Pubdate: Wed, 18 Mar 2015
Source: Stranger, The (Seattle, WA)
Copyright: 2015 The Stranger
Contact:  http://www.thestranger.com/
Details: http://www.mapinc.org/media/2241
Author: Brendan Kiley

WHY IS THIS ROGUE NEEDLE EXCHANGE HANDING OUT METH PIPES?

The People's Harm Reduction Alliance is one of the most daring and 
innovative needle exchanges in the country.

And it's run by users. Five years ago, they started giving out crack stems.

Now they're expanding services for methamphetamine users.

On a sunny afternoon the first week of March, in an alley behind the 
University District post office, volunteers for the People's Harm 
Reduction Alliance needle exchange open the doors, set up their 
outreach table, and begin another afternoon's work.

They greet and chat with clients while handing out clean syringes and 
other injection tools: little metal containers for cooking up a dose, 
tiny balls of cotton, strips of latex for tying off an arm or leg (as 
well as a non-latex option). They also offer kits of naloxone, a drug 
that can be administered via needle or nasal spray to reverse the 
effects of an overdose.

Two young volunteers from the Hepatitis Education Project encourage 
people to go inside for free hepatitis C testing. A nearby shelf 
holds dozens of pamphlets on subjects like proper vein care, which 
parts of the body are safer for injection than others, what to do if 
you're with someone who overdoses, HIV and hepatitis C information, a 
"bad date list" by sex workers about johns who are known to be 
difficult or dangerous, and so on.

The clients who approach the table seem to come from all over the 
place: innocuous-looking people in midrange cars, scruffy older 
gentlemen with baggy clothes and gentle voices, a few cackling, 
wise-cracking ladies, the occasional jagged and angry young man, and 
one very young woman who looks painfully timid as she approaches the 
table. "We love you and respect you," a volunteer reassures her.

It was the kind of afternoon you might expect at any needle exchange, 
but the People's Harm Reduction Alliance (PHRA) is a little different 
than most needle exchanges.

As an independent operation, not run by any government agency, it 
offers services you won't find elsewhere. They're willing to hand out 
many syringes at once, for example, instead of the traditional 
"one-for-one" policy.

And they're willing to hand out more than just needles and naloxone.

That afternoon in the alley, volunteers give clients small glass 
stems for smoking crack and bubble-ended pipes used to smoke 
methamphetamine. Syringes, crack pipes, and meth pipes are all 
technically drug paraphernalia, and handing out drug paraphernalia is 
technically illegal, though Washington State courts have given 
public-health officers broad powers to do what it takes to prevent 
the spread of disease.

Even within the context of lenient local harm-reduction policy, 
PHRA--which took over the University District needle exchange in 
2007--has earned a national reputation for being rogues and 
experimenters. They pioneer new ideas, like trying to bring crack and 
methamphetamine users into the fold, and letting them know there are 
services and health-care options for them, not just the more 
traditionally accepted services for heroin users.

Because of the HIV crisis in the 1980s, says PHRA director Shilo 
Murphy, heroin injectors have gotten decades' worth of attention from 
the public-health community that has passed other drug users by.

Five years ago, PHRA began handing out glass stems to crack users to 
help prevent the spread of hepatitis C. The thin glass tubes used to 
smoke crack get very hot, sometimes blistering users' lips, and 
blisters on lips make shared stems a potential vector for infection. 
Murphy says this was a controversial move, but PHRA did it anyway. 
They let local law enforcement know what they were up to, but the 
police never interfered. "People who inject meth would come to the 
table and say, 'I'm only grabbing these needles because I don't have 
access to a pipe,'" Murphy says. Brendan Kiley

After PHRA took the initiative, other needle exchanges around the 
country began to follow suit--although the effectiveness of the 
crack-pipe program is still unknown.

A 2008 study by the National Institutes of Health concluded that 
transmission of hepatitis via crack stems "seems possible," but a 
2012 study published in the Journal of Public Health found no 
significant connection between sharing crack pipes and hepatitis. 
(Both studies also said there needs to be more research.) PHRA 
provides crack stems anyway--not because of some robust data anyone 
in the organization could point to, but because the local community 
of crack users asked for them. Public-health-run needle exchanges are 
still too timid to do this work. You can imagine what Fox News would 
do if it got wind of a government-funded agency handing out crack pipes.

