At times during her 15-year drug addiction, Jamie injected heroin far more often than she ate — sometimes shooting up as many as 10 times a day. She used the drug so frequently that she regularly ran out of clean needles.
“Any addict will tell you that a brand-new needle works a lot better than a used one,” notes Jamie, who says she has been drug-free since June. Not only does a needle blunted by repeated use become more painful over time, it also carries an increased risk of harmful consequences, such as breaking or transmitting a bloodborne infection.
Two local needle exchange programs, The Steady Collective and the Needle Exchange Program of Asheville, have been working to reduce the harms that often accompany drug use and addiction by supplying users with clean needles and other supplies. Now, in response to a rise in bloodborne infections associated with drug use, the Buncombe County Department of Health and Human Services may sponsor its own program to increase access to needles.
Jamie says she has seen many drug users reuse the same needles over and over again — a habit that, so far as she knew, didn’t lead to them getting sick. So she occasionally reused needles herself.
Although clean needles became more readily available after the state legalized needle exchange programs in 2016, Jamie sometimes still ran out and continued to reuse needles. “When you don’t have a needle, you use one that is dirty if that’s all you have,” she says. In April, the practice finally caught up with her.
After shooting up with a used needle, a skin infection bloomed around the injection site. Abscesses soon sprouted all over her body. “I was really sick for about three or four days, but then my fever went away and the abscesses healed,” she says, “and I thought I was OK.”
And then the infection came back with a vengeance, laying her so low that she could barely get in the car to go to the hospital.
Since June, Jamie has had a valve replaced in her heart, fluid drained from her lungs and surgery performed on her hip and both shoulders. All of those problems, she says, stemmed from her initial infection.
On the front lines
NEPA and The Steady Collective aim to reduce addicts’ reliance on dirty needles, which can cause bacterial infections like the one Jamie contracted, as well as transmit hepatitis and HIV/AIDS when shared.
NEPA, a program of the Western North Carolina AIDS Project that operates out of WNCAP’s offices at 554 Fairview Road, distributed 570,000 needles between July 2016 and June 2017. That number accounted for approximately half the total amount of needles distributed in the state during that period, according to numbers compiled in a report by the N.C. Department of Health and Human Services.
The Steady Collective distributes needles at the Haywood Street Congregation (297 Haywood St.) on Tuesdays and Wednesdays; the group also provides the service at Firestorm Books & Coffee (610 Haywood Road in West Asheville) on Tuesday afternoons. Steady gave out over 100,000 needles between July 2017 and June 2018.
“We are the front line,” says Hillary Brown, a harm reductionist with The Steady Collective. “We meet people exactly where they are and we meet people when they’re engaged in chaotic drug use, and they’re not going anywhere else for care.”
The programs don’t always have the resources to meet the demand. “We’re doing what we can,” says Michael Harney, prevention educator for NEPA. “But we continuously run out of supplies.”
Soon, a new ally could join the effort to protect drug users from the some of the most acute effects of addiction. On June 5, the Buncombe County Board of Commissioners heard a presentation from Dr. Jennifer Mullendore, the medical director for the Buncombe County Department of Health and Human Services, about the possibility of launching a county-sponsored needle exchange program. The program, however, is still in development and would require the commissioners’ approval.
“Commissioners … clearly have expressed interest, but we can’t move forward without their support,” Mullendore told Xpress. “So we’re working on gathering information [and] coming up with a very detailed proposal.”
Do no harm
“We’ve definitely noticed an increase in bloodborne infections that are linked to injection drug use,” Mullendore says. From 2014-16, the number of chronic hepatitis B cases in Buncombe County fluctuated between 12 and 15. But in 2017, that figure spiked to 30 cases, according to preliminary numbers.
The county also saw two new cases of acute hepatitis C and two new cases of HIV related to the use of injectable drugs in 2017.
According to the N.C. Department of Health and Human Services, transmission through shared needles is the leading cause of new hepatitis C cases. From 2012-16, the number of new hepatitis C cases skyrocketed by 200 percent, while cases of hepatitis B increased 62 percent over the same period. The department estimates that roughly 150,000 North Carolinians are infected with chronic hepatitis C and 60,000 with chronic hepatitis B.
