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A public health crisis?

Quick Response Teams Aim to Get More Opioid Overdose Patients into Treatment



One West Virginia city is trying a new approach to persuade more overdose patients to seek treatment. The idea is simple: Within 24 to 72 hours of an overdose, a “quick response team” fans out into the community and tries to meet with the patient to discuss treatment options. A handful of similar programs exist around the country, but West Virginia’s first team launched in December in Huntington with the help of two federal grants. Health officials said it already has been remarkably successful.

The Idea

“We’ve been having a lot of overdoses in Huntington and Cabell County and really the big thing that stood out to many of us is what are we doing afterwards?” said Bob Hansen, director of the Huntington quick response program.

He saw an article about a similar program in Colerain, Ohio. They invited the heads of that program to Huntington, did a training and loved it. So Hansen and several other key players in the local opioid-response programs orchestrated applications for two federal grants. They got both.

Colerain reported more than 80 percent of the people they visited were getting into treatment programs. Huntington was hoping for one in five.

They’re now in their fourth month and Hansen said they’re getting up to 40 percent of the people they engage with into treatment.

“And you think if we maintain that percentage over time it kind of has a cumulative effect. So you have to think by year three we should be really hitting the people to the point to getting more and more into programs,” he said.

In the Field

On a recent afternoon, the team reviewed cases for the day, then hopped in the car to begin tracking down the patients. Its members include police officer Chris Trembley and her teammates, Sue Howland who works for Prestera and Larrecsa Cox, a paramedic.

“I wouldn’t approach her at the hacienda, which is the house she’s been staying at — I would just watch for her. Because the house she’s been staying at, the guy there will make it [harder],” Trembley said to her teammates. “But if we happen to catch her out and about I think she’s kind of at that stage. Because for her to call last night is completely unlike her.”

“So she overdosed last week – on Wednesday. The on-duty supervisor called,” explained paramedic Cox about their first patient of the day. Cox is the only full-time staffer on the team. The representatives from the police department and Prestera rotate.

“She’s kind of — she’s actually a lot depressed,” said Cox. “At first when we went down there she wasn’t all that receptive, but the more we talked to her, she kind of warmed up to us, especially Sue. The next day we went back and spoke to her again … so we’re just going back today to follow up with her again.”

The first time they visited, the patient wasn’t ready to go into treatment, Cox said. “Yeah she’s still not ready. And we respect that. If someone’s not ready it’s best we know that — it doesn’t work if they’re forced into it.”

Howland, the counselor from Prestera, said at least they’re building a rapport with both her and her family. The patient, who’s 26, is living with grandparents.

Meeting with Patients

When the team arrives at the house, the grandfather lets us in and the team winds through the house and down into the basement where the patient is still sleeping.

“We just came by to make sure you went and you’re still doing good. Just touch base with you. Is there anything we can do for you?” Howland said.

The woman shook her head, becoming more animated as they ask about how well she’s eating, how her headaches have been and on her relationship with her grandparents. They’re there for about ten minutes. Then they leave.

Sue Howland talks with Chris Trembley before going out to meet patients. Photo by Kara Leigh Lofton.

Police officer Trembley said it’s all about the little wins.

“Maybe you just didn’t go use today. That’s one day. Maybe you might have used but because folks have talked to you and you were feeling good about things maybe you didn’t go out and shoplift today. Ok, that’s still a thing.”


They visit another patient and then get in the car for one more try before Trembley has to suit up for an evening shift on patrol.

“Fake address.”


“So they didn’t give you a real address?

“Yeah, that’s common.”

“Very common.”

“Or a wrong phone number.”

“Like an area code from Mexico.”

“Got us.”

As the team leaves the fake address, Chris sees a drug exchange.

“That’s worth watching later today,” she said.

“What over here?” said Howland. “That’s a hot spot.”

“No, I’m pretty sure I just saw a hand-to-hand right there.”

The  team goes back to the station to drop off Trembley for her shift.

Charleston health officials are working on their own QRT with the grant from the DHHR in the coming months. Cabinet Secretary Bill Crouch called the move an “essential” part of the DHHR’s State Opioid Response Plan. The goal, he said, is to expand the effort until there’s a QRT in every major city in West Virginia.

This article was originally published on West Virginia Public Broadcasting.

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A public health crisis?

