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Moving the Needle

Can Harm Reduction Roll Back an Epidemic of Drug-Related Deaths and Disease?

Co-published by Newsweek
The practice of harm reduction seeks not to shame people who use drugs into giving them up, but simply to provide them with the tools to improve their health.

Judith Lewis Mernit

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Naloxone kit. (Photo: James Heilman, MD)

Co-published by Newsweek


Between 1999 and 2016, deaths from opioid analgesics in the U.S. quintupled. When the pills ran out, cheap heroin flooded in.


Harm reduction for drug users, which includes everything from distributing clean needles to HIV testing to supervised injection sites, has shown to be one of the most effective strategies for slowing the spread of disease and lowering overdose rates. In some parts of California, however, the approach remains misunderstood and controversial. This week our three-part series, “Moving the Needle,” looks at the obstacles faced by harm reduction organizations in rural Northern California. Today Judith Lewis Mernit begins by reporting from the Mendocino County AIDS/Viral Hepatitis Network in Ukiah, where people who use drugs find acceptance and community without stigma or shame. Mernit’s reporting has been supported by a grant from the the University of Southern California Health Journalism Impact Fund.

Tuesday: A model harm reduction center in Humboldt County divides the city of Eureka — but also saves lives.

Wednesday: Safe injection facilities are at the front line of a health-care revolution for drug users — and of a potential showdown with the Trump administration.


 

Carol Chrysler is doing her best to fulfill the requests of a man sitting across from her in the cramped room of a tiny house in Ukiah, California. Chrysler, 33, is a volunteer with the Mendocino County AIDS/Viral Hepatitis Network; the man, 31, has driven 45 miles south in search of clean needles of many different gauges and lengths. “I’m a 10-pack per use guy,” he tells her, anxiously bouncing one knee. “I need 31s, 29s, 28s, 27s, half-inch, quarter inch, three-eighths.”

“I don’t have any 28s,” she informs him.

“Do you have 29s? 27s?”

“I do,” she says.

“Because I do a lot of rotation. You wouldn’t necessarily know, but I’ve been 13 years at this.”

The man, whose name I promised not to ask when he allowed me to sit in on his visit, tells me that he injects methamphetamine to endure months alone in the outback cultivating cannabis, at a grow site near the town of Laytonville. “It’s what happens when you live alone for 10 months out of the year,” he says. “I can make it about seven.” He found out about MCVHN — which locals pronounce “Macavin” — five days ago, after his last reused needle proved too dull to safely pierce his skin. He’s finding the Ukiah services a considerable step down, he adds, from the People’s Harm Reduction Alliance in Seattle, where he last lived.

“There you would show up and it was like hitting the cafeteria line,” he says. “Crack pipes, crack [pipe] condoms, cookers, everything.”


Overdose deaths skyrocketed once people figured out that dissolving and injecting newly marketed opioids for chronic pain delivered a more satisfying high than the pills did.


Chrysler politely tells him that MCVHN doesn’t do cookers. “But you’re not the first person to ask me this week,” she says, “so I’ll bring it up.”

After some back and forth, Chrysler agrees to give the man two 10-packs of syringes, in two different sizes. He rejects a dose of naloxone, a drug that binds to the brain’s opioid receptors and can arrest an opioid overdose. (Meth is sometimes spiked with fentanyl, a potent synthetic opioid.) He promises that when he returns to resupply, he’ll take a test for hepatitis C, a chronic form of the disease prevalent among people who share needles.

“Next time you come in ask for Wendy,” Chrysler says. “She’ll do a test for you.”


People might find it outrageous that someone can walk in off the street and access the paraphernalia they need to inject their drugs.


Chrysler does not ask the man if he’s interested in treatment. She does not lecture him about the toll methamphetamine might be taking on his mind and body. A former methamphetamine user herself — she’s been eight months clean — Chrysler knows that if she tries that, the man might never come back. And most of all, she wants him to come back.

“Thank you, hon, see you next time,” she says as the man takes the package of supplies and hurries out. “Stay safe!”

Chrysler is a “peer leader” in the field of harm reduction, a practice that seeks not to shame people who use drugs into giving them up, but simply to provide them with the tools and support to improve their health. She started using methamphetamine as a teenager, and still understands the value of a thin, short needle when you’re injecting a second dose with shaky hands, just as she understands why it’s important to get tested for blood-borne illnesses. She is firm; she sets boundaries. But she doesn’t judge. She has been there too recently herself.

To people outside the harm reduction field, the notion that someone can walk in off the street and access, for free and without identification, the paraphernalia they need to inject their drugs might seem outrageous, maybe even criminal. “People will say, ‘You mean you give someone a new needle, and they go an inject drugs with that needle?’” said Alessandra Ross, an injection drug use specialist with the California Department of Public Health, speaking to public health professionals at a September conference on rural opioid use. “That can be a challenge for people.”


Public attitudes about offering drug users assistance without asking for sobriety haven’t changed much — even if it prevents the spread of a blood-borne disease.


But the consequences of not rising to that challenge have too recently been driven home in rural communities all over the country. Once people figured out that dissolving, cooking and injecting extended-release formulations of newly marketed opioids for chronic pain — oxycodone and oxymorphone — delivered a cheaper and more satisfying high than the pills did, overdose deaths skyrocketed: Between 1999 and 2016, the incidence of death from opioid analgesics in the U.S. quintupled. When the pills ran out, cheap heroin flooded in. And where needles were scarce, disease raged unchecked: In rural Scott County, Indiana, more than 200 people became infected with the same strain of HIV between 2011 and 2015, when then-Indiana Governor Mike Pence lifted the state’s ban on syringe-exchange services in the most affected counties. Had the state acted five years earlier, a recent Yale University study found, HIV might never have spread beyond the first 10 people who contracted it.