While a spokesperson with the county DHHS says it’s too early to estimate the cost of providing a syringe exchange program, the program could actually save money in the long run. Treatment for HIV and hepatitis infections can run well into six figures over a patient’s lifetime; the Centers for Disease Control and Prevention says the estimated lifetime cost of HIV treatment is more than $400,000.
The concept of needle exchange started with the HIV/AIDS epidemic in the 1980s, Harney says. Patients contracted a significant number of HIV infections by using needles or having sex with needle-using partners. As understanding of the disease grew, so did knowledge of ways to slow its spread. “By implementing a needle exchange in some of the bigger cities … they scientifically were able to show a reduction of HIV infections,” he explains.
Harney began running a needle exchange in the early 1990s, long before such programs were legal in the state. A supply cabinet that holds clean needles and other supplies at WNCAP’s offices used to sit in Harney’s apartment, where he operated the exchange until 2012, when demand began to increase.
From one or two clients per week in the early days, NEPA now often sees 30-50 people a day seeking needles. Even before North Carolina legalized needle exchange in 2016, Harney points out, the program kept county and city officials apprised of its activities. “I wouldn’t say that we operated completely on the down-low, but certainly even today we don’t have a big billboard somewhere or an ad campaign,” he says; drug users generally learn about the service by word-of-mouth.
In addition to providing clean needles, The Steady Collective and NEPA also supply community members with other harm prevention tools. Both organizations provide naloxone, a drug that rapidly reverses opioid overdoses, and Steady offers testing strips designed to detect the presence of fentanyl.
A white powder that’s up to 100 times stronger than morphine, according to the Drug Enforcement Administration, fentanyl doesn’t add much weight when it’s mixed with other substances. That makes it difficult to detect when incorporated into methamphetamine, cocaine, heroin and other drugs. Since mid-May, Brown says, 33 samples have tested positive for fentanyl using Steady-supplied kits.
Fentanyl and analogous drugs accounted for 97 overdose-related deaths in Buncombe County in 2017 — a massive increase over 2016’s 17 fentanyl-related deaths.
In Mullendore’s view, a county-sponsored program would not replace the work done by NEPA and The Steady Collective. “They each have different populations that they serve … and they are valuable in the community,” she says.
A needle exchange program could mesh well with the offerings already provided by DHHS, which include clinical services as well as food, Medicaid and employment assistance, Mullendore says. The department offers many of the services included in a comprehensive needle exchange program, such as testing for hepatitis and HIV and linking patients with treatment for those conditions. “It would just be adding on a little bit more,” she says.
Still, it’s unclear how drug users would react to a county-run program. If the exchange were housed in the DHHS headquarters at 40 Coxe Ave., the presence of sheriff’s deputies there could keep some drug users away, Brown says, noting that some of those who stop by The Steady Collective have outstanding arrest warrants.
“We know that the folks we serve are engaging [in] a behavior that is criminalized,” she says. “It takes a long time to build trust.”
Steady asks for little identifying information from its clients — the program doesn’t take full names or ask for IDs. “People are very wary about coming in and receiving services,” Brown says. “We want to make sure that people do receive services and don’t think that their information in any way is going to be passed on to law enforcement.”
Taking it to the streets
A mobile unit, Brown argues, would be a better use of the county’s resources. The Steady Collective sees many participants who come from outlying parts of the county, such as Leicester or Swannanoa. “But we don’t have distribution out there, and it’s not really something that we have the resources to do,” she explains.
Tracey Childers, WNCAP’s prevention department coordinator, also thinks a mobile unit could be beneficial — in part because many people don’t feel comfortable visiting the DHHS headquarters downtown. Transportation issues can also make it difficult for those who live farther out to access the building. “It’s a whole other world when we go 20 minutes down the road,” Childers says. She would like to see a comprehensive service vehicle that could provide multifaceted care in underserved communities, including needle exchange, phlebotomy, wound care and rapid testing for sexually transmitted infections.
