is not a police or social problem, it is a disease problem. Vice-Chairman Buhler feels the Board of Health's role is focused on more than just the Public Health issue and thinks the SEP will help identify and treat members of our community. Chairman Frissell suggested adding statistics about Hepatitis B & C to the presentation. She agrees this is a way to make contact and have a positive affect. Dr. Locke distributed a draft form of the resolution the Clallam County Board of Health passed. Member Westerman moved to table a decision on the resolution until the next Board of Health meeting. Member Masci seconded the motion which carried. Commissioner Huntingford abstained. The Board concurred that additional public comments will be taken during the next Board of Health meeting prior to the Board taking action. Dr. Locke said staff will provide additional analysis if needed. Appeal Hearin2 - Rav and Liann Vines: Mr. Fay reviewed the recent documentation the Board received on this Appeal. Member Westerman stated that it is a complicated issue and she is sympathetic to Mr. Vines. His desire to develop his property as he wishes is completely understandable. She agrees that the installation of an on-site sewage system on Lot 2 is not likely to endanger public health. It was clear to her that the Hearing Examiner had ample justification, supported by local and state statutes, to determine that a use variance was in fact being requested by the appellant and to deny such a request. It is clear that a drain field is an accessory use to a permitted use and that these lots would need to be joined in that case. Once the lots are joined, the commercial use has expanded. She agrees with the findings of the Growth Management Hearing Board and the court to not allow commercial use on Lots 2 and 3. She believes the Board of Health must take other local and state regulations into account during the deliberations. HEALTH BOARD MINUTES - March 16, :2000 Page: 4 Member Westerman sees several possible resolutions to this issue: 1. Mr. Vines may be satisfied that he can build a commercial structure on Lot 1 as originally applied. Mr. Vines could file a rezone to amend the Comprehensive Plan to include Lòt 2 in the commercial zone. Mr. Vines could wait until sewer is available to the site at which time he could build the greater commercial density with no need for a supporting septic system. ,., .., :J. Following a review of the commercial business, "Circle and Square" and their zoning situation, Member Westerman said she does not believe the case should serve as a precedent, but signals an opportunity to correct a mistake. Member Westerman would like to see the ordinance amended to be more specific in designating septic drain fields as accessory uses to avoid future misunderstandings. Vice-Chairman Buhler believes that if this is policy and not regulation, the policy has been in favor of Mr. Vines. In her mind, there was precedence with the Circle and Square property. The septic system was placed on that property after it was zoned residential. The other two properties were zoned commercial where the septic systems were put on the commercial side and then were later zoned residential. That negates any argument that says this is anything against policy. She agrees with Member Westerman that the ordinance needs to be addressed, but believes Mr. Vines is well within his parameters to have this overturned. Commissioner Wojt said the Board needs to look at more testimony. The court ruled in favor of the area residents to uphold their covenant for the residential lots. There was a similar situation with property owned by Walter Moa. Mr. Moa owned both the commercial and residential properties. The only way he could do what he wanted with the property was to put the septic on residential land. When the County said "no," he went through the process of requesting a rezone. Because of the restriction on residential land, it was rezoned so that he could place his commercial septic there. Where there have been mistakes in the past and non-clarity with respect to Circle and Square it was certainly not done on a policy decision level. Commissioner Harpole supports the concerns of Member Westerman about this policy and making sure that it is very clear. The Board went through that deliberative process on the Moa decision. He believes that is one of the findings of fact and conclusions of law on the Comp Plan amendment -- the inability to install septic drain fields in general on residential property to support a commercial use. The County has been consistently clear on the issue of covenants in Melwood Terrace as Commissioner Wojt cited. Commissioner W ojt moved that the Board support the staff recommendation to deny the permit for Mr. Vines' on-site sewage system. Member Westerman seconded the motion which carried with a five to two vote. Pre-adoption Briefing Onsite Sewa2e Re2ulations: Larry Fay reviewed the changes resulting in Draft #4 of the regulation. He called attention to 8.15.080 (10) that pertains to the Vines' Appeal discussion today. It reads, "On-site sewage disposal permits shall comply with regulations and policies established· HEALTH BOARD MINUTES - March 16, :WOO Page; 5 in the Jefferson County Comprehensive Plan, Jefferson County Zoning Code, Critical Areas Ordinance and any other duly adopted land use regulations of Jefferson County, the City of Port Townsend in the case of lands within the City, or the State of Washington. " The intent is to recognize in the ordinance that we will adhere to other rules that may pose restrictions on development or placement of on-site sewage systems. Commissioner Harpole said one of the things that was not clear was whether a drain field is part of the septic system. Larry Fay said it does not really address or define a septic system as an accessory use. The problem he has is with the use definitions. Environmental Health runs into difficulties when delving into decisions that fundamentally come from the Planning Department such as, what are the approved, prohibited, and conditional uses. Staff did not feel it was their position to second guess the zoning interpretation. Their decision rested. Linda Atkins said if the Comprehensive Plan determined that accessory uses did not have to be located on commercial land, we would not be in conflict and have to amend our rule. Member Westerman said when someone applies for a septic permit, she would like to see the regulation information available to them at both the Health and Planning Departments. Mr. Fay said 99% of the permits are residential on residential land. The commercial applications are generally going to go through a zoning review and the application for a permit for a commercial use is the red flag. Commissioner Harpole said the links to the customers' septic rights and abilities need to be clear. Larry Fay agreed that to ensure consistency, we need to make sure that links to the different people regulating land development are in place. He does not want to define zoning issues in the Health Code. Chairman Frissell suggested giving the Planning Department the wording to make it clear. Member Westerman suggested the Board of County Commissioners amend the zoning code to define on-site sewage as an accessory use. Once that happens, then revise the 8.15.050 Definitions section under the On-Site Sewage System to refer to the specific Jefferson County Zoning Code. Larry Fay suggested a general statement, "an on-site sewage system is an accessory use to a building." Charles Saddler, County Administrator, asked why the septic permit is dependent upon zoning? They need no other permits to install the septic system. He asked if it is the responsibility of the agency to educate and inform the applicant about all of the responsibilities not just the health code, rules and regulations? Commissioner Harpole said there are competing elements in the zoning codes and in the newly adopted Comprehensive Plan that don't have final development regulations. We are operating in a culture of HEALTH BOARD MINUTES - March 16,2000 Page: 6 uncertainty regarding permitting. As a result, County elected officials and staff are now coming into a more proactive culture, clearly outlining the steps for the customer. Commissioner Harpole inquired about 8.15.060 (3). He asked how long systems and permits' are vested? Commissioner Harpole moved to postpone the Pre-adoption Briefing On-Site Sewage Regulations to the April meeting. Member Westerman seconded the motion and it carried by a unanimous vote. Commissioner Huntingford asked how much does a regulation change really mean in terms of water quality? Member Masci recommended a regulation of limitation that indicates septic permits are good for ten years. If not built, the permit would lapse and a public hearing would have to be held. Commissioner Harpole agreed. .Joint Meetin2s with .Jefferson General Hospital: Chairman Frissell said what started out as a forum for the two Boards to talk with each other has turned into questions and a dialogue with the facilitator. Several Board of Health members agreed that the meeting process was not satisfactory and this message was fOf\Varded to Vic Dirksen. The Board may be asked for direction on these meetings. APPROVAL OF MINUTES Corrections to the minutes were noted as follows: page 9, paragraph 13 "belt environment" should be "built environment." On Page 7, a paragraph should be added before paragraph 9 to read "Mr. Vines said no." Member Westerman asked for a clarification of the intention on Page 10, paragraph 7, the last sentence. Larry Fay said you could combine the lots by doing a boundary line adjustment, by replatting, or by recording a notice to title. Typically what happens is a notice to title. Mr. Fay said what was done was record a notice to title to the property for both lots that says, for the purpose of septic permitting, we are putting these two together and you will not be able to get any more permits. He said the lots are not physically connected. Commissioner W ojt moved to approve the minutes of the February 17, 2000 meeting as corrected. Member Masci seconded the motion which carried by unanimous vote. ANNOUNCEMENTS Olvmpic Area A2encv on A2ing: As the Chair of this organization for Grays Harbor, Pacific, Clallam and Jefferson Counties, Commissioner Harpole announced they are pursuing, as a high priority, bulk prescription drug purchase. Prevention Forum: Commissioner Harpole reported the forum was highly successful. The National Association of County Officials Newsletter will include an article. He has requested an opportunity to present the results of the forum to the State Early Childhood Commission of which Mona Locke is the chair. HEALTH BOARD MINUTES - March 16, 2000 Page: 7 AGENDA CALENDAR / ADJOURN May 4-5: Board of Health Leadership Conference April Pre-adoption Briefing - Onsite Sewage Regulations April or May: Mary Selecky Visit May: Review Draft Policies on Minimum Land Area and Building Additions and Remodels Mayor June: Food Safety Program Outreach and Education Efforts June: Pre-budgeting Intensive Program ReviewlUpdate July: Review Draft of the Solid Waste Ordinance August: State Board of Health Update Other items to schedule: Birth to Age 3 Funding, Solid Waste Regulations, and Review of Best Beginnings. Meeting adjourned at 3:45 p.m. The next meeting will be held on Thursday, April 20 at 1:30 p.m. JEFFERSON COUNTY BOARD OF HEALTH Roberta Frissell, Chairman Geoffrey Masci, Member Jill Buhler, Vice-Chairman Richard Wojt, Member Glen Huntingford, Member Sheila Westerman, Member Dan Harpole, Member 1999 JEFFERSON COUNTY HEAL TH PROGRAMS END OF YEAR REPORT To Jefferson County Board of Health and Jefferson General Hospital Board of Commissioners Jefferson County Health and Human Services strives to assure public health and safety. Our dual mission is the prevention of disease, injury, disability and premature death, and the promotion of optimum health through risk reduction and public education. COMMUNICABLE DISEASE CONTROL PROGRAM Prevention, protection, control, identification, tracking, and reporting of communicable diseases within Jefferson County. IMMUNIZA TION PROGRAM Walk-in clinic provided routine immunizations for 1,118 children and adults. Travel vaccine clinic provided 240 additional vaccines for travelers. Average number of doses JCHHS supplied to private providers per month = 3,780. MA TERNAL AND CHILD HEAL TH PROGRAMS Home visits to parents with babies and children, and families with health or parenting problems; services included assessment, health education, counseling and referral. · Best Beginnings provided 52 home visits to a minimum of 25 first time pregnant women up to infant's 2nd birthday. · Maternity Support Services signed up 125-140 pregnant women a year providing nursing, psychosocial and nutrition education and support to pregnant women and parenting families. · Maternity Case Management followed 125 high-risk pregnant women up to infant's first birthday. · Newborn follow-up for all infants born in a Jefferson County. · Childbirth Education provided for 60 families a year in 6 class sessions a year. · Breast Feeding Tea has been meeting weekly for the past 7 years averaging 8 to 12 women with infants. · Breast Feeding education and support for the community. FAMIL Y PLANNING Services included physical exams, education, infection screening, lab, birth control, pregnancy tests, emergency contraception, and counseling and referrals. Client fees based on sliding scale of client income. Services available at the Health Department and a satellite clinic in Port Hadlock. 95% of the 918 clients were at or below 185% of poverty. 85% are below 133% poverty. 1,779 visits in 1999 compared to 1,375 in 1995. CHILD PROTECTIVE SERVICES Health screening, nursing advocacy, parenting education, and home visits with referrals fi:om the State Division of Children and Family Services to 60 families. CHILDREN WITH SPECIAL HEALTH CARE NEEDS Service Coordination, infonnation and financial assistance for 50 children, age birth to 17, with chronic health problems and developmental delays. HIVlAIDS PROGRAM Services included confidential case management to an average of 10 HIV I AIDS clients during the year, anonymous HIV counseling and testing for 210 individuals, and collaboration with Jefferson AIDS Services in community prevention projects such as the Peer Education, SHARE Program, client speakers in the school, and development of the Syringe Exchange Program. PARENTING EDUCA TION Classes for parents of teens, parents of newborns, and some ongoing support group housed at schools throughout the county. SCHOOL HEAL TH PROGRAM Health screening and health education and school nursing in 5 Jefferson County public school districts. SEXUALL Y TRANSMITTED DISEASE PROGRAM Confidential services included information, diagnosis and treatment of 142 males and 720 females, prevention education, partner notification, and referrals. WIC NUTRITION EDUCA TION PROGRAM Nutrition counseling and food vouchers for pregnant and breast feeding women, infants, and children under five years of age who financially and nutritionally qualify. This supplemental food program served 500 clients monthly and provided food vouchers totalling $240,000 spent in the community yearly. BREAST AND CERVICAL HEAL TH PROGRAM Yearly women's health exams including mammogram and Pap test for women 40 and older that have limited incomes and are underinsured. 300 served over the past three years. PEER-IN AND SHARE Youth peer mentorship program goal is to decrease unintended teen pregnancies-50 high school students and 70 middle school students. Each group met weekly. VITAL RECORDS Certified copies of birth and death certificates. FOOT CARE PROGRAM Care to 1,500s client in 3,280 visits at home and in various senior centers and facilities throughout the county. PREVENTION Programs designed to prevent the misuse of alcohol, tobacco and other drugs, unintended pregnancy and youth violence. Prevention activities included: support for youth activities and school counselors; education; ROPES and portable challenge courses available to build teams and self-esteem, community collaboration on prevention projects. TOBACCO PREVENTION FOR YOUTH AND ADUL TS Free tobacco prevention posters, educational presentations, and information about smoking cessation. LOCAL BOARDS OF HEALTH LEADERSHIP WORKSHOP AGENDA Thursdav, Mav 4, 2000 7:30 a.m. Registration and continental breakfast 8:30 a.m. "The Role of Government in Public Health" What is Public Health?" - Mary C. Selecky, Secretary of Health 10:00 a.m. BREAK 10: 15 a.m. Basic Public Health Standards 11 :00 a.m. Local Public Health Funding / Public Health impacts ftom 1-695 12:00 p.m. LUNCH 1:00 p.m. ROUNDTABLE DISCUSSIONS: TABLE ONE: Battling the Bugs /Infectious Disease Threats TABLE TWO: Water, Water Everywhere /To Drink, Or Not To Drink TABLE THREE Who's Health Is It Anyway /Understanding and MakingDecisions About the Health of Your Community TABLE FOUR: SA VING OUR YOUTH /Local Boards of Health Role in Keeping Your Kids Out of Jail TABLE FIVE: Access Crisis /Local Boards of Health Responsibility to Local Access Problems 2:30 p.m. BREAK 3 :00 p.m. Roundtable Reports 3:30 p.m. State Board of Health / Local Boards of Health Relationships 5:00 p.m. Adjourn 6:00 p.m. No host social hour - an opportunity to discuss the day's topics with the speakers, State Board of Health and other Local Boards of Health members. 7:00 p.m. DINNER and continued friendly conversations Fridav, Mav 5, 2000 8 :00 a.m. Continental breakfast Brief Recap of Thursday, May 4 meeting Governor Locke's Health Policy (Public Health) Local Public Health Policy Development Break between presentations 11 :30 a.m. Local Board of Health Composition 8:30 a.m. 9:00 a.m. 9:45 a.m. 12:00 p.m. LUNCH 12:30 House of Representatives and Senate Health Care Committees 2:00 p.m. Wrap-up / ADJOURN "Have a safe trip home." JEFFERSON COUNTY BOARD OF HEALTH Jefferson Connty Board of Health Resolution No. Whereas, the Jefferson County Board of Health has "supervision over all matters pertaining to the preservation ofthe life and health of the people within its jurisdiction and shall provide for the control and prevention of any dangerous, contagious or infectious disease within the jurisdiction ofthe local health department" (RCW 70.05.060) and; Whereas, the Jefferson County Health Officer likewise enjoys broad authority and is required to; (1) Take such action as is necessary to maintain health and sanitation supervision over the territory within his or her jurisdiction; (2) Control and prevent the spread of any dangerous, contagious or infectious diseases that may occur within his or her jurisdiction; (3) Infonn the public as to the causes, nature, and prevention of disease and disability and the preservation, promotion and improvement of health within his or her jurisdiction; (RCW 70.05.070) and; Whereas, the Jefferson County Board of Health has detennined that the spread of life- threatening bloodbome infections, including HIV, is strongly associated with the sharing of syringes by injection drug users, and; Whereas, the Jefferson County Board of Health finds improper disposal of used syringes which threatens public health by creating a risk of unintentional needlestick injury and disease transmission among law enforcement officials, sanitation workers, and the general public, and; Whereas, the Jefferson County Board of Health finds that the preponderance of scientific research strongly supports the efficacy of syringe exchange programs in reducing the spread of bloodbome diseases caused by intentional sharing of syringes and unintentional needlestick injuries, and; Whereas, the Jefferson County Board of Health has detennined that properly managed syringe exchange programs encourage injection drug users to adopt behavior changes that reduce the risk of communicable disease transmission and promote cessation of drug use and entry into drug treatment programs, and; Whereas, the Washington Supreme Court has detennined that a local health jurisdiction may conduct a syringe exchange program designed to slow the spread of HI V and other infectious diseases (Health District vs. Brockett, 120 Wn.2d 140,839 P.2d 324); 615 Sheridan. Castle Hill Center. Port Townsend. W A (360) 385-9400 Therefore Be It Resolved, that the Jefferson County Board of Health hereby authorizes the Jefferson County Health Officer and the Department of Health and Human Services to proceed with development of a syringe exchange program as part of Jefferson County's Year 2000 HIV Intervention Plan. APPROVED this day of , 2000. JEFFERSON COUNTY BOARD OF HEALTH JEFFERSON COUNTY HEALTH OFFICER Roberta Frissell, Chair Thomas Locke, MD, MPH Jefferson County Substance Abuse Programs Advisory Board April 6, 2000 Dr. Roberta Frissell, Chairperson Jefferson County Board of Health 615 Sheridan Port Townsend, W A 98368 Dear Dr. Frissell and Board of Health, This letter is to support your current efforts regarding a resolution to direct the Jefferson County Health Officer and Health Department to develop a syringe exchange program. The Jefferson County Substance Abuse Programs Advisory Board (JCSAPAB) supports a local syringe exchange program (SEP) for the following reasons: · SEPs provide valuable health care linkages, including substance abuse treatment, for difficult to reach populations. · SEPs help to prevent the spread of blood-borne infections such as HIV and Hepatitis C to injection drug users, their partners and their children. · SEPs decrease public exposure to infectious diseases through contaminated syringes. Syringes discarded in parks, on beaches and roadsides expose the public to unnecessary hazards. · Washington State Board of Pharmacy and Washington State Board of Health have both gone on record as endorsing SEPs as a proven method of preventing the spread of blood-borne pathogens Additionally, JCSAP AB concurs with the recommendations in Prevention of Blood borne Infections joint workgroup report issued by the Governor's Council on Substance Abuse and the Governor's Council on AIDS which includes: · Support the establishment of more SEPs that provide an array of disease