Phoenix's Underground Needle Exchange Offers Lifeline For Opioid Users
On The Road
It’s just after 9 a.m. on Saturday morning and a young woman in scrubs loads up her sedan with boxes of sterile water, band aids and syringes. She’s ready for deliveries.
“Hopefully this is enough,” she said to herself while scanning a list of the dozen stops lined up for today.
This is a monthly ritual for her and a band of volunteers who run Phoenix’s underground needle exchange, called Shot In The Dark.
“Some of us are people who use drugs, some are people who used to use drugs,” she said. We pull away from the storage unit, which houses their medical supplies.
She’s nervous talking about what they do and how that could possibly affect her job, so we’re not using her name.
While dispensing needles isn’t technically illegal, distributing or possessing drug paraphernalia is a felony under Arizona law. It’s difficult to get any public support, let alone funding.
They operate entirely word of mouth, asking participants to text them or show up at one of their “fixed sites” throughout the Valley.
“Just because you are using drugs doesn’t mean your healthcare doesn’t matter and doesn’t mean there’s nothing that can be done,” she said, glancing at the GPS guiding us to our first stop.
The Only Real Option
Needle exchanges are a classic example of the concept of harm reduction — an umbrella term for reducing the negative consequences of drug use, like HIV and Hepatitis C, without forcing people to be abstinent.
More than 30 states have syringe exchanges. Some are publicly funded, others more informal. There are a few in southern Arizona. One even receives public funding from the Pima County Health Department, which began the program about two decades ago with the buy-in of local law enforcement.
But for years, Shot in the Dark has been the only real option in Arizona’s most populous county where overdose deaths have risen dramatically in recent years. That has kept their program busy and expanding to all corners of the Phoenix metro area.
“As people become more aware of us we are getting more and more requests, which is a really good thing,’” she said. “I just wish we could do more.”
Like much of the country, Arizona’s grappling with an opioid epidemic. The state estimates about 800 people died from opioid overdoses last year and deaths from heroin have tripled since 2012. That recently led Arizona Gov. Doug Ducey to declare the crisis a public health emergency.
Soon we’re outside a small house with a tidy lawn. A middle aged woman emerges and comes up to the car. They make small talk as she fills a bag for her with clean syringes. After a few minutes, the two women part ways and she gets back in the car, an orange box with used needles in hand.
"She was asking me for naloxone. Unfortunately, we don’t have any right now,” she said.
The opioid overdose reversal drug, naloxone, has become one of the most powerful tools on the front line of the opioid epidemic. It can be injected or used as a nasal spray, called Narcan. Arizona has recently made efforts to expand access to the lifesaving drugs: passing a law in 2016 that allows people to buy it without a prescription and, more recently, training and equipping law enforcement with it.
But, she said, people who are most likely to witness an overdose, people who actually use drugs, still aren’t getting enough.
She said “part of it is affordability, part of it is access, but I think the biggest part is people fear the discrimination that comes along with asking for naloxone.”
As part of the governor’s declaration, the state’s actually now tracking who buys naloxone in hopes of collecting more data, but she worries that only adds to the unease among users. Some are even suspicious of her at first.
“People are shocked when I pull up sometimes,” she said. “They think we’re just a myth.”
By midday, we have crisscrossed the city, stopping at homes with people who are wheelchair bound and parking lots where a man and woman wait for her in the 105-degree heat.
Eventually we end up outside a trailer where four people come up to the idling car. One man looks impatient, anxious.
When he reaches for the syringes, his arm reveals an abscess, as wide as a baseball. She offers antibiotic ointment to him and then he hurries back inside.
A minute later we are back in the car.
“That was a pretty obvious severe infection, but you saw his reaction when I was like, 'Did you see a doctor?' He immediately walked away,” she said.
That is typical, she said. Many of their participants don’t want to go to the doctor for any reason. They worry about being arrested or put on a list.
“Oftentimes, we are the only people that are left that will talk to them because their family has cut off contact," she said. "Everybody in their entire life is pretty much telling them to get off drugs.”
But their group doesn’t tell them that, and only refers them to a doctor or treatment program if asked.
“We’re not just giving people needles,” she said, while describing some of the pushback they receive.
Helping Or Enabling?
Many believe syringe access programs enable drug use and send the wrong message. But decades of research have led the Centers for Disease Control and Prevention (CDC) to conclude that is not the case. In fact, some research shows people who access these programs are five times more likely to get treatment than those who don’t.
“It’s the craziest thing, you tell people their lives matter. You tell them you care about your health. They start to believe it and they decide that they want to change something,” she said.
She has worked in addiction for years and has seen both sides. Telling people as they leave detox to stay 100 percent abstinent, even though she knows the statistics indicate how difficult that is for most drug users.
