The Drug Dilemma

By Katie Hyslop

Additional Reporting By Tim Covi

Drug Dilemma
Hundreds of doctors, politicians, researchers and frontline workers got together with drug users and ex-users in Austin, Texas, in November 2010 to openly talk about drug use. But unlike the popular trend in drug-policy conversations, which for decades focused on the War on Drugs, the eighth National Harm Reduction Conference featured discussions on opening needle exchanges, legalizing and regulating the drug trade, and overdose prevention methods. 

Hosted by the Harm Reduction Coalition, the conference was an opportunity to discuss what has been a very controversial topic in some communities across the United States—the idea of harm reduction. Differing from most law enforcement strategies, harm reduction doesn’t seek to take drugs off the market, but rather to reduce the negative impact of drugs on communities by making them safer. So where a dirty needle might cause the spread of HIV/AIDS or hepatitis, a needle exchange program would allow users to come in, exchange dirty needles for clean ones, and potentially prevent the spread of disease, a serious public health hazard.

According to Allan Clear, executive director of the Harm Reduction Coalition, “What we do in (the United States) is make drugs as unsafe as they possibly can be, and we do that through laws, which means that, if you get busted with drugs, you go to prison for a long time. And that’s designed as a deterrent to make people stop using drugs, which obviously it isn’t.”

Drug arrests increased from 580,900 in 1980 to 1,889,810 arrests in 2006, according to data from the FBI Uniform Crime Reports. Since 2006, the number of arrests has slightly declined, totaling 1,663,582 in 2009.

Supported by the United Nations and over 93 countries worldwide, harm reduction remains controversial. While over half of the 158 countries where drug use has been reported say they support harm reduction, only 82 countries have needle exchanges, just 73 provide opiate substitution therapies like methadone, and only eight countries have safe drug consumption facilities. There are only two safe consumption facilities in North America, both in Vancouver, British Columbia, Canada.

In the United States, while 35 states had adopted needle exchange programs as a part of harm reduction policies, Colorado steadfastly rejected the idea—until last year. After more than a decade of trying, members of the harm reduction effort in Denver celebrated passage of a law legalizing a syringe exchange. But eight months since its passage, no legal syringe exchange exists, and some complicated questions about the details of the law have everyone wondering how the plan will actually be implemented. 

Rocky Mountain High

The first needle exchange program in the U.S. opened in 1987 in New Haven, Connecticut, but it was only last year that a ban was lifted on federal funding for needle exchanges, introduced by former Republican Sen. Jesse Helms in 1989. The government has yet to provide any guidelines for funding the programs, however, and many states are unwilling to move forward without knowing if their programs will receive funding.

Colorado became the 36th state to gain a legal syringe exchange program this year, but rather than a statewide mandate, each county’s public health board has to opt into the program; only after that can an organization apply to become a needle exchange within that county.

Lisa Raville, executive director of the Harm Reduction Action Center in Denver, said there is a lot of support for a needle exchange program among Denver’s Public Health Department. “Denver’s definitely opting in,” Raville said, “Then there’s a referral process of trying to figure out who’s going to be the syringe exchange. Either is it going to be the Public Health County, or are they going to subcontract with a nonprofit.”

Widely supported by Public Health officials, the controversy of needle exchanges often appears to be more a matter of public perception. In Colorado, passage of SB 189, the legislation permitting legal syringe exchanges, was strongly backed by the Colorado Department of Public Health. But when it came to crafting the legislation, most politicians didn’t want to appear soft on crime. Language was put in the bill ensuring that being caught with a syringe would still be illegal for users. “Right before it was introduced we had seen a sketching of the bill and everyone was trying to push for [complete exemption],” Raville said, “but the lobbyists and the [politicians] were feeling like this was going to make it palatable.” The final bill states that only staff and volunteers of a needle exchange program would be exempted from paraphernalia laws. “It’s still a class II misdemeanor—the paraphernalia law is still an issue,” Raville said.

