No Questions Asked

A nondescript minivan pulls into a parking lot in Cambridge. Zach climbs into the back seat and greets the driver, who hands over a brown paper bag full of needles, syringes, cookers, naloxone and other items related to injection drug use.

The supplies aren’t for Zach, who has been clean of heroin and cocaine for about three years, but for friends who are still in the throes of addiction and need clean injection supplies and naloxone, which reverses the effects of an opioid overdose. 

The van comes from Vivent Health’s Lifepoint needle exchange program, which operates in Madison and nine other cities around Wisconsin. While COVID-19 has changed some of Lifepoint’s procedures, curbside pickup and the van services remain available to those who need it, but all orders must be called in to the patients’ local Vivent Health location.

“It’s beyond a blessing,” Zach says of the program, whose goal is to reduce the spread of dangerous bloodborne diseases among intravenous drug users. He agreed to speak about the program but asked that his last name not be used. 

Vivent Health, formerly known as AIDS Resource Center of Wisconsin, started the needle exchange in 1994 to reduce the spread of HIV, an immunodeficiency virus that, without treatment, can progress to AIDS and be fatal.

With the increase in opioid-related addiction in the past several years, offering free naloxone has become another central component of Lifepoint’s harm-reduction mission.

Zach knows the value of that service firsthand.

“I would honestly be dead if Lifepoint wasn’t around,” he says. “I’ve overdosed and been revived by [naloxone] from them. At least five or six more of my friends would be dead if I hadn’t revived them.”

Top health officials, including at the Centers for Disease Control and Prevention, agree that needle exchanges — also called syringe service programs or syringe access programs — have proven an effective public health initiative, though they remain controversial for some communities even as they struggle to address ballooning opioid addiction trends.

Says Scott Stokes, HIV section chief for the Wisconsin Department of Health Services, “I can’t think of an initiative that has been more heavily evaluated than syringe access programs.” 

Grassroots Origins

The CDC defines needle exchanges as community-based prevention programs offering a variety of services for injection drug users, including access to clean hypodermic needles, syringes and other injection equipment and infectious disease testing services. A majority of those services offer referrals to local drug treatment programs. 

Needle exchanges first appeared in Europe in the early 1980s as an underground effort to stem the rise in HIV and hepatitis B among injection drug users. The bloodborne diseases were spreading through the sharing of injection equipment. 

The first government-sanctioned needle exchange in the world started in the Netherlands in 1984. 

Needle exchanges in the U.S. had similar grassroots origins. In 1988, Dave Purchase started his own needle exchange in Tacoma, Washington, after getting the approval of the local police chief. A year later, the county health department began funding his endeavor, making it the first publicly funded, legalized exchange in the U.S.

In the years since, the health care field has embraced the positive outcomes seen with needle exchange programs. In addition to the CDC, the World Health Organization and American Medical Association endorse these programs.

A hepatitis B vaccine was approved for use in the U.S. in the early 1980s, which curbed that virus, but hepatitis C remains a problem among injection drug users. There’s no vaccine to prevent hepatitis C yet, and it’s easily spread through shared injection equipment. 

Wisconsin law requires that needles and syringes must be in close proximity to illegal substances or have drug residue in them to be considered drug paraphernalia. Otherwise, it is legal for anyone to possess them.

Vivent’s Lifepoint program started in Milwaukee in 1994. With 10 locations across the state, it’s the largest of the handful of needle exchanges that operate in Wisconsin.

Bill Keeton, vice president and chief advocacy officer for Vivent, says the demand for the program’s services increases every year, but they’ve seen a larger spike in recent years due to increased use of both heroin and methamphetamine. The issue affects both urban and rural areas.

“I can say with pretty good certainty that there’s a need for outreach and support for people who inject drugs just about anywhere,” Keeton says.

Lifepoint distributes more than 5 million needles annually, according to Vivent’s most recent annual report. In 2018, the nonprofit served more than 43,000 people, distributed about 43,000 doses of naloxone and received reports of more than 1,500 people being saved by that medicine. 