prevention services and utilize community oversight boards, including law enforcement representation. · Allocate resources to address the unmet need for chemical dependency treatment, particularly for persons who inject drugs or abuse stimulant drugs and those with blood-borne infections. Please keep us informed as to the progress of the SEP and any assistance that you may need from JCSAPAB. Sincerely ~. Suzanne Schmidt, Chair Jefferson County Substance Abuse Programs Advisory Board 615 Sheridan Street, Port Townsend W A 98368 360.385.9400 Jefferson Mental Health Services r~ 884 West Park / PO Box 565, Port Townsend, W A 98368 Phone: (360) 385-0321 Fax: (360) 379-8542 Toll Free: (800) 659-0321 TD( Community Supported Outpatient Care for Mental Health Consumers - Serving the needs of East Jefferson MAR 2 9 2DOO JEFF. CO. HEALTH & HUMAN SERVICES March 24, 2000 To Whom It May Concern This letter is in support of the Jefferson Health Department Syringe Exchange program. The community has a right to be pleased that its Health Department is pro-active in this type of activity. Evidence is clear that activities such as these in no way increase drug use, but are very efficacious in broadening options for treatment. Substance abuse and addiction are frequently co-occurring in the population we serve, and JMHS is very supportive of any activity that may assist in prevention or treatment. We would be happy to consider participating as an exchange site. ". Services for Children, Adolescents, Aduhs and Older Adults - 24 Hour Crisis - Inpatient Access October 1999 Washington State Board of Pharmacy Published to promote voluntary c0'.!lP/iance of pharmacy and drug law. Dept. of Health, P.O. Box 47863, Olympia, WA 98504-7863 No. 742 - Needle and Syringe Distribution ~or several pharmacies. Stan is a graduate of the University of Wash- Recently, the Centers for Disease Control and Prevention (CDC) ~ngton Sch~ol of Pharmacy, and has worked in a variety of positions the N~tional Association of Boards of Pharmacy (NABP), and th~ In comn:umty pharmacy, home health, and hospital pharmacy. ~mencan Pharmac~utical Association (APhA) co-sponsored a meet- . We wIsh to wel~ome .them to ~ur s~ff, and hope that the pharma- Ing to explore the Issues surrounding the restricted sale of sterile CISts of the state wIll enJoy workmg wIth them. nee~les and syringes, ~nd the effect that certain state policies were R.andy replac~s Joseph M. H~nda, RPh, who has been promoted havmg on the spread ot HIV/ AIDS, hepatitis and other blood-borne and IS now the dIrector of operatIons for the Board in Olympia. Stan diseases. ' replaces Judith Willingh;¡m, who resigned last year. Since we were Recent studies by the CDC and various states have found that a una?le to recruit a phamiacist tTom Central Washington to réplace large number of new cases of these diseases are found in persons JUdIth, v:e have reassigned territories so that several of our investi- ¡ho are either injection-drug users, or have had sexual relation- gators wIll be responsible for different parts of that area (see below). hips with such users. Some studies have shown that this may be N "'7'44 A' I . To . . the cause of up to 40 percent of new cases. The CDC has postulated o. " -,yew nspectron I errrtorres that repealing or modifying the state laws and rules that restrict the We have :eassi~ned inspection/investigation territories. Please distribution of injection devices would result in a decrease in the contact the investIgator assigned to your geographic area when incidence of these diseases. ~ou have questions, complaints, etc. The name, telephone number In Washington,. three laws, including the syringe law and two title, ~nd assignment ~f each investigator is lis!ed here. . drug paraphernalIa laws, govern sales of needles and syringes. + Rlch~rd D. Morrison, 425/821-5666, ChlefInvesttgator. Chapter 70.115.050 RCW states as follows: Retail sale ofhvpoder- + PhyIhs L. Wene, 425/649-4359, Investigator, Region #1 : mic syringes, needles _ Duty of Retailer. . North.west counties (Everett to Bellingham) and North-Central "On the sale at retail of any hypodermic syringe, hypodermic Washmgton. needl:, or any injection device adapted for the use of drugs by + Grant B. Cheste.r, 360/407-080~, Investigator, R~gion ~2: In!ectlOn, the reta¡/er sha/l satisfy himself or herself that the device Southwest WashlOgton (OlympIa to Vancouver, mcludlOg wi/I be used for the legal use intended. .. Goldendale) . In r~viewing ~h: CDC information, the Board of Pharmacy has . Stanley Jeppe~en, 206/985-3715, Investigator, Region deten:nm.ed t~at It IS appropriate for pharmacists to be involved in #~:. Suburban KlOg County (east-side south to Kent) and Tri- the dlst?butlOn of sterile needles and syringes in the interest of CI~le.s. . . _ . controllm~ blood-borne diseases. Therefore, the Board has adopted + WIlham W. Krls.tm, :;,09/325-4992, InvestIgator, Region #4: the followmg resolution: Far Eastern Washmgton (Spokane to Walla Walla). "Now Therefore be it Resolved: that the Washington State Board . R~chard L. Hoffman, 206/545-6541, Investigator, Region #5: of Pharmacy has determined that the term, 'legal use' as used in CIty of Seattle and north to King County boundary. 70.115.050 RCW - Hypodermic Syringes includes the distribution . R?bert M. Mabus, 360/895-6109, Investigator, Region #6: of s.terile hypode~i~ syringes and needles for the purpose of re- KJtsap and Olympic peninsulas, Mas~n County, ~nd Tacoma. dUCIng the transmiSSIon of blood-borne diseases. Such distribution . Jame~ J. Doll, 206/840-4714, Investigator, RegIOn #7: Su?ur- shall be performed through public health and community-based HIV ban PIerce County, South King County, and Central Washmg- prevention programs. n ton (Cle Elum to Yakima). r. A!l pharmacists are encouraged to contact their local public health · Randol~h G. Flett, 425/739-1820, Investigator, Regi~n #8: ~ dlstnc~ to develop a program that assures all persons have access North Kmg, South Snohomish County, and Central Washl~gton i" to stenle needles and syringes for this purpose. (Wenatchee to Moses Lake). Any questions may be addressed to the Board office Note: All of the investigator telephone lines will accept voice . and facsimile transmissions. /0. 743 - New Pharmacy Board Investigators . In t.he past few months, we have hired two new pharmacy board Investigators, Ran~y G: Flett. ~Ph, and Stan Jeppesen. Randy, a graduate of the University of Missouri College of Pharmacy, spent over 23 years ~s. a Drug Enforcement Administration (DEA) field agent. After retmng from the DEA, he worked as a staff pharmacist No. 745 - Controlled Substances Scheduling Actions Recently, the Drug Enforcement Administration (DEA) took ac- tion to re-schedule dronabinol (Marinol™) from Schedule II to Sched- Continued on page 4 American MP.dical Association I~ I'IIysIdo. d<diCICIId 111 I!II ha!tII ø{ .\moria ~ ® ~ American /~ Pharmaceutical Association œ (ASTH)) NASfAD NAT1o.~AL AWANCE Of" STAn: AND TERRITORIAL AIDS DIRECI'OaS. . APhA T" Aueda.... .r s.... .... T_oI KcaI"OftIc1aI.I October 1999 HIV Prevention & Access To Sterile Syringes Dear Colleague: Approximately one third of all AlDS cases and one half of hepatitis C cases are directly or indirectly linked to injection drug use. Limited access to sterile syringes contributes to the transmission of these blood-borne infections among injection drug users (IDUs), their sex partners, and their children.' "" The United States Public Health Service recommends that drug users who continue to inject use a new, sterile syringe for each injection to prevent the transmission of blood-borne pathogens and that they obtain syringes from reliable sources such as pharmacies. . . In many states, there are legal and regulatory barriers to the pharmacy sale of sterile syringes to IDUs, including prescription and drug paraphernalia laws and pharmacy regulations on syringe sales. The American Medical Association (AMA), the American Pharmaceutical Association (APhA), the Association of State and Territorial Health Officials (ASTHO), and the National Alliance of State and Territorial AlDS Directors (NASTAD) have suggested that the removal or modification of legal barriers is an important step in increasing the availability of sterile syringes through pharmacies. Connecticut, Minnesota, and Maine have made such changes. AMA, AP~ ASTHO, and NASTAD have adopted the following policies related to pharmacy sale of syringes. AMA (1997) APhA (1999) ASTHO (1995) NASTAD (1997) That the AMA strongly encourages state medical associations to initiate state legislation modifying drug paraphernalia laws so that injection drug users can purchase and possess needles and syringes without a prescription. APhA encourages state legislatures and boards of pharmacy to revise laws and regulations to permit the unrestricted sale or distribution of syringes and needles by or with the knowledge of a pharmacist in an effort to decrease the transmission of blood-borne diseases. ASTHO policy states that as a possible public health strategy to reduce the transmission of injection-related blood-borne infections, states should explore the removal of legal barriers such as drug paraphernalia and prescription laws, which criminalize the distribution and/or possession of needles and syringes. NAST AD calls on state and local legislative bodies to increase access to sterile needles and syringes through needle exchange programs; to deregulate possession of needles, syringes and associated injection equipment as drug Syringe Exchange Program Reference Information Section Number 1 Contents (revised 3/30/00) Jefferson County · Syringe Exchange Press Release 3/00 · Region VI 2000 HIV PreventionlIntervention Plan · Jefferson Mental Health Letter of Support 3/24/00 Board of Health Infonnation · 5/20/99 · 10/21/99 · 2/17/00 · 3/16/00 including opposition handouts provided by Milt Morris, citizen News Articles 2 Washington State · Prevention of Blood-Borne Infections Report issued by joint workgroup Governor's Advisory Council on HIV / AIDS Governor's Council on Substance Abuse · Whatcom County Model · Thurston County Model · Washington State Public Health Association Resolution 99-02: Access to Sterile Syringes and Needles · Washington State Board ofPhannacy October 1999 Newsletter & accompanying letter with several national organizations recommendations regarding access to sterile syringes and needles · 1991 Washington State Department of Health Position Statement and Recommendations Regarding Syringe Exchange Programs 3 Hepatitis C Virus (HCV) · Recommendations for Prevention and Control of Hepatitis C Virus (HCV) and HCV -related Chronic Disease. Morbidity & Mortality Weekly Report 47 (RR19); 1-39; 10/16/98 · Management of Hepatitis C. National Institute of Health Consensus Development Statement, 3/27/97 4 HIV/AIDS Center for Disease Control (CDC) · CDC's Role in HIV and AIDS Prevention · Drug-Associated HIV transmission Continues in the United States · Linking Science and Prevention Programs- The Need for Comprehensive Strategies · Prevention Bulletin for Health-Care Providers Regarding Advice to Persons Who mject Illicit Drugs . Update: Syringe Exchange Programs-United States, 1996 5 National Institute of Drug Abuse (NIDA) · NIDA Notes Heroin Snorters Risk Transition to Injection Drug Use and Infectious Diseases · Drug Use, HN and Other Infectious Diseases-Drug Abuse and Addiction Research, The Sixth Triennial Report to Congress Continued on other side ø 6 Journal ofthe American Medical Association (JAMA) · Drug Use and HVI/AIDS Policy, 4/96. · States Find Needle Exchanges Effective in HIV Prevention, 9/8/97. · The Public Health Impact of Needle Exchange Programs in the United States and Abroad, 1997. · Prevention ofHIV/AIDS and Other Blood-Borne Diseases Among Injection Drug Users, 1/1/97. · Does Needle Exchange Work 7 American Academy of Pediatrics · Reducing the Risk of Human Immunodeficiency Virus Infection Associated With Illicit Drug Use- Policy Statement 8 American Public Health Association · Syringe and Needle Exchange and HIV Disease-Policy 9 Health and Human Services-National · Research Shows Needle Exchange Programs Reduce HIV Infections Without Increasing Drug Use, 4/20/98 · Needle Exchange Programs in America: Review of Published Studies and Ongoing Research. 2/18/97 10 Americans Support Needle Exchange Programs · Bipartisan Poll, 4/29/97 · Poll: 71 % of Americans Support Lifting Ban on Federal Funding for Needle Exchange Programs 11 Lindesmith Center · Research Brief: Needle & Syringe Availability · Drug Paraphernalia Laws and Injection-Related Infectious Disease Risk among Drug Injectors · Fourteen Article Abstracts on Syringe and Needle Exchange Resolution 99-02 Access to Sterile Syringes and Needles WHEREAS sharing contaminated syringes and needles for injection drug use transmits bloodborne infections; and WHEREAS syringe and needle exchange programs have been demonstrated to diminish sharing of contaminated injection equipment by improving access to sterile equipment; and WHEREAS research has demonstrated that syringe and needle exchange programs have slowed the transmission of HIV among injection drug users (lDUs); and WHEREAS syringes and needles are available without prescription in Washington state; and WHEREAS many pharmacists are fearful of selling syringes and needles to people who appear to them to be ID U s because of laws that prohibit the sale of equipment that is used for illicit drug use (paraphernalia); and WHEREAS paraphernalia laws impede access to sterile syringes and needles, therefore BE IT RESOLVED that the Washington State Public Health Association (WSPHA) supports sterile syringe and needle exchange programs as important interventions to diminish the transmission of bloodborne infections; and further BE IT RESOLVED that WSPHA supports removal of barriers to access to sterile syringes and needles. Adopted by the vote of the Membership assembled at the 1999 Annual Business meeting of the Association, October 4, 1999 in Spokane, Washington. Joan B. Treacy President Resolution 99-02 Access to Sterile Syringes and Needles WHEREAS sharing contaminated syringes and needles for injection drug use transmits bloodborne infections; and WHEREAS syringe and needle exchange programs have been demonstrated to diminish sharing of contaminated injection equipment by improving access to sterile equipment; and WHEREAS research has demonstrated that syringe and needle exchange programs have slowed the transmission of HN among injection drug users (IDUs); and WHEREAS syringes and needles are available without prescription in Washington state; and WHEREAS many pharmacists are fearful of selling syringes and needles to people who appear to them to be IDUs because of laws that prohibit the sale of equipment that is used for illicit drug use (paraphernalia); and WHEREAS paraphernalia laws impede access to sterile syringes and needles, therefore BE IT RESOLVED that the Washington State Public Health Association (WSPHA) supports sterile syringe and needle exchange programs as important interventions to diminish the transmission of bloodborne infections; and further BE IT RESOLVED that WSPHA supports removal of barriers to access to sterile syringes and needles. Adopted by the vote of the Membership assembled at the 1999 Annual Business meeting of the Association, October 4, 1999 in Spokane, Washington. Joan B. Treacy, President gov/HEAL TFJap~resources/fueedle.htm §@~;I~I~~i; Health - Seattle & King County NEWS SERVICES , COMMENTS SEA RCH HIV/AIDS Program HIV/AIDS Program Clinic Phone: (206)205-STDs E-mail: hivstd.info@metrokc.gov Disease Prevention Fact Sheet:Needle Exchange NEEDLE EXCHANGE SCHEDULE Seattle-King County Department of Public Health January 1997 Q. What is needle exchange? A. Needle exchange is a public health program for drug users. It is an important component of a comprehensive set of programs designed to reduce the spread of HIV/AIDS and other blood-borne infections among injection drug users, their families' and communities. AIDS is the leading cause of death among American men aged 25 to 44. Nationally, about 2/3 of all new HIV infections stem from injection drug users: half from sharing needles, and the rest either from unprotected sex with an injection drug user or transmission from an infected mother to her fetus or newborn child. Needle exchange programs provide new, sterile syringes in a one-for-one exchange for used, contaminated syringes. But needle exchange programs are not just about syringes. They also help drug users get into drug treatment and health care and provide important risk reduction information. Other services include counseling and testing for HIV infection and distribution of condoms. Seattle's program began operating in 1989. Currently, the Health Department conducts exchange programs at three sites within Seattle and two sites in South King County. Two additional sites are operated by community-based service agencies in the University and Broadway Districts. Exchanges are staffed by paid Health Department employees and volunteers from the community. http://www.metrokc.gov/HEALTH/apu/resources/fneedle.htm 04/13/2000 04/13/2000 govlHEAL TH/apuJresources/fneedle.htm 04/13/2000 Q. Why are needle exchange programs offered? A. Needle exchange is one of the most effective AIDS prevention programs currently available for injection drug users who are not in treatment. Without a vaccine or a cure, prevention is the only tool we have to control the spread of HIV. The Health Department runs a needle exchange program for four basic reasons: · Needle exchange reduces blood-borne diseases in our communities without increasing drug use. Studies have shown decreases in both the number of persons who become infected with HIV and the number of people who get hepatitis in communities that have needle exchange programs. · Preventing HIV infection in injection drug users also prevents HIV in women and newborn children. Many women are at risk for HIV because of their own injection drug use or because they are sexual partners of injection drug users. · By working with injection drug users, we can help them get into drug treatment. · Finally, the Health Department safely disposes of all contaminated syringes turned in to the exchange. This reduces the number of discarded syringes on our sidewalks and in our bus stops, yards, parks and play grounds. Our goal is to get used syringes out of circulation as quickly as possible. The longer a syringe remains in circulation, the more opportunities there are for that syringe to pass on a blood-borne disease. Q. Are needle exchange programs successful? A. Yes. A recent study compared cities that had low rates of HIV infection among drug injectors with cities in which drug injectors had high rates of infection. The study found that each of the low rate cities had started needle exchange and prevention outreach programs early in the AIDS epidemic before AIDS could get a foothold. Most cities that responded early in the epidemic by implementing comprehensive needle exchange programs have kept infection rates among drug injectors below 5%, while rates of infection in cities like New York and Miami (where needle exchange began late or not at all) are between 40% and 60%. Infection rates among injection drug users in Seattle have remained stable over the last seven years. The Health Department estimates that 2 to 4% of local drug injectors are infected with HIV. While there are many factors at work here, these figures strongly suggest that needle http://www.metrokc.govIHEALTH/apuJresources/fneedle.htm 04/13/2000 gov/HEAL TH/apuJresources/fneedle.htm 04/13/2000 exchange has helped keep the numbers of infected low. Q. How much does needle exchange cost? A. Combined cost for needle exchange programs in Seattle- King County in 1997 is $475,000. This compares with $110,000 to $120,000 in medical costs to care for just one person with AIDS from the time of infection to death. By preventing infections in just five people per year, the needle exchange more than pays for itself. By preventing HIV infections in just 1 % of the injection drug users in King County, the program saves over $17 million in AIDS-related medical costs. In this light, the exchange provides both a public health and an economic benefit to the citizens of Seattle and King County. Q. Who pays for the needle exchange? A. The needle exchange is funded by disease prevention funds provided by Washington State, King County and the City of Seattle. Relying on volunteer staff helps keep the cost of the needle exchange program low. Q. Is it legal to give out syringes? A. The Health Department doesn't give out syringes, we EXCHANGE them. And exchanging them was ruled legal by Washington State's Supreme Court in 1992. In a case filed by Spokane County, the court held that exchange programs are an appropriate HIV prevention measure and are legally sanctioned within the broad powers given to Public Health Officers to control disease in communities. Q. Is there any reason to think that needle exchange increases drug use? A. No. Evidence from several research studies shows that because of syringe exchange, more people get into drug treatment and that drug use does not increase. Every needle exchange in the United States recruits drug users into treatment. In Tacoma, the needle exchange is the single largest source of treatment referrals in all of Pierce County. In the last three years, Seattle's needle exchange has helped more than 275 people get into treatment. Q. Do most people support the syringe exchange program? A. Yes. The Washington State Department of Health conducted a series of random telephone surveys of Washington State residents over 18 years of age to describe people=s knowledge, http://www.metrokc.gov/HEALTH/apuJresources/fneedle.htm 04/13/2000 gov/HEAL TH/apulresources/fneedle.htm attitudes and beliefs about AIDS. The survey was conducted in 1988, 1991, 1993, 1995 and it is on-going. When state residents were asked if they would support a needle exchange program, 53% of persons interviewed in 1988 said yes. This support grew to 62% in 1995. In King County, 72% of those interviewed in 1995 reported support for needle exchange. Virtually every scientific body that has studied needle exchange programs supports them: the U.S. Centers for Disease Control, National Research Council, National Commission on AIDS, General Accounting Office, National Academy of Sciences, American Medical Association and the American Public Health Association. For further information on needle exchange, contact: . Seattle-King County Department of Public Health Needle Exchange Program 400 Yesler Way, third floor Seattle, Washington 98104 Phone: (206) 296-4568 Fax: (206) 296-4803 Larry Keil/Susie Mcintyre HIV/AIDS Program WA USA Email: hivstd.info@metrokc.gov Phone: (206) 205-STDs All information is general in nature and is not intended to be used as a substitute for appropriate professional advice. For more information please call (206) 296-4600 (voiceITDD). Updated: April 30, 11 :00 AM .. -................................. .................. .