MCVHN executive director Libby Guthrie.

Harm reduction for drug users is nothing new. Even in rural America, clean-needle distribution has been going on at least since the late 1980s, when the HIV epidemic showed that it respected no urban boundaries. Libby Guthrie, MCVHN’s executive director, started out in 1987 working on HIV prevention among injection drug users in the San Francisco Bay Area, but in 1990 moved to North Carolina, where HIV was rampant throughout the 1990s and all but ignored. “I watched several people die every month in [the HIV support group I led],” she recalls, “and watched other people not talk about why they died.”

Back then, syringe-exchanges operated underground, or, in California, with emergency waivers from county officials. That wasn’t possible everywhere: Dallas Blanchard, who runs a needle exchange on Saturday afternoons in Fresno, California, remembers trying to distribute clean needles in Kern County a decade ago. “If you got caught, you’d do 10 days in jail for every syringe,” he says. But the law has progressed: Since 2012, it’s been legal to possess and distribute syringes. As of 2015, you can even buy them in a pharmacy, although in a syringe purchase trial conducted among pharmacies in Fresno and Kern counties, led by West Virginia University Professor Robin Pollini, only 21 percent of attempts succeeded.

What hasn’t changed much are public attitudes about offering drug users assistance without asking for sobriety, even if it means preventing the spread of a blood-borne disease. A recent survey conducted by researchers at Johns Hopkins Bloomberg School of Public Health found that only 39 percent of adults in the U.S. would accept a legal syringe exchange in their communities, and only 29 percent approved of safe consumption facilities, where people can inject drugs in a protected environment, in the presence of trained medical personnel.

Twenty-six counties and cities in California have some sort of syringe-exchange program, which leaves virtually the entire eastern side of the state without any such services at all. Although Blanchard says he delivers syringes over the Kern-Fresno County line once a week, and also to an outreach stop in Tulare County, neither Kern nor Tulare has a clean needle program for injection drug users, despite nontrivial rates of overdose and disease. One rural California county, Plumas, has successfully reduced its overdose-death rate — once highest in the state — with a harm reduction program that has the support of law enforcement and local officials. But in other rural counties that do have services — Fresno, Humboldt and Mendocino in particular — local opposition has remained so fierce that service providers have turned to the state for authorization, so local authorities can’t shut them down.

Money is also an issue. As the budget for health and social services in California has tightened over the past decade, harm reduction agencies have seen their resources dwindle from scarce to almost nothing. Guthrie remembers when, in the early 2000s, with funding from the state Office of AIDS, she could afford four paid, full-time outreach workers who made regular treks to the tiny northern hamlets of Laytonville and Leggett, and even Covelo, where a confederation of six Native American tribes inhabit the remote Round Valley, a one-and-a-half hour drive from Ukiah. This was important: One of the premises of harm reduction is that offering clean needles is a first point of contact with drug users who might need other health services, counseling or disease testing.

“Every day of the week,” she says, “[the outreach workers] were out doing their thing, getting fresh supplies, testing people and making referrals — ‘Do you need testing? Do you need medical care? Housing?’ They were coming face to face with people and giving them syringes once a week and coming and picking them up.”


“Their perception of an addict is that I’m a bad person. But I’m not. I have integrity. I care about other people more than I care about myself.”


Then came the Great Recession and California’s budget crisis. Facing a $40 billion budget shortfall, California in 2010 eliminated all $33 million from the Office of AIDS’s prevention budget, which had supplemented $9 million from the Centers for Disease Control. The agency was forced to spread its federal funds among 19 “high-burden” jurisdictions, most of them coastal and urban. Mendocino, Humboldt, Lake and 39 other mostly rural counties were completely left out.

“We went from riches to rags overnight,” Guthrie says. “It was like, ‘Boom! You’re done.’ I said, no, we’re not. We have people in need and we have this syringe exchange, and it’s one of the only ways to engage people who are using drugs in the county.” She has kept MCVHN running with a network of volunteers to disseminate what they can. But she admits it’s not ideal. Mendocino County covers 3,800 square miles, much of it rugged and difficult to access. “We can no longer go out and do trainings for HIV and hep C testing, we can no longer do referrals and linkages. We’ve lost that face-to-face contact with people.” Because volunteer delegates — usually people who currently use drugs themselves — collect for their friends and communities in the far reaches of the county, she says, “65 percent of our exchangers we never get to see.”

In some ways, the attention being paid to opioid dependency in the U.S. has been a boon for places like MCVHN, which had been addressing the needs of injection drug users long before substance use disorders became a national focus. When California, in June of 2018, issued a statewide standing order for naloxone, allowing community organizations to obtain and distribute the overdose-reversal drug without a physician’s guidance, the county health department turned to Guthrie for help. “We were the only agency in the county that had any experience with it,” she says.The response to the opioid crisis “means I don’t have to invite myself to the Opioid Safety Committee meetings anymore,” Guthrie says. “We’re no longer those people down the street enabling drug addicts.” With the help of a new county public health director, Barbara Howe, Guthrie is in the process of securing funding for two outreach workers for the first time in 13 years. A new police chief, Justin Wyatt, has even stepped up to serve on the county’s Homeless Action Services Group, which among other things addresses drug misuse issues among people who live without shelter.


“I’ve been six days clean and I’ve already made up my mind I’m going to go out and get loaded today. I’m dopesick.”


But “we’re still the red-headed stepchild,” says Guthrie. “Not everyone embraces what we do.” Not everyone understands, in other words, that an overdose prevention kit and revised prescribing protocols aren’t the answer to everyone’s struggle with substance use.

At MCVHN, I meet Sean Jardstrom, who’s been using methamphetamine for 34 years — since he was 14 — and injecting for 15 of them. As dogs large and small — a poodle named Snickers, a border collie, Finn — circle in and out of the room, he tells me that he’s just left his fourth attempt at rehab. “I’ve been six days clean,” he told me, “and I’ve already made up my mind I’m going to go out and get loaded today. I’m dopesick.”