Public Health Madison & Dane County runs its own needle exchange program on a smaller scale than Lifepoint. The city-county agency also started its program in the mid-1990s in responses to HIV trends. Agency data shows that staff distributed more than 211,000 needles in 2019, an increase of 3,000% from 2010, when 5,799 needles were given out. There were 6,434 client visits in 2019, about 26 clients per working day. The agency also distributes naloxone, reporting more than 850 overdose response kits given out between 2017 and 2019, with 318 reported successful uses.

Public Health Supervisor Karri Bartlett says her agency and Vivent have a good working relationship and refer people to each other’s services in order to ensure anyone who needs those supplies can access them.

“Clearly there is a need for these,” Bartlett says.

How it works

Pre-COVID-19, anyone could walk into one of Vivent’s 10 offices in Wisconsin to ask for clean injection supplies; for now, they can call the office to arrange a pickup and drop-off. Customers can still set up an exchange through the mobile service. 

According to Keeton, staff at each location will ask consumers some questions to understand their drug use habits as well as any potential health concerns (this conversation is currently being held over the phone). They also ask if the person would like HIV, hepatitis C or STD testing, which can be done quickly at the office or in the mobile van, though Vivent has temporarily stopped its disease-testing services in light of COVID-19 health safety precautions.

If the person is receptive to it, staff will also provide information about local treatment programs. 

“The whole process is designed to be nonjudgmental, nonconfrontational,” Keeton says. 

Lifepoint offers needles, syringes, cookers, ascorbic acid (used in heating the drug), clean-water pellets, cotton balls, wound-care kits, sharps containers, tourniquets, condoms, naloxone and fentanyl-testing strips.

The latter can be used to test if a batch of drugs has been laced with fentanyl, an extremely potent opioid that can be fatal even in small doses.

Keeton says people are encouraged to return used needles to Lifepoint so that they can be properly disposed of. Vivent, in collaboration with local public officials, established a public sharps box in La Crosse to provide easier disposal options. Lifepoint posts a schedule for its mobile van, with contact information, on Facebook. Staff members can also arrange to meet people in more rural areas using a van stocked with various supplies and educational pamphlets. 

Keeton says the mobile vans are also being used to take food from their office food pantries to those in need.

Inside the van there is information about Vivent’s services, as well as cards outlining the specifics of Wisconsin’s drug paraphernalia laws and the new Good Samaritan protections. The latter protect drug users from being arrested when they call 911 to report another user’s overdose, though the protections don’t extend to people who have active warrants or are found to be drug dealers. 

Zach says he grabs copies of these pamphlets to hand out with supplies so that people are aware of that protection and will call 911 if needed. 

He began using Lifepoint’s mobile services in 2015 a short time after he began using heroin intravenously. His opioid addiction started with painkillers, which he took as a way to unwind from work. For a while, he felt in control. At one point, however, he had difficulty finding more pills to buy. A friend suggested he try heroin. Zach initially refused, but when he couldn’t find more pills and began feeling withdrawal symptoms, heroin was the easily accessible answer.

“That’s the shittiest thing about heroin,” he says. “It’s so much stronger and way cheaper than pills. For $60 a day you can get pills that would last you five hours, or you can get a half gram of heroin for $60, and when you’re first starting out, that will last you three to five days.”

Zach says that when he first used Lifepoint’s mobile service, he was impressed by how friendly and helpful the driver was. “He was really down to earth and easy to talk to,” Zach says. “He gave me a bunch of pamphlets of information. I didn’t know anything about [naloxone] either; I was just getting into it. They have really good resources for people.”

Like Lifepoint, Public Health Madison & Dane County is focused on providing free resources without judgment or pressure, says Bartlett. The agency offers safer injection supply kits, which include naloxone, at all three of its locations in Madison. Bartlett says anyone who needs one can get it with no questions asked.

“It is meant to be a stigma-free, judgment-free place to be able to access supplies to be able to [inject] safely,” she says.

However, she says, frequent consumers get to know staff and become more comfortable asking questions about their health and, sometimes, treatment options. When they do, staff members will offer any relevant services to them.

