The USF Health Tampa Bay Street Medicine, Hillsborough County and Pioneer Foundation Needle Exchange Program is ready to hit the road as Florida’s second needle exchange or syringe service program (SSP). In conjunction with Tampa General Hospital, the Health, Equality and Linkage Project (HELP) Medical Van will offer to persons who inject drugs (PWID), a safe place to turn in used syringes for clean ones to avoid sharing blood-borne diseases like HIV and Hepatitis C, get anonymously tested for those diseases and be linked to free primary care, wound care, or drug treatment programs among other social services. Targeted locations in Hillsborough County will be those with the highest rates of HIV and opioid overdoses such as around the University Square Mall and downtown Tampa.

Representatives for the USF Health Tampa Bay Street Medicine, Hillsborough County and Pioneer Foundation Needle Exchange Program during a mock run through outside the University Square Mall.

Formed in 2014, Tampa Bay Street Medicine (TBSM) is a USF Health Morsani College of Medicine (MCOM) student-run service organization supervised by faculty that provides medical care to underserved populations. It was initially started to meet the needs of Tampa’s homeless community but continues to evolve as student leaders recognize opportunities to help elsewhere. TBSM students conduct biweekly street runs in unsheltered settings near the I-275 bypass, operate continuity clinics at First Presbyterian Church, and staff a medical van at a variety of clinic sites in partnership with Pioneer Medical Foundation.

USF Health Tampa Bay Street Medicine students talk with a homeless man during a night of biweekly street runs in unsheltered settings near the I-275 bypass. Pre-COVID photo.

“We’re going to the same locations where we’ve built that relationship, where they know that we have providers for primary care and they can trust us already,” said Asa Oxner, MD, FACP, faculty advisor for the USF Health TBSM and vice chair of the USF Health MCOM Department of Internal Medicine. “We have around 800 reoccurring customers in these locations, so we can first start by serving the people we already know well and work on marketing and growth.”

At a PWID’s first visit to the program, they can receive up to 10 clean hypodermic needles and every visit after that, it’s a 1:1 exchange. SSP volunteers will also distribute condoms, alcohol swabs, portable sharps containers and Naloxone (or Narcan), an emergency treatment for narcotic overdose. Pioneer also staffs the Lily Pharmacy free medical clinic inside the University Square Mall, adding another layer of resources along with the other community agencies partnering to offer downstream care for clients who engage in the SSP’s services. Enrollees in the program are tracked with a nickname and an ID number associated with a laminated card they’re asked to carry that identifies them as part of the SSP. If the card holder is arrested for drug paraphernalia, USF providers are working with the local police authorities to have our clients placed in drug rehabilitation instead of jail. At the same time, when PWID carry clean needles and a portable sharps container, it protects the law enforcement and first responders in return.

From inside of the medical van, Jerren Creak, MPH, patient care services research associate for Tampa General Hospital, explains the disease testing options to a mock patient, a member of the community in remission from a substance use disorder, during a mock run through of the needle exchange program.

“In communities where drug users are invited to swap out used needles without retribution, hospitals have reported major declines in the spread of blood-borne infections like hepatitis C and HIV, increased enrollment in drug treatment programs and fewer opioid-related overdose deaths,” said Khary Rigg, PhD, associate professor at the University of South Florida’s Department of Mental Health Law & Policy, in a report from the Tampa Bay Times. “As for the cost, research has shown that every $1 spent on needle exchange programs yields an average $7 savings in avoided costs for HIV-related medical treatment.”

According to the Centers for Disease Control and Prevention, more than 140 Americans die from drug overdoses every day. The U.S. Opioid Epidemic was declared a public health emergency by the United States Department of Health and Human Services (HHS) in 2017. SSPs are a key part of harm reduction strategy, meeting people who use drugs “where they’re at,” and addressing conditions of use along with the use itself. SSPs have been legal in many other states for decades, but it was not legal in Florida until recently. Thanks to the relentless fight for legislative approval and the resulting success of the University of Miami’s IDEA Exchange, a pilot program that was approved in a 2016 exception policy, Governor Ron DeSantis signed into law the Infectious Disease Elimination Act (IDEA) on June 27, 2019.  IDEA allows county commissions to authorize sterile needle and syringe exchange programs for PWID. The law states that disease prevention must be the goal of every exchange program, they cannot use state, county or municipal funds to operate, and they are required to be funded through grants and donations from private resources and funds.

