The 2016–2017 Santa Cruz County Civil Grand Jury Requires that the Santa Cruz County Health Services Agency Director

The current SSP Advisory Group is composed of city and county employees as well as those working in the drug and rehabilitation community, with no members from the general public who can add a community perspective. AGREE PARTIALLY DISAGREE – explain the disputed portion X DISAGREE – explain why Response explanation (required for a response other than Agree): The Santa Cruz County Health Services Agency (HSA) has been very responsive to public input. In April 2013, through HSA’s commitment to community engagement and listening to public stakeholder’s input, HSA began directly administering the Syringe Services Program (SSP). Since inception of the SSP, HSA convened and staffed an SSP Advisory Group. While not a requirement of state legislature, HSA identified the need and value of convening a group of community representatives including law enforcement, County Probation, City of Santa Cruz executive management, community pharmacy representatives, California Department of Public Health (CDPH), physicians, community based organizations serving injection drug users and other subject matter experts to help guide the process and mitigate any unintended consequences of operating a syringe services program. Now that HSA is in Phase 3 of the SSP program, additional members will be welcomed in order to broaden the community perspective. Inviting residents, especially those impacted by addiction, will expand the perspective of the SSP Advisory Group.

The SSP leadership creates an atmosphere of poor communication and a lack of transparency by not holding public meetings or forums for community input. AGREE PARTIALLY DISAGREE – explain the disputed portion X DISAGREE – explain why Response explanation (required for a response other than Agree): The HSA leadership team has participated in many public forums related to SSP. Most recently, the team participated in the Forum on Criminal Justice Reform and Our Community where SSP was a topic and several questions, comments and concerns from the community were addressed. The leadership team has attended neighborhood group meetings, public Board of Supervisors meetings, meetings sponsored by elected officials, law enforcement agencies and community-based organizations. SSP leadership and staff have made every effort to talk to the public via email, phone, and face-to-face meetings and through the online dialogue feature of the SSP webpage. Through Facebook and other social media outlets, the SSP stays engaged in public discussion, education and uses the aforementioned outlets as a way to notify the public about important meetings, reports, and news related to the SSP. In 2016, HSA convened 11 countywide community health dialogues in which SSP was a regular topic of discussion. In 2013, 2015 and 2017, the SSP presented annual reports to the Board of Supervisors under Brown Act rules and open meeting policies in order to assure public participation and voice of the community. Poor communication and lack of transparency are not characteristic of the SSP program.

The SSP provides an abundance of information on its webpage but does not have an avenue for public dialog. AGREE PARTIALLY DISAGREE – explain the disputed portion X DISAGREE – explain why Response explanation (required for a response other than Agree): SSP has provided multiple ways for the public to contact program staff including, but not limited to: 1. Dedicated SSP phone line that is always answered during business hours. 2. General SSP program comment/feedback link on our website. (http://www.santacruzhealth.org/HSAHome/HSADivisions/PublicHealth/SyringeS ervicesProgram.aspx) 3. Specific comment/feedback link associated with the monthly published data reports. 4. Facebook postings and dialogue. 5. Eleven community health dialogues were held countywide in 2016 regarding all public health issues, including syringe services. Whenever possible, all community inquiries, feedback and comments are responded to by SSP leadership within 1-2 days. The public is also invited to provide ideas and potential solutions to programmatic challenges.

The SSP needle exchange site on Emeline Street is a confined shared space, making it difficult to provide all services to those in need. X AGREE PARTIALLY DISAGREE – explain the disputed portion DISAGREE – explain why Response explanation (required for a response other than Agree): As the result of the 2017 SSP annual report to the Board, there will be a change in the direction of the SSP program (Phase 3). There will be further integration of SSP into clinical services. Along with clinic redesign, expansion and improvement, we will see similar improvements to the SSP throughout this process. Funding and space shortages have been an ongoing issue for all of HSA’s departments; this issue is not unique to the SSP.