Jardstrom, who is gruff-voiced and tall, dressed in cargo pants and a Yosemite National Park T-shirt, doesn’t necessarily need free needles from MCVHN. Though he’s homeless, he has enough money from his disability payments to buy them at Walgreens. He’s managed to remain both HIV- and hep C-negative, and knows enough now to stay that way. What he comes to MCVHN to find, he says, is a community of people who accept him for what he is — people he considers his adopted family, people who don’t judge him.

“I’m scared that I’m going to die an addict,” he says. “But I can’t see how I won’t.” His family — mom, stepdad, a brother and a sister —refuse to speak to him until he gets clean. “Their perception of an addict is that I’m a bad person. But I’m not. I have integrity. I care about other people more than I care about myself.”

Jardstrom and I talk for a long time, until he gets restless and has to do something else. At one point, talking about his father, the only member of his family who stood by Jardstrom until he died in 2008, he starts to cry. “He never gave up on me,” he says. “He was the only one.” I want to help him. I know I can’t. I am grateful he has found his way here.


Judith Lewis Mernit’s reporting on harm reduction in rural California was supported by the USC Annenberg Center for Health Journalism’s 2018 Impact Fund.

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Moving the Needle

Science Supports Supervised Injection Sites. Why Don’t Politicians Agree?

Safe injection facilities represent the highest ideal of harm reduction services for people who inject drugs, yet in the United States remain almost prohibitively controversial.

Judith Lewis Mernit

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Supervised injection stations at Vancouver's Insite. (Photo: Insite)

 Any state that opens a supervised consumption site risks running afoul of federal law. Yet several U.S. cities and nonprofits plan to go ahead with the facilities anyway.


Harm reduction for drug users, which includes everything from distributing clean needles to HIV testing to supervised injection sites, has shown to be one of the most effective strategies for slowing the spread of disease and lowering overdose rates. In some parts of California, however, the approach remains misunderstood and controversial. This week our three-part series, “Moving the Needle,” looks at the obstacles faced by harm reduction organizations in rural Northern California. 

Monday Judith Lewis Mernit reported from Ukiah, where people who use drugs find acceptance and community without stigma or shame. Tuesday Mernit described how a model harm reduction center divides the city of Eureka — but also saves lives.

Today: Safe injection facilities are at the front line of a health-care revolution for drug users — and of a potential showdown with the Trump administration.


 

Somewhere in the U.S., at a location disclosed only to a select few, there exists a clean, bright room where people sit in comfortable chairs and inject illegal drugs with sterile equipment, under the watchful eyes of caring staff. They bring their own drugs, obtained on the street or through a dealer, and can test them, if they choose to, for the presence of fentanyl, a dangerously powerful synthetic opioid often mixed into heroin supplies (and possibly methamphetamine as well). They can relax, take the time to clean the injection site thoroughly with an alcohol wipe, find a useful vein without having to hurry.

When they are done injecting, they safely dispose of their syringes in a biohazard box and move into an adjoining room, where they continue to be monitored for signs of overdose. If a person nods off, appears to have trouble breathing, or turns pale and clammy, a trained technician can administer naloxone, an opioid overdose-reversal drug, and save that person’s life. In this one facility’s four-year history, 18 overdoses have been reversed, according to Alex Kral, an infectious disease epidemiologist in San Francisco with the nonprofit research agency RTI International.


In a dozen countries — including France, the Netherlands and Australia — only one fatal overdose has ever been associated with supervised consumption.


Supervised consumption sites, also called safe injection facilities or SIFs, represent the highest ideal of harm reduction services for people who inject drugs. While syringe-exchange programs help reduce the spread of blood-borne diseases such as HIV and hepatitis C, and naloxone distribution among first responders, community members and the drug users themselves helps reduce overdose deaths, supervised consumption sites virtually eliminate fatalities.

Among the 120-some SIFs that have operated legally, some for more than 20 years, in a dozen countries — including France, the Netherlands and Australia — only one fatal overdose has ever been associated with supervised consumption. (That one death, which happened later at a hospital near a SIF in Canada’s capital city, Ottawa, may have been caused by a heroin supply adulterated with a fentanyl analog such as carfentanil, a drug used to sedate elephants.)

The sites have also been found to have a positive, or at least neutral, impact on drug-related crime and violence in the neighborhoods where they exist. Supervised consumption in a contained facility could also address the biggest problem communities say they have with syringe-exchange programs, which is that, whether or not the exchange is to blame, needle litter turns up in playgrounds and parks. “I talked to a police captain here in San Francisco,” Kral reports, “and he said, ‘You mean the drug users go in a building, inject their drugs, and the needles stay there when they leave? I’m in!’”

Syringe discarded by heroin user. (Getty Images)

Supervised consumption sites, like syringe-exchange programs, also serve as a point of connection with health care for people with substance use disorders who want to stop, or at least change the way they use drugs — which includes nearly everyone who uses drugs. “Most people are thinking every day, ‘I’ve got to stop using drugs. I’m going to die like this,’” says Barry Zevin, medical director of Street Medicine and Shelter Health in the city of San Francisco. “But it’s really hard to walk into a treatment program and ask for help when you’re actively using.” Much better to go to where people are using, in the places where they feel comfortable, maybe even safe.

Nevertheless, supervised consumption sites in the United States remain almost prohibitively controversial. Last year, a California bill that would have authorized pilot programs in eight counties with high overdose rates — Humboldt and Mendocino among them — failed in the state legislature. This session, the bill’s authors, Assemblymember Susan Eggman (D-Stockton) and state Senator Scott Wiener (D-San Francisco), pared down their ask to a single four-year experiment in San Francisco, and rebranded it as an “overdose prevention” bill. It passed both houses, only to die by Governor Jerry Brown’s pen.


