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5.03.2016

Years of Effort by Miller School Students Pay Off as Florida Governor Signs Needle-Exchange Law

More than five years of research, letter-writing, meetings, lobbying and other activities finally paid off this spring, when Florida Governor Rick Scott signed the Miami-Dade Infectious Disease Elimination Act (IDEA), the fourth version of a bill authorizing a pilot needle-exchange program for Miami-Dade County, into law.

Under the program, which will be run by the Miller School of Medicine, users of injection drugs will be given free, clean needles and syringes in exchange for used ones at specified clinics and via a mobile van that will travel to reach those without transportation. Participants will be educated on proper injection technique (using a clean syringe every time), and offered immunizations, as well as viral hepatitis and HIV testing, and linkage to treatment. Importantly, these programs will provide access to detox and drug treatment programs. The goal will be to get the drug users into rehab without having contracted HIV or hepatitis C.

The lengthy efforts to get the bill passed were initially spearheaded by a group of Miller School students, with support from faculty, fellow medical students across the state, civic and professional groups, and legislators.

“Timing was key this year,” said Chanelle Diaz, a fourth-year M.D./M.P.H. student who was one of the program’s original proponents and who traveled to Tallahassee six times during this year’s legislative session to lobby for its passage. “In 2015, Indiana approved emergency needle exchange in response to an outbreak of 153 cases of HIV linked to the injection of oxymorphone and the sharing of needles. West Virginia and Kentucky soon followed. Rising public awareness about the explosion in heroin use, and its consequences for HIV transmission, gave vital support to our effort.”

It became evident that syringe-exchange programs have an important role to play in linking drug users to drug treatment. West Virginia, for example, found that 50 percent of the individuals attending the exchanges entered drug treatment within six months. Over the years, the students had built a coalition of support that included the Miami-Dade County commissioners, the Miami-Dade mayor, the State Attorney’s Office, and more recently, the Miami Dade County Association of Chiefs of Police. The legislation also became a priority for the Miami-Dade delegation this session.

“Nothing, however, conveyed the urgency of the bill better than the consistent media coverage it received,” said Diaz.

Ironically, for one of the other student leaders — Hansel Tookes, M.D., M.P.H., now a second-year resident at Jackson Memorial Hospital — the bill’s signing came almost as a surprise after the long wait.

“I only found out about 45 minutes before it was signed,” he said. “I was on the Special Immunology inpatient service at Jackson — the team that focuses on HIV and tuberculosis — when I received a text message.”

Sharing used needles is one of the primary causes of the spread of HIV, hepatitis C and other diseases. Miami-Dade County is the nation’s epicenter of new HIV infections, with more cases than all but four states.
Meanwhile, Florida ranks as the No. 1 state overall in new HIV infections, and it also has the highest number of chronic hepatitis C cases.

Those unenviable rankings, combined with the success of similar efforts in other states, finally convinced Scott and legislators who had opposed the bill to take action. The new law authorizes the exchange only on a pilot basis within Miami-Dade County, instead of as the statewide program originally proposed by Miller School students in 2012, and it specifically forbids the use of state, county or municipal funds to pay for it, although there is no prohibition against federal funding.

Nonetheless, its supporters view it as an important start. Florida has also stood out nationally, despite the size of its drug problem, because conservative lawmakers feared that giving needles to drug users was sending the wrong public message. In voting down prior bills, they had maintained the state’s status as one of only 15 in the country without a legalized program.

The students’ hard-fought campaign had its origin in research conducted by Tookes. Published in the journal Drug and Alcohol Dependence in December 2011, “A Comparison of Syringe Disposal Practices among Injection Drug Users in a City with Versus a City without Syringe Exchange Programs” revealed that eight times the number of publicly discarded needles had been found on the streets of Miami as on the streets of San Francisco, a city with twice the estimated number of injection drug users.

In the spring of 2012, Tookes and Diaz, working with fourth-year students Marek Hirsch (now a psychiatry resident at Harvard South Shore) and Dyani Loo (now a psychiatry resident at the University of New Mexico), began lobbying legislators. Tookes and Hirsch also wrote a supporting resolution for a statewide needle-exchange law that was adopted by the Florida Medical Association. The first bills were finally sponsored in the spring legislative session of 2013, but until now have been unsuccessful.

In 2015, Tookes and Diaz published the results of a second study in the journal PLOS ONE, an online journal from the Public Library of Science. “A Cost Analysis of Hospitalizations for Infections Related to Injection Drug Use at a County Safety-Net Hospital in Miami, Florida” revealed the high cost to the public when drug users are treated for infections resulting from the use of dirty needles — sometimes for weeks or months — as inpatients at Jackson Memorial Hospital at taxpayer expense.

Despite ongoing opposition among some in the legislature, the students never let up on their efforts. Tookes, who says his first priority as a resident is patient care, still found time to attend all of the Senate committee hearings and the initial House committee hearings. He and Diaz also met with Scott’s Deputy Chief of Staff and were present for the floor votes.

Diaz graduates this spring and is moving on to a residency in primary care and social internal medicine at Montefiore Hospital in New York City. As she prepares to leave Miami, she has mixed feelings about the four years she has spent getting the bill passed.

“I’m relieved, knowing that our patients will no longer be denied a proven medical intervention,” she said, “but I am frustrated that it took this long, given the overwhelming evidence. There have been more than 800 cases of HIV related to injection drug use in Florida since the bill was first introduced. I’m hopeful that we will make it easier for other cities in Florida to follow.

“This project has given me a deeper understanding of the legislative process and the challenges of translating research into policy. It has also expanded my notion of a physician’s role in patient advocacy. Giving up was not an option — we owed it to our patients to get it passed.”

Tookes will remain actively involved, and there will be both need and opportunity for public health and medical student involvement with the program evaluations and the required quarterly reports to the Department of Health.

“This is a big win for Florida, and the entire state is looking to us to successfully implement this program,” said Tookes. “It’s an exciting time for Miami, because we can finally put into practice this very well-studied intervention. There will also be opportunities for new research. I will continue focusing on what I can do to help other Florida communities, but what we can do moving forward will, in large part, be influenced by what we are able to achieve right here.”

Without public financial backing, the challenge for the Miller School will be obtaining funding to run the program. Some of that will come from grants, said Tookes, but there will also be a fundraiser May 12 at the home of Joy Fishman, a Bal Harbour resident whose son died of a heroin overdose 12 years ago, and who has been a strong supporter of the students’ campaign for a needle-exchange law. Those interested in making a donation should contact Clovis Thorn at the Drug Policy Alliance at .(JavaScript must be enabled to view this email address).

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