Training medical students to be successful community health advocates

Needle exchange programs are an effective way to promote health among people who inject drugs. A new commentary published in Substance Use Prevention, Treatment, and Policy describes the important role health professions students can take in needle exchange programs and the benefits to both themselves and the community.

The rapid rise in prescription opioid and heroin use in the United States has drawn significant public attention in the past several years. Between 2000 and 2015, over half a million Americans died from a prescription opioid or heroin overdose, and 91 Americans continue to die each day from opioid overdoses.

91 Americans continue to die each day from opioid overdoses.

Because heroin and opioids are often injected, they contribute to the spread of HIV and hepatitis C (HCV) through needle sharing. In 2013, deaths from HCV surpassed the number of deaths from the next 60 leading infectious diseases, combined. The Centers for Disease Control and Prevention estimates that there may be as many as 30,000 new cases of HCV each year due to injection drug use.

For communities in which injection drug use is perceived as a new phenomena, people who inject drugs (PWID), their family members, medical providers, and public health systems are seeking solutions to these harms that can be associated heroin and opioid use: death or illness related to overdose, the transmission of HIV and HCV, chronic liver disease and ultimately death that result from HCV.

Needle exchange programs

In a new commentary published in Substance Use Prevention, Treatment, and Policy, the authors describe their work to develop a new syringe exchange program in Orange County, CA. The commentary advocates for health professions students in other communities to do so as well.

Syringe or needle exchanges often draw strong criticism, with opponents suggesting that they promote drug use and crime. However, the authors remind us that syringe exchanges are supported by a large body of research, and that they reduce the transmission of HIV and HCV among their participants, while reducing needle-sticks to law enforcement and taking needles out of communities. For communities seeking ways to stop the spread of HIV and HCV related to injection drug use, the authors (as well as the current U.S. Surgeon General) remind us that needle exchange programs are the only evidence-based prevention programs.

As a counter point to one of the most common misperceptions of needle exchanges, no research supports the idea that they promote drug use.

Because needle exchanges meet participants “as they are,” and provide non-judgmental services, participants often receive all of their health and social services through their needle exchange program. As a counter point to one of the most common misperceptions of needle exchanges, no research supports the idea that they promote drug use. Some evidence suggests that needle exchange participants, in fact, are more likely to reduce or cease drug use as compared to non-needle exchange participants.

The authors note, “By engaging with PWIDs instead of rigidly adhering to abstinence or criminalization approaches, needle exchange programs embody a harm reduction approach, dramatically reducing infectious disease transmission rates.”

Involving health professions students

As a medical student at the University of Iowa and a co-founder and director of the Iowa Harm Reduction Coalition, I work with a group of health professions students to provide safer injection materials and prevent opioid overdose. Like many new harm reduction programs or needle exchanges across the country, the development of our program was spurred by the increase in opioid use in Eastern Iowa communities and a desire to positively impact the health of our community beyond the hospital walls.

The commentary’s authors advocate for other health professions, graduate, and medical students to develop community-based harm reduction programs because of the need for these programs, but also because of the benefits to students’ education. Along with the authors, I have found that building these types of programs requires navigating systems of political power while working in partnership with community members, media, legislators, and public health organizations. These skills are critical to future physicians’ practice, but they often are not part of traditional health professions’ education.

In Iowa, students have worked to write and introduce legislation at the state-level by partnering with think-tanks, lobbyists, legislators, community members, and advocates.

The Association of American Medical Colleges (AAMC), the National Academy of Medicine (formerly the Institute of Medicine), and other organizations that work to shape health professions education have repeatedly called for an increased focus in medical education on the social determinants of health, health equity, advocacy, and inter-professional education. Yet, medical schools like my own struggle to implement effective educational programming in these areas.

For example, our curriculum instructs us on the importance of adverse childhood experiences (ACEs). An ACE might include growing up in a household with an incarcerated parent, and a high number of ACEs may pre-dispose a child to mental health and substance use disorders later in life. But this type of education is inadequate. It doesn’t ask us to understand the structural forces that underlie ACEs, like the post-reconstruction era system of incarcerating black and brown bodies under Jim Crow and drug war policies, that perpetuate inter-generational trauma, and potentially predispose individuals to substance use disorders.

Through the creation of needle exchange and harm reduction programs, health professions students are able to gain deeper understandings of these structural forces, how to address them through their work, and develop necessary skills as community and policy advocates.

In Iowa, students have worked to write and introduce legislation at the state-level by partnering with think-tanks, lobbyists, legislators, community members, and advocates. In doing this work, not only are we learning skills to change health policy by working in inter-professional teams, we are directly applying the privilege and responsibility we gain through medical education to responding to public health crises and contributing to improved health for our community members.

As do the authors, I encourage other students to work with PWID and the harm reduction community to promote health equity in their communities through the development of needle exchange programs.

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