Within two years of its 2003 opening, North America’s first supervised consumption site, in Vancouver, Canada, was associated with a 30 percent increase in detox enrollment.


Brown’s press secretary, Evan Westrup, claims the Governor acknowledged the research on supervised consumption when he wrote, in his September 30 veto letter, that “The supporters of the bill believe these ‘injection centers’ will have positive impacts, including the reduction of deaths, disease and infections resulting from drug use.” But “the governor also considered the views of those opposed to the legislation,” including law enforcement and drug court judges. “After weighing both sides,” Westrup wrote in an email, “[the governor] ultimately concluded that” — as he wrote in the letter — “the disadvantages of this bill far outweigh the possible benefits.”

“I do not believe,” reads the veto letter, “that enabling illegal drug use in government sponsored injection centers — without any corresponding requirement that the user undergo treatment — will reduce drug addiction.”


“Nobody wakes up one morning and says, ‘Hey, there’s this supervised consumption site in my neighborhood! I’m going to go and inject drugs now.’”


But the supporters of the bill aren’t relying on anything so malleable as belief. Instead they cite decades of scientific research demonstrating that supervised consumption sharply reduces the incidence of death, disease and infection among injection drug users. There is also ample evidence that coercive treatment fails, 12-step programs work only five to 10 percent of the time, and supervised consumption often serves as a pathway to voluntary treatment. Within two years of its opening in 2003, North America’s first supervised consumption site, Insite in Vancouver, Canada, was associated with a 30 percent increase in detox enrollment. Later studies have confirmed that the trend continues.

Nor is there evidence to support the claim that supervised consumption “enables” drug use. “There’s nobody who wakes up one morning and says, ‘Hey, there’s this supervised consumption site in my neighborhood! I’m going to go and inject drugs now,’” says Kral, who with Peter Davidson of the University of California, San Diego, is one of two researchers allowed in to study the clandestine supervised consumption site.

In fact, he says, the people who access the facilities “are people who’ve been injecting for a long time and have to come to some sort of terms with the fact that it’s gotten so bad that they’re willing to go to one of these places. It’s not like stepping into a bar. These aren’t fun late-night hangouts. They’re not enabling people to do anything.” Except stay alive.

“That’s what it all comes down to,” Kral says. “The first thing you’ve got to do is keep them from dying. Then let’s think about treatment and all of the other options.”

Kral remembers a time when the “enabling” argument was used against another harm reduction effort, the distribution of the overdose-reversal drug naloxone. “The words people used back then were, ‘This is a parachute drug. You’re giving people a parachute, so now they’re going to think it’s fine to jump off planes.’” That criticism has fallen away as the crisis has grown more severe, but it still persists in some circles, as does the idea that people who use drugs have no agency to make decisions for themselves.


If it hadn’t been for opioids, the country would still be in a crisis of substance use disorders. Only the substances would be different.


Elinore McCance-Katz, the assistant secretary for mental health and substance use at the Substance Abuse and Mental Health Services Administration (SAMHSA), recently wrote that she opposes fentanyl test strips on the grounds that “people who are severely addicted will actually use the test strips to seek fentanyl, which might be able to give them the high that their current opioid no longer gives them.”

It’s that kind of “paternalistic attitude,” Kral says, that often stands in the way of services that can protect the health of people while they’re using drugs. But it also reflects a misunderstanding of how and why people get high. Leo Beletsky, an associate professor of law and health sciences at Northeastern University, argues that the nationwide opioid crisis wasn’t born simply of a loose prescribing environment for new and misleadingly marketed painkillers. It happened because those drugs became available during a time when people were feeling the sting of shrinking incomes, home foreclosures and disappearing opportunities.

“Opioids were the spark,” he says, “but broader societal changes created the fuel. The decline of unionization, poor job conditions, the dismantling of public assistance — all of it gets swept under the rug with this simplistic view of opioids being the causal factor.” If it hadn’t been for opioids, the country would still be in a crisis of substance use disorders. Only the substances would be different.


There already exist injection sites in every city, town and county: They’re called public bathrooms.


It’s worth remembering that, decades before opioids were a national obsession, overdose rates were already at crisis levels in urban communities of color, as well as in certain desperately poor counties in Appalachia and New Mexico. “Opioids were able to penetrate communities that would have been more likely to use alcohol, or other substances, like Valium,” Beletsky says. And “the use of benzodiazepines and amphetamines is [also] through the roof” right now.

As is the use of heroin and fentanyl. One of the consequences of restricting the prescription drug supply has been a sharp uptick in the use of far more dangerous street drugs. In 2015, law enforcement personnel who submitted illicit drugs for testing found twice as many tainted with fentanyl as they’d found the year before.

The discussion we should be having then, Beletsky continues, “isn’t an opioids-only discussion,” based on the idea that opioids are a contagion that needs to be contained. “It’s a discussion about our physical and mental health as a nation.”

Governor Brown was right about one thing in his letter: Any state that opens a supervised consumption site risks running afoul of federal law. The “crack house law,” enacted in 1986, prohibits maintaining “any place, whether permanently or temporarily,” for the purpose of using any controlled substance. In an August 27 New York Times opinion piece, Deputy U.S. Attorney General Rod Rosenstein promised “swift and aggressive action” against local jurisdictions that sanction supervised consumption facilities. He also claimed — again, without evidence — that SIFs “normalize drug use and facilitate addiction.”

Several U.S. cities and nonprofits plan to go ahead with the facilities anyway. San Francisco Mayor London Breed has been adamant that she won’t bow to state and federal authorities on the matter; Seattle’s Human Services Department is discussing a mobile supervised consumption site. Ithaca, New York has a site “fully outfitted and ready to go,” Kral says. New York City advocates have floated the idea of applying for a research license from both state and federal governments, in order to get around the legal constraints of opening a SIF.