A grant already pays for prescription medications for patients of existing programs operating through partnerships with the University of South Florida, Tampa General Hospital, the Drug Abuse Comprehensive Coordinating Office and Gracepoint, and the SPP will be allowed to use that money to buy the county’s first batch of hypodermic needles and syringes.

With this green light, TBSM and USF faculty began advocating for an SSP in Hillsborough County with the Hillsborough County Commissioner’s Office Opioid Task Force Behavioral Health subcommittee. They used the robust data from Miami’s IDEA Exchange and their program was approved. The needle exchange was supposed to kick off in April but was delayed due to COVID-19.

During a mock run through of the SSP, Heather Henderson, MA, CAS (second from left), USF Applied Medical Anthropology PhD Candidate and director of social medicine programs for Tampa General Hospital, hands a prop to mock patients, members of the community in remission from a substance use disorder, to represent the needle exchange.

In preparation for the official start of the program in December, the USF Health and Pioneer team met in the University Square Mall parking lot with two members of the community in remission from a substance use disorder serving on the SSP advisory board, to do a mock run through and receive their feedback. “This was really great,” said one of the mock patients. “You guys came across that you care and you’re nonjudgmental.”

TBSM will be joined at the needle exchange by USF Health College of Public Health and USF Applied Medical Anthropology students to create a true interprofessional effort to make life better for people in the community. “Preventing acquisition of HIV/HCV requires a complex understanding of the interconnection between biomedical and social dimensions of infectious disease,” said Bernice McCoy, MPH, USF PhD Candidate in Applied Anthropology. “These students will apply both epidemiological and ethnographic methods to contextually assess our SSP’s potential impact and further explore the drug-using habits of PWID. Through this assessment that we can and identify facilitators and barriers towards HIV/HCV risk-reduction within the Tampa Bay community.”

The Opioid Crisis in Florida          

According to the National Institute on Drug Abuse, nearly 68% of the 4,698 reported drug overdose deaths in Florida involved opioids in 2018—a total of 3,189 fatalities (Figure 1).

Figure 1. Number of drug and opioid-involved overdose deaths in Florida. Deaths may have involved more than one substance. Source: CDC WONDER

The increase in substance use has resulted in consequent increases in injection drug use across the country. This has caused not only large increases in overdose deaths, but also the transmission of blood-borne diseases. According to the CDC, the majority of new acute hepatitis C virus (HCV) infections are due to injection drug use and Florida is in the top 10 states with the highest rates of infection. According to the Florida Department of Health HIV/AIDS Surveillance Program, about 7% of the new diagnoses of HIV in Florida in 2018 were from injection drug use (IDU) (Figure 2) and 11% of persons living with an HIV diagnosis were persons who inject drugs (PWID) (Figure 3).

Figure 2. HIV modes of exposure in 2018. Source: National HIV Behavioral Surveillance System (NHBS).

Figure 3. The number of persons who inject drugs (PWID) living with an HIV diagnosis in Florida in 2018. Source: NHBS.

According to the CDC, the HIV burden in Florida is the highest in Broward, Duval, Hillsborough (Figure 4), Miami-Dade, Orange, Palm Beach, and Pinellas. It was announced in the February 2019 State of the Union Address that these counties are a part of 57 jurisdictions that are the focus of the Trump administration’s, “Ending the HIV Epidemic: A Plan for America” or EHE initiative, which aims to end the HIV epidemic in the United States by 2030.

Figure 4. Hillsborough County is one of Florida’s HIV hotspots. Source: NHBS.

