A measure to extend state approval for syringe services programs in Indiana became law earlier this month, without the governor's signature.
Clark County, one of six counties with programs in the state, recently changed some of its practices to comply with the new requirements.
Syringe services programs were first authorized in 2015 in response to a historic HIV outbreak in Scott County.
They give clients clean needles and take in used ones. They also offer other services, such as access to HIV and Hepatitis C testing and referrals for addiction treatment.
"For a lot of these folks, this is their only interaction with the health care system at all," Clark County Health Officer Dr. Eric Yazel said. "So by coming in to get their syringes, this is our opportunity to say, 'Hey, let me get you some recovery options. Let's look at some employment opportunities.'"
The law puts new requirements on the programs and their participants: clients have to show ID, and programs must exchange needles at a one-to-one rate based on how many used needles a participant returns. The facilities have to be at least 1,000 feet from buildings like schools and child care centers.
"It's like one law fits all," said Dorothy Waterhouse, director of Clark County's program. "But it's something that we're going to work around and we're going to fix and we're going to keep this program up and running."
Clark County's approach
Waterhouse said staff are now checking IDs to confirm a residency requirement in the law. She said they're making sure the clients live in a county they can serve.
"I don't want to see a name, I don't want to see anything like that," Waterhouse said. "That just breaks anonymity."
To comply with the one-to-one syringe exchange requirement, staff are weighing the containers people bring back.
In the past, staff would find ways to work with clients, such as by giving them a smaller number of needles to build back up if they came in with few or no syringes.
Waterhouse said that's no longer allowed. She worries they also may not be able to get first-time clients set up with syringes, since they likely wouldn't be bringing any in.
She's concerned that if people aren't able to get syringes, they'll have less reason to come in.
"If they can't get that clean needle, they're gonna start reusing needles, number one, which is gonna cause a lot more health issues and then even the sharing that can cause HIV and Hep C," she said last week.
On Monday, when the Clark County program implemented changes to its processes, Waterhouse said they weren't able to give out any needles because people didn't have returns or ID.
But by mid-week, she said visits were pretty steady, and that people were coming in with ID. She said clients have been understanding of the changes.
Waterhouse said they've given some people bus passes to get to Louisville's program so they can get clean needles. She hopes clients will return them in Clark County and be able to participate in that program.
The law also prevents programs from giving out syringes within 1,000 feet of certain buildings, like schools, places of worship and child care centers, unless they give permission.
Waterhouse said there are several of those institutions near the health department. She said earlier this week that, until they get approval, they're offering some services inside the health department, and distributing the syringes from the mobile unit outside.
Impact from the law
Yazel, the Clark County health officer, said the extension itself is a win. Earlier this year, he was worried it might not happen at all. Without it, the state approval would have expired this summer.
"Any ability to serve our citizens that way is a win for us," he said. "There are some concessions that had to be made, but we want it to be a program that everybody's comfortable with."
He thinks there will be challenges, though.
The requirements could limit the opportunity to reach clients for some services, and it could actually lower the overall syringe return rate.
A lot of clients may not return all their needles their first few visits, but that can improve as staff build rapport and teach about personal responsibility and clients gain more stability, Yazel said.
"Those folks who may have had a five or 10% return rate, now, all of a sudden, are bringing back 100% and encouraging community returns," he said.
Last year, Clark County's program saw around an 89% syringe return rate from participants. When counting community-wide returns, that jumped to nearly 124%.
"If a program has [an] 80% return rate, I think the community thinks, 'OK, there's 20% of those that are just laying out in the street,' and that's not really the case," Yazel said. "They're just not necessarily brought back to us."
And Waterhouse said they've found some containers they distribute in the larger community collection boxes, which means they wouldn't be counted as a participant return to the program – but they are being turned in somewhere.
Public health
Some lawmakers who supported the bill say offering the services is a public health effort.
Republican state Rep. Brad Barrett chairs a House committee where some of the bill's biggest changes were added, including the one-to-one exchange and ID requirements. He supported the changes and said before the full House vote that the requirements address concerns.
"As long as I've been in this body, all we've done is kick the can down the road," he said. "Every two years, every four years, we change the sunset date. This is the first time that I remember we've actually put some guardrails and some accountability and some one-to-one on this."
Republican state Rep. Ed Clere sponsored the bill in the House, and also crafted the legislation authorizing the programs in 2015.
"These programs get people in the door with sterile syringes and then they provide so much more," Clere said on the House floor last month, pointing to state data on referrals to substance use treatment, HIV testing and naloxone distribution over the past decade.
Indiana Governor Mike Braun pushed for the changes, but let them become law without signing.
"The reason I didn't sign it is because I think that's treating a symptom and I think we need to get at the underlying issue of what it was done for in the first place to where you don't use that as a crutch going forward," he said.
But advocates say harm reduction methods work. Tony Hostetler is with the Care, Not Cuffs chapter of Hoosier Action. He said in February, before the bill's final approval, he had an issue with the one-to-one requirement, and that the ID part could be a barrier.
It already takes a lot for people to walk in the door.
"It takes a while to build those relationships with anybody in the recovery world," he said. "Especially if they're actively using, they're on the defense all the time, living in survival mode… at all times. So yeah, they're scared."
Waterhouse said staff make it a priority for people in the program to know they are there to help them, but that programs and participants have to follow the rules.
"And we have a lot of clients that are invested in this program," she said. "They want to make sure we're doing what we need to do, and they're going to help us with it."
Coverage of Southern Indiana is funded, in part, by Samtec Inc., the Hazel & Walter T. Bales Foundation, and the Caesars Foundation of Floyd County.
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