In Philadelphia, the harm-reduction nonprofit Safehouse has already begun raising funds for what it calls an “overdose prevention site” (and which the regional U.S. Attorney calls a “deadly drug injection site”), with the support of former Pennsylvania Governor Ed Rendell. “It’s somewhat possible,” Rendell acknowledged to the Associated Press, that “they will come and arrest me.”

Or maybe they won’t. Beletsky has written that the law “was never intended to interfere with a legally authorized public health intervention,” which supervised consumption sites clearly are. After all, there already exist injection sites in every city, town and county: They’re called public bathrooms. And alleys, park gazebos and just about any place else one can find a place to hide. “We need to play that game where we require politicians to finish every sentence denouncing supervised injection facilities with the phrase, ‘and that is why I think injecting alone in a McDonald’s bathroom is better,’” wrote physician and harm reduction advocate Jonathan Giftos on Twitter.

“If you think this through at all, [the objections] are not about reality,” Alex Kral says. The science, he notes, is clear on the benefits for both the community of people who use drugs and the community of people who want drug use to stop. Everything else “is just politics.”


Judith Lewis Mernit’s reporting on harm reduction in rural California was supported by the USC Annenberg Center for Health Journalism’s 2018 Impact Fund.

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Moving the Needle

Drug Users Fight for Acceptance in California’s Deep North

The Humboldt Area Center for Harm Reduction is more than a syringe exchange. It’s a place where people who use drugs also find community, treatment for their psychic and physical wounds, and advice to help them stay alive and disease-free while they continue to use drugs.

Judith Lewis Mernit

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Peer volunteer Jamie and program coordinator Jessica Smith at the Humboldt Area Center for Harm Reduction. (Photos by Judith Lewis Mernit)

The battle over a harm reduction center in Eureka, California reflects battles being fought across America about how to treat, rehabilitate and care for people who use drugs.


Harm reduction for drug users, which includes everything from distributing clean needles to HIV testing to supervised injection sites, has shown to be one of the most effective strategies for slowing the spread of disease and lowering overdose rates. In some parts of California, however, the approach remains misunderstood and controversial. This week our three-part series, “Moving the Needle,” looks at the obstacles faced by harm reduction organizations in rural Northern California. 

Yesterday Judith Lewis Mernit reported from Ukiah, where people who use drugs find acceptance and community without stigma or shame. Today Mernit describes how a model harm reduction center divides the city of Eureka — but also saves lives.

Wednesday: Safe injection facilities are at the front line of a health-care revolution for drug users — and of a potential showdown with the Trump administration.


Wednesday morning, 10 a.m., Eureka California.

Mikey, a man in his 30s with smooth tanned skin, light-blue eyes and brown curls tumbling out of his baseball cap, stands in a cramped and busy kitchen, 20 slices of bread laid out before him. “I’m making bologna sandwiches,” he tells me when I ask. “As many as I can get out of two loaves of bread.”

As the kitchen manager at the Humboldt Area Center for Harm Reduction, or HACHR, Mikey prepares meals every day for people who come by here for supplies — alcohol wipes with which to prepare an injection site, sterile water in which to dissolve powder, clean needles to prevent blood-borne disease. He asks that I not use his last name, or his face in a picture; he’s too worried about reprisals from people who don’t approve of what he does. When I ask him whether he’ll let me quote him in this story, he consents only because he’ll do whatever it takes to defend the place where he’s found friends, work and acceptance. Like most of the people who visit this house, Mikey is dependent on drugs.

“Yeah, yeah, I’m a drug fiend,” he admits. During the day he uses heroin to control his panic disorder. “The doctors won’t give me ‘benzos,’” a class of sedatives that includes Xanax, Klonopin and Valium. “They say they don’t trust me with them.” At night, he sometimes injects methamphetamine to stay awake on Eureka’s streets, so he doesn’t get robbed or beat up.

Mikey works swiftly, constructing his sandwiches and piling them into a cooler for an outreach trip to the nearby city of Arcata. Within the hour, he’s ready to go.

“This is the best job I’ve had in the world,” he says. “I don’t want it to go away.”


“I grocery shop like I’m Jackie Onassis. If anyone sees me wearing sunglasses indoors they’ll say, ‘See? We told you she uses drugs.’”


When I visited HACHR in June of this year, the fear that it might go away was perilously real. Three months earlier, Eureka’s city council had passed an ordinance requiring agencies that distribute clean needles file quarterly reports and steer people into treatment — a practice HACHR volunteers consciously avoid. (“If you push people too hard, they don’t come back,” HACHR board member Rachel Waldman told the council.) Discussions had unfurled on Facebook and NextDoor, in which people threatened to come for HACHR staff with “torches and pitchforks.”

HACHR’s founder and executive director, Brandie Wilson.

Worried that the council would rescind the ordinance that allows HACHR to operate in the city, Brandie Wilson, HACHR’s founder and executive director, had applied for authorization from the state of California, which would override local control. In public comments regarding the application submitted to the California Department of Public Health, one Eureka resident accused HACHR of actions “bordering on terrorist activity” and “helping children to shoot up.” Another called the agency “a radical militia group.”

The animosity peaked on June 5, when protesters associated with the anti-HACHR group Take Back Eureka faced off against HACHR supporters on the steps of Eureka’s City Hall. Two weeks later, two city councilmembers, Heidi Messner and Kim Bergel, showed up at a HACHR board meeting, announcing that they felt compelled to address the community’s concerns. From both sides’ accounts, the meeting turned hostile, and in the aftermath, Wilson reported that someone had keyed her car, that stalkers were videotaping HACHR’s activities through the windows and that more than one threat had been made on her life.