The Vexing Vape: Officials Say Small Vaping Device Juul A Major Health Risk To Youth



The vaping device is popular with teens in part because it is easy to hide. Photo: Mary Meehan, Ohio Valley ReSource

A slender, black, rectangle, the Juul fits easily in the palm of your hand. You don’t light it, you trigger it with a click of a finger. The mist that is exhaled is so fine it’s hard to see. The nicotine is delivered via a pod the size of a AAA battery, with each pod containing the equivalent of 20 cigarettes.

That combination of small size and potent power makes the Juul the vaping device of choice for many teen users. A group of students from Casey County, Kentucky, affirms those features make “Juul-ing” – yes it has become a verb – rampant in class.

“Yes, oh yes,” they all nod in agreement.

Casey Youth Coalition students. Photo courtesy: Foundation for A Healthy Kentucky

The group has been honored by the Foundation for a Health Kentucky for work to reduce tobacco use in the middle and high school. They’ve made progress through community polls and education campaigns. But they said Juul’s portability and ease of use creates a whole new set of problems.

Casey County student Hannah McQuery is part of that anti-smoking group. She said she was surprised when a classmate started puffing quietly into the sleeve of his hoodie during Social Studies.

“Right next to me a boy pulled out what I thought was USB drive because it was black, and small like that,” she said. “He put it up to his mouth.”

The Surgeon General has declared teen vaping a health epidemic and the Juul already dominates the teen market. Now, a merger between Juul and tobacco giant Altria has raised concerns among health advocates, setting the stage for a battle with Big Tobacco over that small device.

Taking the Vapers

According to the Centers for Disease Control and Prevention teen vape use is exploding. There was a 78 percent increase between 2016 and 2017.

Surgeon General’s Report

It is a compounding health risk in states like Kentucky, West Virginia, and Ohio where tobacco use is already high. The CDC says about 14 percent of teens across the country use e-cigarettes, which can be harder to detect. Juul makes up about 70 percent of e-cigs used by teens.

Legally, no one under 18 in the Ohio Valley should have an electronic cigarette. Penalties among the states range from having the device confiscated to a $100 fine.

But local health officials said that isn’t a deterrent for teens.

Catie Kelly, a senior at Martha Layne Collins High School in Shelbyville, Ky., said Juul first appeared in classrooms at her school about 18 months ago. Now, she said, “everybody is doing it.”

“Everybody is doing it,” Shelbyville, KY, student Catie Kelly says of vaping. Photo: Mary Meehan, Ohio Valley ReSource

Even though her mother is a health educator, Catie admits to trying vaping herself. She liked the slight buzz and the mango and watermelon flavors. She said she didn’t realize there was nicotine in the product. Now she is the one telling her friends to put the Juul down.

“They don’t really listen,” she said. “They just say, ‘whatever.’”

She said her school’s parking lot is littered with empty pods.

Kelly said that there is a black market for Juuls where teens over 18 buy in bulk and resell at a mark- up. According to the Juul website, a starter kit including the vaping device, a charger and four pods sells for $49.99.

Another challenge is that educators are simply not aware that kids are vaping at their desks. Casey County prevention specialist Cathy Williams said that while a lot of educators know to look for smoke or track down the smell of a cigarette, “they are still missing the kids who are vaping in the classroom.”

Even the scent can go unnoticed. Williams said that even if a number of students are vaping they are competing with a lot of other odors such as hand sanitizers and lotions so, “what’s a little mango?”


Angela Brumley-Shelton is tobacco coordinator for the Lexington-Fayette County Health Department in central Kentucky.  She said many kids and parents consider e-cigarettes harmless. Most don’t think they contain nicotine at all. She said that is a dangerous assumption.

Surgeon General’s Report

“When young people are exposed to chemicals that are in e-cigarettes, specifically, and especially the nicotine, that affects their brain as it continues to develop and that has lifelong consequences,” she said. “That is something we are just beginning to talk about.”

She said that the impact on brain development can lead some people to use other addictive substances such as cocaine or methamphetamine.

It can also lead to the use of traditional tobacco products which contributes to a host of health issues like heart disease and diabetes.

She said some parents even provide a Juul to their children as a reward for good behavior. As the culture as a whole has drifted away from smoking fewer teens took up tobacco products. But, she said, now students are vaping because they say it helps them concentrate on homework or do better on tests.

And that is a problem, she said. Nicotine is highly addictive. And, she said, the methods used to help people traditional cigarettes don’t seem to work on e-cig users.

“Our old tricks for combustible cigarettes they don’t work for e-cigarettes so we are worried and we haven’t found anything that works yet.”

The research on the subject hasn’t determined why that is the case, she said.

Brumley-Shelton said she has had people who have been addicted to heroin say quitting nicotine is harder.

