Dr. Duwve serves in dual roles – as the Associate Dean of Public Health Practice at the Fairbanks School of Public Health and Chief Medical Officer at the Indiana State Department of Health (ISDH). At the ISDH she works on a range of projects including outbreak investigations and co-chaired, with the former state’s Attorney General, a Task Force on prescription drug abuse.
In January 2015, warning signs started coming in to ISDH from Scott County, Indiana. The ISDH received reports of three diagnoses of HIV linked to injection drug use. In response, disease investigation specialists were sent to the area to confirm the tests and identify risk factors and patterns of contact.
“On average, Scott County would see fewer than one new case of HIV in a year and 11 were diagnosed in a month,” said Duwve. “We quickly started to see connections between those infected who named the same contacts.”
As a microcosm of an alarming national trend in opiate addiction, Scott County became home to a significant number of people who had started with prescription painkillers, namely OxyContin, and transitioned to the injection of drugs. When OxyContin was reformulated so it couldn’t be injected, a stronger opioid named Opana quickly filled the void. The sharing of needles to inject drugs led to the spread of Hepatitis C and HIV. Between November 2014 and November 2015, 181 cases of HIV infection were diagnosed in Scott County. Of them, 87.8% had reported using the opioid oxymorphone (Opana) and 92.3% also had Hepatitis C virus.
Then-Governor Pence issued an executive order on March 26, 2015 declaring a public health emergency in Scott County. The order called for a coordinated, multi-agency response to provide means to address the outbreak of HIV. The order also allowed for a needle exchange program and a regional public awareness campaign called “You Are Not Alone” which focused on drug treatment, infection prevention, safe sex, needle disposal, and HIV testing and treatment.
“One of the particular challenges of Scott County is that there was nowhere to get treatment for HIV or drug addiction,” said Duwve. “They have only one family doctor and there weren’t any addiction treatment providers in Austin, the community most affected. Half the people we interviewed in Austin reported they had bought Suboxone [a drug used to treat opioid addiction] on the street to stop using.”
The ISDH and the local health department set up a community outreach center with testing, counseling, insurance enrollment, and care providers. Several infectious disease doctors from IU School of Medicine worked with the family doctor to start treating people with HIV. Churches offered transportation and meals.
The Scott County situation highlights the need to address how the medical community deals with pain and overreliance on prescription medications.
“We know we have a prescribing problem,” said Duwve. “The Task Force worked with the state medical licensing board to develop rules and a toolkit for using best practices for prescriptions, to set realistic patient expectations, and to encourage use of alternative methods to address pain.”
As a result, Indiana and Rhode Island led the nation in decreasing opioid painkiller prescriptions.
Another complexity to this issue is the severe shortage of treatment providers for persons with addictions. One estimate is that one million people nationally aren’t able to access effective treatment. To address this, the federal government increased the limit on the number of patients a physician can prescribe Suboxone to and the Task Force worked with the legislature to permit an expansion of opioid treatment programs affiliated with community mental health centers or hospitals. Most primary care doctors have not been trained to treat addiction. But, that is changing.
“We need to address the stigma of HIV, addiction, and treatment,” said Duwve, who believes that a turning point in the Scott County situation was when Jeanie White Ginder, mother of Ryan White, spoke at the local high school about the stigma of HIV.
Now, LifeSpring community mental health center is co-located with the syringe exchange program run by the Scott County Health Department right in the community so people can get clean syringes and meet with counselors if they are ready to get treatment for their addiction. The family doctor in the community is treating HIV and Hepatitis C. Everyone works together to provide food and clothing, and help with other needs of people in the community.
When Dr. Duwve was offered an opportunity to become a faculty member at the Fairbanks School of Public Health, she was intrigued by the prospect of introducing students to public health practice and helping local health departments with academic support.
“It has created great opportunities for students including paid internships with hands on experience,” said Duwve. “And I’ve had the opportunity to connect many colleagues at the university to people at the Department of Health for projects.”
The students and faculty will continue to work on our society’s wicked problems.