The IDEA Exchange

On July 1, 2016, after years of struggling to win legislative approval, Miami-Dade became the first county in Florida with a legal hypodermic needle exchange program and on December 1, 2016, World AIDS Day, the IDEA Exchange opened its doors as a pilot program. The IDEA Exchange in Miami was started by Hansel Tookes, MD, MPH, an assistant professor at the University of Miami’s Miller School of Medicine and principle director of its harm reduction research group. NBC Miami reported in June 2019 that the Miami program has disposed of more than 317,000 used needles since it received temporary authorization from lawmakers in 2016. The program also distributes naloxone and Tookes told the Miami Herald in November 2019 that since March 2017, “the IDEA Exchange has handed out 2,871 boxes of the drug and those who have taken naloxone from the clinic to carry with them have reported 1,529 overdose reversals in that time.” Miami is the only place in Florida seeing a decrease in opioid-related mortality while death tolls spike across the state.

Video by Torie Doll, USF Health Communications & Marketing, with interview footage assistance provided by Ian Vancattenburch, Movie Magic Productions.

TAMPA, Fla. (Nov. 6, 2018) – A new report released by the Drug Enforcement Administration finds most overdose deaths are caused by prescription drugs, including opioids. While opioid abuse continues to plague certain states more than others, each state is unique in how it attempts to stem the crisis and its effect on families. These differences have resulted in significant variation across the country between opioid prescription rates and the number of children placed into foster care.

A new USF Health study published in Child Abuse and Neglect finds between 2010-2015, 60 opioids were prescribed for every 100 people in California and New York. While in West Virginia, Kentucky and Louisiana, it was more than 100 prescriptions per 100 people.

Troy Quast, PhD

Lead author, Troy Quast, PhD, associate professor at the University of South Florida College of Public Health, found the county average annual number of children removed from their homes due to parental substance abuse also varied substantially. One out of every 2,000 children were impacted in California and New York, and it was five out of every 2,000 in West Virginia.

Not only do the rates vary, but so do the relationship between the two rates. In 23 states, increases in opioid prescription rates were associated with increases in the child removal rate. For instance, in California, a 10 percent increase in the county average prescription rate was associated with a 28 percent increase in the child removal rate. By contrast, in 15 states, the association was flipped, where increases in the opioid prescription rate were associated with decreases in the child removal rate.

While Dr. Quast’s study does not definitively identify the reasons for such variation, he believes differences in state criteria for removing children from their homes plays a role.

“States also differ in their legal treatment of opioid prescriptions through prescription drug monitoring programs and legislation regarding pill mills,” Quast said. “The differences could also reflect varying stages of the opioid epidemic.”

Quast believes higher opioid prescription rates in some states may be associated lower levels of illicit opioid consumption. Given the especially potentially drastic effects of illicit opioids on families, prescribed opioids may be less likely to lead to a child removal.

Percent change in the rate of child removals due to parental substance abuse associated with a one-standard deviation increase in the opioid prescription rate, 2010-2015.

This recent study follows another published by Quast and colleagues earlier this year in Health Affairs, which analyzed the association between the rate of opioid prescriptions in Florida and the number of children removed from their homes due to parental neglect.

The national opioid epidemic, years in the making, will require more than the effort of government agencies to alleviate.

Deaths from drug overdose last year escalated to an all-time high of more than 63,000 nationwide – killing more Americans than car accidents. These deaths were largely driven by a five-fold increase in deaths involving illicit opioid drugs such as fentanyl and heroin, according to  data released by the Centers for Disease Control and Prevention (CDC) in December 2017. Some of the steepest increases have been in Florida, where Gov. Rick Scott last year declared a public health emergency to draw on federal funding for statewide prevention, treatment and recovery services.

This national opioid epidemic has been years in the making and mitigating its effects will take the effort of more than government agencies. The University of South Florida’s academic medical center has joined medical schools across the country in evaluating and strengthening education and prevention measures needed to help derail the devastating toll taken by the opioid crisis.