-.....-...... --... .........._..............................._.................m ........................................ Public Health Homepage I Safe Food I Safe Water Communicable Disease I STD I HIV I Birth/Death Records Public Health News I Contact King County I Public Health I News I Services I Comments I Search Links to extemal sites do not constitute endorsements by King County. By visiting this and other King County web pages, you expressly agree to be bound by terms and conditions of the site. The details. http://www.metrokc.gov/HEALTH/apulresources/fueedle.htm 04/13/2000 04/1312000 Pre"V"e:n.:tio:n.. o£ B1ood-Bor:I1e I:n£ec~ioI1s February 2000 .-._---_..-'-" - .- Wor~woup Participants: _;:4,.:.. . . ',' . Virginia Almeida, Center for Álcohol and .. - Abuse Vince Collins, DOH . _ .. cäpta.in Dan-Dayis,wsp .. Fred Garcia;osHs/DASA Michael Gqrrnan, PhO, University of Michael Hanrahan, Seattle-King County Ron Jackson, MSW,Evergreen Jack Jourden, DOH Jim Moeller, Vancouver City cOuncn Kim Murillo, Stonewall Recovery Services Carol Owens, PhD, CTED John Peppert, DOH Pam Sacks, DSHS/DASA Karl Swenson, Northwest ÅIDS Foundation Linda Thompson, Greater Spokane Council Bob Wood, MD, Seattle-King County Fritz Wrede, DSHS/DASA Report issued by joint workgroup: Governor's Advisory Council on HIV/AIOS Governor's Council on Substance Abuse STATE OF WASHINGTON DEPARTMENT OF HEALTH Olympia, Washington 98504 February 8, 2000 The Honorable Gary Locke Governor of the State of Washington Legislative Building Post Office Box 40002 Olympia, Washington 98504-0002 RE: Recommendations to Prevent the Blood-Borne Infections associated with Chemical Dependency Dear Governor Locke: In response to the outbreak of human immunodeficiency virus (IllY) infection which began among injection drug users in Downtown Eastside Vancouver, British Columbia in 1993, your Advisory Council on HIV / AIDS recommended to you the formation of a panel to study situations in Washington which might have similar outcomes and to formulate recommended actions. As you suggested in your letter of January 1998, a committee comprised of members of the Governor's Advisory Council on HIV/AIDS (GACHA) and the Governor's Council on Substance Abuse (GCOSA) was convened. The joint committee met from spring through fall during 1999. The joint committee report: "Recommendations to Prevent Blood-Borne Infections Associated with Chemical Dependency" details the public health impacts in Washington communities that result when blood borne infections, such as HIV/AIDS, occur in conjunction with chemical dependency. The broad range of stakeholders represented by the membership of the two Councils has voted unanimously to accept the recommendations and to support their transmittal to your office. However law enforcement representatives to the Governor's Council on Substance Abuse asked that their constituent organizations' concerns about needle exchange programs be included as part of this transmittal letter. Their concern centers around the dilemma these programs can present for cops on the street. Law enforcement officers are sworn to uphold laws that make possession of drug paraphernalia (including syringes) illegal. While most officers understand that needle exchange programs may provide a useful public health intervention, some law enforcement officers still have concerns that allowing the possession of needles and syringes may condone the continuation of illegal drug use. With those concerns acknowledged, it is on behalf of The Governor's Advisory Council on HIV/AIDS (GACHA) and the Governor's Council on Substance Abuse (GCOSA) that ..~.~;.... o Governor Gary Locke Page Two February 8, 2000 we submit this report to you for your consideration. It is our hope that our report can be of assistance in public policy development for the 2001 legislative session. The majority of our recommendations do not require legislative action. If assistance is requested, the joint committee is willing to meet again prior to the next session to update these recommendations. We would appreciate response from your office by mid-2000 to inform our members of any planned action or request for follow up that may result from this report. Sincerely yours, ç~c;.~ Judith A. Billings, Chair Governor's Advisory Council on InV/AIDS yJ~~ (;:;t'((7't:,iJ- Dr Priscilla Lisicich, Chair Governor's Council on Substance Abuse TABLE OF CONTENTS I. Executive Summary Pages 1 - 5 II. Recommendations for the Prevention of Chemical Dependency and Transmission of Blood-Borne Infections 6-9 In. Recommendation to Improve Access to and 10 - 15 Funding for Chemical Dependency Treatment IV. Reçommendations to EnsureAccess to Sterile 16 - 20 Syringes v. Appendix A 21 - 23 VI. Endnotes 23 - 26 VII. Appendix B 27,;,28 VITI. Attachments · RCW · WAC · Senate Bill 5019 Recommendations to Prevent Blood-Borne Infections Associated With Chemical Dependency Executive Summary Chemical dependency, particularly that involving the injection of drugs, continues to be a prevalent social problem, and is increasingly associated with the transmission of blood-borne and often life-threatening infections (e.g. human immunodeficiency virus [HIV], and hepatitis B and C virus, [HEV, HCV]). To reduce these public health impacts of chemical dependency among drug users, the Governor's Advisory Council on HIV/AIDS (GACHA) and the Governor's Council on Substance Abuse (GCOSA) formed a task force to identify problems and develop recommendations. The task force established three goals: - · To foster renewed and coordinated prevention efforts for chemical dependency and blood borne infections (BBl) among state agencies; · To ensure that dependency is treated as soon as possible in every treatment-ready client; and · To amend or rescind legislation and rules which impede these treatment and prevention efforts. The need for such efforts is greatest among persons using or about to use illicit injectable drugs or by users of stimulant drugs either by injection or non-injection. There are an estimated 41,000 injection drug users (IDU) in Washington State, 70% of who are primarily addicted to heroin. Injection drug use directly or indirectly accounts for an increasing proportion (currently 21 %) of the state's cumulative .;\IDS cases and more than one-third (36%) of cumulative cases nationwide. 1 HIV among injection drug users continues to be a growing problem, with as many as three-quarters of all new infections nationwide attributed to this group.! The numbers of stimulant abusers are less well known, but there is an estimated 2-3,000 in King County who are also men who have sex with men (MSM). This subgroup has the highest rate of mv infection (47%)3 of any group in the state due to combined risk factors of high-risk sex and drug injection. Nearly all (85%) of the injection drug users in Seattle-King County a¡;e infected with HCV, most likely from continued needle sharing.4 The high cost of care for HIV and HCV as well as the devastating impact these diseases have on injection drug userS, their families and society in general, and the great social costs of on- going drug abuse (including crime and incarceration) underscores the need to review the treatment, prevention, and law and justice barriers that impede or prohibit efforts to reduce the public health impacts of chemical dependency and blood-borne infections. Blood-Borne Infections - Of major concern are HN, HCV virus infection, and to a lesser extent HBV infection. While there are now treatments for AIDS and HN that currently prolong and improve the quality of life, these treatments are expensive and require strict lifetime adherence. '. 1 In the face of imperfect adherence, HIV mutates to drug-resistant forms which may be retransmitted. The emergence ofHIV resistance has recently been demonstrated in 16-26% of newly HIV -infected personsS.6 and is a problem that is expected to worsen over time.7 Treatments for HEV & HCV have not been universally effective or readily available. For example, treatment for HCV is only 40% effective at best8. Prevention of initial infection continues to be the best intervention for all these life-threatening illnesses. Drug Treatment Issues - National research9 and local studies1o,'1 have consistently demonstrated that chemical dependency treatment is a highly cost-effective way to reduce the adverse health and social consequences of chemical dependency on individuals and society. To be effective, treatment services must be accessible geographically and financially. The lack of locally . available chemical dependency treatment services with greatest effectiveness is a substantial barrier to recovery, since requiring clients to travel great distances at ftequent intervals for treatment is both inefficient and costly. The cost of treatment is another substantial barrier, as many chemically dependent individuals have difficulty maintaining employment and do not have personal financial resources or insurance coverage. Despite recent important revisions to the state's insurance regulationsl2 which have greatly expanded coverage requirements for chemical dependency treatment, even individuals with health insurance may still have limited coverage for chemical dependency treatment. In addition, limits on the number, size, and location of programs, and restrictions on forms of treatment (e.g., methadone) that may be provided create significant barriers to treatment~ready clients. Inhibiting the use of illicit intravenous drugs through chemical dependency treatment is an important intervention in the prevention of blood-borne infections. Chemical Dependency Prevention - Chemical dependency may be one of the most important problems in our society. The capacity of our prevention system to support sustained, targeted efforts to prevent initial use is limited by financial resources, lack of community acceptance, and limits on the number of available treatment slots. Planning and integration of all of the elements needed for a comprehensive approach to chemical dependency prevention is an even greater factor when resources are' limited and often results in the exclusion of high-risk sub-populations.I3' 4' S To be successful, the socioeconomic, cultural, educational and contextual elements of the environment, linked with the values and norms of the individual, peer group, family and community, must become an integral part of the prevention equation. 16017 Prevention of Blood-Borne Infections - For those already addicted to drugs who cannot access effective treatment, effective strategies to prevent blood-borne infections must be fully implemented. Such strategies include outreach, education, and motivation of drug users, counseling & testing for blood-borne infections, and help in obtaining effective services. The public health community and the state Supreme Court have concluded that needle exchange programs are effective and legally authorized preventative interventions. Many experts in public health, the medical community, phannacy leaders, and legal scholars support access to equipment sold in phannacies and the possession of equipment to prevent the spread of blood- borne infections.18 2 Law and Justice Issues - A variety of legislative and regulatory factors impede effective public health efforts to make sterile equipment more available. Many of these regulations represent well-intentioned efforts to prevent drug abuse; however, at the time that these laws were implemented, the public health impact of blood-borne infections was unknown. Thus, legislators could not have considered their public health ramifications. Several key legislative changes to these laws would dramatically improve and expand the public health efforts to prevent the reuse of contaminated hypodermic syringes and needles, as well as to increase access to drug treatment and other care services. Such changes should decrease the transmission ofblood-bome infections. 3 RECOMMENDATIONS The Joint Workgroup has developed the following recommendations for preventing the tranSmission of blood-borne infections among chemically-dependent individuals. URGENT PRIORITY: We recommend immediate action on these items. · Allocate resources to address the unmet ne~d for chemical dependency treatment, particularly for persons who inject drugs or abuse stimulant drugs and those with blood-borne infections. · Amend the state's methadone treatment regulations through the adoption of a bill similar to Senate Bill 5019 (1999) as a means of improving statewide access to opiate substitution treatment. · Amend RCWs 70.115.050 and 69.50.4121 to allow for the pharmaceutical sale and deregulation of clean syringes for the prevention of blood-borne infections. · Support efforts by the State Board of Pharmacy to allow pharmacists to voluntarily 'participate in blood-borne disease efforts. · Allocate resources to augment substance abuse prevention efforts. · Oppose any congressional attempts to limit the ability of state or local public health officials to support needle exchange programs with state or local resources. IM:PORTANT: We recommend action within the next year on these items. · Direct Washington State government agencies to coordinate existing advisory groups to assure the consistency of prevention messages. · Direct and fund DSHS/DASA to undertake a statewide needs assessment survey to determine gaps in comprehensive treatment for stimulant abusers at risk for blood-borne infections. · Direct and fund DOH to undertake a statewide needs assessment survey to detennine gaps in health care for blood-borne infections; prevention policies and programs; and access to substance abuse/dependency evaluation and referral. · Amend RCW 69.50.412 to allow for the limited possession of sterile syringes for legitimate public health purposes to reduce the transmission of blood-borne infections. . · Support the collection of information and appropriate assessment measures regarding adolescent risk behaviors leading to transmission of blood-borne infections. · Support the establishment of more needle exchange programs that provide ~ array of disease prevention services and utilize community oversight boards, including law enforcement representation. 4 · Direct DOH to work with care provider organizations to review and recommend procedures, as appropriate, to get licensed health care providers to employ routine and careful screening for chemical dependency, particularly among high-risk patients. · Direct DSHS/DASA to work with care provider organizations to identify and recòmmend solutions to communication barriers that interiere with coordinated patient care. · Reaffirm the commitment of the State of Washington to provide treatment and prevention support for populations where blood-borne infections are most prevalent. · Integrate a skill building program statewide that encourages state employees to become skilled at how to address judgmental attitudes in their work environments and communities. · Encourage the universal integration ofblood-bome infection prevention into current substance abuse prevention programs and vice versa. · Assure that needle exchange staff are trained to refer to chemìcal dependency treatment and that resources are available in the community to provide clients with comprehensive drug treatment services. · Continue the Corrections Outreach to Communities for Offenders with HIV/AIDS (COCOA) project with state funds to strengthen the collaborations and communications among federal, state and local jai1/prison systems and to improve the prevention and care of blood-borne illnesses in these settings. 5 I. Recommendations for the Prevention of Chemical Dependency and Transmission of Blood-Borne Infections The prevention system is insufficient to prevent the initiation of substance use, which directly or indirectly leads to chemical dependency and behaviors which promote the transmission of blood- borne infections. Discussion Efforts to reduce or prevent people, especially children and teenagers, from becoming substance abusers has been a national focus since 1968. Chemical dependency prevention technology has evolved from scare and shock:tactics to a more scientifically based, multi-disciplinary approach. Research projects, including longitudinal assessments and evaluations, by the National Institute of Drug Abuse, National Institute of Alcoholism and Alcohol Abuse, and the Centers for Disease Control and Prevention, have demonstrated that prevention efforts can be effective in a context of adequate dosage and maximum duration. Chemical dependency does not happen overnight, or from one trigger, but results from a myriad of factors occurring throughout the developmental stage of a child's life. Research clearly shows that multiple systems must give consistent prevention messages to most effectively prevent chemical dependency.19 The duration of services, as well as the frequency and intensity of chemical dependency prevention programs, is all important to sustaining these preventative messages. As a result of these studies and efforts, several ideas regarding chemical dependency prevention have become widely accepted by the treatment community. These include: · It costs less to prevent initiation of alcohol, tobacco and drug use (primary prevention) .than to stop use after addiction occurs; · Primary prevention of drug abuse is also cheaper than the costs of its consequences, including treating subsequent blood-borne infections and/or incarceration; · The initiation of alcohol and drug use results from complex decisions, influenced by a wide variety of personal and environmental factors; . Any significant delay of the initial use of alcohol and other drugs is a positive outcome and may positively influence risk-taking behavior in other aspects ofthat person's life.20.16 Recommendations · Augment statefundingfor the development, implementation and evaluation ofprevention efforts prioritized to the highest risk populations, sub-populations or groups. · Direct agencies of Washington State government to coordinate existing advisory groups for the following purposes: · To assure consistency of messages regarding prevention of substance abuse and the consequent transmission of blood-borne infections. 6 · To collaboratively support the development and maintenance of a comprehensive and sustained prevention model that impacts primary prevention of chemical dependency and its consequences. .p'--"" 'b'i1'''~-' ....._.>c~~. .~ -'"'~"~.' ~~~..~. .~ 1:&.:~··' ~"':r.::" "':~'''''''''' ,.~, '~~. , -Xi~· ...._~..~ '.. ._~.. ro em~"~· ~ ~."" <! . ~ ""','1 . ,.,"""" .'f~í.;>. . '. ~~"~~-'I, . . '~'~.¡.i1.-.: '1L''>''.4'''J'VI~-¡¡...,.>:......:...·,~__ ~At9~tt.~ .~\. ~.. A/H- t!:.. 'w -.. ,,-_; _ ~ltit:<{'¥.;.,. ~ ';~\....~.. .__ ...~_" . Data about adolescent health behaviors are incomplete and inadequate to best develop and target chemical dependency and blood-borne infection prevention programs. Also, threats exist to current data sources. Background Adolescents' health problems are often the result of preventable behaviors. Habits formed in adolescence can lead to diseases that do not manifest until adulthood. 21, Empirical data about adolescents' health behaviors are needed at the state and local level to effectively target prevention efforts to reduce adverse outcomes. Surveys of adolescent health behaviors must be representative of the population being studied _ not biased by unnecessary constraints on survey methods. Anonymous and confidential self- report surveys by students at schools have been identified as a valid and reliable method of collecting health behavior data; however, schools which do not voluntarily participate create gaps in this important lmowledge base. Current Situation In 1998, the fifth student survey measuring alcohol and drug use was conducted. The Washington State Survey of Adolescent Health Behaviours assesses the health-related attitudes and behaviors of Washington's students in public middle and high schools. The 1998 survey collected data on: intentional injury, including fighting and weapon carrying; alcohol, tobacco and other drug use; and risk and protective factors related to these adolescent health behaviors. Previous surveys have included information on other health issues, including sexual behavior, HIV, diet and suicide. The Youth Risk Behavior Survey conducted in 1999, also assessed alcohol, tobacco, and other drug use, fighting and weapon carrying, and other health-risk behaviors of adolescents. Community controversy has influenced state agencies to eliminate survey questions on sexual behavior in this and other statewide surveys. Also, WAC 180-52-030 requires parental signature for surveys asking about sexual behavior. Existing survey methods include random selection and voluntary participation of schools, and parental notification and opportunity to refuse student participation. In recent Washington State legislative sessions, bills (e.g., 1998 House Bill 2308) have been·introduced to require active written consent from parents prior to administration of the survey. This change could bias survey results by restricting participation in the survey to those students with more involved parents, thus under-representing youth at higher behavioral risk. Survey administration costs would also increase significantly. 