Because of health restrictions due to COVID-19, Bartlett says Public Health Madison & Dane County is offering those kits in a way that eliminates face-to-face interaction with staff. People can call the agency at 608-266-4821 to request that supplies be left in a container outside their offices for pickup.

Stokes, of DHS, says needle exchanges aren’t subject to any licensing requirements or oversight from the department. However, those that do HIV and hepatitis C testing report their results to state officials for data tracking. Stokes says the programs also are willing to share additional data from their annual reports, including people served, naloxone usage and amounts of supplies given.

“It’s pretty collaborative,” he says. “They work well with us.”

Exchanges receiving federal funding do have to follow guidelines on best practices set up by the CDC.

Declining infection rates

The CDC reports that the increase in injection drug use, largely due to opioids, has led to increases in hepatitis C and HIV infections nationwide.

Reported cases of acute hepatitis C increased from 850 in 2010 to 3,216 in 2017, mainly driven by injection drug use. More than 2,500 new HIV infections occur annually among injection drug users. 

The CDC website includes a page of resources about needle exchanges, advocating their public health benefits. It states that needle exchanges are linked to a 50% drop in HIV and hepatitis C incidences. That number decreases further when program users also receive medication-assisted treatment for opioid dependence. New needle exchange users are five times more likely to enter treatment and three times more likely to stop using drugs than those who don’t use exchanges.

In Wisconsin, only four of the 216 new HIV diagnoses in 2018 were attributed to injection drug use, according to the 2018 HIV Surveillance Annual Report. Stokes says HIV infection among injection drug users has stayed very low since the needle exchange programs started.

Asked what the HIV statistics would look like without those services, Stokes says, “I cannot imagine.” He notes that when Lifepoint was launched, the HIV infection rate among injection drug users in Wisconsin was about 25%. 

“Everywhere these programs are, you see the percentages [for new HIV infection] decline greatly,” he says. 

DHS data show the number of new hepatitis C cases among people age 15 to 29 has more than tripled between 2008 and 2017, and that trend is being driven by injection drug use.

Stokes says that hepatitis C is hardier than HIV and can live on surfaces outside of the body for much longer. Research indicates the virus can remain infectious on a surface at room temperature for up to six weeks.

Because of this, Stokes says it’s extremely important for drug users not to share any of the same injection equipment — not just needles, but also syringes and cookers.

“That’s why a lot of transmissions are occurring,” he says. 

Other health risks include bacterial infections and endocarditis, a rare life-threatening infection of heart tissue that could require surgery. That can be caused by people reusing needles, even if they don’t share with someone else.

Stokes says DHS does not track endocarditis data, but he has heard from emergency room physicians who say they are seeing more people with the infection.

The Mayo Clinic states hepatitis C is usually curable with a course of medications taken daily for two to six months. HIV still has no cure, but it has become much more treatable than in the past. Keeton says if any Lifepoint user is found to have HIV, that person is put into Vivent’s continuum of care, which includes access to physicians and medication regardless of their ability to pay.

Opposition

While prominent medical experts have endorsed the results of needle exchange programs, they still meet resistance in some states and at the federal level.

The CDC has classified 44 states as being eligible for federal funding to support needle exchange programs, based on the risk or actual trends of significant increases in hepatitis or HIV. However, federal law prohibits that money from being used to pay for needles or syringes — it can only be used for other support services.

Vivent’s Lifepoint program costs about $1.3 million annually to operate, according to Keeton. 

About $900,000 of that comes from public and private grant funding, and the remainder from donations and fundraising. 

Public Health Madison & Dane County funds its exchange through city and county tax dollars, along with grants for HIV and overdose prevention. The 2020 operating budget for the exchange is $163,445, with 44.8% of that covered by the city of Madison and the rest by Dane County.

Bartlett says the program benefits from strong support by both city and county officials.

“We fully recognize how lucky we are,” she says. 