Boosting pain management education

In Florida, the USF Health Morsani College of Medicine (MCOM) plays a leading role in providing faculty, residents and students with the tools to address the opioid crisis while caring for patients in acute and chronic pain. USF’s medical college is among nine across the state working together to educate the next generation of physicians in pain management best practices, including appropriate opioid prescribing.  MCOM Vice Dean for Education Bryan Bognar, MD, co-chairs the Council of Florida Medical School Deans’ Pain Management Working Group, along with Diane McKay, PsyD, director of behavioral health and assistant professor of psychology at Lake Erie College of Osteopathic Medicine, which has a branch campus in Bradenton, FL.

The group, including members from the state’s six public and three private medical schools, coordinates with Florida’s Surgeon General, policymakers, the state’s allopathic and osteopathic medical associations, and others. Participants are developing a set of core competencies that can be readily integrated into existing curricula to better prepare Florida’s medical students and residents to manage different types of pain, to recognize the risks for addiction and mental health conditions affecting substance abuse, and to safely prescribe opioids when appropriate while keeping pace with changing practice guidelines for pain management.

MCOM Vice Dean for Education Bryan Bognar, MD, co-chairs the Council of Florida Medical School Deans’ Pain Management Working Group.

“All our medical schools are already addressing substance abuse and pain management to some extent,” Dr. Bognar said. “Our goal is to fill in any gaps that we find, and also assess that students achieve these competencies, whether through test modules or standardized patient simulations.”

The Florida group has built upon initiatives in Pennsylvania and Massachusetts, states where medical schools have already gone through the exercise of creating core competencies to strengthen pain management education for undergraduate and graduate medical students, Dr. Bognar said.

“Pain management education is an incredibly important pillar in addressing the opioid epidemic,” Dr. Bognar said. “At USF Health, we are teaching future physicians and other health care professionals to be skilled in best practices, so it is incumbent upon us to be part of the solution to this pervasive public health problem.”

“The misuse and abuse of opioids is a serious public health problem because the numbers of individuals, families and communities affected are staggering and the costs are borne by society,” said Donna Petersen, ScD, dean of the USF Health College of Public Health. “Solutions will require a team-based approach to bring various disciplines around the same table for discussion.”

Within a core course taken by all USF public health master’s degree students, Dr. Petersen teaches a new segment on the opioid epidemic that encompasses surveillance of narcotic-related risks and outcomes, effects of opioids on the brain, prescribing practices, roles of law enforcement and the medical community, and changing the conversation of addiction as weakness toward chronic illness.

Donna Petersen, ScD, dean of the USF College of Public Health, says addressing opioid misuse and abuse will require a team approach.

With a focus on interprofessional collaboration among its colleges of medicine, nursing, public health and pharmacy and school of physical therapy, USF Health faculty members are also looking for ways to bring students together as teams to learn about the complexities of substance abuse and pain management within the context of the opioid epidemic. Led by Tricia Penniecook, MD, MPH, vice dean for education at the College of Public Health, an Interprofessional Education Workgroup on Opioids was recently formed at USF Health to develop and implement common teaching modules to address the issue comprehensively.

Taking the lead in opioid prescribing practices

The Morsani College of Medicine is one of the first medical schools in Florida to develop clinical practice guidelines for opioid prescribing, said Charles J. Lockwood, MD, senior vice president for USF Health and dean of the Morsani College of Medicine.

The current opioid crisis emerged following substantial increases in per-capita frequency and dosages of prescription opioids, a trend begun in the late 1990s. Researchers hypothesize that this increase was due in part to palliative care experts seeking to address the burden of chronic pain without sufficient evidence of either the long-term effectiveness or risks of opioid dependence. The Joint Commission’s classification of pain as a “fifth vital sign” contributed to hospitals and physicians seeking to improve patient satisfaction scores through aggressive pain relief – sometimes without managing patient and family expectations of a pain-free experience.

