Markian Hawryluk
The Bulletin

Markian Hawryluk is reporting this series during a yearlong Reporting Fellowship on Health Care Performance sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund. For the rest of the series so far, visit

A merica’s approach to battling illegal drug use has focused for decades on making the consequences as harsh as possible. Those caught selling or using drugs faced stiff criminal penalties, filling the nation’s prisons with mostly minority and low-income offenders. And any policy that made drug use safer was largely seen as enabling addiction or sending the wrong message.

The opioid overdose epidemic is starting to change the way Americans view people who use drugs. Public support has increased for approaches that aim to prevent death and disease without insisting on abstinence, for once-unimaginable strategies to keep people alive long enough for them to enter treatment and quit.

Across the United States, public health departments and outreach organizations are promoting distribution of needles and other drug use supplies, supervised rooms where drug users can inject under medical oversight and the use of physician-prescribed heroin to treat severe addictions.

More than needles

Tucked into a back alley, operating out of the basement of the University Temple Methodist Church in Seattle, The People’s Harm Reduction Alliance got its start exchanging clean needles for dirty ones during the HIV/AIDS epidemic of the late 1980s. Today, the group hands out much more, with a science-based, public health argument driving everything it does.

New needles and syringes ensure clients don’t have to reuse or share needles, reducing the spread of bloodborne viruses such as hepatitis C and HIV.

Injection kits include a metal bottle cap, called a cooker, in which heroin can be mixed with water and heated to speed dissolving, a dental cotton roll to filter out impurities before injection, and a small tube of clean water, all aimed at preventing soft tissue infections that can lead to abscesses.

“When they don’t have access to clean water, they’re using puddle water, which is terrible, or back-of-the-toilet water,” said Lisa Al-Hakim, director of operations for the Alliance exchange.

Once a month, the group brings a mobile wound care clinic to the site. Tuesdays are Women’s Night with pregnancy testing and other women’s health services. Fridays, there are tests for hepatitis C. Over the years, the group has expanded its reach, driving needles out to delivery points that stretch from Everett, Washington, to North Bend.

“Everybody who comes to access care is in much better health than they would otherwise be,” Al-Hakim said. “Some people are going to get on that path to treatment.”

Still, many places around the United States lack needle exchange programs. In Central Oregon, the Deschutes County Public Health Services runs a needle exchange program that distributed more than 11,500 syringes in 2015, but Crook and Jefferson counties are still exploring ways to launch them.

In Seattle, when public funding for the Alliance exchange was pulled in 2007, Shilo Murphy and two friends poured their own money into keeping the exchange alive as they pursued grant funding and other donations to continue the mission. For all the clean supplies and services they provide, their most important commodity might be hope and self-respect.

“I constantly tell people, look if you feel that you’re worthless, you’re going to make decisions as if you’re not going to be here tomorrow,” said Murphy, executive director of the Alliance. “But if you can have self-worth, and you know that you are going to be here tomorrow and that there’s a whole huge world out there for you, you’re going to make different decisions.”

People who think they’re going to be around another day, he says, are going to be less likely to share syringes, more likely to clean up and pick up syringes, than people who think that they’re worthless and deserve to die.

Meth pipes

The Alliance exchange has always pushed the boundaries of legality to lower the risks for drug users. The group handed out naloxone to reverse overdoses years before it was legal. In 2015, it started handing out glass pipes to meth and crack smokers.

“If you’re a smoker, we want you to smoke,” Al-Hakim said. “If you don’t have access to a pipe — it might seem crazy, but it’s a real thing — you’ll probably inject.”

That’s led to a documented reduction in injection drug use among clients since the Alliance started to hand out pipes.

It’s particularly important in the context of the current overdose crisis. The country has gone through different drug epidemics, said Dr. Ricky Bluthenthal, a professor of preventive medicine at the University of Southern California: heroin in the ‘60s, cocaine in the ‘70s, crack in the ‘80s, meth in the ‘90s, and now the ongoing prescription opioid and heroin epidemic. Bluthenthal has documented that opioid users today proceed to injection use much faster than drug users in past decades, increasing their risk of infection or overdose.

“People who use heroin are injecting at twice the rate as people who use meth, and people who use meth inject at twice the rate in that first year as people who use cocaine,” Bluthenthal said. “So the drug matters.”

That trend is borne out in infection rates. Until recently, it was mainly baby boomers who had hepatitis C infections, a holdover from the first wave of heroin use in the ‘60s. It’s only in the past decade that a second cohort of younger injection drug users has launched another wave of infections.

“You’re already seeing outbreaks of acute hepatitis C. You’re seeing changes in the demographic characteristics of chronic hep C with younger people reporting it, and then obviously overdose deaths,” he said. “We’re sort of in for it.”