7 Recommendation · Direct state agencies to adopt policy positions that support the collection of confidential and anonymous information on adolescent health issues, including alcohol/drug use and sexual behaviors, in scientifically valid methods. · Request revision of WAC 180-52-030 to allow passive parental consent (notification and opportunity to refuse) to improve our ability to measure risk factors for blood-borne infections among adolescents. There is a gap of effective education at both the community and individual level which addresses attitudes towards substance abuse, mv disease, blood-borne infections and injection drug use. Background To reduce substance abuse and the spread of blood-borne infection, communities must recognize and support the need for treatment of individuals with chemical dependency and blood-borne infections. Through inclusive, and scientifically sound educational opportunities, it is essential to build trust and acceptance of substance abuse, mv I AIDS, and other blood-borne infections as disorders that affect individuals, families, and communities like any other disease. Current Situation Washington State citizens need more education regarding the facts, fallacies, myths, and stigmas attached to the diseases of substance abuse, HI\! I AIDS, and other blood-borne infections. The fear and shame often attached with these diseases must be replaced with compassion and understanding of these as medical conditions. Empathy for the impact of these diseases on individuals, their families, and on the entire community is essential to the prevention of blood- borne infections being transmitted through substance abuse. Apathy must be removed and judgmental attitudes resolved. Prevention efforts must be designed and implemented to reduce judgmental attitudes while increasing the awareness of the connection of substance abuse and blood-borne infections. 22 Planning must take advantage of the synergy that can result from the combined application of several efforts. Public leaders, together with public health officials and community coalitions, should increase cooperation and reduce the barriers that limit the effectiveness of community- based agencies' efforts. Community settings in which these efforts must take place include schools, neighborhoods, workplaces, faith communities, treatment programs, and enforcement agencies.23 Although several HIV and substance use prevention programs are operating in the state, few have been able to integrate prevention and treatment strategies. It is necessary to integrate alcohol, tobacco and other drugs, blood-borne infection prevention programs and substance use treatment to build a better continuum of care. 8 Recommendations · The Governor should lead the state of Washington in periodically reaffirming a commitment in support of the populations where blood-borne infections are most prevalent by publicly stating such a proclamation. · DSHS/DASA should integrate a skill building program that encourages all state employees to become skilled at how to address judgmental attitudes in their work environments and communities. · DSHS/DASA together with DOH should encourage the universal integration of Blood Borne Infections/Diseases prevention into existing substance abuse prevention programs and chemical dependency prevention into blood-borne prevention efforts. 9 II. Recommendations to Improve Access to and Funding for Chemical Dependency Treatment '~~~~r"'*''" :-'nrò'biêiD~Lr~~~~~~~t~~~~.J;.~t~;~~!ti~t".· . ~.__..~_...........u:¡.~l':~"':;~~~·~~;~: ~ ~~":'~I ....._~"....~..t"..c'7. ..,' ~~~.-~~..~...,. .... . ~'". The lack of adequate treatment capacity, highly restrictive regulations on methadone treatment services, and inadequate information about and access to effective treatment for "stimulant drugs" (e.g., methamphetamine and cocaine), have led to competing treatment priorities and an uneven and inadequate distribution of services across the state. Background While not all drug users are ready for treatment at a particular point in time, state funding has never kept pace with the demand for chemical dependency treatment. While there may only be short waits before treatment is available for chemically dependent individuals who have adequate insurance or personal resources, Washington State government allocations provide treatment for only about 20% oflow-income individuals in need oftreatment.24 Although this figure is based on a broader population than the injection drug use population, this estimate is conservative, and that the lack of treatment resources for injection drug users may be even worse. Those at highest risk for blood-borne infections, injection drug users, generally have to wait many weeks or even months before drug treatment services can be obtained. In Seattle, for example, over 500 injection drug users are currently on a waiting list for opiate substitution treatment. The political will and state funding to provide the broad range of social support necessary to successfully modify and stabilize the often chaotic lifestyles of drug users in a consistent fashion has yet to be demonstrated. Furthermore, the social stigma frequently placed on chemical dependency and its treatment has liniited the distribution and placement of treatment programs. Methamphetamine ("crystal") abuse appears to be an increasing problem statewide. These drugs promote prolonged and high-risk sexual activity among users, and some use this drug by injection, adding additional risk of blood-borne infection. On the West Coast, methamphetamine use is particularly prevalent among men who have sex with men (MSM).25 MSM who use methamphetamines have the highest prevalence ofHIV (47%) of any population in the state.3 Thus, methamphetamine abuse is likely the second leading drug-associated means of blood- borne infection transmission in our state. Additional study is necessary to fully understand the impact methamphetamine use is having on chemical dependency treatment centers, drug-related crime, fatalities, and HIV prevalence among at-risk populations. Since access to chemical dependency treatment is severely limited, the public health goal to minimize the transmission of blood-borne infection indicates that services be prioritized for persons already carrying these infectious agents, as well as to persons at highest risk fòr acquiring and transmitting them. Without treatment, chemically dependent individuals with a blood-borne infection will continue their risk behaviors, resulting in further disease transmission. .' 10 This will in turn adversely impact their own health, the health of their partners, and public health in general. Current Situation The economic costs of treatment for alcohol and other drug abuse in Washington State totaled $160 million in 1996.26 The majority of the treatment costs (58%) were paid by public funding, such as Medicaid and Medicare. Despite these public expenditures of more than $93 million, only 21 % of indigent Washington State residents needing treatment actually received it. According to the report, "the degree ofunmet need for treatment when viewed in light of the economic cost of substance abuse raises compelling questions about the adequacy of Washington State's investment in treatment services". Current figures estimat&7 that there are about 41,000 active injection drug users in Washington State, of which approximately 29,000 (70%) primarily inject opiates. Of these opiate abusers, only about 2,000 are enrolled in publicly funded opiate substitution treatment programs.2S Due to restrictive state regulations, opiate substitution treatment is only available in four counties: King, Pierce, Spokane, and Yakima. Placement of approved programs is detennined by local political processes and state law limits the enrollment in each program. Altogether, these programs are limited to serving 3,5000 opiate dependents, 2,150 in King County and 1,400 persons in the other three counties. None of these state slots are prioritized for clients with HIV, hepatitis, or other blood-borne infections. (Clark County, meanwhile, provides funds to a neighboring Portland, Oregon treatment agency, but Clark County residents must commute to Oregon, often six days per week, for treatment.) Without additional funding or changes in program caps, recovery for many opiate addicts is severely limited. In 1998, the city of Seattle had an all-time high in opiate overdose deaths, and showed the third highest rate of opiate positive urinalysis tests for male arrestees in the country.29 The caps and licensing restrictions for methadone clinics limit the geographic distribution of such treatment centers. In 1999, chemically dependent persons testified before the State Legislature about the need to expand capacity and the locations of opiate substitution treatment programs and described having to travel many miles by car or bus in order to reach available services. Senate Bill 5019, introduced in the 1999 Legislative Session but left unconsidered by the representatives, would have greatly expanded the number of available methadone treatment slots, as well as relaxed the state's overly restrictive licensing requirements resulting in greater access to treatment. Chemical dependency treatment agencies have helped people become aware of behaviors that increase their risk of getting blood-borne infection. Focusing on this risk helps attract substance abusers into treatment programs. Results for the US Center for Substance Abuse Treatment (CSAT) demonstration programs are being used as evidence that focusing on disease prevention can encourage reluctant substance abusers to seek and enter chemical dependency treatment. Now is a critical time to accurately assess and evaluate gaps in s~rvices to bridge prevention and treatment and to position the state for future funding opportunities. 11 Methamphetamine is a drug of particular concern given the recent significant increase in the manufacture and abuse of these drugs in Washington. Usage rates have been increasing at an alanning rate from the late 1980's to the present. Data compiled by the Department of Ecology and DSHSIDASA trace steep increases in the number of laboratory incidents and the rate of treatment admissions for methamphetamine. Publicly funded treatment admissions for amphetamine use as the primary drug have increased 100 fold statewide between the fiscal years 1993 and 1999 (from 486 cases in 1993 to 4,864 in 1999). Finally, in jailor prison settings, there are disproportionate numbers of inmates with crimes related to drug (including alcohol) use. The National Center on Addiction and Substance Abuse at Columbia University noted in their analysis of prison and jail inmate sùrVeys30 that 81 % of state, 80% of federal and 77% oflocaljail inmates used an illegal drug regularly (at least weekly for a period of at least one month); had been incarcerated for drug selling or possession; had been driving under the influence of alcohol or another alcohol abuse violation; were under the influence of alcohol or drugs when they committed their crime; committed their offense to= get money for drugs; had a history of alcohol abuse; or shared some combination of these characteristics. In Washington State, the Corrections Outreach to Communities for Offenders with IDV/AIDS (COCOA) project is a collaboration between DOC and DOH. The COCOA project (whose current one-time funding is dependent on federal carry-over funds ) is the result of an effort to improve access to IDV / AIDS treatments for persons incarcerated in state and local correctional facilities and to address transition issues to help assure continuity of care upon their release to the . community. The project objectives are: · Reducing the cost ofHIV/AIDS care in correctional institutions. . · Improving continuity of care for HIV+ offenders during transition and release. · Defining and sharing infonnation on community resources for HIV concerns. · Providing correctional staff infonnation and continuing education to support their work with HIV + inmates. · Collecting and analyzing current HIV+ data within the correctional institution. Given that screening for blood-borne infections among Washington State Department of Corrections inmates has shown a 1 % prevalence ofHIV infection31,32 and a 25% prevalence of HCV infection, 33 it is imperative that drug treatment programs in correctional settings address BBl prevention. Even though there are 32 chemical dependency treatment programs in Washington State correctional settings, the opportunity to address the dual nature of disease and substance abuse by these programs needs to be expanded and enhanced. Screening at classification in Department of Corrections facilities has found that 80% of new prisoners have a chemical dependency problem.34 This is also true in juvenile detention centers where the involvement with drug use is also high. It has been estimated that 82% of adolescents incarcerated in state juvenile correctional facilities are dependent upon or abuse alcohol, drugs or both.3s Finally, the White Hose Office of Drug Control Policy has called for more drug treatment options in the criminal justice system, since Department <;>f Justice statistics show that some 65% to 70% of untreated 12 parolees who have used cocaine and heroin return to the drugs within three months of being released. ]6 Recommendations · Persons with blood-borne infections, should be given a high priority for chemical dependency treatment "on-demand" to reduce chances offurther spread of infection; · Resources are needed to substantially increase capacity for chemical dependency treatment, targeting persons with limited or no insurance [and those within correctional settings}. · Due to the lack of adequate chemical dependency treatment capacity, the Governor's Council on Substance Abuse should be charged to work with DSHS/DASA to clearly identify priorities for chemical dependency treatment that include consideration of the societal/public health need to prevent the transmission of blood-borne infections. · The Governor should strongly support the passage of a bill similar to Senate Bill 5019 (1999) as a means of improving statewide access to opiate substitution treatment. Senate Bill 5019 would hdve: · Removed treatment program size limitations; · Permitted DSHS/DASA to identify local jurisdictional opiate substitution treatment needs and to place treatment programs in those locations; and · Implemented a pilotprogram through which approved physicians could assume the methadone treatment management of stabilized clients. · Direct and fund DSHS/DASA to undertake a state-wide needs assessment survey in collaboration with other public partners - to determine gaps in treatment for stimulant abusers, and whether specific chemical dependency treatment an4 prevention programs need to be added for these and other special populations. · Direct and fund DOH to undertake a statewide needs assessment survey to determine gaps in blood-borne infection health care and prevention policies and procedures to assess for chemical dependency evaluation and referral. · Continue the Corrections Outreach to Communities for Offenders with HIV/AIDS project with state funds to strengthen the collaborations and communications amongfederal, state and local jail/prison systems and to improve the prevention and care of blood-borne illnesses in these settings. Many care providers remain unaware of the increasing association between chemical dependency and blood-borne infections of the predictors of these conditions, and do not optimally screen their clients for them. Background While some providers are aware of the connection between chemical dependency and blood- borne infections, many others are reluctant to identify new and complex client problems that increase visit duration, often without commensurate increases in reimbursement. This problem is compounded by the increasing efforts to move people into managed care plans, and to further restrict reimbursement. Several studies demonstrate this lack of problem recognition in screening for HIV risk.37 13 Opportunities for problem recognition - the first step towards problem correction - are too often missed, jeopardizing the health ofthese individuals and the public health in general. The extent of these gaps is unknown. Current Situation Chemical dependency is not evenly distributed in all segments of the population. It is well documented that drug dependencies are substantially more prevalent among incarcerated persons3! and those with mental illness.39 More recently it has become clear that higher proportions of people at-risk for, or already infected with, HIV and otherblood-bome infections are also chemically dependent.40 AE the HIV epidemic increases in socially disadvantaged and marginalized populations,41 these proportions appear to be growing. Additionally, the increasing prevalence ofHCV, infecting four times as many people as HIV in the United States, is greatly associated with injection drug use.42 Recommendation . The Governor should direct DOH. working with provider organizations, to review and find ways to improve screening for chemical dependency by licensed health care providers, especially among: · All persons at some risk of chemical dependency and blood-borne infection; · All persons being treated for mental illness; and · Persons in high-risk settings, such as at correctional facility intakes, at STp clinics, and at HIV and blood-borne infection counseling and testing sites. Effective treatment addressing patient needs and helping to keep chemical dependency patients in treatment is hampered by communication barriers between chemical dependency treatment providers and other health care providers (including primary medical care providers, mental health providers, and HIV/AIDS case-managers). Background Chemical dependency treatment programs policies may prohibit the use of certain drugs (e.g. benodiazapines, narcotics) while in treatment. Thus clients admitted to chemical dependency treatment may be required to discontinue needed medications resulting in exacerbations of psychiatric illnesses or lack of pain management, unless infonnation fTom the primary physician is received regarding diagnoses and prescribed medications. Linking chemical dependency treatment services to mental health and medical services is important in providing comprehensive services and for the retention of clients in all programs. Studies show that better outcomes result fTom coordinated services.43 Effective communication between a client's providers at all levels is essential. Communication should occur routinely to (1) assure that necessary medications are not withheld while in chemical dependency treatment and (2) provide the patient with wrap around services which respects all providers and the client. Upon admission to chemical dependency treatment, clients are surveyed about their medical and mental health history. Often times, clients choose not to disclose needed infonnation and , 14 chemical dependency staff are not aware of their medical or mental health diagnoses. In addition, current federal chemical dependency regulations place special protections on chemical dependency information, requiring special releases and authorizations for chemical dependency treatment information to be shared. Therefore, chemical dependency treatment staff may be unable to pursue communication with other providers for wrap around services without the client's consent. Current Situation Some clients compartmentalize their care, so that chemical dependency treatment staff are not aware of their medical or mental health backgrounds and vice versa. In addition, current federal chemical dependency regulations place special protections on chemical dependency information, requiring special releases and authorizations the order for chemical dependency treatment information to be shared. Therefore, chemical dependency treatment staff are often unable to or do not pursue these important communication connections or take the time to explain to clients the importance and potential benefits of coordinated care. Recommendation · The Governor should direct DSHS/DASA to work with DOH and other care provider organizations (e.g.,. Washington State Medical Association) to identify and solve communication barriers that inteifere with coordinated patient care. 15 III. Recommendations to Ensure Access to Sterile Syringes . '...... ··.._,;.r·."";.c>-~;.u~~~~"'J ...~. ·nlt.,~· ~"'ê?:~""'.>t.iW~.., . 'A!o'~Jx»·~~~~".i:'····~·'- .P.toõ1em",",'f:'~$'-::'~"':~~4):ì'-'''';''';..ii.t~~.· '. . ~~"ì.'f:. ~..,:¡j.~¡;På:ifo" '~;;;~~';"'i;i~~~~.!"~::"':"" ......:..J'"_ ..~~..-Io-..,~..~._.~ ~ ~_.._.......'_.' ,~~_ ," .'.. '¥'~ .'''".. .. ,.. - ~T .-.. ,-.,. ..'...,.....