Charles Lockwood, MD, senior vice president for USF Health and dean of the Morsani College of Medicine, has written editorials on opioid abuse and how obstetrician-gynecologists can help prevent it for February and March 2018 issues of Contemporary OB/GYN.  Dr. Lockwood is editor-in-chief of the publication.  | Photo by Sandra C. Roa

While doctors now prescribe opioids less often, the overall rates remain high and vary substantially across the country, a recent CDC surveillance report indicates. In 2016 prescribers wrote 66.5 prescriptions for every 100 people, down from 72.4 in 2006; however the prescribing rate remains three times as high as in 1999 and the average days of drug supply for each opioid prescription continues to trend upward.  The explosion of opioid prescribing in this decade has contributed not only to rising emergency department and hospital admissions and overdose deaths — but also to far-reaching psychosocial ills. A USF-led study published in the January 2018 issue of Health Affairs found an association between the rate of opioid prescriptions in Florida and the alarming number of children placed into foster care.

“Physicians can play a critical role in curbing the epidemic by returning to our traditionally stringent criteria for opioid prescriptions, using a multimodality, non-opioid approaches to chronic pain management and by better understanding opioid pharmacology,” said Dr. Lockwood, who, as editor-in-chief of Contemporary OB/GYN, has written editorials on opioid abuse and how Ob-Gyns can prevent it for the publication’s February and March 2018 issues.

The USF Health proposed guidelines clearly lay out for all practitioners who “prescribe, administer or dispense” controlled substances — including opioid medications such as OxyContin, morphine and fentanyl, to name a few — evidence-based standards for safely treating pain. Among other provisions, they specify recommended prescribing limits and exceptions, strongly encourage practitioners to complete approved continuing education training on pain management and addiction, and recommend that conservative and non-drug alternatives be considered to control non-cancer pain.

Mark Moseley, MD, chief medical officer for USF Health Care, says the new guidelines are intended to reinforce prescribing and practicing in a safe and thoughtful way.

The executive board of USF Health Care, the university’s multispecialty faculty practice group, is expected to approve the guidelines in February.  Mark Moseley, MD, chief medical officer for USF Health Care, and Kevin Sneed, PharmD, dean of the USF Health College of Pharmacy, led development of the guidelines with input from faculty leaders in neurology, psychiatry, pharmacy, nursing, physical therapy and legal counsel.

Creating a culture of patient safety

“Our intent is to reinforce evidence based prescribing and practicing in a safe and thoughtful way, given that these (opioid) drugs can be highly addictive in some,” Dr. Moseley said.

“At USF Health we are creating a culture of safety and putting the patient first, and these guidelines are important in setting that expectation,” Dr. Sneed said. “Ultimately, we have to be mindful about not creating an unintended problem while trying to treat a (pain-related) problem. Opioids are not a long-term solution for managing chronic pain.”

When prescribed prudently opioids are useful in helping physicians relieve pain, especially extreme pain or the chronic pain suffered by cancer patients at the end of life.  But research on the long-term effectiveness of these agents for chronic pain relief has been inconclusive or suggests ineffectiveness, and some studies indicate misuse and abuse of the prescription painkillers has led to a rise in addiction and overdose deaths from heroin.

Kevin Sneed, PharmD, dean of the USF College of Pharmacy, says opioids are not a long-term solution for managing chronic pain.

“Opioids as a class of medications are an important tool in our full armamentarium of pharmacological agents,” said Dr. Moseley, an emergency physician. “If you come into the emergency room with a broken bone, I need to have that as an option to give some immediate relief… but for a patient with back pain there may be more appropriate and effective options than prescribing three months of highly potent opiate medication.”

Both Dr. Moseley and Dr. Sneed agree that non-medication alternatives like exercise, physical therapy and biobehavioral treatments should be considered and discussed when evaluating an individual’s condition.

“Patients want their physicians to have an open discussion with them about how to best manage their pain,” Dr. Moseley said. “Most are pretty agnostic of the modality used if you can help alleviate the pain.”

CRNA advanced pain management fellowship among nation’s first

A USF Health College of Nursing postgraduate program for practicing certified registered nurse anesthetists (CRNAs) was granted accreditation in August by the Council on Accreditation of Nurse Anesthesia Educational Programs.

