Spotlight on the Safety Net

When Brittany of Asheville began injecting drugs after the suicide of her roommate, syringes were easy to buy from pharmacies. After a few years, however, as the statewide heroin problem worsened, many pharmacists stopped selling syringes to people without a prescription. Unfortunately, this crackdown created a black market where those who could still purchase syringes legally would sell them to those who could not—after they were already used. “I was playing Russian Roulette every time I used [a dirty syringe],” said Brittany. “I couldn't guarantee the syringe had only been used by the [seller] who swore he [didn't have HIV or hepatitis C] … It wasn't unusual for me to prick my veins with the same rig well over 20 times because it was so hard to get new [syringes]. I had to get high and a haggard needle wouldn't stop me” (oral communication; February 13, 2016). Other current or former injection drug users describe similar circumstances in which syringes were sold, shared, or scrounged from parks, trash cans, or roadside ditches.

According to surveillance data from the North Carolina Department of Health and Human Services, the number of acute hepatitis C virus (HCV) infections in the state has almost tripled over the past 4 years, during which time there has been a 565% increase in heroin deaths [1]. Substance use treatment centers and methadone clinics that test patients for HCV report infection rates of 60%–90% among injection drug users (written communication with Anthony Steele, DNP, FNP-C, PMHNP-C; Director of Medical Services, Alcohol and Drug Services, Greensboro, North Carolina; March 15, 2015). Hospitals and emergency rooms across the state are also seeing a sharp increase in the number of wounds and infections caused by people sharing syringes. In addition to HCV infection, these medical issues can include HIV infection, cellulitis, abscess wounds, Staphylococcus infection, tetanus, collapsed veins, bacterial endocarditis, and necrotizing fasciitis (written communication with Cheryl Moss, RN, BSN; Substance Abuse and Behavioral Health Center, Gastonia, North Carolina; February 3, 2016).

The North Carolina Harm Reduction Coalition (NCHRC), a statewide nonprofit organization, is working to reduce death and disease among people who use drugs. Founded in 2004 and incorporated in 2006, NCHRC connects people who use drugs to harm reduction services, such as overdose prevention programs, HIV/HCV prevention, and diversion programs that help low-level drug offenders get treatment instead of going to jail. NCHRC's 2016 campaign is to advocate for syringe exchange programs, which collect old syringes for disposal and offer sterile syringes and other injection equipment to people who inject drugs. Syringe exchange programs can also connect people who use drugs with education on how to avoid infections and viral diseases and introduce the idea of recovery to people who may not have seriously considered it before. Currently in North Carolina, syringe exchange programs are illegal due to a statute prohibiting the distribution of any item that could be used for illicit drugs [2].

In other states, typical participants in a syringe exchange program come daily or weekly to collect new syringes and turn in used ones. Such exchange programs can offer onsite HIV and HCV testing, and they can provide referrals to treatment for people who test positive. Ideally, staff members are compassionate, knowledgeable individuals who can offer information on treatment services and even help participants find a treatment center when they are ready for recovery. The staff can also offer resources about other community services such as housing, food banks, and career development.

Mike from Wilmington stopped using illicit drugs thanks to a syringe exchange program in Arizona, where he lived at the time. “Had it not been for outreach teams providing clean needles, I wouldn't have made the decision to get off drugs,” he said. “They made me feel safe and showed me there is a better way to live. They told me about resources in the community and planted a seed in me of thinking about health and recovery every time I got needles from them. When I was ready to make a change, I knew where to go for help” (oral communication; February 6, 2016).

Decades of data on syringe exchange programs worldwide have revealed striking benefits: up to 80% reduction in HIV transmission among injection drug users [3]; 50% reduction in HCV infection [4]; 66% decrease in needle-stick injuries to law enforcement officers [5] (because more needles are collected by the program, fewer are contacted by police while searching suspects); fewer syringes discarded in public places where they could harm children or others [6]; and an increase in the number of people entering drug treatment programs or being connected to social services [7].

NCHRC hopes to reframe the drug debate as a public health issue—rather than solely a criminal one. That means emphasizing access to drug treatment and health care services, while decreasing the use of purely punitive measures such as incarceration to deter drug use. Harm reduction programs may not keep people from making mistakes, but they keep them alive long enough to learn from them.

• ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.