~ Access to sterile syringes is limited in Washington State, even in communities with needle exchange programs, due to state laws which prohibit the pharmaceutical sale of syringes, and paraphernalia laws that regulate their possession, distribution, and sale. The lack of access to sterile syringes continues to promote risk of transmitting blood-borne infections among continuing inj ection drug users. Background . Ensuring access to clean syringes is the simplest means of reducing the spread ofblood-bome infections among injection drug users. Current state law, RCW 70.115.050, prohiþits a pharmacist from selling clean syringes unless he/she can "satisfy himself or herself that the device will be used for the legal use intended." Washington State is not alone in these restrictions: Ten other states place restrictions on the pharmaceutical sale of syringes, and eight states and one territory prohibit their sale without a prescription.44 However, a growing number of states have recognized the negative public health impact of such restrictions and have begun to remove, or at least partially repeal, laws which impede access to clean syringes. In 1992, the Connecticut State Legislature amended its prescription drug law to allow for the purchase of up to ten syringes without a prescription. This change helped reduce needle sharing among injection drug users by 40 percent; furthermore, the percent of injection drug users purchasing potentially contaminated needles on the black market decreased from 74% to 28%, and the percentage of injection drug users obtaining sterile syringes from a pharmacy increased almost 400% (from 19 to 78 percent).45 At the same time, needle stick injuries to police officers declined three-fold.46 Based on this success, other states, including Maine (1993), Minnesota (1997) and Massachusetts (proposed in 1999) have followed suit to improve legal access to clean synnges. Connecticut, Maine, Minnesota, and Massachusetts (proposed) all limit pharmaceutical sales to ten or fewer syringes. Maine and Massachusetts limit sales to individuals of at least age 18. Minnesota and Massachusetts require pharmacies to provide on-site means for the safe disposal of used syringes, and provision of educational pamphlets for pharmacists (clarifying state law) and injection drug users (detailing the dangers of injection drug use, safe disposal techniques, and the availability of drug treatment services). Pharmacies are the most common and simple means of accessing sterile syringes. However, Washington State law (RCWs 69.50.412 and 69.50.4121) prohibits the possession, sale, and distribution of drug paraphernalia which, according to RCW 69.50.102 includes "hypodermic syringes, needles, and other objects used, intended for use, or designed for use in parenterally injecting controlled substances into the human body." Forty-seven other states and the District 16 of Columbia have similar laws. -17 Washington, together with seven other states (HI, ME, MD, MA, NY, RI, VT) and DC, provides an exception in its paraphernalia laws for needle exchange programs48.-19 Some states, including Maine (I997) and Minnesota (1997), have gone further to ensure that all aspects of the public health effort to prevent blood-borne infections,·inèluding pharmacies, are exempted from existing drug paraphernalia restrictions. Nationally, most drug paraphernalia laws were developed in response to the rapid increase in recreational drug use and the proliferation of the drug paraphernalia industry, beginning in the late 1960s. These laws were passed long before the beginning of the IllV/AIDS epidemic, and with little realization of, or regard for, the potential adverse public health impacts of these restrictions. With today's scientific knowledge regarding the transmission of blood-borne infections and the effectiveness of needle exchange programs, it is clear drug paraphernalia laws are a serious obstacle in the effort to ensure access to clean syringes for injection drug users. In fact, researchers at the S1. Louis University School of Public Health found that states with neither drug paraphernalia laws restricting the poss:ession of needles nor restrictions on the pharmaceutical sale of syringes have much lower AIDS rates than states with such restrictions. so State drug paraphernalia laws limit the role pharmacists can play in the public health effort to prevent the spread of blood-borne illnesses. Simply allowing for pharmaceutical sale dòes not address the additional roadblocks which possession laws place on injection drug users who seek to obtain, possess, and dispose of sterile syringes in order to reduce their risk for blood-borne infections. Although law enforcement officers rarely arrest individuals for simply possessing sterile needles, these statutes force injection drug users to avoid reliable suppliers such as pharmacists and to rely on black market sellers. Current Situation Support for improved pharmaceutical access to clean syringes is strong in Washington State. The Washington State Department of Health, the State Board of Pharmacy, the Governor's Advisory Council on IllV/AIDS, and AIDS service organizations across the state have advocated for changes to current state laws which impede pharmacists from assisting in public health efforts to prevent the spread ofblood-bome infections. In March 1999, the American Pharmaceutical Association encouraged all "state legislatures and boards of pharmacy to revise laws and regulations to pennit the unrestricted sale or distribution of sterile syringes and needles by or with the knowledge of a pharmacist in an effort to decrease the transmission of blood-borne diseases."sl Recently, the Washington State Board ofPh~acy moved to adopt a definition of "legal use" for RCW 70.115.050 which includes "the distribution of sterile hypodermic syringes and needles for the purpose of reducing the transmission of blood- borne diseases." Most pharmacists recognize the important role they playas part of the public health effort to prevent the spread of blood-borne infections. A recent survey of pharmacists in Louisiana found that a substantial majority (61 %) had sold needles and syringes without prescriptions to customers they knew were not diabetics.52 However, many pharmacists reported a level of discomfort with this fonn of sale and the majority indicated they would be more likely to sell needles and syringes to injection drug users who were referred from an agency or clinic for that purpose. 53 17 Similarly, many injection drug users would prefer to purchase syringes over the counter rather than obtain them free of charge through needle exchange programs. In a 1990 study in Miami, 90% of injection drug users indicated approval of purchase, and 87% of these said they would purchase syringes in this way if it were legal. 54 A 1994 study in Baltimore, Maryland' found that if current legal restrictions were lifted, pharmacies would be a preferable means of access to clean syringes for many clients of needle exchange programs, particularly women. These studies indicate that pharmacies can play an important role in disease prevention,s5 particularly as the HIV epidemic expands among women and heterosexual men. V/hile needle exchange programs are not subject to drug paraphernalia laws under a decision by the Washington State Supreme Court, 56 pharmacists who sell clean syringes to injection drug users may face professional sanctions and criminal prosecution. This situation was further exacerbated by 1998 amendments to RCW 69.50.4121 which only exempted "public health and community based HIV prevention programs" from the statutes' prohibition on the distribution of drÚi paraphernalia. Unless pharmacies are included in this exemption, they believe they must adhere to the strict prohibition on the sale or distribution of clean syringes and needles. Experience in other states demonstrates the need for a combined effort to expand pharmaceutical access to syringes and repeal some drug paraphernalia laws in order to achieve the desired goal of reducing the transmission ofblood-bome infections. In 1993, the Maine legislature removed restrictions on the pharmaceutical sale of clean syringes, but the state continued to have laws which made it illegal for a person to possess a syringe for the purpose of injecting illicit drugs. 57 This "Catch-22" confused both pharmacists and injection drug users, who could legally purchase syringes but then be arrested for carrying them. In 1997, Maine passed a bill that removed criminal penalties for the possession often or fewer syringes. 58 The bill had the support of public health officials, law enforcement and community-based organizations. Other states have learned from the example of Maine, and have revised their pharmacy sale and drug paraphernalia laws simultaneously. The Minnesota Legislature went so far as to remove needles from the state's list of restricted. drug paraphernalia when they are sold through a pharmacy in quantities of 10 or fewer. Connecticut provides a similar dispensation and proposed legislation in Massachusetts would do the same. In order to limit access to sterile syringes, Connecticut and Minnesota require that pharmacies keep them behind the counter, rather than placing them on the sales floor. A growing number of states recognize that by pennitting injection drug uses to legally purchase and possess a limited number ofhypodennic syringes and needles, it is easier to ensure that injection drug users comply with the public health advice to.use a new syringe for each injection. Access to sterile syringes has become a highly politicized issue amongst those most removed from the front-line of disease prevention efforts. Despite the clear disease prevention benefits associated with needle exchange, many members of Congress equate these programs with a defeat in the war on drugs. Although no federal dollars are currently spent to support needle exchange programs, local public heaIthjurisdictions and HIV/AIDS prevention agencies across the country support more than 150 exchange programs. Washington State has been at the forefront of this effort. In the past few years, Congress has attempted to pass legislation or include policy riders on appropriations bills that would prohibit even local public health 18 juri.sdic.tions. from oper~ting needle exchange if they received any federal funding. Such legIslatIOn dIsagrees wIth the ideals of local control, would jeopardize the existence of the needle exchanges currently operating in Washington State, and disagrees with accepted scientific evidence. .. Recommendations . Amend RCW 70.115.050 and 69.50.4121 to allow for the pharmaceutical sale ofsterile syringes. · Sales should be limited to ten syringes. · Sales should be limited to individuals at least eighteen years old. · Pharmacists should be required to provide drug prevention and treatment materials at the point of sale. The Governor should strongly support efforts by the State Board of Pharmacy to allow pharmacists to voluntarily participate in dŽSease prevention efforts. · Amend RCW 69.50.421 to allow for the limited possession and sale of sterile syringes for legitimate public health purposes. . Oppose any congressional attempts to limit the abžlžty of state or local public health officials to operate or support needle exchange programs. . . Needle exchange programs are limited in their capacity to meet client needs for the prevention of blood-borne infections. Background Many chemically dependent individuals have a wide variety of often-urgent medical, situational and emotional needs in addition to their chemical dependency. Many of them have limited options for obtaining help to address these issues due to their addiction, concurrent mental or physical health problems, and lack of insurance and/or personal resources. In addition, many chemically dependent persons are homeless. 59 Programs serving chemically dependent persons should be responsive to the clients' multiple health care needs and must be prepared to assist these individuals with problem-focused interventions either directly or through specific referrals. In particular, because needle exchange programs provide access to clients that are often not reached through other public health venues, needle exchange programs must be able to provide an array of disease prevention services, not just one-for-one exchange of sterile for contaminated injection equipment. Comprehensive services at needle exchange sites should include services such as: education about HIV and other blood-borne infections; provision of clean paraphernalia (including sterile syringes, alcohol swabs, clean cotton, bleach, etc.) and condoms; referral to drug treatment and medical care; on-site HIV and hepatitis counseling and testing, or at minimum referral to such services; vaccination or referral for vaccination for hepatitis; and assistance and advice about housing or other needed social services.60,61 The processes whereby such programs are considered, implemented and maintained should be initiated or overseen by local public jurisdictions and include law enforcement leaders, 19 community and govemrnentalleaders, and drug treatment agency representatives. Community and law enforcement support of these programs hinges on the capacity of the needle exchange program to provide a wide array of disease prevention services. Current Situation In Washington State, needle exchange progfams are operational in the following counties: Spokane, Walla Walla, Yakima, Whatcom, Island, Skagit, Snohomish, King, Pierce, Thurston, Clark and Skamania. In addition, the "Prevention Plus Program" (linking Regions I & II) is in the process of setting up a mobile syringe exchange in other counties. While all programs provide educational materials and referrals, some programs do not have sufficient resources to provide on-site services (e.g., HIV counseling and testing) or provide follow-up to assure that referrals were completed. Some persons, including local law enforcement staff, will continue to have concerns about needle exchange programs. Therefore, law enforcement officials must nave opportunities to continue to be involved in decisions about these programs and be educated about the array of disease prevention services provided. Recommendations . Needle exchange sites serving chemically dependent individuals must be properly trained and able to provide clients with assistance (on-site when feasible or through referral when necessary) to a broad array of frequently needed services, including drug detoxification, chemical dependency treatment, case management, medical care, and other social support services. Additional resources maybe needed to enable programs to develop and maintain appropriate service models and to adequately train and support staff to provide these services. . Representatives from law enforcement public health, chemical dependency treatment and prevention and other interested persons need to be involved in the establishment, implementation, and maintenance of needle exchange programs. 20 Appendix A: The Role of Needle Exchange in the Prevention of Blood-Borne Infections The transmission of blood-borne infections, including HIV, is largely the result of two major risk behaviors: unprotected sex with exposure to infected semen or vaginaVcervical fluids, and . parenteral exposure to infected blood (mostly through shared needles). The risk of transmission of blood-borne infection through injection drug use remains high, supporting the continued need for non-shared, sterile syringe use by injection drug users Many of the most effective means of reducing the transmission of blood-borne infections håve become highly politicized issues, particularly needle exchange programs and the placement of drug treatment programs. Despite the politics at play, the need for prevention and treatment is great and the scientific evidence ís clear: clean needles help to prevent the spread of disease and do not encourage drug use.62 Background As of July 1999 it is estimated that there are over 150 needle exchange programs operating in 39 states.63 Needle exchange programs arose in the latter part of the 1980s in the Netherlands in response to the spread of hepatitis B virus infection among injection drug users. Early AIDS data that indicated that injecting drug users were transmitting mv via non-sterile syringes and needles argued for similar programs to prevent the spread of disease. Needle exchange in Washington State was initiated in Tacoma in August 1988 and currently operates in eleven counties. Needle exchange was challenged legally by the Pierce County Prosecuting Attorney in 1989. The 1990 ruling in that instance supported the exchange of syringes. As additional communities across the state adopted syringe exchanges, a second legal challenge by the Spokane County Prosecuting Attorney occurred in 1992. In that case the Washington State Supreme Court upheld the earlier Pierce County ruling solidifying syringe exchange as a legal public health intervention as ''within the prerogative of the local health officer as a public health intervention.'764 The Supreme Court ruling, however, left in its wake a conflict with existing law, specifically RCW 70.115.050 which states in part that "the retailer shall satisfy himself or herself that the device (i.e., a syringe, needle or other device used for injecting drugs) will be used for the legal use intended." The code (RCW 69.50.4121) further states, "Every person who sells or gives, or permits to be sold or given to any person any drug paraphernalia in any form commits a class I civil infraction under 7.80 RCW." These sections consequently create a conflict for selling or distributing syringes outside an authorized needle exchange program. Discussion Conflict between pre-existing paraphernalia laws and the State Supreme Court's needle exchange decision have resulted in confusion and interpretative differences between public health officials, pharmacists, law enforcement and community-based organizations. Some of these concerns have: led local governing health boards, most often composed of citizens and elected officials, to differ 21 in their interpretation of either the cost-benefit or potential legal ramifications of permitting needle exchange programs to operate within their jurisdictions. Similar concerns have been raised by phannacists. The current contradiction between case law supporting needle exchange and statutory law restricting the sale of syringes leaves them in a potentially vulnerable position. They are not covered in the scope of the Supreme Court ruling empowering local health officials to conduct needle exchange. Yet, they remain on the front lines of the epidemic as injection drug users seek to purchase sterile syringes from them in retail settings. Regardless of the legal interpretation or the resource issues involved, there are multiple pros and cons that have been used to support or oppose needle exchange programs, or the phannaceutical sale of such equipment, as viable public health interventions. The majority of those arguments can be lumped into several categories: the promotion of drug use, the bridge to treatment, conflicting evidence on whether needle exchange programs do anything to contain the spread of disease, and concerns that needle exchange programs send mixed messages to youth. A brief discussion of each of these points follows but is by no means an exhaustive representation of the substantial body of literature that has arisen around needle exchange programs. The promotion of drug use - A report by the National Institutes of Health (NIH) concluded that needle exchange programs "show a reduction in risk behaviors as high as 80 percent in injecting drug users, with statements of a 30 percent or greater reduction ofHIV." In addition, the panel concluded that the preponderance of evidence "shows either a decrease in injection drug use among participants or no changes in their current levels of drug use".65 Decrease of sharing - While many needle exchange programs have recorded information about the decrease of equipment sharing, a 1998 article in the American Journal of Public Health noted that rates ofHIV in injection drug users in Hawaii dropped from 5% in 1989 to 1.1% in 1994-96, a drop attributed to a 74% decrease in needle sharing among needle exchange clients.66 Most evaluative studies of needle exchange programs, including a recent study conducted in Seattle, indicate a reduction of needle-sharing among program participants.67 Bridge to Treatment - Needle exchange programs are often associated with, or provide referrals to, drug treatment programs. In Washington, needle exchange programs are an important source of referral to drug treatment in the state. In 1998 for instance, the Spokane Needle Exchange Program referred 214 clients to drug treatment. Most programs at least offer information about treatment options, but some even provide clients with vouchers that provide immediate program access in some cases. A lack of available treatment slots, particularly for methadone treatment for opiate users, is a major impediment to successfully breaking the cycle of drug abuse. Needle Exchange Programs as protection against Blood-Borne Infections - There have been mixed reports as to the effect of needle exchange programs on the reduction of blood-borne infections in injections drug users. Two Canadian studies (one in Montreal in 199668 and another in Vancouver in 199769) found that needle exchange program participants were more likely to be exposed to HIV than those inj ection drug users who did not participate in a needle exchange program. 22 These findings are different from the experience at the Seattle-King County needle exchange program, where the rate ofHIV transmission among injection drug users has remained low and fairly stable. However, the incidence of hepatitis Band C remains at 10% and 21% annually among needle exchange program participants.4 The prevalence of hepatitis Band C in this same study was nearly 70% for hepatitis B and 80-90% for hepatitis C. Further studies are needed to determine why hepatitis seems to be transmitted much more readily than HIV in this population and better hepatitis prevention programs need to be developed for injection drug users. The mixed "message" _ Since the introduction of needle exchange programs, there have been on-going concerns that they send a "mixed" message about drug use. There is. the possibility that by supplying injection drug equipment, needle exchange programs undermine the nation's "War on Drugs" effort. While the focus of this paper is not to explore the ramifications of either position, a recent study in Baltimore found that the presence of a needle exchange program near a school was not likely to encourage students to begin injecting drugs.70 Several other studies have reported that injection drug users reduce or maintain their rate of injection while participating in exchange programs.71,72,73 Regardless of any of these concerns, there remains an overarching public health need to reduce the transmission of blood-borne infections that are transmitted through the use of contaminated injection equipment. The cost-benefit of this approach has been addressed in various studies and the US Centers for Disease Control and Prevention has estimated that preventing a single case of HIV saves more that $150,000 in IDV/AIDS-related medical care. ENDNOTES: 1 Centers for Disease Control and Prevention, IllV/AIDS Surveillance Report, Midyear edition, 1999, Vol. n, No. I 2 Holmberg SD. The estimated prevalence and incidence ofHIV in 96 metropolitan areas. Amer. Journal of Public Health 1996. 