“I got involved with this because I didn’t actually feel I was helping anyone. And now, I think I am,” she said.
Shot in The Dark gave out more than half a million syringes and more than 1,000 naloxone kits in 2016. They’ve already surpassed those numbers this year. They rely on private donations, including from those they serve.
But without steady funding, they are running low on money and supplies. She wishes the Arizona Department of Health Services — the agency tasked with addressing the state’s epidemic — would support their work. A spokesperson for the department said they would not comment for this story.
“A group of community members decided to start doing this because of the complete inaction of the Arizona government,” she said.
Many would disagree that the state has done nothing to address the epidemic overall. There have been laws to curb opioid overprescribing and “doctor shopping,” diversion programs for drug users, prevention programs in public schools and most recently the governor’s declaration of a public health emergency.
In The Parking Lot
George Patterson knows why people come to him on Tuesday afternoons in the parking lot of a mall and not the pharmacy down the road.
"All you have to do is find us. You don't need to bring your ID. You don't need to sign anything. You just get what you need," he said.
What most of the IV drug users who are gathered around Patterson's car in Mesa need are clean needles and naloxone. He's another one of the Shot In The Dark's volunteers.
This empty parking lot is one of the group's "fixed sites," where they come weekly to distribute clean syringes, band aids, tourniquets and other medical supplies, all out of the trunk of a car.
"It should be a location. It should be a clinic. There should be safe injection sites. There should be places for people to go so they don't overdose in QT bathrooms," Patterson said as he hands out bags of needles to their participants.
Over the years, some states have revised their drug laws to make these programs explicitly legal, but Arizona has not.
Some sites, like this one in Mesa, attract a few dozen people, Patterson said, while others can see as many as 400 in just a few hours.
One man, who wouldn't give his name, said he picks up naloxone every time he comes here and uses it often, including just the other day on a friend. "There's still a lot of people that don't even know about it," he said. "They are still using dirty needles. It shouldn't be so hidden."
A 'Well-Intentioned, Misguided Program'
The county's top prosecutor is clear about how he views the idea.
"It's a well-intentioned, misguided program," said Maricopa County Attorney Bill Montgomery. "We don't have a free case of beer a month program for alcoholics. It sends the wrong message and it's not providing the treatment."
A syringe only facilitates an ongoing addiction, he said, but giving out naloxone is different. That drug, he calls a "lifesaving measure" and Montgomery supports getting law enforcement and others to carry it.
Just because he's against exchanges Montgomery said, doesn't mean he wants to punish addiction.
"The criminal justice system isn't looking to prosecute the substance abuser where we don't have to," he said.
Montgomery points to a pretrial diversion program now expanding statewide that began in his office. It allows some non-violent drug offenders to opt for treatment instead of prison.
"Law enforcement really does look at treatment first as an option for those who are addicted," Montgomery said. "We can change that understanding. We can change that narrative."
He doesn't necessarily think Arizona needs to change any of its drug paraphernalia or sentencing laws in order to chip away at the stigma surrounding addiction. Instead he recommends more community partnerships, like a pilot program launched last year called the "Angel Initiative."
"It's slowly increasing in familiarity with the community," said Phoenix Police Commander Ed DeCastro, who runs the program based in Phoenix's West Valley.
People who are addicted, and without prior drug convictions, can walk into the precinct, turn over any drugs and get help finding treatment.
"So that there isn't this barrier between what they think we are going to do and what we think of the," DeCastro said. "It's more of lets 'work together.'"
The original aim was to keep parents from having their children taken away from them, but DeCastro said they are still sorting out how that will work.
Since October of last year 16 people have come into the precinct. About another 100 have been referred by officers on the street, he said.
DeCastro admits it's difficult to reach people who are so fearful. He knows about the under-the-radar needle exchange.
"If these organizations are going out there and helping people to not overdose, to not get sick, to not share needles, those kinds of things, then we are here to help," he said. "We're not for it or against it."
In other words, they're not going to arrest them. It's not illegal to simply give someone a syringe on private property, DeCastro said, but acknowledges law enforcement must walk a thin line on this issue.
Dealing With A Crisis
Dr. Andrew Kolodny co-directs the Opioid Policy Research Collaborative at Brandeis University's Heller School for Social Policy and Management. He said making clean syringes and naloxone more available is a "no-brainer."
"These are really important strategies," he said, but added that those are "downstream" interventions in the fight against the country's epidemic.
"If you treat opioid addiction effectively, people are going to be much less likely to overdose. And even more upstream would be preventing opioid addiction through more cautious opioid prescribing," Kolodny said.
The state has mainly emphasized that approach.
A recent report published by the department of health services examines what other states are doing about the crisis and whether Arizona could model some of those approaches. But expanding needle exchanges? That wasn't mentioned.