Casey County student Delaney Sowders said she has seen as many as five teens vaping at the same time in a single class. She is president of the high school anti-smoking group which worked hard to stem the smoking of tobacco in school bathrooms. And it worked.

But she said as Juul users discover how much it costs to continue to use the pricey pods they are taking up the old-fashioned combustible cigarette again. The anti-smoking group is taking a community poll to help create a new strategy.

Juul Of Denial?

But just as health advocates look for ways to keep kids from vaping, they could be facing a huge new challenge. Altria, a giant in the tobacco market, recently purchased 35 percent of Juul. That partnership brings convenient placement of products and big money for advertising and political lobbying.

Angela Brumley-Shelton of the Lexington-Fayette Co. Health Dept. Photo courtesy: Lexington-Fayette Co. Health

Kentucky Youth Advocates Director Terry Brooks said tobacco ad spending has already helped e-cigarette use skyrocket. A former educator, Brooks said he was skeptical when he first heard that kids were vaping in the classroom. He asked his own family focus group for a fact check. His grandchildren confirmed it was true.

Many of those young users, he said, were first enticed through advertising on the internet.

“Nationally when advertising goes from $3.6 million in 2010 to over $125 million in 2014, those dollars are being well spent,” he said.

Brooks said there is wide support for restricting youth access to e-cigs. Democratic and Republican legislators agree that there should be restrictions. And, he said, the Surgeon General pointedly did not include adult vaping in his recent warning about e-cigarettes to limit any backlash from pro-smoking advocates.

Many key decisions will be made by state legislators and local governments to determine smoke-free zones in their communities. But he said health advocates are ready to take on the tobacco lobbyists who will certainly come in from other states.

The little Juul is at the center of a big debate about public health. Photo: Mary Meehan, Ohio Valley ReSource

“There is nothing we like better than out of state money and people who can’t say y’all.”

Brooks said the underdogs of public health have learned from earlier tangles with Big Tobacco. Nearly 30 percent of Americans smoked in the late 70s. Public pressure has changed that. In the 90s, health advocates pushed back against marketing that targeted youth, such as Joe Camel to hawk Camel cigarettes. Joe Camel was retired after 10 years in 1997.

Brooks said youth vaping is shaping up as the next skirmish in the long fight against tobacco.

Juul officials, under pressure following the Surgeon General’s declaration, have created a multi-million advertising campaign focusing on adult smokers who are using vaping to give up traditional cigarettes.

In a video statement, Juul CEO Kevin Burns said the company is not targeting kids with its flavor pods such as mango and mint.

Our intent was never to have youth use Juul, but they are,” Burns said.  “As the industry leader, we must lead the category in decreasing underage use.”

Pods about the size of a AAA battery contain the nicotine equivalent of a pack of cigarettes. Photo: Mary Meehan, Ohio Valley ReSource

Brooks is skeptical.

“Why in the world would you focus on those kinds of flavors if it was not intended to specifically target, you know, seventh graders?”

Brooks isn’t the only one with doubts. It’s been reported that Food and Drug Administration officials are concerned that the Altria merger is a way to work around industry pledges to restrict access to young users. Brooks said that by enticing younger users companies are trying to create customers who will use their product for life.

This article was originally published by Ohio Valley ReSource.

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‘A Failure of Public Health’: Sexually Transmitted Diseases Rise as Health Budgets Fall



Officials are concerned about antibiotic-resistant gonorrhea. Credit: Centers for Disease Control and Prevention

Health officials are tracking record-breaking rates of sexually transmitted disease, including a resurgence of some infections which had been considered rare, such as gonorrhea and syphilis. These STDs are on the rise amid cuts to public health budgets dedicated to testing, prevention, and public outreach.

In the Ohio Valley, for example, a review of state and federal government data shows some communities in Kentucky, Ohio, and West Virginia have seen chlamydia infections rise by more than 200 percent between 2011 and 2017. And in four counties in Kentucky and West Virginia, reported cases of gonorrhea jumped by an astonishing 1,000 percent or more in that period.

Matt Prior is the spokesperson for the non-profit National Coalition of STD Directors. They are the folks on the front lines. Prior says STDs now represent a public health crisis, especially in parts of Appalachia already struggling with an opioid epidemic.

“We are seeing an increasing number of syphilis and other STD outbreaks associated with the opioid crisis,” he said. “States that are particularly hard hit by the opioid crisis are states that are particularly hard hit by the STD epidemic.”