PHRA cofounder Tom Fitzpatrick, a medical student, says the 
crack-stem program has had one undeniable effect: It's diversified 
PHRA's client base. The community they served used to be "very, very 
white," he says. "Whether it's correlation or causation I don't know, 
but since we began handing out crack pipes, the percentage of people 
who come here and identify as white has decreased every year." (PHRA 
conducts annual surveys and elections, where users can vote on what 
they'd like the organization to do differently--like hand out crack pipes.)

A few weeks ago, PHRA quietly launched its latest project: providing 
pipes to methamphetamine users.

Meth can be consumed several different ways, but injecting it is said 
to pack the most punch. (Preparing a meth injection is similar to 
preparing a heroin injection--the drug is mixed with water, but isn't 
heated.) Smoking is generally considered a safer way to take any drug 
than injecting it, especially if there's a risk that you're injecting 
with a needle that has been used by somebody else. But handing out 
meth pipes has another more long-term benefit: starting a 
conversation with meth users.

As Allan Clear, executive director of the Harm Reduction Coalition in 
New York City, puts it, "If you want to engage with drug users and 
build their trust, you have to provide something meaningful to them. 
A stem or a pipe helps build that relationship... it makes it more 
likely that they'll return for advice or medical care if you have 
provided them with something useful in your first 
interaction--something you didn't have to give them."

In the alley behind the post office, Murphy, the PHRA director, makes 
the point a little more strongly: "Drug users need more respect and 
love," he says. "Why is it always us that has to step up? Because 
we're drug-user run instead of run by bureaucrats?"

PHRA, like some other independent needle exchanges, is "peer 
run"--meaning that the board, staff, and volunteer base include 
active narcotics users.

Just then, Murphy calls out to a client as she steps away with a new 
meth pipe: "We love you! We love you just the way you are!"

Shilo Murphy came out as an active opiate and cocaine user in 2011 at 
a national harm-reduction conference in Austin. While sitting on a 
panel, he told the stunned audience that "heroin saved my life" and 
that he had no intention of quitting.

The reaction was swift and strong, especially among harm-reduction 
experts who see needle exchanges as a short-term solution to a 
long-term problem, and treatment and abstinence as the eventual goal. 
One renowned needle-exchange leader told Murphy he'd set the 
harm-reduction world back 25 years.

But Murphy maintains an unapologetically activist stance.

Shortly before his watershed moment in Austin, he'd founded the first 
chapter of the Urban Survivors' Union (also called the "users' 
union"), an advocacy group for people who use more stigmatized drugs 
such as heroin and methamphetamine. To become a member of the USU, 
you have to be a user--marijuana doesn't count.

The idea for the users' union occurred to Murphy after a PHRA member 
described him as a hero. He didn't think that label could possibly 
apply to him. "I thought, 'Heroes don't use heroin,'" Murphy says. 
"The union came out of my own inner struggle."

"Our program is run by drug users for drug users," Murphy says about 
PHRA. "Our program is a reaction to our community's needs... we don't 
provide a service that's pretty, we provide a service that's 
necessary." Then he repeats his frequent refrain: "I'm a drug user 
and I'm proud."

The meth-pipe project could be PHRA's most controversial move yet. 
Unlike crack pipes, meth pipes are not suspected to have any more 
infectious potential than marijuana pipes.

Murphy thinks PHRA is the first group to distribute meth pipes in 
North America--and he's proud to be doing it. Usually, Canada beats 
the United States to the punch on harm reduction for hard-drug users.

Clear, of the Harm Reduction Coalition in New York City, says he 
isn't 100 percent certain that PHRA is the first to pass out meth pipes.

Regardless, he says the organization has certainly "taken the 
leadership role on this."

Just like the crack stems, PHRA is offering meth pipes primarily 
because its clients have said they want them. "People who inject meth 
would come to the table and say, 'I'm only grabbing these needles 
because I don't have access to a pipe,'" Murphy says. "Eventually, I 
was handing them needles and I'm like, 'This is dumb.'" He points out 
that men who have sex with men and inject methamphetamine have the 
highest rates of HIV infection in King County. Why not give them the 
option to smoke instead?

Kris Nyrop--who ran the University District's needle exchange before 
PHRA, back when it was under the aegis of a group called Street 
Outreach Services--says smoking drugs is generally preferable to 
shooting them, and not just because of the potential for infection. 
"Every time you put a needle in your arm, you run the risk of hitting 
an artery and losing a finger or thumb or a whole appendage," Nyrop 
says. "As part of the general public-health, harm-reduction thing, I 
would encourage people to smoke their drugs instead of inject them."