86: 642-654. 3 Jackson TR., et. aI., Recent Trends in Dmg Abuse, Seattle-King County, June, 1999. . 4 Hagan H, McGough JP, Thiede H, Weiss NS, Hopkins S, Alexander ER, Syringe exchange and risk of infection with hepatitis B and C viruses, Am J Epidemiol1999; 149; 203-213. S Little SJ, Daar ES, D' Aquila RT, et aI. Reduced antiretroviral drug susceptibility among patients with primary HIV infection. JAMA 22/291999.282: 1142-1149. 6 Boden D, Hurley A, Zhang L, et aI. HIV~l drug resistance in newly infected individuals. JAMA 22/291999.282: 1135-1141. 7 Pomerantz RJ. Primary HIV -1 Resistance: A new phase in the epidemic? JAMA 9/22-29 1999 282: 1177-1179. 8 National Institutes of Health (1997). Management of hepatitis C. Nlli Consensus Statement March 24-26, 1997. 15(3):1-41 [On-line] opd.od.nih.gov/consensuslconsll05/105 statement.htm. 9 Institute of Medicine (USA). Treating drug problems, vol. Ï: A study of the evolution, effectiveness, and fmancing of public and private drug treatment systems. Washington, DC: National Academy Press; 1990. 10 Wickizer T, Longhi D. Economic benefits and costs associated with substance abuse treatment provided to indigent clients through the Washington State's Alcoholism and Dmg Addiction Treatment and Support Act (ADA TSA) program. Report prepared for the Division of Alcohol & Substance Abuse, Department of Social and Health Services. Nov. 25,1997. Excerpt: "...for every $1 invested in the treatment ofa Medicaid high-risk client, 67 cents would be recouped during the first 12 months following treatment, in reduced Medicaid costs alone." 11 Luchansky B, Longhi D. DSHS Briefmg paper #4.30: Cost savings in Medicaid medical expenses- An outcome. of publicly funded chemical dependency treatment in Washington State. Excerpt: "Over the five year follow-up . 23 p'riod, tt"',<:d di,ots oos, 00 av,cag" $4,500 I"" in m,dio.l m, than uO(reared di,nts. . . Our OOst savings figw-, compares very favorably with the $2,300 invested in an average treatment episode." (page I). .. 1: Revised Code of Washington 34.05.360 and Washington Administrative Code 284-53-005. " P"v,nrioo Prognuns, Wha, are th, oririo.l fao_ tha, spell sno",s? pl<:nary S",sion, William B. Han.en. Promdings of th, Narional Conf_ce on Dmg Abo.s, R"'"""b, Pr"'''"tarioo.s, PaP'"S, and R<:comm'ndarioo.s. September 16-20, 1996. Washington D.C. " P,otz MA, "aJ. A mulrioommnnity trial for primary P"""'rion of adol",,,,,,, <hug abuse, Eff,,,, on <hug o.s, prevalence. JA.:\1A 1989.261 (22): 3259-3266. " Botvin GJ, "aJ. Long-,,,,,,, follow-up results of a randomized <hug abus'p,,,v,,"rion trial in a whi', middI,-class population. JA.:\1A 1995. 273 (14): 1106-1112. "Making P"v""rion Work. 1993. Cen,,, for Snbstance Abus, Prev""rion [On-Lin"J www.hoalth.org/pnWmpw_ booklmpw-book.htm#Questions ] " Ch"" K, Kand,1 DB. Th, tWnraJ m,tory of <hug nse from adol""o,,"ce '0 th, mid-thirties in a general po¡>n1arion sample. Am. Jour. Public Health 1995. 85(1): 41-47. 18 American Medical Association, American Pharmaceutical Association, The Association of State and Territorial Health Officials, National Alliance of State and Territorial AIDS Directors, Joint Position Statement, mv Prevention and Access To Sterile Syringes, October 1999. 19 Goldstein A. Addiction: From biology to drug policy. New York, NY: WE Freeman & Co; 1994. " Cent" for Substance Abnse Prev""ûoo (CSAP). Th, Futur, by D"'i&n' A <:ommunity fuunework for preventing Alcohol and other drug problems through a systems approach. 1991. 21 Washington State Survey of Adolescent Health Behaviors 1988-1992 22 Gohen, Ph.D., Allan, KIòel, Ph.D., Bany, and Stewart, Kathryn. Guidelines and Benchmarks for Prevention Programming, An Implementation Guide from Substance Abuse and Mental Health Services Administration. D.HHS Publication No. (SMA) 95-3033 1997. 23 Robert Wood Johnson Foundation, Boston University School ofPubIic Health. Join Together. Community Action Guide to Policies for Prevention, The Recommendations of the Join Together Policy Panel on Preventing Substance Abuse 24 Kabel, J, Kohlenberg E, ShakIee M, Clarkson S, Substance Use, Substance Use Disorders and Need for Treatment among Washington State Adults - Findings from: the 993-94 Washington State Needs Assessment Household Survey & the 1994 Arrestee Estimates of Substance Abuse Need for Treatment Study. Department of Socail and Health Services - Research and data analysis, pp. 40, 12/96. 25 Sul1ivan PS, Nakashima AK, PurcelI DW, Ward JW, et a!. Geographic differences in noninjection and injection substance use among HIV-seropositive men who have sex with men: Western Unites States versus other regions. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998. 19: 266-273. 26 Washington State Division of Alcohol and Substance Abuse, Department of Social and Health Services, "the Economic Costs of Drug and Alcohol Abuse in Washington State, March 1999. 27 Personal communication: Fritz Wrede, Division of Alcohol & Substance Abuse; Washington State Department of Social & Health Services. 28 Department of Social & Health Services, Division of Alcohol. & Substance Abuse _ Target system and estimates projected from those data. . .29 1998 Annual Report on Opiate Use Among Arrestees, ADAM...Nationa1 Institute of Justice. 30 http://www.casacolumbia.org "Behind Bars: Substance Abuse and America's Prison Population."Jan. 1998. Columbia University. 31 Ryland LM, Petrasek L, Holmes S. mv Seroprevalence in Incoming Female Inmates, Washington State Correctional Facilities, 1995-1996, HIV/AIDS Quarterly Epidemiology Report, IS! Q 1997, 16-18. 32 Ryland LM, Petrasek L. HIV seropreva1ence in Incoming male inmates, Washington State correctional facilities, 1987-1995. HIV/AIDS Quarterly Epidemiology Report, 4th Q 1995,8-11. 33 Personal communication, Adam Jonas, Medical Director, Washington State Department of Corrections. 34 Personal communication, Patty Terry, Washington State Department of Corrections. 3S Steiger J, and Noble D, (1991). Profiles of juvenile offenders in Washington State Division of Juvenile Rehabilitation facilities: Results of a 1990 survey of youth in residence. Olympia, WA: Washington State Department of Health. 36 Seper J. McCaffrey Wants More Addict Options. Washington Times (12/08/99). P. A4. 24 37 Makadon HJ, Silin JG. Prevention ofHIV infection in primary care: Current practices, future possibilities. Ann Intern Med. 1995; 123: 715-719. 38 Belenko S, Peugh J, Califano JA, Usdansky M, & Foster S. (1998). Substance use and the prison population: A three year study by Columbia University reveals widespread substance use among the offender population. Corrections Today, 60(6) 82-89.; Arrestee Drug Abuse Monitoring Program, Seattle Quarterly Report 1(1). 1999. 39 Regier DA, Fanner ME, Rae DS, Locke BZ, Keith SJ, Judd LL,& Goodwin FK (1990). Comorbidity of Mental Disorders With Alcohol and Other Drug Abuse, JAMA. 264(19) 2511-2518. 40 McCoy CB,Metsch LR. McCoy HV. Weatherby NL. (1999) mY seroprevalence across the ruraVurban continuum. Substance Use Misuse. 34(4-5),595-615.] and that participation in substance abuse treatment reduces HIV risk behaviors in those participating (Metzger DS; Navaline H; Woody GE, (1998), Drug abuse treatment as AIDS prevention., Public Health Report 113 Suppl 1, 97-106). 41 National Research Council (U.S.). Panel on Monitoring the Social Impact of the AIDS Epidemic. Albert R. Jonsen & Jeff Stryker, Editors. The social impact of AIDS in the United States. 1993. National Academy of· Sciences. National Academy Press; Washington DC. 42 Alter MJ, Kroszon-Moran D, Nainan OV, et al. The prevalence of hepatitis C virus infection in the US, 1988 through 1994. NEJM 199; 341:556-562. 43 McLellan AT, Grissom G, Zanis D, Brill P. (1997) Problem-Service "matching" in addiction treatment A prospective study in four programs. Archives of General Psychiatry 54: 730-735. 44 Gostin. La, et aI, "Prevention of mY/AIDS and Other Blood-Borne Diseases Among Injection Drug Users," Journal of the American Medical Association, Jan. 1, 1997, Vol. 227, No.1, pgs. 53-62. Retrovirology, Vol. 10, N45 Groseclose, Samuel L., et aI, "Impact of Increased Legal Access to Needles and Syringes on Practices of Injecting-Drug Users and Policy Officers," Journal of Acquired Immune Deficiency Syndromes and Human o. 1, 1995, pgs. 82-89. 46 Ibid. 47 Wassennan Stephanie. "mY/AIDS Facts to Consider: 1999," National Conference of State Legislatures, March 1999, pg. 65. 48 Ibid. 49 AIDS Policy and Law, Volume 14, Number 18, October 1, 1999. so Romeis James. "Higher Transmission Rate Among IV Drug Users May Be Linked to State Laws," AIDS Weekly Plus, August 19, 1996, pg. 23. 51 American Phannaceutical Association, House of Delegates. 1999. 52 Farley TA, et aI, "Attitudes and Practices ofPhannacy Managers Regarding Needle Sales to Injection Drug Users," Journal of the American Pharmaceutical Association, VoL 39, No.1, Jan/Feb. 1999, pgs. 23-26. 53 Ibid. 54 Commerford M, et aI, "Attitudes of IDU toward needle exchange and over-the-counter purchase of syringes," International Conference on AIDS, 1990; 6(2):417. 55 Junge B, et aI, "Phannacy Access to Sterile Syringes for Injection Drug Users: Attitudes of Participants in a Syringe Exchange Program," Journal of the American Pharmaceutical Association, Vol. 39, No.1, Jan/Feb. 1999, pgs. 17-22. 56 Health District v. Brocket, 839 P2d 324 (Washington State Supreme Court 1992). 57 Beckett, GA. "Maine Removed Criminal Penalties for Syringe Possession in 1997 After Allowing Sale of Syringes Without a Prescription in 1993," Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, July 1998, Vol. 18, Supplement 1, pg. S145. 58 Ibid. 59 Of Seattle-King County needle exchange clients, 53% self-identify as homeless (M. Hanrahan, personal communication). 60 Washington State Department of Health Position Statement and Recommendations Regarding Syringe Exchange Programs, November 1991 61 Preventing mY Transmission: The Role of Sterile Needles and Bleach, Jacques Normand, David Vlahov, and Lincoln E. Moses, editors National Academy Press 1995 . 62 "Consensus Development Statement on Interventions to Prevent HIV Risk Behaviors" National Institutes of Health, March 1997. ' 63 ~idweI1 and Watson, "Needle Exchange and Access to Sterile Syringes," Health Policy and Tracking Service, Natlonal Conference of State Legislatures, July 23, 1999. 25 64 Health District v. Brocket, 839 P2d 324 (Washington State Supreme Court 1992). 65 Consensus Development Statement on Interventions to Prevent HIV Risk Behaviors, National Institutes of Health, March 1997. 66 Vogt RL, Breda MC, DesJarlais DC, (Tates S, Whiticar P. American Journal of Public Health, Sept. 1998 v 88, 9, pgs. 1403-04 67 Hagan H, McGough JP, Thiede H, Hopkins S, Alexander ER, Reduction in injection risk behavior among users of the Seattle syringe exchange, Proc 12!h World AIDS ConfGeneva, June 28 _ July 3, 1998. 68 Bruneau J, et al. "High rates ofHIV infection among injection drug users participating in needle exchange programs in Montréal: results of a cohort study," American Journal of Epidemiology, Vol. 146, Month (?) 1997, pgs. 994-1002. 69 Schechter MT, et al. "Do needle exchange programmes increase the spread ofHIV among injection drug users?: an investigation of the Vancouver outbreak," AIDS, Vol. 13, No.6, 1999, pgs. F45-F51. 70 Strathdee S. "No Evidence That Needle Exchange Increases Crime or Encourages Drug Use Among Youth," International Harm Reduction Conference, Geneva, Switzerland, March 23-25, 1999. 71 Paone D, Des Jarlais DC, Caloir S, Friedmann P, Ness I. New York City syringe exchange: An overview. Proc Workshop on Needle Exchange and Bleach Distribution; National Academy Press, Washington DC, 1994. 72 Hartgers C, Buning EC, van Santen GW, Verster AD, Coutinho RA. The impact of the needle and syringe exchange programme in Amsterdam on injecting risk behaviour, AIDS 1989; 3: 571-576. 73 Hagan H, Des Jarlais DC, Purchase D, Friedman SR, Reid T, Bell TA. An interview study of participants in the Tacoma syringe exchange. Addic 1993; 88: 1691-1697. 26 American Medical Association tl~' MTys (,:.&nS ()("dJe.ut"d to ttlc: I':r,¡;th cJ .\mII:!1C'¡ ~~ ~\. ~& APPENDIX B ® ~ American /~ Pharmaceutical Association @ (ASn-tO ) :\¡\ST\I) ~ \TID'\; \1. :\1.11 \'\t'" lJlo S1':\n: .\NO T"J\¡':IIII~I \1. \IDS nl~t:c:ro~s APhA 1 he' AUO('I.IIO" .r :-;t.tc- ..d lC'rTllon.! Hull" nrnd..h Octobèr 1999 HIV Prevention & Access To Sterile Syringes Dear Colleague: Approximately one third of all AIDS cases and one half of hepatitis C cases are directly or indirectly linked to injection drug use. Limited access to sterile syringes contributes to the transmission of these blood-borne infections among injection drug users (!DUs), their sex partners, and their children. The United States Public Health Service recommends that drug users who continue to inject use a new, sterile syringe for each injection to prevent the transmission of blood-borne pathogens and that they obtain syringes from reliable sources such as pharmacies. In many states, there are legal and regulatory barriers to the pharmacy sale of sterile syringes to !DUs, including prescription and drug paraphernalia laws and pharmacy regulations on syringe sales. The American Medical Association (AMA), the American Pharmaceutical Association (APhA), the Association of State and Territorial Health Officials (ASTHO), and the National Alliance of State and Territorial AIDS Directors (NASTAD) have suggested that the removal or modification of legal barriers is an important step in increasing the availability of sterile syringes through pharmacies. Connecticut, Minnesota, and Maine have made 'such changes. AMA, APhA, ASTHO, and NASTAD have adopted the following policies related to pharmacy sale of syringes. AMA (1997) APhA (1999) ASTHO (1995) NAST AD (1997) That the AMA strongly encourages state medical associations to initiate state legislation modifying drug paraphernalia laws so that injection drug users can purchase and possess needles and syringes without a prescription. APhA encourages state legislatures and boards of pharmacy to revise laws and regulations to permit the unrestricted sale or distribution of syringes and needles by or with the knowledge of a pharmacist in an effort to decrease the transmission of blood-borne diseases. ASTHO policy states that as a possible public health strategy to reduce the transmission of injection-related blood-borne infections, states should explore the removal of legal barriers such as drug paraphernalia and prescription laws, which criminalize the distribution and/or possession of needles and syringes. NASTAD calls on state and local legislative bodies to increase access to sterile needles and syringes through needle exchange programs; to deregulate possession of needles, syringes and associated injection equipment as drug 27 · . .-...... ..#9....~"-.. . IU ·'HI\. P\ llhIl1Ildlll'S: allU [0 Increase aCl'l'SS (0 drllg trcarl1lent for [hose inJiviJuals rl'a~¡v for slid, tn.:all1lcnl. . NAST AD encourages each slatc hcalth department 10 work with pharmacy boards and local law enforcement agencies to change local laws which would increase access to sterile injection equipment. A\:A, APhA, ASTHO, NAST AD, and the National Association of Boards of Pharmacy (NABP) beJ¡eve that coordinated efforts of state leaders in pharmacy, public health, and medicine are needed to address access to sterile syringes as a means of preventing further transmission of blood-borne diseases. We encourage you and other state leaders in these fields to meet, assess the situation in your state, and decide on appropriate approaches to these important public health issues. Other issues that may be important to consider are the availability of substance abuse treatment and options for safe disposal of syringes. For more information, you can contact the foUowing staff members of the organizations issuing this letter: AMA APhA ASTRO NABP NASTAD U Tan at (312) 464-4147, litjen_tan@ama-assn.org Jann Skelton at (800) 237-2742 ext 7198,jbs@mail.aphanet.org Helen Fox Fields at (202) 371-9090, hffields@astho.org Jan Teplitz at (847) 698-6227,jteplitz@nabp.net Julie Scofield at (202) 434-8090, Jscofield@NASTAD.org We look forward to working with you to address these significant public health problems. Sincerely, æ~~ ~- John A. Gans, PharmD Executive Vice President American Pharmaceutical Association E. Ratcliffe Anderson, Jr., MD Executive Vice President American Medical Association 1P=. Ói1w'd¿" ~)~ Julie M. Scofield Executive Director National Alliance of State and Territorial AIDS Directors Patti Shwayder Interim Executive Vice President Association of State and Territorial Health Officials C~ff Carmen Catizone, MS, RPh Executive Director / Secretary National Association of Boards of Pharmacy 28 REVISED CODE OF WASHINGTON http://search.leg.wa.gov/pub/texts...Item=1&X=209150252&p= 1 &X =2091503C RCW 69.50.102 Drug paraphernalia -- Definitions. (a) As used in this chapter, "drug paraphernalia" means all equipment, products, and materials of any kind which are used, intended for use, or designed for use in planting, propagating, cultivating, growing, harvesting, manufacturing, compounding, converting, producing, processing, preparing, testing, analyzing, packaging, repackaging, storing, containing, concealing, injecting, ingesting, inhaling, or otherwise introducing into the human body a controlled substance. It includes, but is not limited to: (1) Kits used, intended for use, or designed for use in planting, propagating, cultivating, growing, or harvesting of any species of plant which is a controlled substance or from which a controlled substance can be derived; (2) Kits used, intended for use, or designed for use in manufacturing, compounding, converting, producing, processing, or preparing controlled substances; (3) Isomerization devices used, intended for use, or designed for use in increasing the potency of any species of plant which is a controlled substance; (4) Testing equipment used, intended for use, or designed for use in identifying or in analyzing the strength, effectiveness, or purity of controlled substances; (5) Scales and balances used, intended for use, or designed for use in weighing or measuring controlled substances; (6) Diluents and adulterants, such as quinine hydrochloride, mannitol, mannite, dextrose, and lactose, used, intended for use, or designed for use in cutting controlled substances; (7) Separation gins and sifters used, intended for use, or designed for use in removing twigs and seeds from, or in otherwise cleaning or refining, marihuana; (8) Blenders, bowls, containers, spoons, and mixing devices used, intended for use, or designed for use in compounding controlled substances; (9) Capsules, balloons, ~nvelopes, and other containers used, intended for use, or designed for use in packaging small quantities of controlled substances; (10) Containers and other objects used, intended for use, or designed for use in storing or concealing controlled substances; (11) Hypodermic syringes, needles, and other objects used, intended for use, or designed for use in parenterally injecting controlled substances into the human body; (12) Objects used, intended for use, or designed for use in ingesting, inhaling, or otherwise introducing marihuana, cocaine, hashish, or lof3 02/09/20003;1 REVISED CODE OF WASHINGTON http://search.Ieg.wa.gov/pub/texts...Item=I&X=209150252&p= 1 &X =209150300 hashish oil into the human body, such as: (i) Metal, wooden, acrylic, glass, stone, plastic, or ceramic pipes with or without screens, permanent screens, hashish heads, or punctured metal bowls; (ii) Water pipes; (iii) Carburetion tubes and devices; (iv) Smoking and carburetion masks; (v) Roach clips: Meaning objects used to hold burning material, such as a marihuana cigarette, that has become too small or too short to be held in the hand; (vi) Miniature cocaine spoons, and cocaine vials; (vii) Chamber pipes; (viii) Carburetor pipes; (ix) Electric pipes; (x) Air-driven pipes; (xi) Chillurns; (xii) Bongs; and (xiii) Ice pipes or chillers. (b) In determining whether an object is drug paraphernalia under this section, a court or other authority should consider, in addition to all other logically relevant factors, the following: (1) Statements by an owner or by anyone in control of the object concerning its use; (2) Prior convictions, if any, of an owner, or of anyone. in control of the object, under any state or federal law relating to any controlled substance; (3) The proximity of the object, in time and space, to a direct violation of this chapter; (4) The proximity of the object to controlled substances; (5) The existence of any residue of controlled substances on the object; (6) Direct or circumstantial evidence of the intent of an owner, or of anyone in control of the object, to deliver it to persons whom he knows, or should reasonably know, intend to use the object to facilitate a violation of this chapter; the innocence of an owner, o~ of anyone in control of the object, as to a direct violation of this· chapter shall not prevent a finding 'that the object is intended or 20f3 02/09/20003:09 PM REVISED CODE OF WASHINGTON http://search.Ieg.wa.gov/pub/texts...Item=1&X=209150252&p= 1 &X =2091503 C designed for use as drug paraphernalia; (7) Instructions, oral or written, provided with the object concerning its use; (8) Descriptive materials accompanying the object which explain or depict its use; (9) National and local advertising concerning its use; (10) The manner in which the object is displayed for sale; (11) Whether the owner, or anyone in control of the object, is a legitimate supplier of "like or related items to the community, such as a licensed distributor or dealer of tobacco products; (12) Direct or circumstantial evidence of the ratio of sales of the object(s) to the total sales of the business enterprise; - (13) The existence and scope of legitimate uses for the object in the community; and (14) Expert testimony concerning its use. [1981 c 48 § 1.] NOTES: Severability -- 1981 c 48: "If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [1981 c 48 § 4.] 