As rates go up, Prior said, funding has gone down. So while STDs have increased by 30 percent in the last five years to reach an all-time high, the amount of federal money for prevention and education has consistently gone down since 2003. Prior says that federal funding is critical for states like Kentucky, West Virginia and Ohio.

“The federal STD prevention line is the only line or funding streams these states have so it is really the first and last line of defense,” he said.

Generational Risks

Prior said a recent Centers for Disease Control and Prevention report was especially troubling. The report showed a rise in infant deaths as more newborns contract syphilis from their mothers during birth.

According to the report, the number of babies born with syphilis rose from 362 in 2013 to 918 in 2017. The cases were primarily found in Western and Southern states. In the report, Dr. Jonathan Mermin, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, said syphilis can result “in miscarriage, newborn death, and severe lifelong physical and mental health problems.”

The cause of syphilis is a bacterium called Treponema pallidum. Credit: Centers for Disease Control and Prevention

Syphilis during pregnancy is easily cured with the right antibiotics. However, if left untreated, a pregnant woman with syphilis has up to an 80 percent chance of passing it on to her baby, the report said.

Prior said the mortality rate among those infected infants is high. His coalition is encouraging syphilis screening as a mandatory testduring a woman’s first prenatal visit. He said this outbreak shows the depth of the need for access to preventative care and prenatal care.

“It is essentially a failure of the public health system and a failure for our nation because we should not see mothers and children, children dying for very easily treatable and identifiable diseases,” he said.

“It’s Frightening”

Jim Thacker is the spokesperson for the Health Department in Madison County, Kentucky. He said public health officials expect spikes in infectious disease. Adapting to the changes and responding to them is the core mission of public health.

But, he said, the recent resurgence of diseases such as chlamydia, gonorrhea, and syphilis is something different. Overall the CDC reported 2.4 million new cases of those diseases in 2017. Thacker said a handful of cases in Madison County reflected a 300 percent jump in syphilis.

“It’s frightening any time you see something come back that you thought you had under control,” he said. Syphilis, he said, was essentially eradicated for more than 50 years.

Credit: Alexandra Kanik/Ohio Valley ReSource

Thacker added that discussing sexually transmitted disease makes people uncomfortable. “It’s not something people want to talk about,” he said.

In recent months he increased his efforts to speak to middle, high school, and college students about STDs. Thacker said part of the increase in STDs could be linked to a lack of fear of HIV among people born after the AIDS epidemic. That and effective, long-term birth control makes condom use seem less urgent to teens and young adults.

If provided with the correct information, Thacker said, people can change their minds. If they get tested they can avoid the most serious consequences of the diseases.

Thacker said many younger people know very little about some of the STDs that are now resurgent, including the symptoms. He said by the time they are diagnosed significant damage can occur. Untreated syphilis, for example, can cause serious neurological disease. And untreated gonorrhea can cause serious health problems, particularly for women, including chronic pelvic pain, life-threatening ectopic pregnancy and infertility.

Thacker said health officials are also concerned about the possibility that gonorrhea is becoming drug resistant. According to the CDC gonorrhea has become resistant to a series of drugs, beginning with penicillin.

Get Tested

People between the ages of 15 and 25 have the highest rates of STDs, representing 40 percent of the new cases, according to the CDC.

Eastern Kentucky University student Priscillana Cawood is also working to educate her peers. She takes STDs seriously.

Priscillana Cawood is majoring in infectious diseases at Eastern Kentucky University. Photo: Mary Meehan/Ohio Valley ReSource

“On my personal social media, I follow the CDC and various health departments. I like to keep up to date,” she said.

Cawood’s major focus of study is infectious disease and she’s the daughter of a straight-talking nurse. That combination could explain why she has long been “the friend.” She’s the one among her peers that friends turn to for information about STDs. It’s a role she’s played since middle school. She understands it’s common for young people to push their sexual boundaries. But she tries to help people know there can be consequences.

Especially when first at college or out on their own, people can be reckless, she said.

“Some people take extreme advantage of that and they end up with a disease that they don’t want or never intended to get because A) they didn’t know all the facts, B) they were careless,” she said.

Cawood is also an intern at the Lexington-Fayette County Health Department where she sometimes assists with testing. She understands there can be a mental block to getting tested.

Credit: Alexandra Kanik/Ohio Valley ReSource

“Sometimes you need just need to know the answer but you don’t want to know it,” she said.

She still encourages everyone to get tested on a regular basis.

For information on STD testing check with your primary care doctor, on-campus clinic or local public health department.

This story was originally published by the Ohio Valley ReSource.

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A public health crisis?