But not everyone agrees that handing out meth pipes will have a 
significant impact on public health.

Susan Kingston, who worked with King County's HIV/AIDS prevention 
program from 2002 to 2008 (a high-water mark of meth use among gay 
men), says she's a little perplexed by PHRA's meth-pipe initiative. 
Kingston knows better than anyone that men who have sex with men and 
inject meth have high rates of HIV. But she says that's because of 
the sex, not the meth: "The primary mode of transmission was not the 
injection, but unprotected sex while high on methamphetamine--and lots of it."

Methamphetamine injectors, she says, use relatively few needles, 
injecting once a day or even once a weekend.

Regular opiate users, on the other hand, tend to inject several times 
a day. In her mind, giving out pipes isn't really addressing a major, 
population-wide health concern and burns up resources that could be 
used to address more urgent problems.

During our interview, she even questions the newsworthiness of this 
article, saying the pressing harm-reduction story right now is about 
pharmaceutical companies "jacking up" prices for naloxone just as 
opiate-overdose-prevention programs are finally getting more traction 
with the public and demand for the drug is increasing. "I guess 
that's just capitalism and entrepreneurialism at its best," she says. 
(For the record, King County public health officials say the naloxone 
price hikes have not affected their access to naloxone because the 
county qualifies for a federal program to provide medications to the 
public at significantly reduced rates--but, they admit, things are 
unstable and could change at any time.)

"Smoking would, in theory, reduce your risks," Kingston says. "I'm 
all for providing drug users, if they're not going to quit, any 
measure to make their drug use safer." But she questions the logic 
behind devoting resources to any program, such as the distribution of 
meth pipes, that isn't going to show a statistically significant 
return on the investment. "I don't dismiss this as a potential 
harm-reduction strategy that would have a benefit for individuals," 
she says. "But on a larger scale, I don't think it's going to have a 
big impact."

That difference between the PHRA approach and Kingston's 
approach--give the people what they want versus give the people what 
the data says they need--reveals a difference between user-union 
needle exchanges and government-run needle exchanges. "Harm-reduction 
programs, the activist ones, begin work in an environment where what 
they're doing isn't strictly authorized," says Clear. The very first 
needle exchanges in the country were committing crimes by 
distributing drug paraphernalia, but the HIV crisis led 27 
states--including Washington--to carve out explicit exemptions for them.

Crack stems and meth pipes do not enjoy similar legal protection.

Clear argues that independent operations like PHRA are vital for 
staking out new territory that is not officially sanctioned (yet) and 
widening the bandwidth for what government-run programs might be able 
to get away with in the future.

It's not unlike the old conventional wisdom of politics--radicals 
make extreme demands to broaden the political field, giving 
mainstream parties more room to maneuver while still appearing moderate.

We need people at the fringes to change what mainstream culture will 
eventually consider acceptable.

Activist needle exchanges in New York are starting to experiment with 
supervised-injection sites, which aren't legal but could reduce the 
number of deaths and infections associated with opiate injections. 
(The only legal supervised-injection site in North America, called 
Insite, is located in Vancouver, Canada.) "If you run a syringe 
exchange and do it indoors, you spend an awful amount of time 
figuring out how to patrol the bathrooms," Clear says. "People swear 
they're not going to inject drugs in there, but then they do. So 
switch it around: If people are already injecting, how do we make it 
safer?" One New York program, he says, has installed a countertop (a 
more sanitary place to prepare an injection than a toilet seat) and 
an intercom to check on people if they've disappeared for a 
worryingly long period of time.

Independent activist groups can get away with that--and take the 
political heat, when it comes--without jeopardizing their jobs, their 
funding, or the services they provide to their clients.

While organizations like PHRA are occasionally accused of being 
reckless, they have the luxury of operating without the same degree 
of fear. King County doesn't provide funding to PHRA, although it 
does provide some in-kind support, including roughly 40 percent of 
PHRA's syringe stock. PHRA is funded primarily by foundations and 
private individuals who support its work, even if it pushes at the 
boundaries of what's legal or considered acceptable.

"That's the history of harm-reduction movements in the US," Clear 
says. "Those activist programs, underground programs, are in the 
vanguard. They make the connections, do the outreach, do the HIV and 
hepatitis C prevention. Then they see if they can get health 
departments to do something about it afterward."