Denver has an illegal needle exchange program, however, that’s been running since 2007. Previous exchanges operated in the late 1990s and in 2003-2004, but never lasted long.

According to Andrew—one of the founding members of the Underground Syringe Exchange of Denver, who requested his last name be withheld—from a political perspective legalizing a needle-exchange could seem like an invitation to do drugs.

“Everybody kind of assumes that if you’re going to give syringes to the users on the street that people are gonna be lining up around the corner. It’s kind of like this, don’t put it in my neighborhood, don’t give it to my community, because if you don’t give them the syringes they’re not going to inject drugs. It’s not true. And it’s also not true that more people are going to use because they have easier access to clean syringes.”

Senator Pat Steadman reinforces this claim. In an April blog post about SB 189, Steadman points out that Boulder County has effectively had an accepted public syringe exchange since 1992. “The Boulder County Health Department struck a deal with the district attorney for their jurisdiction,” he wrote. “An agreement not to prosecute was carefully negotiated, and it has been in place ever since.  Boulder County runs a syringe exchange program that by all accounts has been successful in preventing HIV and hepatitis B and C infections.  … There is no indication that drug use or crime has increased in Boulder County as a result of this program, and the local law enforcement agencies are supportive of its continuation,” he concluded.

Critics point out that maintaining a policy of prosecuting for paraphernalia can detract from the effectiveness of the needle exchange. Needle drug users often exchange needles for others they use with; so one person might bring in several syringes. “If you’re coming in with 100 used, they’re going to catch you for the residue in there as well,” Raville said, which can create a strong deterrent to coming in at all.

Andrew added that from his experience there’s a big risk because of the volume of needles people carry when they do secondary exchanges, where they take dirty needles for friends and exchange them. “We average probably, on one day of exchanging, seeing 5-10 people and exchanging 200-800 syringes in a three-hour block,” he says.

Though Denver has opted into the new needle exchange law, a legal exchange program might be a while in the works. In addition to ensuring that users can participate safely without fear of being arrested, a few other aspects of the legislation need to be worked through before an effective exchange can be created.

Previous attempts to set up a syringe exchange are actually creating unexpected roadblocks. A Denver city ordinance on syringe exchanges was actually passed in the late 1990s. Though no exchange was ever established, the ordinance remains and restricts the number of needle exchange sites to a maximum of three; it also states that they must be one-for-one exchanges, and that they cannot be within 50 feet of a dwelling. With an estimated 10,000-15,000 IV drug users in the city according to the Harm Reduction Action Center’s estimates, Andrew says the ordinance needs to be changed in order for the program to be effective.

“Some of these items in this city ordinance are actually more restrictive barriers than the senate bill [189] was itself,” Andrew said, “I think back then they were trying to find some way to weasel their way into the door. And unfortunately here 10-12 years down the road it’s actually inhibiting our progress.”

Andrew pointed to World Health Organization guidelines to demonstrate why these restrictions might only ensure failure. “If you look at the World Health Organization…guidelines on starting a syringe exchange programs, one of the most significant pieces that I find in there is it says: [the] best placement for a syringe exchange is in a neighborhood where injection drug users live and have easy access to this place.”

Andrew said he thinks it would be counterproductive to start an exchange that wouldn’t meet the community’s needs. “The fact that there’s still nothing happening is why we still have an underground syringe exchange,” he said, “And it’s going to continue until we have an effective exchange running in Denver.”

Elsewhere in the United States and Canada, communities are struggling with decisions about various aspects of harm reduction, highlighting areas of the topic that Denver can learn from.

No needles in Nashville

Nashville, Tennessee, runs harm-reduction programs on both sides of the law. The city’s Annual Vulnerability Index, released in October, interviewed 885 homeless people (out of an estimated 4,000) and found 64 percent abused substances at some point, while 44 percent had received addiction treatment.

There was a tolerated needle-exchange program in 2001-2002, recognized by City Hall as well as the local law enforcement, but for reasons unknown the exchange died off, and now clean needle distribution has gone underground. Legal harm reduction comes in the form of mobile outreach vans run by groups such as Street Works, which offers free HIV testing, condoms and lubricant to drug users, sex workers, and the homeless.