Lessons Learned as Charleston Needle Exchange Decertified



If you’ve been paying attention, you know by now that Appalachia is in the middle of an opioid addiction crisis. You may have seen suffering with substance abuse disorders in your own neighborhood.

But John Law, spokesman for the Kanawha-Charleston Health Department, says what isn’t as visible could be just as dangerous: blood-borne diseases like hepatitis and HIV.

So Law’s department set out to implement a needle exchange program in Charleston. Drug users could bring in a maximum of 30 dirty needles and exchange them for 30 new, clean ones. Programs like this are often part of what’s referred to as “harm reduction programs.”

“We often think of the people who use needles and the people who use drugs are those unfortunate individuals huddle doorways and those sleeping on the streets,” Law said. “But it’s also people who work in restaurants and secretaries and people who work in all facets of life who came through the harm reduction program and realized that they needed clean needles to stave off another health problem besides their addiction.”

While needle exchange programs have been proven to lower the rates of blood-borne illnesses like HIV and hepatitis, they are also designed to help people who are addicted to drugs find treatment, and provide them with basic medical care. They can also generate data to help medical practitioners track the program’s effectiveness.

The original program started with just five people in December 2015. Eventually 6,000 individuals visited 24,000 times. The health department distributed 650,000 needles and collected about 425,000 needles. That leaves about 225,000 needles unaccounted for. Law says these missing needles were never turned in — so when dirty needles were found on the streets, it was a mystery just where they came from.

First responders like the city police chief said needles were found in public places and accused drug users of leaving exposed needles in their clothing during pat downs.

“There were excess needles there, everybody realizes that,” Law said. “We are certainly not denying that. We went out on several times with city officials and there were needles on the street but there are needles on the street all over the country not because of the needle exchange but because we have an opioid epidemic.”

As a result of the outcry over the excess needles, the police chief issued a list of recommendations to address the program’s flaws. But because some of the suggestions were difficult to implement, the city decided to suspend the program altogether in March. One of the problematic recommendations was to require participants to show photo ID, which Law says is impractical.

“Many of the people we deal with are homeless or don’t have photo ID,” he said.

The police chief also wanted the program to only distribute retractable needles, but Law is concerned that distributing retractable needles is not the best practice. Retractable needles are meant to be used one time, once the needle is retracted, it can’t be used again. That’s how it’s supposed to work, but Law says this often isn’t realistic for drug users who shoot up several times per day. Without ready access to multiple needles, they’re likely to use the same one more than once.

“The experts in the field will tell you that retractable needles are probably not a good idea because one it can cause tissue damage,” Law said. “People usually won’t retract the needle totally and they’re more inclined to share it and that’s what causes the spread of disease.”

Law said the health department has a responsibility to take best practices seriously but is continuing to evaluate the recommendations to see if the department can successfully implement them.

Despite the public outcry and the program’s suspension, Law said he still considers it a success.

“We measure success because the hepatitis rate in Kanawha County declined, it was a slight decline but it declined,” he said. “We had more than 100, probably closer to 150 people, enter recovery so that was very gratifying.”

Law said the program was a national model that was used other places like Huntington, West Virginia.

“I think if we failed we were probably not quick enough to respond to concerns that were expressed because it was a nationally reviewed program,” Law said. “We were following best practices you need to listen very closely and you have to do what is right for your community at the time.”

Law said the exchange program is important to public health and the department will continue to look into implementing the Charleston police chief’s recommendations. Meanwhile, in May, the West Virginia Department of Health and Human Resource’s Bureau for Public Health confirmed 72 cases of hepatitis A in Cabell, Kanawha, Lincoln, Putnam, Wayne and Wyoming counties. Of those cases, 64 have occurred in Kanawha and Putnam counties. Additionally, there are possible cases still under investigation, but not yet confirmed by the state laboratory.

“There is certainly a sense of urgency knowing the potential out there with HIV and hepatitis C, but there is a same sense of urgency to be responsive to the community and really do what the community needs and wants,” Law said.

Shortly after our interview with Law, the West Virginia DHHR released results of an investigation into the program. The DHHR listed six items in the report that were problematic including missed opportunities for linking users with treatment, messy data entry, and lack of an oversight committee missing committee. They also concluded that the Charleston-Kanawha Health Department’s Harm Reduction Syringe Services Program certification be suspended until some of their recommendations can be implemented.

The Charleston police chief did not return our requests for comment. Current Mayor Danny Jones would not grant us an interview but he’s spoken out frequently against the program.

This article was originally published by West Virginia Public Broadcasting.

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