In many parts of the country, underground and user-union exchanges 
are all people have. In Greensboro, North Carolina, government-run 
syringe exchanges don't exist, because they're against the law. 
"Things that are accepted as totally okay in Seattle are illegal in 
North Carolina," says Louise Vincent of the Urban Survivors' Union. 
The organization was founded in Seattle but went national in 2013. 
Vincent is now the president of the USU Greensboro chapter.

She admits she's been arrested many times for her own drug offences, 
but also says she's been arrested several times for simply doing 
harm-reduction work. On one occasion, she was charged with heroin 
possession for having used syringes in a biohazard container, she 
says. (Robert BB Childs of the North Carolina Harm Reduction 
Coalition confirmed the risks of running a syringe exchange there, 
saying, "There have been arrests in North Carolina related to syringe 
exchanges.")

"North Carolina is conservative," Vincent says. "We are backward." 
And being "backward" comes with real costs.

According to a 2011 report by the Centers for Disease Control and 
Prevention, the Greensboro area has one of the highest rates of HIV 
infection in the United States--and is number one for HIV infection 
among women.

King County, on the other hand, has one of the lowest rates for HIV 
infection among injection-drug users in the country.

Vincent says that when she learned about the harm-reduction movement 
10 years ago, "I really felt like I'd found something 
wonderful--something that made sense, was based in science, and was 
compassionate." Users are among the most likely people to be cut out 
of social-services programs, she says. "If you can't abstain or won't 
abstain, you are told to leave treatment until you're ready," she 
says. "Basically, 'Come back when you're well.' It's outrageous, when 
you think about it."

Regg Thomas, current president of the USU Seattle chapter and former 
volunteer with PHRA, says the stigma against drug users is more 
dangerous than the drugs themselves--the shame, the furtiveness, and 
the cycle of incarceration make users' lives unnecessarily perilous. 
Thomas speaks from firsthand experience: He's 48, has been using 
methamphetamine off and on since his early 20s, and has been to 
prison several times. "The users' union is all about undoing the 
stigma against drug users laid out by the war on drugs," he says. "Of 
course, we don't have any problem with people abstaining, but if 
you're going to use, I want you to be the safest user you can be." He 
says activist and user-union-type programs like PHRA are on the front 
lines of changing attitudes that could eventually change legislation.

Michael Hanrahan, who manages King County's HIV/STD prevention 
program, cautions against thinking there's any significant schism 
between independent and government-run needle exchanges. "I don't 
think there's any more tension there than there is among alternative 
newspapers," he says. "Weekly newspapers have different approaches, 
but they have more in common than differences."

He points to the origin of King County's syringe-exchange program in 
1989 as an example--that was a collaboration between public health 
officials and activists from ACT UP, who pushed for an exchange while 
the county worked to align support from the mayor, the police, the 
county executive, and the city and county councils.

Within three months of ACT UP's start date for the syringe exchange, 
the county public-health department was able to assume responsibility 
for the program. Hanrahan also points out that King County has 
supported PHRA for a long time--like the syringes it donates--and 
that independent needle exchanges aren't the only ones that respond 
to clients' needs. "We talk to our clients with quite a bit of 
regularity," Hanrahan says. "Suggestions and requests that people 
make pretty often find a way into the program."

But Clear says the partnerships between activists and government-run 
needle exchanges aren't always so amicable. "I've been in that 
position, I've been really frustrated with health departments, and 
I've done my share of screaming and yelling," he says. "And there are 
a fair number of idiots working in public health--just like there are 
a fair amount of idiots in activism and harm reduction.

We can be shrill and annoying."

Out behind the post office in the University District, Murphy talks 
about trying to reverse the lack of solidarity in the drug community. 
"When we first had crack pipes, injectors would ask why," Murphy 
says. Five years later, he thinks the heroin injectors and crack 
smokers are getting closer to seeing themselves as part of the same 
constituency. Moving the organization to become more inclusive of 
methamphetamine users is the logical next step. PHRA's work is not 
just about preventing infections and overdoses, and not just about 
getting new faces to the table to see what other programs might be 
available to them.

"It's about creating a community," Murphy says. "Our thing is that 
whoever you are, you should be the best damn drug user you can be."
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MAP posted-by: Jay Bergstrom