LawAtlas.org, part of Temple University’s Beasley School of Law, reports that 41 states, as well as Washington, D.C., currently have needle exchange programs. However, four of those states — Arizona, Iowa, Missouri and Pennsylvania — don’t have laws explicitly allowing them, so they either operate underground or with sympathetic officials looking the other way. Bills to allow them in those states have stalled. Opponents say they fear an increase in discarded dirty needles around communities and worry such programs enable drug users and dissuade them from getting treatment to kick their habit.

Keeton says he can understand those fears, and Vivent has been looking into ways to put more sharps disposal boxes around communities so drug users can dispose of used needles more easily. 

Bartlett says individuals can also dispose of used syringes through the needle exchange program.

The CDC reports that studies of needle exchanges have shown a decrease in needle litter in the communities studied and finds there is no cause and effect relationship between crime and the presence of needle exchanges.

Stokes says needle exchanges were controversial even when Lifepoint was proposed in 1994. And while there has been intense scrutiny of such programs, the science has proven them to be worthwhile. 

“The early evaluations [of needle exchanges] that were done, were by entities that were designed to discredit them, and hands down the results were always really in favor of the programs,” Stokes says. “They did not increase injection drug use. They did not increase crime rates in the areas where the exchange was, infections had gone down and access to treatment had increased.”

Joel DeSpain, public information officer for the Madison Police Department, says in an email that police officials are not aware of any issues with high needle litter, and fortunately there are few officers who have been accidentally stuck by a needle while on duty. 

“We give naloxone out,” he writes. “We do not confiscate it.”

All About Safety

Zach says Wisconsin is lucky to have a program like Lifepoint, since not every state has allowed needle exchange programs. While he no longer needs those services himself, he still wants to support the mission and get supplies to friends who are nervous about contacting Lifepoint themselves.

Zach can understand that fear — he admits he thought it was too good to be true when he first heard of it. He is able to get large quantities at a time so anyone who calls him will have fresh supplies, and he knows his friends will pass extra clean supplies to others too.

“I usually call [Lifepoint] two to three times a week and I’ll grab a case of about 500 needles, and I’ll go through one of those in about a week,” Zach says. 

One thing Zach wishes Lifepoint would do is offer weekend availability. His friends frequently reach out to him on Saturdays for fresh supplies. 

Zach says he can see why people would view needle exchanges as enabling drug users, but the health and lifesaving benefits of the program are key.

“It’s all about safety,” he says. “If they can’t shoot it, they’ll snort it, but at least if they shoot it, they have clean stuff, they’ve got the [naloxone], and hopefully they have a friend with them [in case of overdose].”

Zach says for people who haven’t experienced addiction, it’s tough to understand what it’s really like. 

He says he was naïve when he started using drugs, believing that he could just use them here and there. A “functioning addict” compared to others he knew, Zach was able to hold down a job and plan out when he would need his next fix. He could go up to two days between uses without feeling withdrawal symptoms. However, most of the people he knew could not go more than a day without more heroin.

Zach entered an intensive outpatient treatment program through UW Health Behavioral Health and Recovery Clinic in February 2016. He spent up to 12 hours a week in counseling sessions and took Suboxone, a medication used to curb opioid cravings. He highly recommends the program, though he cautions families that an addict will succeed in recovery only when he or she is ready. 

“They have to want it,” he says. “If they don’t want it and someone’s pushing them in, it’s not going to work.”

Addiction changes a person’s brain, Zach says. The need for the drug outweighs everything, which leads to desperate measures such as stealing. Shame keeps users from admitting problems even to loved ones, so they’ll use alone. That’s what leads to deaths. 

“My brother [fatally] overdosed in a bathroom by himself because he didn’t want to tell his girlfriend he was using,” Zach says. “You can’t use alone.”

[Editor's note: This was one of the final cover stories we had in the queue when Isthmus paused print publication in late March, due to COVID-19. Thanks to a collaboration with Madison Magazine, this article will still see print in the June issue of the magazine. As Madison Magazine editor Andrea Behling notes, "We hope this collaboration demonstrates Madison Magazine’s and Isthmus’ dedication to hyper-local storytelling, no matter the circumstances."]