“Everyone’s out there believing that only bad people do drugs. When in reality, everyone uses drugs. Everyone.”


“I grocery shop like I’m Jackie Onassis,” she told me. “I cover my head and wear big sunglasses.” She realized the disguise could backfire: “If anyone recognizes me and sees me wearing sunglasses indoors they’ll say, ‘See? We told you she uses drugs.’”

Wilson and her staff reported the alleged keying incident and threats to the police, but Eureka’s Chief of Police, Steve Watson, dismissed them as below the threshold of legal action. Comments posted on social media, he said, “fall under the protection of the First Amendment.” He did not condone the threats, but neither was he unsympathetic. “As a law enforcement leader I’m unwilling to sacrifice the community’s sense of safety on the altar of a syringe exchange program,” he told me. “Parents should be able to take their children to our parks without living in fear of being stuck by a discarded needle.”

As to whether HACHR would be held responsible for such an incident — and for the needles that people say clog public toilets and accumulate in Eureka’s gutters — Watson demurs. Those needles could come from a lot of places, including Humboldt County’s own syringe exchange program or any of the local pharmacies, which in accordance with a 2015 state law, are allowed to sell syringes on demand. “The issue is more whether having this kind of syringe exchange program is right for a community like Eureka,” he says. Enlisting people like Mikey as volunteers, he says, makes it seem like drug use is okay. “But it’s not,” he insists. “Illegal drug use is never okay.”

The battle over HACHR is roughly the same as the battles being fought all over the country about how to treat, rehabilitate and care for people who use drugs. The nationwide crisis believed to have begun with loosely regulated access to prescription opioids has now become a nationwide crisis of injection drug use — along with blood-borne diseases and deadly infections from paraphernalia shared and misused. In Charleston, West Virginia, a program that provided clean syringes in addition to counseling and medical services was shut down after the police chief imposed onerous restrictions, such as ID checks and a strict one-to-one exchange. (A wide body of decades-old research shows that a more permissive “needs-based” exchange saves more lives.) In Grand Traverse County, Michigan, where injection drug use fueled an epidemic of hepatitis C — a chronic form of the disease that spreads almost exclusively among people who share needles — county health officials sustain a clean needle program over the ongoing protests of the county sheriff.


People who use drugs also die from infections caused by unsterilized needles and dirty water, wounds that turn septic and can’t be reversed.


The Orange County Needle Exchange Program in Santa Ana, California, lasted only from February, 2016 until December, 2017 before city officials pulled its permit on the grounds that not only was syringe distribution increasing the number of dirty needles found on the streets, but also facilitating drug use among Orange County’s swelling ranks of the unsheltered. (Neither claim has empirical evidence to support it.)

Like the Charleston program in its heyday, HACHR is more than a syringe exchange. It’s a place where people who use drugs also find community, treatment for their psychic and physical wounds, and advice to help them stay alive and disease-free while they continue to use drugs. Since 2017, when Wilson settled her crew into a 19-room Victorian house in downtown Eureka, it has functioned as an all-purpose gathering place for a few days a week, welcoming people who use drugs, be they opiates or stimulants or both. “We even have a nap room for people who are in chaos from lack of sleep,” Wilson says.

Wilson also relies on people who use HACHR’s services – “consumers,” she calls them — to staff the facility. “Drug users are front and center here,” Wilson tells me. “They make decisions, they help people connect with services. They’re the reason we can even function.” The people who mend the roof, who facilitate the art days, who offer workshops in medicinal teas — almost all of them use drugs once in a while, weekly or every day. Wilson demands only that they not use drugs on the premises and treat each other with respect.

This, more than anything, is what confuses HACHR’s detractors. “HACHR is the only [county needle exchange program] that has [current drug] users as a part of their team, in charge of needle exchange,” says Heidi Messner, who represents Eureka’s Ward 2 on the city council. “The term ‘best practices’ is being thrown around [by HACHR staff] but it’s a lie,” she says. “‘Best practices’ is when [people] who were users and are now clean work with users. To take that term and use it in a completely different context frustrates people.”

Messner also objects that Wilson isn’t pushing her consumers into treatment. “If [treatment] was part of the model, it [would probably] look different to people,” Messner says. “If the model is just, ‘Let’s corral people and keep them safe while moving toward their own destruction,’ that’s a challenge for people. Do we make sure they don’t trip over anything, make sure they don’t fall and get hurt on their way to jumping off a cliff?”

Wilson has little patience for that kind of talk. “That’s why we’re dying,” she says. “Everyone’s out there believing that only bad people do drugs, that if you use drugs you’re not a part of society or you’re not a part of the community. When in reality, everyone uses drugs. Everyone.”

Humboldt County, where 135,000 people are spread out across 4,000 square miles, has in recent years become notorious for its large number of homeless people, and people who inject drugs. It is also known for its drug-related deaths, and not just from opioids: Of the 49 people in the county who died from a drug overdose in 2017, according to the Humboldt County Sheriff’s Department, close to a third of them overdosed on stimulants, primarily methamphetamine. Some of those drug supplies may have been tainted with other substances, such as fentanyl, a cheap but potent opioid first developed for use in patients undergoing cardiac surgery. The quality of street drugs is difficult to control.

People who use drugs also die from infections caused by unsterilized needles and dirty water, wounds that turn septic and can’t be reversed. They contract diseases from sharing pipes with raw and chapped lips. They often don’t know they’re infected, and consequently don’t seek care. The Humboldt County Department of Public Health estimates that nearly one in every 18 residents in the county are currently living with hepatitis C. The rate of new infections in the county is currently three times the state average.