Harney, however, believes a mobile unit is the wrong fit for Buncombe County’s needs. Heavily populated cities such as Chicago or Baltimore, he explains, have areas known for their drug issues; in smaller communities, a mobile unit is more likely to broadcast an individual’s personal medical challenges to their neighbors.
The health department would be a better site for the county’s program, Harney says, because people are already going there for other services such as immunizations and vaccinations. “It needs to be logistically set up so that when people are going in it’s not identifiable that you’re going through door No. 1, and everybody knows that that’s for needles,” he says.
Needle exchange programs also offer a place for the safe disposal of used needles. In Harney’s shared office, for example, a pile of plastic laundry detergent containers await reuse as receptacles for used sharps.
NEPA offers the containers to participants and encourages them to return filled containers to the office for disposal at the Buncombe County Transfer Station.
Without access to a safe disposal site, people often discard used needles just about anywhere, Harney says — on sidewalks, front lawns and trash cans. Inadvertently coming into contact with a discarded needle can result in an injury or, worse, contracting an infection.
The problem has become so prevalent that local nonprofit Asheville GreenWorks, which performs many river cleanups in the area, has taken precautions to ensure that volunteers don’t get injured by littered syringes.
“Encountering needles on cleanup projects is a risk that is becoming more common,” says Executive Director Dawn Chavez. She says the organization is working on creating safe disposal options so that needles stay out of the waterways.
WNCAP’s stated service region encompasses 18 counties, but the organization actually sees people from at least 32 counties and four states, with clients traveling up to two hours to access services, according to Harney. That demand puts a severe strain on the organization’s resources, he says.
“I don’t think it should be the obligation of small agencies, whether it’s the WNCAP or The Steady Collective, that we be responsible for providing the prevention tools that we are providing to such an extensive, wide base of people,” Harney says.
If WNC counties outside Buncombe dispensed a significant number of needles on their own, Harney adds, some of the pressure on independent organizations such as NEPA and The Steady Collective would be relieved.
“It’s not going to close us, it’s not going to close The Steady Collective down if the county health department operates, but I think it’s a good model for other counties that people don’t have to drive an hour here, two hours here,” he says.
Power to the people
In contrast, Brown believes county health departments can do more good by funding community exchanges, as Buncombe County does for The Steady Collective. According to the county, The Steady Collective received $25,000 in fiscal year 2018 and $36,826 in FY 2017, which was the first year the county contracted with the organization. County funds made up a “significant” portion of the organization’s budget in those years, Brown says.
Because community organizations operate in direct contact with the people they serve, Brown says, these groups can involve clients in major decisions that affect them.
“We consult with people who use drugs,” Brown says, “so at every step, we’re making sure that directly impacted people are centered and they’re getting to have a say in the future of Steady Collective. We want Steady to be a ‘nothing about us without us’ kind of thing.”
Client involvement, Brown says, can help the program refine the type of syringes it buys and decide what supplies work best in a wound care kit. She isn’t sure that the county’s DHHS would be able to maintain a similar, ongoing one-on-one relationship with participants in its program.
Crawford, however, is optimistic about the potential of a county-run program. “Every addict that I know would get needles anywhere they could,” Crawford says. “Period. Especially if they were offered free.”
But to be successful, the process would have to be somewhat anonymous. “I think that if people had to show ID or give their real names or write their address down, I think that would deter people,” Crawford says. She also anticipates that drug users with outstanding warrants would avoid the Coxe Avenue building if deputies were present.
Still, Crawford says needle exchange services are a needed resource in Buncombe County. “Every addict I know and every addict they know uses these services,” she says. “It’s not a wasted thing by any means, and it’s saving lives.”
And while local leaders disagree about how a county-sponsored program would fit into the area’s existing landscape of care, they are united around reducing the harm associated with drug use. “We know that people use drugs, we know that they’re going to, it’s not going to stop it,” Harney says. “But how can we make it a little healthier, how can we reduce those harms, how can we make you feel like a human being and that you’re valid and you’re worthwhile and you might have another chance at getting into treatment if you want it?”