Leslie Davis, outreach team leader for Street Works, has been doing harm reduction work with the organization for 10 years. Davis says needle use is actually down in the city, likely because the grade of heroin has improved and can be snorted or smoked instead, which decreases the chance of contracting HIV/AIDS.

Davis wants more than clean supplies to pass out, though. He also wants to see drug use decriminalized and treatment focused on lifting users out of poverty, as well as counseling for the personal traumas that led them to drug use in the first place.

“There are success stories around. At Street Works, we have several success stories … people celebrating five or six years clean. … (But) the odds of turning your life around are not good,” he said. “I’ve seen ‘em die in this town and never get clean.”

Conservative Cincinnati

Like Tennessee, needle exchanges are illegal in Ohio unless they are sanctioned by a city’s health commissioner under an emergency order. Such an order was issued in Cleveland, where a needle exchange has been operating since 1995. At that time, according to the Centers for Disease Control and Prevention, 17 percent of the city’s new HIV infections were among IV drug users. Today that number has dropped to 3.4 percent.

But it’s a different story in Cincinnati, where it’s a crime to possess a dirty syringe, regardless of whether you’re the user or a volunteer at a needle exchange. While both the city’s mayor and health commissioner say they support a needle exchange in theory, STOP AIDS Cincinnati, a local AIDS prevention and support group that operates on a harm-reduction model, must make the case for a needle exchange to the entire city council and health board.

“Cincinnati is notably a fairly conservative city, and we have some groups in the city who kind of coalesce around what they identify as being family and community values, that are a little further out there than most of the community. But they do a good job rallying their forces,” said Amy McMahon, CEO of STOP AIDS.

HIV/AIDS levels among IV drug users in the city are 5 to 10 percent for HIV, while hepatitis C is much higher, at 35-38 percent. It’s numbers like these that drive McMahon to push for needle exchange on top of the condoms, lube, and testing STOP AIDS Cincinnati already supplies.

Methadone not covered in Midwest state

Needle exchanges are legal in Chicago, Illinois, but since the federal ban has been repealed, Dan Biggs hasn’t seen a flood of government money coming in. Instead, the Chicago Recovery Alliance (CRA), of which Biggs is founder and director, is funded by the Chicago Health Department and the Illinois Department of Health, and has become one of the largest harm-reduction outreach programs in the country.

CRA provides the clean rigs and condoms common to harm reduction in other parts of the world, also offering free vaccines for hepatitis A, B, and C, as well as the flu and pneumococcal pneumonia, through their mobile van and their office. But due to a federal law that limits distribution of opiate substitutes to specialized clinics, CRA can’t provide methadone or buprenorphine to marginalized drug users.

“[Treatment is] not available to most people who want it. …Right now I can’t get you into methadone treatment unless you have good resources—money. Most insurance don’t pay for it. [It costs] $60 a week,” Biggs said. “But I can get you a cell and court date for $50,000 a year. What kind of insanity is that?”

The Centers for Disease Control and Prevention estimates there are 60,000 to 90,000 injection drug users in Chicago, but only 7,000 to 8,000 use CRA’s services per year. Biggs says some areas of the city see no services at all, particularly the southwest side, which has high rates of injection drug use.

“Insite” into harm reduction

“We were coming to work and people were overdosing and people were dying, and at its height it seemed like it was happening every day, and it just seemed unnecessary. If people were dead, there was no chance of detoxing,” said Mark Townshead, executive director of the Portland Hotel Society, a nonprofit supportive housing organization in Vancouver, British Columbia. Portland Hotel Society runs Insite, one of the two safe consumption sites in North America, open since 2003.

“[Insite opened] because lots of people worked hard to make it happen, including the mayor—all the different mayors—and [Premier] Gordon Campbell.”