Wilson is 44, although she looks younger, in part because of the way she wears her dark blond hair: in a wavy bob with a shock of magenta painted into it. She argues with a passion that endears her to many but which others find off-putting — especially those who have a less generous opinion of people who use drugs. She founded HACHR in 2014, in response to what she saw as a crushing need for health services in Eureka’s homeless encampments in Cooper Gulch Park and the Palco Marsh, which upwards of 200 people once occupied in tents or ramshackle shelters adjacent to Humboldt Bay. In 2015, her organization subsisted on a single $20,000 grant, from the Humboldt Patient Resource Center.

“We didn’t have a vehicle,” she says. “We’d go down there with a wagon — one of those fold-up ones you get at Costco — and give out wound-care kits, hygiene kits and referrals.” In 2016, the same year the Eureka Police Department began evicting the marsh residents to transform the area into a city park, the city passed a resolution authorizing HACHR’s syringe-exchange program. By then, HACHR had incorporated, secured nonprofit tax status and assembled a board of directors. Cobbling together grants and individual donations, Wilson raised enough to fund an operating budget of $100,000 without any taxpayer funds from the city.

The next year, Open Door Community Health Centers, a nonprofit that operates several rural Northern California clinics, offered as a headquarters the big Victorian house on Third Street, which had variously been a trap house, a vacant eyesore and a treatment clinic, for rent at $1 a month. Wilson insists on keeping every surface clean as a surgical table, often furiously wielding a bottle of bleach solution to wipe down counters herself. (When I complain the spray is making me cough, she tells me to open a window). Bright educational posters and memorials to fallen friends cover the walls.

The California Department of Public Health donates supplies, including syringes and naloxone, a drug that reverses the effects of opioids and can halt an overdose in progress. Other supplies, such as tourniquets and condoms, HACHR buys, and volunteers neatly sort into compartmentalized boxes.

Last year, HACHR volunteers and staff counted 2,674 encounters with drug users, slightly more than three times as many as they saw the year before, when they were still an itinerant service. Because there are no ID requirements or other tracking information that might deter a potential consumer, that number includes people who accessed services more than once. The syringe-exchange program began as a “needs-based” effort — if you came in the door, you could get as many clean needles as you asked for. Because there are many places in the hills above Eureka where there is almost no access to doctors, let alone clean needles, there were times when a single person would walk away with 300 needles. “This is a vast rural community that we serve,” says Jessica Smith, HACHR’s program coordinator. “Sometimes we hadn’t seen someone for months. Sometimes someone would be collecting for their entire community.”

After the city council passed the March ordinance, HACHR switched to a one-to-one trade, to the extent that it’s feasible: The federal Occupational Health and Safety Act prohibits the opening of sealed sharps containers to count their contents, so HACHR staff has to count based on estimates of how many sharps fit in a given container. (Eco-Med, the company that processes discarded needles, later verifies the count by weight.) In 2017, 688,390 of the 735,823 needles HACHR distributed came back — a 93.5 percent return rate.

HACHR is something of a pay-it-forward enterprise for Wilson, who grew up in Terra Bella, a small rural California town in the Sierra Foothills, and early on developed her own problems with drug and alcohol abuse, cycling in and out of drug courts and 12-step programs punctuated by stints in jail. “The [drug court] system was set up to fail,” she says. “Any small thing would put you back in jail.”

After California voters passed Proposition 36 in 2000, redirecting drug offenders into treatment, Wilson struggled with rehabilitation programs that failed to address the mindset of the smart young rebel atheist she was. “Everything was about God,” she says. “And I didn’t believe in God.” Then she met a woman she calls Nickie C., at a Narcotics Anonymous meeting. (The abbreviated last name is in accordance with N.A. traditions.) “Her husband, Bob, had been in prison for 16 years on a drug charge,” she says. “He got out of prison, and got a Ph.D.” The couple helped her understand that recovery wasn’t about steps, but about guiding principles for how to live. “They taught me that there’s a lot of space in between chaotic drug use and abstinence,” she says.

Most of all, they encouraged her to go to back to school. She began in a certificate program for drug and alcohol counseling at Porterville College, but in her first job at a drug court-authorized counseling facility, one of her clients, a mother of three, was sent back to jail after a urine test came back positive for cannabis. “Being a drug court counselor sucks if you don’t believe in the drug war, if you don’t believe in incarceration,” Wilson says. So with Nickie and Bob “cheerleading” for her, she enrolled in Humboldt State University — first as a psychology major, but quickly switched to sociology. She graduated with a master’s in 2011. “Sociology is all about the ‘isms’ that drive the fight in me,” she says. “It helped me understand that it wasn’t just me being bad. It was a system that was corrupt and fucked. I was responding appropriately.”

There is such a thing as a functioning drug user,” says Christina Donnell, a jocular redhead who facilitates art days at the center on Tuesdays and Thursdays. Donnell was once an injection drug user herself, but hasn’t used in months. “I just segued out,” she says. As she started taking on more responsibility at HACHR, working as a volunteer, she started to crave more mental clarity, and her drug use tapered off. “I don’t like to use the word ‘clean,’” she says, “because that implies I’ll never get high again, and that’s not true. I might use drugs again from time to time. They just don’t control my life.”

Donnell’s story is not uncommon. Jessica Smith watched her own mother segue out, after 16 years of using heroin. “She fell in love and got married to another drug user who was on the outs with his family,” Smith says. When the two of them took a trip back east to mend the husband’s relationships, they both stopped using drugs and never went back.

No treatment plan, 12-step program or incarceration could have accomplished that, Smith says. “You’re not ready until you’re ready.”

Some people might never be ready, in which case intervention takes the form of support for integrating into society, of becoming that functioning drug user Donnell refers to. Community helps; so, in some cases, does a dog. Smith has been trying to help Mikey get Rebel classified as a service dog so he can take him on the bus with him; Rebel “alerts” on Mikey when he has a seizure. “You have a right under the ADA to keep him with you,” she instructs. “You just have to tell people what he does.”