The distinction makes the nursing school’s Simulation-Based Academic Fellowship in Advanced Pain Management one of four such specialty fellowship programs for nurse anesthetists in the United States and the only one in Florida, said John Maye, PhD, CRNA, the fellowship program’s coordinator. The program, combining online courses with an intensive simulation clinical experience at the USF Health Center for Advanced Medical Learning and Simulation (CAMLS), will graduate its first class of 25 fellows this spring, including some from rural areas of America hit hard by the opioid epidemic.

John Maye, PhD, right, coordinator of the USF College of Nursing’s Simulation-Based Academic Fellowship in Advanced Pain Management, with Erik Rauch, DNP, center, and Alan Todd, DNP — all members of the college’s nurse anesthesia faculty. In this simulation exercise they are evaluating vertebral column anatomy. | Photo by Ryan Noone

CRNAs work with physicians to provide anesthesia and related care to patients before, during and after diagnostic, surgical or obstetric procedures. They can order and administer controlled substances based on state law and/or facility-specific protocols.

New research reported last year in JAMA Surgery cited an under-recognized complication of perioperative care among certain patients who never used opioids before surgery – whether they undergo minor or major procedures, some prescribed these painkillers for postsurgical relief may face a risk for developing opioid addiction.

Health care practitioners traditionally receive minimal exposure to the science of pain medicine, yet education is a “huge part” of preventing or reducing pain without inadvertently promoting opioid dependence, Dr. Maye said. “Our fellowship program focuses on educating CRNAs to understand the transmission of pain within the central and peripheral nervous systems and how specific drugs other than opioids can be used to help control that pain perioperatively.”

USF College of Public Health researcher leads newly published Florida study

The study published in the January 2018 issue of Health Affairs found an association between the rate of opioid prescriptions in Florida and the number of children removed from their homes due to neglect.

TAMPA, Fla. (Jan.  8, 2018) — The opioid epidemic has become so severe it’s considered a national public health emergency. Addiction to prescription painkillers, such as oxycodone and morphine, has contributed to a dramatic rise in overdose deaths and health care costs. What many don’t realize, it’s also associated with an alarming number of children placed into foster care.

In a study published in this month’s issue of “Health Affairs,” researchers analyzed the association between the rate of opioid prescriptions in Florida and the number of children removed from their homes due to parental neglect.

“Through my experience as a foster parent, I’ve seen first-hand how the foster system has been overwhelmed by children removed from homes where the parents are opioid-dependent,” said lead author Troy Quast, PhD, of the University of South Florida College of Public Health. “My goal in this study was to gain insight into the factors behind this surge.”

Troy Quast, PhD

Quast and his colleagues reviewed 2012-2015 data on Florida’s 67 counties submitted to the federal government’s Adoption and Foster Care Analysis and Reporting System. They found that in 2015, roughly two out of every 1,000 kids and teens were removed from their homes due to parental neglect, reflecting a staggering 129 percent increase since 2012.

According to the Florida Drug-Related Outcomes Surveillance and Tracking System, the number of opioids prescribed during this same time period rose 9 percent. In 2012, doctors prescribed 72.33 prescriptions for every 100 residents. The rate grew to 81.34 by 2015, averaging 74.1 prescriptions during the 2012-2015 time frame. It’s important to note the rate dropped 2.5 percent in 2013, following the implementation of several new state policies regarding pain clinics and a prescription drug monitoring program.

The range of Florida’s opioid prescription rate was dramatic. Some counties averaged about one prescription a year for every three people, while other counties had as many as 1 ½ opioid prescriptions per person each year. The highest rates were found in predominantly white counties.

The analysis by Dr. Quast and his colleagues showed that on average, for every additional 6.7 opioid prescriptions per 100 people, the removal rate for parental neglect increased by 32 percent. This estimated increase corresponds to roughly 2,000 additional children removed, resulting in an annual state fiscal cost of $40 million. Previous studies have shown children removed from their homes due to parental neglect have a greater likelihood of juvenile delinquency, teen motherhood, mental and physical health problems and adult criminality.

“While the reported drop in opioid prescription rates over the last two years is encouraging, unfortunately it appears illicit opioid use has more than offset the decrease,” said Dr. Quast. “We need to keep affected children in the forefront of our minds when tackling this crisis.”