Limited hours, space, and staff hamper referrals to counseling, treatment, and support programs, reducing the number of people receiving assistance. AGREE X PARTIALLY DISAGREE – explain the disputed portion DISAGREE – explain why Response explanation (required for a response other than Agree): HSA has increased harm reduction education provided to SSP clients, from 70 percent in June 2016 to 86 percent in June 2017. In addition, HSA was recently awarded the Whole Person Care (WPC) Pilot grant program that will provide funding for evidence based approaches. This will allow HSA to effectively and efficiently provide care to individuals with mental illness, substance use disorder, and co-occurring health conditions who are homeless or are at risk for homelessness. HSA will also maximize capitalization of funding advantages through future Drug Medi-Cal expansion and other relevant resources offering potential opportunities to enhance the SSP and usher SSP clients into recovery. Lastly, the Public Health Division is currently drafting their Strategic Plan, and Substance Use Disorder Services was identified as one of the Goal Areas to improve over the next five years. Further prioritizing and subsequent monitoring of this issue will provide additional resources to substance use disorder efforts in Santa Cruz County.

The strict one-to-one needle exchange policy can’t be followed as the SSP policy prohibits the actual physical counting of syringes. AGREE PARTIALLY DISAGREE – explain the disputed portion X DISAGREE – explain why Response explanation (required for a response other than Agree): As authorized by the Board of Supervisors, the SSP adheres to a one-for-one policy. The number of used syringes being returned for exchange for new syringes is confirmed both by visual inspection as well as reviewing the database to see how many syringes the client received at their prior visit. Asking staff or clients to physically count and handle syringes would place staff at risk and be in violation of one of the primary goals of the program, which is to prevent the spread of infectious disease. In order to participate in the state Syringe Exchange Program (SEP) Clearinghouse, all SEPs must adhere to California Department of Public Health/Office of AIDS (CDPH/OA) guidelines for safe handling of sharps waste. Individual SEPs must not adopt policies or procedures that cause individual staff or program participants to come into contact with sharps waste. Specifically: “SEPs that receive syringe exchange supplies through the California Syringe Exchange Supply Clearinghouse or are funded with OA funds though contracts with local health departments to provide syringe exchange services must have policies and procedures in place that are consistent with harm reduction principles. These policies and procedures must include the following…Syringe collection and disposal policies and procedures that a) encourage program participants to return used syringes to the program, and/or to dispose of them properly; [and] b) collect sharps waste in such a way to minimize direct handling by program staff, volunteers and clients" (emphasis added)

Some injection drug users don’t travel to SSP exchange sites, thus preventing them from receiving assistance from other health programs. X AGREE PARTIALLY DISAGREE – explain the disputed portion DISAGREE – explain why Response explanation (required for a response other than Agree): HSA agrees that satellite programs would be useful in reaching these more marginalized populations. Now in Phase 3 of implementation, the SSP is increasing its reach to more marginalized injection drug using populations by offering immediate medical evaluation on an as- needed basis when clients are seeking SSP services. The mission of this phase of the SSP is to engage and monitor SSP individuals in the clinic setting to receive ongoing primary care, specialty care, and mental health and substance use disorder services.