Mikey went to city hall to get Rebel a license, but he wasn’t yet neutered, so they turned him down. He comes back visibly defeated. “I was so excited to make him official,” he says. “That was such a letdown.”

But he’s still proud that he comported himself with dignity in the face of resistance. “There was another time in his life when I would have started yelling at people,” he says. “But now I’m representing this place. I don’t want to give it a bad name. So I was calm.”

“Mikey wants to go to culinary school,” Smith says. “We’re trying to help him with that.”

Early one Thursday afternoon, seven people crowded into HACHR’s small, barely furnished kitchen. The room still smelled of fried onions and tomato sauce from the spaghetti lunch Mikey made earlier in the day. Jessica Smith had laid out a blanket of paper large enough to nearly cover the table. On it were the names and office phone numbers of city council members and other elected officials who were publicly contemplating whether to rescind the 2016 ordinance authorizing HACHR’s existence.

“If you call Natalie, remember to just thank her,” Wilson shouted out to the room, referring to City Councilmember Natalie Arroyo, who stood up for HACHR when no one else did. (She was rewarded, Wilson and Watson both claim, with a syringe dropped on her front porch.)

Across the table from Smith sat Jessica Fox, a county mental health case worker who spends two hours a week at HACHR. “I help people connect to services,” she explained. “If they want to get into detox, I can help with that. If they just want to see a therapist I can help with them that. Just trying to connect people, helping people navigate the right path — instead of just making people go around in circles until they get arrested or die.”

“That is our city’s plan,” interjected Wilson. “The genocidal plan.”

The group was obviously on edge. When a tiny chime rang indicating an open door or window somewhere, Kenneth Boyd, the peer leader of HACHR’s cleanup crew, ran up the stairs in a panic. “It was just the wind,” he said when he returned. “Somebody didn’t close the door too tight.”

Boyd settled back in his position at the head of the table, where he’d been holding forth about how he got his nickname, Sidetrack. (In 1984 he went on a grocery run for his friends, he says, and didn’t come back for five days.) “Everyone here is pretty nervous,” he told me. “That’s what happens when you’re getting kicked all the time.”

On July 17, Jessica Smith and Rachel Waldman, HACHR’s board treasurer, stood at a podium before four of Eureka’s five city council members to present the organization’s first two-year report, an exercise required of syringe-exchange programs by state law. Projected on a screen above them was a slogan familiar to advocates for people with disabilities: “Nothing about us without us.”

“Everything in our program is informed by the people that we serve,” Smith explained. “We have a very in-depth peer program.”

Messner had trouble with this concept. “When you’re using that term ‘peer,’ are you referring to current addicts? [Because] the definition I’m familiar with is someone who’s successfully overcome some of the unhealthy habits that are involved in drug use.”

“Maybe what they’ve overcome are unsafe injection practices,” Smith said. Maybe they used to get a lot of abscesses and now they know how not to do that.”

Messner seemed unconvinced, so Smith kept on. “We’ve had peer leaders move on to have jobs and cars and insurance and all kinds of things they didn’t have before.” To “come into a role and have purpose and meaning,” she explained, can save your life.

Other councilmembers asked questions, too. “Does HACHR provide drugs to people?” asked Councilmember Kim Bergel.

“Absolutely not!” Smith answered. Councilmember Austin Allison, clearly sympathetic, asked the women to explain why harm reduction costs society less than treating people in the hospital for disease. “Preventing one case of HIV could save $450,000” in public health costs, Waldman said.

In the end, instead of revoking the organization’s authorization to operate, the council voted to establish an advisory board to address problems related to syringe distribution, including the city’s litter problem. One of the most persuasive arguments came from Kim Bergel, who in June had been inclined to shut HACHR down. “Any new business is going to have growing pains,” she said. HACHR staff has learned a lot in its first two years; rescinding the ordinance would put the city back at square one.

“We won the battle,” Wilson tells me when I see her next, in August. She confirms that, after a long heart-to-heart, Bergel had come around, and was now lauding HACHR for winning an award from the California Hepatitis Alliance for its work in community organizing.

Neither Bergel nor Wilson will divulge exactly what happened in their talk. Bergel will only say that she was tired of the divisiveness in the community. “I decided to look at my part in that,” she says. “And that led me to ask different questions.” Now she’s lobbying for a consumer to sit on the advisory board. “I mean, that’s who we’re talking about, right?”

On October 8, the California Department of Public Health announced, after a long delay, that HACHR had met the requirements for state authorization to operate as a syringe exchange in Eureka and Arcata, plus at four more outreach locations around the county. And Wilson has big hopes for the future. She plans soon to start up a foot-care clinic — feet and toes are common sites of infection for unsheltered people who inject drugs. She also wants to find a way to offer in-house treatment for hepatitis C, which is now curable in most cases. She’s counting on the state’s imprimatur to help her in the next local battle, which will no doubt come: In November, the city will vote on a new slate of councilmembers. Bergel’s seat is at risk, and at least three candidates, Michelle Constantine, Jeannie Breslin, John Fullerton and Bergel’s challenger, Joe Bonino, have promised to come down hard on Eureka’s public drug use and stray needles. All three have been explicit about who they hold responsible.

“The thing that hurts me the most is the lack of empathy people have,” Wilson says. “That people aren’t worth their care unless they stop using drugs.” If some people in the community want HACHR shut down, she says, it’s not because of the needles. “It’s because we’re demanding space in the system. We’re demanding civil rights for drug users.”

It might be starting to work. “Maybe the anger and outrage,” she says, “means that we’re successful.”


Judith Lewis Mernit’s reporting on harm reduction in rural California was supported by the USC Annenberg Center for Health Journalism’s 2018 Impact Fund.

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