Injecting drugs, meanwhile, raises the overdose risk by delivering the drug directly into the bloodstream in one massive dose. Public health officials in Europe have experimented with providing heroin users with foil so they can inhale heroin vapors, a method known as “chasing the dragon,” instead of injecting it.

Advocating for users to continue a less dangerous method of using drugs, for many people, comes perilously close to endorsing drug use, despite the obvious potential to prevent disease and death. But evaluations of needle exchange programs have overwhelmingly found that providing people with clean needles and other supplies doesn’t increase drug use, and states with the strongest prohibitions against needle exchange have higher rates of HIV transmissions.

“It’s a little chicken and the egg, because some of those also had the most injection drug use in the first place,” said Dr. Sharon Stancliff, medical director with the Harm Reduction Coalition in New York. “But I think there’s ample data to suggest that restriction to access to clean needles, unfortunately, does not keep people from using the needles that are available.”

Front door to services

Beyond the provision of clean supplies, needle exchanges have become a front door to the health system for a population that has learned to avoid hospitals and clinics where they’re often treated poorly and stigmatized as drug users. That leads many to avoid seeking care at traditional health care settings, letting problems linger until they become a crisis.

Over time many drug users begin to trust the staff at needle exchanges, becoming increasingly open to talking about other services, including help with quitting.

“We see a transition from walking into the syringe exchange, and grabbing their needles and running out the door, to eventually sitting down for a few minutes, and maybe having a cup of coffee,” Stancliff said. “And then eventually perhaps even taking part in the various activities, whether they be counseling, getting a flu shot, getting acupuncture.”

That’s readily evident at the King County Public Health’s downtown needle exchange in Seattle. Just beyond the counter where clients can pick up clean needles and supplies, a second door leads to nurses and social workers who can connect patients to drug treatment, provide risk reduction counseling and crisis intervention, sign people up for health insurance and help them navigate the health care and social services systems.

Before the Affordable Care Act, about 40 percent of people with access to the exchange had health insurance. Now the rate is at 89 percent. That opened the door to office-based medication assisted treatment, often within 24 hours, compared to an 18-month waiting list for an opening at a methadone clinic.

“How do you tell somebody that when they are in the moment saying, ‘I’m ready to make a change. Help me.’ OK, in 18 months, we will be able to help you?” said Joe Tinsley, King County needle exchange coordinator. “Then you have to think, ‘OK, I’ve got you on this list; what are some other things that we can do to help keep you alive until then?’”

In January, King County launched a low-barrier buprenorphine program housed at the downtown exchange, offering drug users same-day treatment with few prerequisites. Many clinics require patients to stop using illegal drugs in order to get the treatment, even drug testing them to ensure compliance. But studies suggest that even without abstinence, the treatment significantly reduces the risk of overdose.

The exchange had planned to do a slow rollout of the program starting Jan. 17. But that day, the first three people through the door came in asking about it.

“Word had already gotten out,” Tinsley said. “We had days in February and March where we had to turn away 20 people, or we had people lining up in front of the door at 10 a.m. to try to be the first person in, so they could get enrolled.”

With limited space, the program can only handle about 40 people at any given time. The exchange has more than 80 people on its waitlist.

The original plan was to get people stabilized on buprenorphine and then to refer them to a community provider. But the exchange found few providers were willing to take on their clients.

“A lot of prescribers that are out in the community want to have the ideal opiate user, only using opiates, who is housed, and has a job, has transportation and can make appointments,” he said. “That person exists; it’s just not in huge masses.”

Divisions remain

While the changing demographics of the opioid epidemic have created greater empathy for all drug users, advocates say there’s still a great divide along socioeconomic and racial lines.

“The public’s perception of harm reduction has shifted dramatically. I would be lying, if I said it hasn’t,” said Haven Wheelock of Portland-based Outside In, which runs the third oldest needle exchange in the country.

“As this population has shifted, we have seen more patient-centered policy, better levels of education for everyone. Med schools are starting to talk about it. These conversations are coming up in different political spheres, very differently than they were at the peak of the war on drugs.”

In the ‘80s and ‘90s, the constant messaging was that drug users were criminals who were dangerous to the community, she said, and that predominated how people were treated.

“We’ve kind of moved away from that,” Wheelock said.

“That being said, the more marginalized you are, the harder it is. If you go to an emergency room as a drug user who has a job and a house and private insurance and you’re dressed nice, you’re going to be treated differently than if you come in as a drug user who is currently homeless.”

When critics can’t be swayed with appeals for compassion and humanity, Wheelock often points to the bottom line.

“It’s cheaper to prevent illness than it is to treat it,” she said. “Harm reduction interventions are way cheaper than treating HIV or hepatitis, or treating overdoses. These interventions actually do save money.”

— Reporter: 541-633-2162,