Insite is located in the city’s Downtown Eastside, often referred to as Canada’s poorest postal code. Injection drug users in that area have a mortality rate 14 times higher than the rest of B.C., with an HIV rate of 4 in 10, and a hepatitis C rate of 9 out of 10 users.

The facility consists of 12 safe-injection booths, monitored by nurses, where clients are provided with clean syringes, cookers, filters, water, and tourniquets, as well as education on safe injection practices that limit the spread of diseases like HIV and hepatitis C. Injection drug use is illegal in Canada, but Insite applied for and received an exemption from the federal government to run the site, though the current government is trying to shut the facility down.

There are approximately 12,000 registered clients at Insite, but in 2009 only 5,447 used the clinic, with an average 491 injections per day. Four-hundred-and-eighty-four overdose interventions were performed that year, with no fatalities—in fact, no one has died at Insite since it opened, but the long lines mean some people walk away without injecting.

Because the local health authority funds it, Insite acts as a gateway to other medical services, such as treating infections and diseases and referrals to mental health treatment. In its second year alone, Insite made 2,000 referrals to outside services, including 800 to addiction counseling. There is also a detox center called Onsite located upstairs if people want to quit.

The Canadian federal government opposes safe injection on moral and ethical grounds, and this stance has prevented other Canadian cities from opening their own safe injection sites, including B.C.’s capital city, Victoria. While drug users in Vancouver have access to needle exchanges all over the city, Victoria lost its only fixed-site needle exchange in 2008 after complaints about noise, crime, garbage and human waste in the area.

The Vancouver Island Health Authority secured another location for the needle exchange in March 2008, but complaints from neighbors resulted in an indefinite hold on a fixed-site needle exchange. Volunteers drive mobile exchange vans in the city, but they have also been banned from that neighborhood, commonly referred to as the “no-go zone.”

Support for Harm Reduction

Efforts for harm-reduction services, particularly needle exchanges and safe consumption sites, has gained ground in both Canada and the United States, but proponents still face hurdles.

Despite being the subject of 30 peer-reviewed studies by the B.C. Center for Excellence in HIV/AIDS, which showed a significant reduction in public injections and in HIV and hepatitis C infections, as well as an increase in the number of users seeking treatment, Insite is in danger of being shut down by the Canadian federal government. After two separate cases before the B.C. Supreme Court and Court of Appeal, which ruled in Insite’s favor, the decision now lies with the Supreme Court of Canada.

“The Canadian Medical Association, normally a very conservative body, has stepped in twice to defend Insite, and they will be intervening in the Supreme Court to say, ‘This is ridiculous. (Prime Minister) Stephen Harper needs to give his head a shake,’” Townshead said. “You can find an opinion from a fool, but ultimately the information is in and the evidence is utterly clear.”

It’s not just the government that stands in the way, however. Members of the public who don’t experience the realities of drug addiction in their lives often do not understand the reason for harm-reduction services, particularly because illicit drug use is illegal in North America.

“We live in a society that doesn’t often turn its thoughts to those who are least among us,” said Andrew of the Underground Syringe Exchange of Denver. “And injection drug use affects a very small portion of the population, so, since it’s not on their radar, and it’s one of those icky topics that they’re not interested in delving into because it challenges their moral boundaries, they just kind of look at it and say, ‘You know, let ‘em die off,’ basically.”

Clear, of the Harm Reduction Coalition, believes it is the politicians, not the public, who are holding back harm reduction, and with the retraction of funding bans on needle exchanges in the United States and the support of safe injection sites by the provincial courts of British Columbia, the future of harm reduction in North America is one of growth.

“The funny thing is that topic opinion polls, the few that exist, have always been pretty consistent that the general public actually supports them. It’s not overwhelming, but they are pretty consistent. It’s something like 55 to 45, or 52 to 48 in favor of syringe exchange programs,” Clear said.

“And I think that the changing in the legislation around the federal ban on the funding on needle exchange means that some of those programs that have been around for a while, but have not strictly been legal, will be tolerated a lot more by their local health departments. Hopefully we can build upon that, and then they can get funding and be legal and everything.” •