Good samaritan clauses are an evidence-based means to reduce overdose deaths and a critical part of naloxone legislation. 48 states (including DC) have expanded naloxone access, and 35 (including DC) have a good samaritan clause. These provisions protect individuals who place a 911 call in the event of an overdose from facing civil or criminal drug paraphernalia or possession charges. While several states, including Iowa, have faced opposition to these clauses from law enforcement officials, the research suggests that law enforcement, health care, and communities all stand to benefit when good samaritan clauses are enacted. After the introduction of a good samaritan clause in Washington, 88% of drug users were likely to summon emergency personnel in the event of an overdose. Research completed after the passage of this law shows no indication from police or prosecutors that the good samaritan law is a serious impediment to the conduct of their work. The Robert Wood Johnson Foundation and a recent study from Massachusetts indicate that law enforcement officers in states that have adopted Good Samaritan laws report that these laws have improved citizens' image of law enforcement.
We also know that these laws matter because the people most likely to reverse an overdose are active drug users. A 2015 CDC report of naloxone reversals in the U.S. reported that 82.8% of opioid overdoses are reversed by drug users. 9.6% are reversed by family members of drug users, and 0.2% are reversed by public service providers.
In most states that have expanded Naloxone access, community-based organizations are given standing orders for Naloxone. This allows treatment programs, social workers, homeless shelters, schools, and local non-profits to distribute the drug to their clients and students. Other states have found that this strategy works best for getting Naloxone into the hands of people who can benefit from it: some folks who use opioids have had negative experiences with the health care system, and are unlikely to visit a physician to obtain a naloxone prescription. Community-based organizations can be trained to distribute the drug, and to educate others on how to use it. And funding exists to distribute naloxone in community settings: The Clinton Foundation has pledged to provide naloxone for every school in the U.S. where it is legal to do so.
Syringe Service Programs
Overdose is not the only harm of opioid use and addiction. As future physicians, we are concerned about the increasing number of Iowans being diagnosed with two preventable illnesses: Hepatitis C and HIV. The majority of those who are diagnosed are people who inject opioids.
Hepatitis C (HCV) is a viral infection that causes severe liver inflammation and increases the risk of developing liver cancer. Currently, HCV is the leading reason for liver transplantation, and directly causes a number of non-liver related illnesses which are estimated to amount to $1.5 billion in direct medical costs at the national-level. Until recently, HCV was incurable – but curative treatments for HCV remain out of reach for many people, as treatments can cost over $100,000 per course of medication.
In Iowa, there are over 20,000 people living with HCV (as of March 2016). The Iowa Department of Public Health reports that this number is likely a gross underestimate. Many cases are currently undiagnosed, and as many as 110,00 Iowans may have the virus without being aware. Between 2000 and 2015, there was a 300% increase in HCV diagnosis among people 18-30 years old. Of these new HCV diagnoses, at least 55% occurred among people who inject opioids. This high rate of hepatitis among drug users is due to sharing needles, which allows for disease transmission and spread.
35 states (plus the District of Columbia) operate successful syringe exchange programs, in which people who inject drugs may obtain new needles for free, and turn in needles they have previously used. These simple programs can make a big impact. Running for over twenty years in some states, they are well known to reduce the risk of disease transmission among drug users. Some critics suggest that needle exchanges encourage drug use. However, the Surgeon General and reports in several major medical journals (including the New England Journal of Medicine) tell us that there are no data to support this claim. In fact, new syringe exchange program participants are five times more likely to enter into drug treatment than non-syringe exchange program participants. Former participants in syringe exchange programs are more likely to report significant reduction in drug use or to stop using all together, and to remain in drug treatment programs. For people who are struggling with addiction, needle exchanges can be a way to keep them healthy until they potentially choose to seek treatment. They are a reliable source of support for folks who often have a hard time finding the help they want.
Methadone & Suboxone
Methadone and Buprenorphine are full and partial opioid agonists (respectively) used for the treatment of opioid addiction. Sometimes referred to as Medication Assisted Treatment (MAT), these drugs are prescribed to people with opioid use disorders as they minimize drug cravings. Methadone must be taken daily, and under supervised treatment. This means patients must visit a treatment location each day.
Currently in Eastern Iowa, Methadone is accessible at a small number of private clinics in Cedar Rapids (the Cedar Rapids Treatment Center), Marion, Cedar Falls, and the Quad Cities. Generally, health insurance does not cover treatment at these clinics for daily methadone administration. Patients pay $18-20 each day for their methadone.
For patients who chose this treatment option, there are many barriers to access. Some of these are financial. A September 2016 Health Affairs report found that 39% of active drug users do not have health insurance. Other barriers are geographic: with few treatment facilities in Iowa, many people do not have the necessary daily access to these medications.
Currently UIHC does not provide these medications to patients. Individual providers must obtain a special license and complete a full day of training before they can provide methadone. However, UIHC providers report that if they began to prescribe these medications, their practice might quickly be overwhelmed with the high demand for these drugs, creating longer wait times. In order to meet the need for MAT in Eastern Iowa, a systematic response to provide these mediations is needed at UIHC.
Naloxone is a drug that reverses an opioid overdose via intra-muscular injection or nasal spray. In April 2016, Governor Brandstad signed into law a bill that expanded access to naloxone in Iowa. This bill allows physicians to prescribe naloxone to families and individuals at risk of overdose from opioids. Naloxone is indicated for many patients in family medicine, internal medicine, emergency medicine, psychiatric, and palliative care settings. However, many providers have minimal knowledge of this drug and are unfamiliar with its indications. In order to launch a systematic response to opioid overdose deaths in Iowa and prevent future deaths, it is necessary that UIHC disseminate prescribing information to all relevant departments and ensure that providers have easily access to naloxone's indications.