The community is at risk with syringes found in public and private spaces throughout the county. X AGREE PARTIALLY DISAGREE – explain the disputed portion DISAGREE – explain why Response explanation (required for a response other than Agree): It is the mission of the Public Health Department to protect, prevent and promote public health. Through the Santa Cruz County SSP, HSA aims to reduce the risk of disease transmission caused by re-use or improper disposal of used syringes in Santa Cruz County and provide recovery from the national opioid epidemic. Research has found that syringes obtained from syringe service programs are more likely to be safely disposed than syringes obtained from other sources. And, syringes are more likely to be safely disposed in cities with syringe service programs compared to those without1 2 3 4 5 6. While the risk of disease transmission to the public from improperly discarded needles is not nonexistent, studies have found the risks to be negligible.7 8 9 10 11 1 Cleland CM1, Deren S, Fuller CM. (2007). Syringe disposal among injection drug users in Harlem and the Bronx during the New York State Expanded Syringe Access Demonstration Program. Health Educ Behav, 34(2):390-403 2 Coffin PO, Latka MH, Latkin C, et. al. (2007). Safe syringe disposal is related to safe syringe access among HIV-positive injection drug users. AIDS Behav, 11(5):652-62. Wenger LD1, Martinez AN, Carpenter L, et. al. (2011). Syringe disposal among injection drug users in San Francisco. Am J Public Health, 101(3): 484-6. Quinn B, Chu D, Wenger L, et. al. (2014). Syringe disposal among people who inject drugs in Los Angeles: the role of sterile syringe source. Int J Drug Policy, 25(5): 905-10. Riley ED, Kral AH, Stopka TJ, et. al. (2010). Access to sterile syringes through San Francisco pharmacies and the association with HIV risk behavior among injection drug users. J Urban Health, 87(4):534-42. Tookes HE, Kral AH, Wenger LD, et. al. (2012). A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs. Drug Alcohol Depend. 2012 Jun 1;123(1-3): 255-9. Makwana N, Riordan FA. (2005). Prospective study of community needlestick injuries. Arch Dis Child. 90(5):523-4. Nourse CB, Charles CA, McKay M, Keenan P, Butler KM. (1997). Childhood needlestick injuries in the Dublin metropolitan area. International Journal of Medicine 90(2): 66-9. Aragon Pena, A.J., Arrazola Martinez, M.P., Garcia de Codes, A., Davila Alvarez, F.M. and de Juanes Pardo, J.R. (1996). Hepatitis B prevention and risk of HIV infection in children injured by discarded needles and/or syringes. Atencion Primaria, 17: 138-140. Montella, F., DiSora, F. and Recchia, O. (1992). Can HIV-1 infection be transmitted by a discarded syringe? Journal of Acquired Immune Deficiency Syndromes, 5: 1274-1275. Russell FM, Nash MC. (2002). A prospective study of children with community-acquired needlestick injuries in Melbourne. Journal of Pediatric Child Health. 38(3): 322-3.

Without posted signage explaining how to report hazardous waste, the public is confused as to whom to notify or what action to take about found, discarded syringes. AGREE PARTIALLY DISAGREE – explain the disputed portion X DISAGREE – explain why Response explanation (required for a response other than Agree): The SSP webpage has detailed information on what to do if members of the public find a discarded syringe. All publicly accessible kiosks have signage for proper disposal. SSP staff will continue to listen to and consider public input and collaborate with other jurisdictions and agencies in order to continuously improve and simplify the process and increase access to proper syringe disposal. The Board has given direction, and this issue will be added to the SSP Advisory Group agenda, to identify and strategize the highest priority locations for additional sharps disposal access points.

There are only three county syringe disposal kiosks, limiting access to proper disposal. X AGREE PARTIALLY DISAGREE – explain the disputed portion DISAGREE – explain why Response explanation (required for a response other than Agree): The County purchased and offered kiosks to all Santa Cruz County jurisdictions, resulting in the placement of only three outdoor kiosks. There are several other sharps disposal access points throughout the county. Under Board direction, SSP program staff continue working with cities to identify and install additional public sharps disposal access points. This issue will be added to the SSP Advisory Group agenda to identify and strategize the highest priority locations for additional sharps disposal access points.

There is no combined syringe clean-up effort between local agencies to protect the public. AGREE PARTIALLY DISAGREE – explain the disputed portion X DISAGREE – explain why Response explanation (required for a response other than Agree): HSA, Department of Public Works and the Sheriff’s Office have worked cooperatively with community agencies on ongoing cleanup efforts. Beginning in Fiscal Year 2014-15 funds were designated for community cleanup efforts. This issue will be added to a future agenda of the SSP Advisory Group to discuss and analyze options for future clean-up efforts and multi-jurisdictional collaborations.