30f3 02/09/2000 3:09 P~f REVISED CODE OF WASHINGTON http://search.leg. wa.gov/pub/texts...Item=I&X=20915021 0&p=I&X=209 1502I- RCW 69.50.412 Prohibited acts: E -- Penalties. (1) It is unlawful for any person to use drug paraphernalia to plant, propagate, cultivate, grow, harvest, manufacture, compound, convert, produce, process, prepare, test, analyze, pack, repack, stor.e, contain, conceal, inject, ingest, inhale, or otherwise introduce into the human body a controlled substance. Any person who violates this subsection is guilty of a misdemeanor. (2) It is unlawful for any person to deliver, possess with intent to deliver, or manufacture with intent to deliver drug paraphernalia, knowing, or under circumstances where one reasonably should know, that it will be used to plant, propagate, cultivate, grow, harvest, manufacture, compound, convert, produce, process, prepare, test, analyze, pack, repack, store, contain, conceal, inject, ingest, inhale, or otherwise introduce into the human body a controlled substance. Any person who violates this subsection is guilty.of a misdemeanor. (3) Any person eighteen years of age or over who violates subsection (2) of this section by delivering drug paraphernalia to a person under eighteen years of age who is at least three years his junior is guilty of a gross misdemeanor. (4) It is unlawful for any person·to place in any newspaper, magazine, handbill, or other publication any advertisement, knowing, or under circumstances where one reasonably should know, that the purpose of the advertisement, in whole or in part, is to promote the sale of objects designed or intended for use as drug paraphernalia. Any person who violates this subsection is guilty of a misdemeanor. [1981 c 48 § 2.] NOTES: Severability -- 1981 c 48: See note following RCW 69.50.102. I of 1 02/09/20003:08 PM REVISED CODE OF WASHINGTON http://search.1eg.wa.gov/pub/texts...Item=I&X=209150110&p=I&X=20915011' RCW 69.50.4121 Drug paraphernalia -- Selling or giving Penalty. (1) Every person who sells or gives, or permits to be sold or given to any person any drug paraphernalia in any form commits a class I civil infraction under chapter 7.80 RCW. For purposes of this subsection, "drug paraphernalia" means all equipment, products, and materials of any kind which are used, intended for use, or designed for use in planting, propagating, cultivating, growing, harvesting, manufacturing, compounding, converting, producing, processing, preparing, testing, analyzing, packaging, repackaging, storing, containing, concealing, injecting, ingesting, inhaling, or otherwise introducing into the human body a controlled substance. Drug paraphernalia includes, but is not limited to objects used, intended for use, or designed for use in ingesting, inhaling, or otherwise introducing marihuana, cocaine, hashish, or hashish oil into the human body, such as: (a) Metal, wooden, acrylic, glass, stone, plastic, or ceramic pipes with or without screens, permanent screens, hashish heads, or punctured metal bowls¡ (b) Water pipes¡ (c) Carburetion tubes and devices¡ (d) Smoking and carburetion masks¡ (e) Roach clips: Meaning objects used to hold burning material, such as a marihuana cigarette, that has become toò small or too short to be held in the hand¡ (f) Miniature cocaine spoons and cocaine via1s¡ (g) Chamber pipes¡ (h) Carburetor pipes¡ (i) Electric pipes¡ (j) Air-driven pipes¡ (k) Chillums¡ (1) Bongs¡ and (m) Ice pipes or chillers. (2) It shall be no defense to a prosecution for a violation of this section that the person acted, or was believed by the defendant to act, as agent or representative of another. (3) Nothing in subsection (1) of this section prohibits legal distribution of injection syringe equipment through public health and community based HIV prevention programs. [1998 c 317 § 1.] 10f2 02/09/20003:07 P:-'1 REVISED CODE OF WASHINGTON http://search.leg.wa.gov/pub/texts...Item=I&X=209150110&p= 1 &X=209150 I ¡ NOTES: Reviser's note: 1998 c 317 directed that this section be added to chapter 26.28 RCW. This section has been codified in chapter 69.50 ~, which relates more directly to controlled substances~ 20f2 02/09/20003:07 P\f REVISED CODE OF WASHINGTON http://search.leg.wa.gov/pub/texts...Item=1&X=209145948&p= 1 &X=2091500C RCW 70.1.1.5.050 Retail sale of hypodermic syringes, needles -- Duty of retailer. On the sale at retail of any hypodermic syringe, hypodermic needle, or any device adapted for the use of drugs by injection, the r~tailer shall satisfy himself or herself that the device will be used for the legal use intended. [1981 c 147 § 5.] 1 of 1 02/09/20003:06 PM http://search.leg. wa.go...180%20-%2052%20-030.htm http://search.leg.wa.gov/wslwacIWA...PTER/W AC%20 180%20-%2052%20~030.hri- WAC 180-52-030 Pupil tests and reçords -- Certain tests, questionnaires, etc. __ Limitations. No written or oral test, questionnaire, survey, or examination shall be used to elicit the personal beliefs or practices of a stùdent or his parents as to sex or religion except with the written consent of parent or guardian. [Order 10-69, § 180-52-030, filed 12/5/69.] 1 of 1 02/09/20003:14 P:vf ENGROSSED SUBSTITUTE SENATE BILL 5019 State of Washington 56th Legislature 1999 Regular Session By Senate Committee on Human Services & Corrections (originally sponsored by Senators Patterson, Thibaudeau and McAuliffe) Read first time 02/17/1999. 1 AN ACT Relating to opiate substitution treatment programs ¡ amending 2 RCW 70.96A.400, 70.96A.410, and 70.96A.420¡ creating new sections¡ and 3 providing expiration dates. 4 BE IT ENACTED BY THE LEGISLATURE OF· THE STATE OF WASHINGTON: 5 Sec. 1. RCW 70.96A.400 and 1995 c 321 s 1 are each amended to read 6 as follows: 7 The state of Washington declares that there is no fundamental right 8 to opiate substitution treatment. The state of Washington further 9 declares that while «methadone and other like pharmacologica.l)) opiate 10 substitution drugs«,») used in the treatment of opiate dependency are 11 addictive substances, that they nevertheless have several legal, 12 important, and justified uses and that one of their appropriate and 13 legal uses is, in conjunction with oth~r required therapeutic 14 procedures, in the treatment of persons addicted to or habituated to 15 opioids. 16 Because «methadone and other like pharmacological» opiate 17 substitution drugs, used in the treatment of opiate dependency .are 18 addictive and are listed as a schedule II controlled substance· in 19 chapter 69.50 RCW, the state of Washington «and authorizing countie~ p. 1 ESSB 5019 1 on bch~l: 0: t~ci~ citizCfi3 hùve)) has the legal obligation and right 2 to regulaie the use of opiate substitution treatment. The state of 3 Washington declares its authority to control and regulate carefully, in 4 ((coopcr~tion)) consultation with «(the authorizing)) counties and 5 cities, all clinical uses of ((mcthadone and othcr ph~rm~cological)) 6 opiate substitution drugs used in the treatment of opiate" addiction. 7 Further, the state declares that the primary goal of opiate 8 substitution treatment is total abstinence from chemical dependency for 9 the individuals who participate in the treatment program. The state 10 recognizes that a small percentage of persons who participate in opiate 11 «3ubstit~te (sub3titution])) substitution treatment programs require 12 treatment for an extended period of time. Opiate substitution 13 treatment programs shall provide a comprehensive transition program to 14 eliminate chemical dependencY«(Î))~ including opiate and opiate 15 substitute addiction of program participants. 16 Sec. 2. RCW 70.96A.410 and 1995 c 321 s 2 are each amended to read 17 as follows: 18 (1) (A county legislati-,..-e authority may prohibit opiate 19 ::mb3ti tution trcatment in that county. ':Phe department shall not 20 ccrtify an opiate 3ub3titution trcatment program in a county \;here the 21 county legi31ative authority ha3 prohibitcd opiate sub3titution 22 treatment. If a county legi31ative authority authorizes opiate 23 :mbstitution treatmcnt progrÐ.IR3, it shall limit by ordinance the number 24 of opiate substitution treatment progr~s opcrating in that county by 25 limiting the number of licenscs granted in that county. If a county 26 has authorized opiate 3ubstitution treatment programs in that county, 27 it shall only license opiate substitution treatment program3 that 28 comply .lith the department's opcrating and treatment 3tandards under 29 thi3 section and TI;CW 70. 96A. 420. ...'"". county that authorize3 opiatc 30 substitution treatment may operate the programs directly or through a 31 local health department or health district or it may authorize 32 certified opiate sub3titution treatmcnt progn.ufl3 that the county 33 liccn3e:J to provide thc 3crJ"icc:J "Jithin t~c county. Countie3 3hall 34 monitor opiate sub3titution trcatmcnt progræn3 for compliance "lith the 35 department's operating and treatment regulations under thi3 3ection and 36 ncw 70.J6A.420. 37 (2) A county that authorize3 opiate .3ubsti tution treatment programs 38 shall dcvelop and enact by ordinance licensing standards, consi3tent ESSB 5019 p. 2 1 wit~ ~~~3 chQpter and the operating ùnd treatment 3tandard3 ùdo~:ed 2 undcr thi3 chapter, that gover:1 the application for, issuance of, 3 rene".ml of, .J.nd revocation of the lieen3cs. Certified progrD..'1'.s 4 exi3tinç before Hay 18, 1987, applying for rene".;al of licensure in 5 3ubsequent years, that maintain certification and meet all other 6 requi~ement3 for licensure, 3hall be given preference. 7 (3) In certifying programs, the department 3hall not di3criminùte 8 against an opiate sub3titution treatment program on the ba3i3 of its 9 corporate 3tructure. In licen,:3Ìng program3, thc county shall r..ot 10 di3criminate against an opiate 3ubstitution treatment program on the 11 basis of it3 corporatc 3tructurc. 12 +4+») For Durooses of this section and section 3 of this act, 13 "area" means the county in which an applicant Droposes to locate a 14 certified 'Órogram and counties adjacent. or near to. the county in 15 which the Drocrram is Droposed to be located. 16 When makincr a decision on an application for certification of a 17 procrrarn. the deDartment shall: 18 (a) Consult with the county lecrislative authorities in the area in 19 which an ap~licant Droposes to locate a Droaram and the city 20 lecrislative authority in any city in which an apDlicant DrODoses to 21 locate a Drocrram; 22 (b) Certify only Drocrrams that will be sited in accordance with the 23 appropriate county or city land use ordinances; 24 (c) Not discriminate in its certification decision on the basis of 25 the coroorate structure of the apDlicant; 26 (d) Consider the size of the Dopulation in need of treatment in the 27 area in which the Drocrram would be located and certify only aDDlicants 28 whose Droarams meet the necessary treatment needs of that Dopulation; 29 (e) Consider the availability of other certified Drograrns near the 30 area in which the apDlicant Droposes to locate the Dro~ram; 31 (f) Consider the transDortation systems that would provide service 32 to the program and whether the systems will provide reasonable 33 oDDortunities to access the proaram for persons in need of treatment: 34 (a) Consider whether the aDplicant has. or has demonstrated in the 35 past. the caDability to Drovide the aDDroDriate services to assist the 36 persons who utilize the Drocrram in meetina aoals established by ·the 37 legislature. includina abstinence from oDiates and oDiate substitutes, 38 obtainina mental health treatment. imDrovinq economic independence. :and 39 reducinq adverse conseauences associated with illegal use of controlled p. 3 ESSB 5019 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 1 substances. The de artment shall rioritize certification to 2 a clicants who have demonstrated such ca 3 h Hold at lea ublic hear in in the count 4 facilit ld at osed to be located and one hear in ln the a ea in which the facilit osed to b located. The hear in a time and location that are most likely to Dermit the laraest number of interested ersons to ttend and resent te timon Tent shall notify all aDDropriate media outlets of the time. date. and location of the hearing at least three weeks in advance of the hearina. ill A program applying for certification from the department and a program applying for a contract from a state agency that has been denied the certification or contract shall be provided with a written notice specifying the rationale and reasons for the denial. ( (:A: program applying for a licen3c or a contract from a county that has becn denied the license or contract shall be· provided -.v'"ith a -.n-ittcn notice specifying the rationale ~~d reason3 for the denial. (5) A lic~nse is effecti7e for one calendar year from the date of issuance. The license shall bc reneí..-ed in accordancc -1IVith the pro7isions of this section for initial approval, treatment programs under new 70.96A.400, the standards 70.96A.420, and .thc rulcs adopted by thc secretar}". ~) ill For the purpose of this chapter, opiate the goals for set forth in new substitution treatment means~ (a) Dispensing an opiate substitution drug approved by the federal drug administration for the treatment of opiate addiction~ and (b) Providing a comprehensive range of medical and rehabilitative services. (4) The deDartment may expand the number of certified proarams at an annual rate not to exceed ten Dercent. subiect to aDpropriations. The deDartment shall DrODose in its biennial budaet reauest sDecific fundina necessary to e~and the number of certified Droarams in areas certified as needinq additional treatment caDacitv. but not to exceed the" maximum annual arowth rate. NEW SECTION. Sec. 3. (1) The department may operate a pilot the benefits and costs to the public by of opiate substitutes under t?is section. The limited to not more than ten physicians around program to determine authorizing dispensing pilot program shall be ESSB 5019 p. 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 the state and shall be subject to the conditions established ~n this section. (2) The department shall establish by rule, and in consultation '. with the Washington institute for public policy, inform<?-tion to be provided by physicians who participate in the pilot proj ect for purposes of the evaluation requirement established in section 6 of this act. (3) A physician licensed· under chapter 18.57 or 18.71 RCW may operate a certified program at the physician's usual place of business. Physician-operated certified programs are not subject to the siting requirements of section 2 of this act if the physician operates the program within his or her existing medical practice and his or her existing medical practice serves patients with a variety of medical conditions. Opiate substitution services =cannot be the physician's exclusive practice. (4) The department shall not certify any physician to dispense opiate substitutes unless the department determines: (a) There is a need for an a~propriate physician-based dispensing program; (b) The physician is adequately trained to diagnose the need for opiate substitutes; and (c) There are adequate safeguards in place to assure (i) regular and ongoing testing of patients to verify there is no unlawful use of controlled substances; and (ii) opiate substitutes dispensed bya certified physician are taken only by the patient to whom the substitute is dispensed. (5) In determining whether there is a need for a physician-based dispensing program, the department shall: (a) Consider the size of the population in the area who would be appropriately served by physician dispensing of opiate substitutes and certify only the number of applicants necessary to meet the treatment needs of that community; (b) Consult with the county legislative authorities in the area in which the certified physician will conduct business; (c) Consult with the city legislative authority in any city in which an applicant will conduct business; (d) Certify only physicians who will dispense opiate substitute~ in facilities sited in accordance with appropriate county or city land use ordinances; and p. 5 ESSE 5019 1 (e) Consult with any other individual or entity the secretary deems 2 necessary. 3 (6) In determining the adequacy of training, the department shall: 4 (a) Give strong consideration to certification and educational 5 standards developed by appropriate professional associations; 6 (b) Determine whether the physician is willing and able to work in 7 consultation with certified opiate substitution programs to assure that 8 patients served by the physician are appropriate for physician-based 9 services rather than by a certified program established under RCW 10 70.96A.4l0; and 11 (c) Determine whether the physician is capable of recognizing and 12 referring patients to appropriate mental health treatment services and 13 agrees to do so. 14 (7) This section expires June I, 2002. 15 Sec. 4. RCW 70.96A.420 and 1998 c 245 s 135 are each amended to 16 read as follows: 17 (1) The department, in consultation with opiate substitution 18 treatment service providers and counties «authorizing opiate 19 3ub3titution treatment programs)) and cities, shall establish state- 20 wide treatment standards for certified opiate substitution treatment 21 programs. The department «and counties that authorize opiate 22 3ub3titut~on treatment programs)) shall enforce these treatment 23 standards. The treatment standards shall include, but not be limited 24 to, reasonable provisions for all appropriate and necessary medical 25 procedures, counseling requirements, urinalysis, and other suitable 26 tests as needed to ensure compliance with this chapter. «A opiate 27 sub3titutior. treatment program shall not have a caseload in excess of 28 three hundred fifty persons.)) 29 (2) The department, in consultation with opiate substitution 30 treatment programs and counties «authorizing opiate substitution 31 treatment programs), shall establish state-wide operating standards 32 for certified opiate substitution treatment programs. The department 33 «and countics that authorize opiate 3ubstitution treatment programs)) 34 shall enforce these operating standards. The operating standards shall 35 include, but not be limited' to, reasonable provisions necessary to 36 enable the department and «(authorizing)) counties to monitor certified 37 and licensed opiate substitution treatment programs for compliance with 38 this chapter and the treatment standards authorized by this chapter and ESSB 5019 p. 6 , to minimize the. impact of the opiate substitution treatment programs 2 upon the business and residential neighborhoods in which the program ~s 3 located. 4 (3) The department shall es tablish criteria for evaluating the 5 compliance of opiate substitution treatment programs with the goals and 6 standards established under this chapter. As a condition of 7 certification, opiate substitution programs shall submit an annual 8 report to the department and county legislative authority, including 9 data as specified by the department necessary for outcome analysis. 10 The department shall analyze and evaluate the d~ta submitted by each 11 treatment program and take corrective action where necessary to ensure 12 compliance with the goals and standards enumerated under this chapter. 13 (4) Before January 1st of each year. the secretary shall submit a 14 report to the leaislature and aovernor. The reDort shall include the 15 number of ~ersons enrolled in each treatment proararn durina the Deriod 16 covered bv the report, the number of persons who leave each treatment 17 Droaram voluntarilv and involuntarily. and an outcome analysis of each 18 treatment Droararn. For pUrDoses of this subsection, "outcome analysis" 19 shall include but not be limited to: The number of DeoDle who, as a 20 result of DarticiDation in the -proararn. are able to abstain from 21 oDiates; reduction in use of oDiates; reduction in criminal conduct; 22 achievement of economic indeDendence; and reduction in utilization of 23 health care. The report shall include information on an annual and 24 cumulative basis beqinnina on the effective date of this section. 25 NEW SECTION. See.·S. (1) The governor and the department of 26 social and health services shall seek all necessary exemptions and 27 waivers from and amendments to federal statutes, rules, and regulations 28 to secure the federal changes to permit physicians to dispense opiate 29 substitutes at their usual place of business in accordance with RCW 30 70.96A.410 at the earliest possible date. 31 (2) This section expires June 30, 2004. 32 NEW SECTION. See. 6. (1) The Washington institute for public 33 policy shall evaluate the pilot project established in section 3 of 34 this act. The evaluation shall determine: 35 (a) Whether dispensing of opiate substitutes by physicians cau~es 36 an increase in the use of the substitutes by persons other than the 37 clients of physicians; p. 7 ESSB 5019 1 (b) The impact of physician dispensing on the achievement of 2 legislative goals established as set forth in RCW 70.96A.410(1) (g); 3 (c) The impact of participation by a physician in the pilot project 4 on the remainder of the physician's professional practice; 5 (d) Whether there are conditions or restrictions which impede the 6 achievement of legislative goals through physician dispensing of opiate 7 substitutes and, if so, how those conditions or restrictions can be 8 addressed. 9 (2) The evaluation shall be presented to the legislature and the 10 department of social and health services not later than June 1, 2001. --- END --- ESSB 5019 p. 8 JEFFERSON COUNTY BOARD OF HEALTH Agenda Item Information/Description .... Regular Business FOR MONTH OF: April 12, 2000 1. Description -- a brief description of the agenda item: Please include project, road, contract, grant, etc. number if one is available for the Commissioner Index. Annual awards issued to food service establishments that have demonstrated a high level of standard in terms of safe food handling practices. 