Homeless Diabetics - Stolen Syringes - Heroin Safe Injection House


California State Assembly has recently introduced a bill into legislation (Assembly Bill 186) that would provide safe facilities for drug users’ to inject illegal drugs such as heroin. The supporters feel that this type of program has the potential to decrease drug use in public areas, reduce syringes on the street, decrease HIV and hepatitis and lower overall overdose death rates. 

Assembly Bill 186 applies to just 8 counties throughout California, including Alameda, Fresno, Humbolt, Los Angeles, Mendocino, San Francisco, San Joaquin and Santa Cruz counties. This program is being introduced as a test model as an attempt to decrease the sharp rise in opiate related adverse events and deaths. 

As a pharmacist who practices in the center of one of these counties, I provide pharmaceutical services to many patients who live in a city that will most likely adopt a “safe haven” policy.  This is an extremely contentious topic in our town; however, it is not my intent to debate the merits of faults of such a program.

More importantly, I would like to discuss a compelling concern that is not being addressed. Our particular town has an ever-growing homeless population. Just last night, a little after 9 pm, my wife and I drove from downtown to our house, about 2 miles from town center.  As we were leaving town we passed not less than 10 encampments along the sidewalks; in front of the mayor’s office, the post office, the town clock, and city hall. 

These were just the visible folks camping under tarps draped over shopping carts. Our town has a river that runs through town with many hidden embankments and treed areas that are home to many more individuals.

I practice in an out-patient pharmacy for the local community hospital, which also doubles for the county hospital. Any given day we are working with the social workers in the hospital to help expedite the discharge of a homeless person to the shelter downtown. Our goal is to assure the individual has 30 days’ worth of their medication with them as they head back out onto the street.

Over the last few months we have noticed a steep rise in our homeless diabetic patients coming back to the hospital. After a few interviews with patients, it happens that these homeless diabetic patients are regularly having their needles stolen. After a few days (and nights) on the street without their insulin, they end up back in the emergency room.

Patients are then treated for comorbid conditions, stabilized, then re-prescribed their medications and sent back to the shelter and onto the street. Unfortunately, our county Medicaid program does not offer the pen needles as a formulary alternative. Over the past couple months we have begun completing treatment authorization requests for these patients so they may be discharged with an insulin pen rather than a vial of insulin and a box of needles. This process may limit the possibility of stolen needles while allowing for the individual to treat their diabetes as required.

Of course, this is just a small point in the large problem. The first issue we come up against is storage of the pen needles. As we know, only the current pen needle may be kept out of the refrigerator. The others need to have safe storage at some location that will be accessible to the individual when they need it.  Also, the individual will need to understand how to use the needles that are attached to the needle and, importantly, how to properly dispose of them.

My point here is this; why is the state not concerned about having a safe house for homeless diabetic patients to self-administer their insulin? Clients could come and go throughout the day and be assured that their diabetic supplies would be kept safe in the house for their return.  Whether they are using insulin needles and vials, or insulin pens, their product would be stored in a clean and safe environment. 

Assuredly, needles and syringes would be disposed of properly.  Clients would have a table to sit at to check their blood glucose, rather than laying their supplies on a weather beaten blanket and tarp by the river.  Their numbers could then be logged into a book that stays safely in the building and be available for their clinic visits when necessary. Patients would have the opportunity to wash their hands prior to handling the diabetic supplies, wipe the injection area with a sterile alcohol swab, and use a new needle with each injection.

If a state can go as far to create an assembly bill that strives to create a safe house for drug addicts to inject heroin, surely it is not too much to ask to have a safe house for homeless individuals to administer their insulin.


What is the FINANCIAL COST of Low Health Literacy

We all know that lack of literacy skills can pose a challenge for anyone navigating their way through every day obstacles. Place this person in a health care environment, and the problem increases significantly. Furthermore, discharge this patient from the hospital with current standards and they are sent home with stacks of paper that promptly get set aside with many questions left unanswered.

On average, individuals with low health literacy can read at a fifth-grade level, while consumer medication information is written at a tenth-grade level. Health professionals regularly overestimate patients’ level of understanding and commonly do not allow ample time for questions and answers. As well, it is not uncommon for hospitals to focus on meeting the regulatory requirements of the facility by sending patients home with all the required documents, rather than assuring a complete understanding of their discharge protocol.

As defined by the Institute of Medicine, health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

In 2003, the US Department of Education National Assessment of Adult Literacy (NAAL) measured, among other items, health literacy. Based on the results of this study, it was found that over 36% of the adult US population was either basic or below basic health literacy. In 2007, an analysis of this report, Low Health Literacy: Implications for National Health Policy, attempted to define the impact of this astounding statistic.1 The US population in 2003 was approximately 242 million adults. This corresponded to an astounding 87 million US adults with at or below basic health literacy.

Empirical research on a conceptual model placed the cost of low health literacy between 7-17% of all healthcare expenditures. In 2003 this dollar amount was estimated to be between $106- $238 billion annually. In the year 2015, the annual health care expenditures are estimated to be $3.6 trillion, which would provide a cost of low health literacy at approximately $612 billion dollars.

Let’s take this a little farther and see the impact on individual hospital admissions. The 2007 analysis calculated that individuals with low health literacy cost, on average, an additional $993 per admission. 

Furthermore, according to a Veterans Health Administration study, performed between 2007-2009 in northern Florida and southern Georgia, meeting the needs of those with marginal and inadequate health literacy could produce economic savings of approximately 8% of total hospital costs for this population.2This is a savings of $2480 per patient.

Currently, it is estimated there are approximately 35,000,000 hospital admissions per year in the United States. 
Based on the NAAL 2003 study 36% rule, 12,600,000 of these admissions are challenged with Health Literacy. We have one study that estimates an additional $993 per admission and another study that estimates an additional $2480 per patient, so it would be considered conservative to use an average of $1000 for our calculations.

Based on an average of $1000 extra per admission for patients challenged with literacy, the increased cost to hospitals alone is $12.6 billion dollars per year.  Your average mid-sized community hospital that sees 5000 admissions per year spends an additional $1.8 million dollars covering the costs associated with low health literacy.

One small portion of the answer lies in our profession as pharmacists. Take the time to help patients understand their medications.  Listen to their concerns, address their obstacles, help patients achieve the understanding they need in order to obtain their best possible outcome of therapy.

1. Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low Health Literacy: Implications for National Health Policy. 2007;
Accessed April 3, 2017. 

2. Haun JN, Patel NR, French DD, Campbell RR, Bradham DD, Lapcevic WA. Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study. BMC Health Services Res. 2015; 15: 249.