2. Issue -- a short outline of the issue: including policy issue falls within; strategy or objective issue supports; key reference areas (Iaw/policy/regulation): Food service establishments receive at least two compliance inspections annually. Inspections focus on condition of facilities and on food handling practices. Regulatory response to food service compliance inspections centers on actions taken when violations are noted. There is no provision for recognition of high standard of compliance in the food service rules. A number of years ago the Department, at the suggestion of the food service advisory committee, decided to offer outstanding achievement awards to those establishments that had excellent inspection reports throughout the year. Awards are based on a number of factors including; the business must have been in operation for at least one year, the business operations must include the preparation of potentially hazardous food, the business must operate year round, there must have been at least two inspections of the facility, there can be no repeat red items, not more than 10 red points during anyone inspection and not more than 20 points total in anyone inspection. In addition there must be a demonstrated responsiveness in correcting violatons. The establishments named here have maintained that standard. It is significant to note the high percentage of establishments that are receiving repeat awards, in some cases as long as five years running. Environmental Health Division Review of Building Permit Applications A policy is being developed to provide the details and to address non- residential structures. The basics incl:.Jde: For residential building applications there is a need to establish an accurate record for a site and assess the ability of the existing system to treat the waste water. The record shall inclade: a) Location of the septic tank and pump chamber if present and b) Location of the distribution box or beginning of the drainfield/distribution system and c) Length and width of drainfield/distribution system and d) Depth of usable soil, vertical separation from the bottom of the drainfield/distribution system and e) Designation of a reservelrepair area that complies with the code in effect at the time of building permit application. The record shall be established through examination of approved asbuilt records in Jefferson County files or by inspection by the Health Division, licensed Designer or licensed Professional Engineer. Systems found to be in compliance with current treatment standards, meeting vertical separation. standards, shall comply with the Table 1 inspection schedule for the system type identified. The owner of a system not in compliance with current treatment standards, not meeting vertical separation standards, shall install two (2) monitoring ports on the contour of the drainfield/distribution system to a depth of three (3) feet below the bottom of the drainfield to determine the level of compliance with treatment standards and assure that the system does not contaminate ground water. Owners of these system shall sign a contract with the PUD for monitoring and the systems shall be inspected annually. If the system is found to be contaminating ground water repair/upgrade of the system shall be required. For non-residential building applications: On lots of five (5) acres or less a record of the system shall be established as in a) - e) above. On lots greater than five (5) acres a reserve area shall be established if based on the plot plan there is clearly no interference with the existing system and there is a permit on record. ??? The question remains on larger sites where there is no record at all?? Do we just establish reserve/repair area based on review of the plot plan? Make a driveby check for additional assurance? On completely unknown sites do we need to establish some record for any building permit? RECOMMENDATION Retain revised 8.15.060 (3) and continue development of Policy. On sites larger than 5 acres establish reserve/repair area based on review of the plot plan unless the site is adjacent to a surface water or other critical area as mapped. Staff will use best professional judgement to determine if a driveby inspection is necessary. - -~ - OPERATIONS AND MONITORING PUD AS PRIMARY MONITORING ENTITY BENEFITS o Consistency of inspection & knowledge that inspections are completed o Lower Cost $50 - $1 DO/inspection. PUD is a public entity and cannot make a "profit" on the inspection program. o Oversite on limited # of people conducting inspections o Owner retains the right to choose the maintenance person of their choice. They are not locked into a contract for maintenance. ' o No vested interest in finding problems o Ability to tie the PUD into our existing database, Permit Plan. DISADVANTAGES o PUD would not provide maintenance services. Still the responsibility of the owner to maintain or contact maintenance person (installer or pumper as necessary) PRIVATE CONTRACTOR/CERTIFIED 0 & M SPECIALIST BENEFITS o Potential to involve a larger # of inspectors by creating a pool to choose from. May create more choice. DISADVANTAGES o Higher costs -$150 - 450 ¡year. This typically includes 1 or 2 inspections and basic maintenance such as washing off screens and may include flushing of the laterals. The mechanism for inspection is typically a maintenance contract. o Time and cost to County to develop the program, test and certify Specialists. o Time and cost to County to provide oversite of Certified Specialists, both submittal of inspection reports and quality of work. o Time and cost to County to track non-compliance with inspection requirements. RECOMMENDATION PUD as the primary monitoring entity. Reduces the cost to the County to develop a "new" program element. It retains currently Certified professionals as maintenance providers to complete work currently included under their license to practice. For example: pumpers can pump, clean and replace pump screens and baffles, repair, replace or install risers, flush laterals. Installers can complete all of the above except pumping and all other work on systems (except that requiring an electrician). We would retain the section on 0 & M Specialist so that if we find there is a need to certify additional practitioners this is available. Jefferson County Health and Human Services MARCH ~ APRIL 2000 NEWS h. These issues and more are brought to you every month as a collection of news stories regarding Jefferson County Health and Human Services and its program for the public: 1. "Opposition surfaces to needle exchange" - P.T. LEADER, 3-22-00 2. "Locke urges meth lab cleanup funds for states" - Peninsula Daily News, 4-2-00 3. "Tip leads to two suspects in animal shelter break-in" - Peninsula Daily News, 4-11-00 4. "Board of health invites public comment on syringe exchange" - P.T. LEADER, 4-12-00 5. "Public needle program risky" - Opinion Forum, P.T. LEADER, 4-12-00 .-' A 8 · Wednesday, March 22, 2000 (,~ItDer2- . -- - -.-. .<-"_.~-.._-~.- Opposition surfaces to needle exhange By Janet Huck leader Staff Writer An estimated 36 percent of HIV infections nationwide are caused by sharing dirty needles. Sixty percent of hepatitis C virus cases, which can lead to liver can- cer, are associated with needle use, according to the Center for Dis- ease Control. As intravenous drug use in- creases in rural pockets like Jefferson County, local health boards are considering needle ex- change programs that can cut down on the transmission of com- municable diseases. The Clallam County health board approved an exchange program two months ago. And 11 other Washington counties have already began them. Now Jefferson County's board of health is examining a similar program. Last summer the board asked the health department to develop a syringe exchange pro- gram to cut down on the transmis- sion of infectious diseases. Public hearings have begun. The first was March 16 and the next is April 20, both at I :30 p.m. If adopted, the health department could imple- ment the program this summer. ((This is to stop a communicable disease epidemic before it starls," Jean Baldwin, community health director for the Jefferson Health and Human Services Department Exchange used for clean The needle exchange pro- gram would serve a smalI popu- lation, said Jean Baldwin, the community health director for the Jefferson Health and Human Resources Department. Survey- ing local treatment providers. she estimated there woul¡j be only 25 to 50 clients the first year. The exchange would Occur only once or twice a month. Basically, the syringe exchange program would exchange used syringes for clean ones. It would also be an opportunity to provide not only infonnation about the dangers of IV drug use, but coun- seling about substarice abuse treat- ment programs, HIV testing and tuberculosis testing, said Baldwin. "This is to stop a communi- cable disease epidemic before it starts," said Baldwin. It could reduce public exposure to infectious disease, increase pub- lic safety and decrease the occu- pational hazards faced by law en- forcement officers and health care providers, she told the board. "If five people who used to share needles stopped sharing, there are five who aren't sharing diseases, and there could be an- other 100 people who aren't in- fected," said City Council and health board member Geoff Masci. Local substance abuse profes- sionals and the law enforcement community support the effort, said Baldwin. The state Board of Health supports the implementa- tion of the exchange programs in every county because members believed it encourages drug users to seek treatment and reduce HIV transmission rates without increas- ing drug use. Program questioned A few Jefferson County resi- dents, however, were concerned the exchange could encourage drug use. "I think giving addicts free needles is like giving an alco- holic.a bottle of scotch and s.ay.ing, use a clean glass," said Port Hadlock resident Milt Morris. At last Thursday's public hear- ing, Morris brought a number of newspaper anicles and national studies that suggested needle ex- change programs don't reduce AIDS and actually lured addicts away from treatment. He told board members he has talked to about 100 people in the Tri-Area, encouraging them tD contact health board members. "There are a whole lot of folks opposed to the program," he told them. "I understand trying to cor- ral drug use, but I think the money is better spent in law enforcement and making [drug addicts] ac- countable. If it means putting them in jail, we should lock them up." Jefferson County Commission Glen Huntingford also thought the program might send an inadvert- ently pro-drug message. "It's hard for me to tell [high school] kids with problems, 'just get a clean needle,'" he said. "I don't want them to die, but I don't want to tell these kids they can continue doing drugs." Health board member Sheila Westennan answered Huntingford. "It's not saying you can do drugs," she said. "In Yakima, the [exchange program officials] said they made more CDntact with users and got more people into treatment than ever before. If it encourages people to get help, that outweighs the risk of ap- pearing to condone drug use." Roberta Frissell, chairwoman of the board, echoed Westennan. 'There are so few opportunities for contacts [with addicts] outside of the criminal justice system. If you give a lot of needles and infonna- tion to one person, maybe somt: day the infonnation will click and they will reach out for help." One member of the public supported the program. "I have seen the effect of people who used unclean needles - they die," said Mark Gorden, who has been living with HIV for 15 years. Then he looked directly at several board members. "I ·wan¡ you to think, when you are go- ing to skep: Could you sa\'e someone from HIV by appro\'- ing this program?" J Northwest ~- Z -00 PENINSULA DAILY NEWS Locke urges meth lab cleanup funds for states PENINSULA DAlLY NEWS Law enforcement officials got good news as Congress began working on funding to help states with the cleanup of methampheta- mine laborato- nes. Gov. Gary I..ccke said Fri- day that the state's growing meth lab prob- lem qualifies as a genuine threat Locke to public health and safety. "I want to thank the state's House delegation who supported the additional funding, and urge both our senators to do the same when the bill reaches the Senate," he said. "This continued federal fund- ing, along with increased state funding I've asked the Legisla- ture to provide, will help us meet the growing need. " Sen. Slade Gorton, R-Seattle, said late last week that he intended to ask the Senate to approve $15 million for meth lab cleanups. Last Wednesday the U.S. House of Representatives adopted an amendment to the supplemen- tal appropriations bill for the cur- rent year, shifting $15 million in unused law enforcement funds to help states with costs of cleaning up meth labs. . In Washington state, funding and assistance is handled by the state Department of Ecology, using money from the U.S. Drug Enforcement Agency. Ecology learned last month that DEA's budget for meth lab cleannps had been used up. Jeffefson, Clall~m labs During the first two months of this year, Jefferson County uncov- ered and needed cleanup funds for five meth labs. Jefferson County Sheriff Pete Piccini said in his department's most recent bust in February, deputies were left gwirding a lab site for four days before the state could respond. Clallam County law enforce- ment officials, while involved in a number of meth lab busts, hasn't: had to call on Ecology for cleanup . assistance since 1998. Toxic lab sites Meth - a highly addictive and potent nervous system stimulant· - can be extracted from chemi- cals found in over-the-counter. products as innocent as deconges- . tant medication. The drug induces hallucina- - tions and aggression - factors linked to criminal behavior - and : can damage the user's heart and kidneys. Sometimes, it can harm or kill innocent bystanders. The process of producing meth, or "cooking," creates a highly toxic, potentially explosive site that takes days and thousands of dollars to clean up. . In 1999, Ecology provided ini- tial stabilization and cleanup ser- . vices in response to 789 meth labs across the state. In the first two months of this year, Ecology has responded to 218 labs, including the five in Jef- , ferson County. That's a 65 per- cent increase from the number at this time last year. J Tip leads to two suspects in animal shelter break-in Routine call leads to teen-agers already linked to unrelated crimes BY PHILIP L. W ATNESS PENINSULA DAlLY NEWS PORT TOWNSEND - When three teen-agers caught the eye of a Jefferson County deputy sheriff ón Sunday, two other teens were caught red-handed. Deputy Brian Graves discov- ered a tranquilizer gun and darts stolen March 1 from the Jefferson County Animal Shelter when he questioned two girls and a boy at the Evangelical Free Church in Irondale. Graves went to the shurch on a call regarding suspi- 'cious characters. ~ Sgt. Bob Haynes said the boy ~ld Graves the names of the sus- ','Deets who broke into the shelter rJ) N 1-1/ -ðCJ jail, pending a Wednesday hearing on other burglary and break.in charges. He will also be charged with burglary and theft in the animal shelter case. and where they had hidden other Huth set Doyle's bail at $1,500 stolen property, including a digi- and scheduled his arraignment tal camera. for 9 a.m. April 21 in Superior The boy said Justin R. Doyle, Court. 18, of Port Hadlock and a.17 -year.. :. Doyle allegedly acted as the old Port Townsend boy were - look-out for the; 7-year-old, ,who respo sible for th br ak.in. allegedly bu.rglarlzed the anlmal nee. d shelter. Doyle w~ alre~dy lp custo y Employees found a complete for probatlOn vlOlatlOns and mess when they arrived at work appeared MOI7da~ before Jeffer- March 1. Vandals had emptied a son County DIstrict Court Judge fire extinguisher, broken three Mark Huth. windows overturned bins of ani. He has been charged with sec- mal food, dumped files, wrote ond-degree .burglary and first- graffiti, destroyed disks, comput. degree theft m another case. Each ers and other equipment and felony charge carries a maximum released animals. The graffiti penalty of 10 years in prison and included profanity, threats and a $20,000 fine. the name of one Animal Services The 17·year-old boy was also in employee. J ,_ port Townsend Ii;( Jefferson County L~ader 4-/2.-0(,' Board of health invites public cOl11Jl1ent on syrjIlgeexchange The Jefferson County Board of Health plans a public hearing at 1 :30 p.m. Thurs- day, April 20 at the héa1th department, 615 ~heridan St., Port Townsend. The purpose ~(this hearing is to receive public comments concerning the implementation of a syringe ~xchange :program (SEP) in Jefferson c:ounty. The syringe exchange program will be part 6f communicable disease prevention programs within the health department and is anticipated to be a joint effort of Jefferson ánd Clallam counties. ' . . The overall goals of the syringe exchange program are to decrease public exposure to infectious diseases, including HIV and hepa- titis C, from contaminated syringes; increase public safety by providing for safe disposal òf contaminated syringes; and increase di- rect contact and outreach to injection drug users and decrease occupational hazards. Syringe exchange services will include the exchange of contaminated syringes for clean syringes; provide infonnation on ways to reduce the spread of blood-borne diseases; and provide linkages to substance abuse treat- "ment, HIV and hepatitis counseling and test- ing, and health care referrals. According to Centers for Disease Con- trol (CDC), about 60 percent of hepatitis C infections are due to injection drug use and ,36 percent of HIV infections are directly or indirectly related to injection drug use. CDC recommendations include that to reduce the risk of infectious disease, injection drug us- ers unable to stop using drugs should "use a new, sterile syringe to prepare and inject drugs" and practice safe injection techniques. According to several sources, public con- cerns raised include the belief that SEPs pro- mote drug use. Six government reports con- cur that access to sterile syringes does not increase drug use, and no reports contradict this finding. Additional public concerns high- light that SEPs send the "wrong message" about drug use. SEPs provide infectious dis- ease prevention and reach populations with long histories of injection drug use. Clients who utilize SEPs have more exposure to drug abuse treatment than injection drug users who do not use SEPs. In Washington state, the state board of health supports implementation of SEPs in every county 1) to decrease mv infection rates among injection drug users and 2) because SEPs act as a gateway to substance abuse treat- ment and exchange sites are a leading source of drug treatment referrals in Washington state. Washington state has SEPs in operation in numerous counties, including Whatcom, Cowlitz, Island, Skagit, Snohomish, TacomaJ Pierce, Seattle/King, Spokane, Walla Walla, Thurston and Yakima. National and state syringe exchange ref- erence infonnation is available for public review at the Port Townsend Library, Jeffer- son County Library and at the health depart- ment. For additional infonnation contact Jean Baldwin, director of nursing services at the health department, at 385-9400. J Letters Public needle program risky Editor, The Leader: Without much fanfare, the Jefferson County Board of Health is going for- ward with a plan to implement a needle exchange program (NEP) for intrave- nous drug users. The board of health believes such a program will significantly reduce the number of cases of infectious diseases such as hepatitis C (HCV) and B (HCB) along with the HIV virus and AIDS cur- rently being spread through the use of shared needles. The board claims that six government reports concur that access to sterile sy- ringes does not increase drug use and that no reports contradict these findings.' It claims the program will protect the pub- lic from exposure t~ infectious diseases and increase public safety, protecting law enforcement officers from the hazards of being stuck with a dirty needle during an arrest. Unfortunately, these reasons are all subject to suspicion. There are no cases ofHCV, HCB, HN or AIDS in the county directly attributable to sharing of dirty needles, and apparently never have been. What about the risk to law enforce- ment personnel? Jefferson County Sher- iff Pete Piccini and Port Townsend Police Chief Kristen Anderson both told me if one of their officers is stuck with a needle, they have no idea if it was con- taminated or not and the officer must go through an extensive and costly'regimen to be sure he or she is not infected. Studies throughout this country have shown there is little if any reduction in the spread of diseases or the number of needles discarded in public places as the result of needle exchange programs.. Why? Because intravenous drug users continue to share needles and discard them at random. Thirty-nine to 40 per- cent of HIV-positive addicts have lent their used needles to someone else or have borrowed a used needle during the previous six months. The users receive another benefit from these programs. This is little talked about by the proponents. By their very nature thesè programs establish 'a net- work öfdrug users; because only people with drugs come to get free needles. These facts and more are supported by studies in the United States, Australia, Canada, New Zealand, Great Britain and other European countries. Over the long haul, these programs ~imply have not worked, have .cost thousands of tax dol- lars and have been st1Ut:pown. Piccini and Anderson both agree this program puts them in an awkward posi- tion from a law enforcement prospec- tive, and neither of them truly supports it for that reason. And at least one of our judges has also gone on record with me stating he would probably have to dis- miss charges against someone caught with needles if he or she claimed to be on the NEP. Contact members of the health board: Richard Wojt, Dan Harpole, Glen Huntingford, Sheila Westerman, Geoff Masci, Jill Buhler and Roberta Frissel!. Voice your disapproval. Attend the next health board meeting April 20. Lellhem know in person you don't agree with their plan. MILT MORRIS Port Hadlock f-/2 -()Ø J