House Speaker Greg Hughes says he “laughed out loud” when Rep. Steve Eliason first broached the idea of handing out clean needles to drug addicts. It proved to be no joke.

Eliason won over his fellow Republican and the others — save two state senators — with sources like the Centers for Disease Control and the World Health Organization. Syringe-exchange programs prevent diseases like HIV and hepatitis C, save taxpayer dollars, and are uniquely positioned to deliver treatment referrals and overdose reversal drugs to the hardest-to-reach drug users.

Eight months in, though, Hughes says the result has been “a farce.” Two rural county sheriffs have threatened to arrest the state’s leading provider, and Salt Lake County’s Health Department — at the suggestion of Salt Lake City administrative staff — has considered tacking more regulations onto Eliason’s statute.

“Syringe exchange” has been a misnomer, say some. Addicts are getting free “cookers” — or tins that look like large bottle caps — twist-ties to hold them to the flame, and cotton balls to filter their heroin when they draw it in through the needle. Throw in a tourniquet, some alcohol wipes and a condom, and Hughes calls it a “party pack.”

Others say it’s not much of an exchange. Nearly three syringes have been given out for every one brought back. Though the law doesn’t call for a 1-to-1 ratio, there are whispers that it should, and that more needles than ever are being found illegally discarded.

“They’re all over the place,” said Brian Besser, district agent in charge of the Drug Enforcement Administration. “They’re in the gutters. They’re on the streets. They’re on the sidewalks. … I don’t want to see addicts get hurt, but there’s a simple principle to this: Don’t shoot heroin. That’s why it’s illegal.”

The politics of syringe exchange are “toxic” right now, said Utah Naloxone’s Sam Plumb. His sister, Primary Children’s Hospital pediatrician Jennifer Plumb, told county health officials recently that the “lion’s share” of the nonprofit’s 1,700 overdose reversals have involved naloxone received through the exchange. But in June, the group stopped hosting the exchange, hoping it will start up again when the debate cools down.

“The last thing you want to do is say, ‘We’re going to do this because it’s legal and you can’t do anything about it,’” Sam Plumb said.

(Steve Griffin | The Salt Lake Tribune) Volunteers Crystal Yazzie, Damon Harris and Jenna Vitdenhowen help members from the Utah Harm Reduction Coalition as they exchange needles on 500 West between 200 South and 300 South in Salt Lake City on Thursday, July 27, 2017.

—

Finding a way

Working feverishly beneath a white, four-post tent that’s erected twice weekly on the median at 500 West and 300 South, two Utah Harm Reduction Coalition volunteers shared a sideways glance as a woman shifted from one foot to the other and said “Hurry, come on, let’s go.”

Most queued patiently and expressed gratitude when they were handed their syringes, rolled up in sheet packaging and stuffed into a brown paper bag. When a passer-by shouted “Anybody got a used point that I can turn in?” a man in line said, “Gotta find one, bro.”

“Clients” — in the parlance — get as many needles as they bring, rounded up to the nearest denomination of 10 with the justification that that’s how they’re packaged. Eleven to 20 are worth 20, for instance. First-timers can get 30 for one in a “starter kit.”

Public health officials recommend a clean needle for each injection, and it’s common for heroin addicts to use a dozen times per day.

A thin, mid-30s man going by “Howard” returned enough needles to receive 60 and said afterward that he would likely give most of them away.

The exchange is a “godsend,” he said: Far fewer of the area’s users are sharing needles, and they no longer have to scrounge up $2 to buy a fresh one from a secondhand dealer.

“Even people reusing their own needles has been cut down,” he said, adding that the majority of clients dispose of their syringes properly and are “pretty damned pissed” when they see others leave them on the street.

Asked if an exchange affected the frequency of his drug use, Howard scoffed.

“Whether there’s a needle exchange here or not, I’m gonna get mine, and I’m going to find a way to put it in my body.”

A man who identified himself as “Shylo,” deeply tanned with newly opened sores on his face, counted five times that he’s administered naloxone to another user after picking it up at the exchange. He himself was revived by the drug a month ago, he said.

(Steve Griffin | The Salt Lake Tribune) Volunteer Damon Harris shows users how to use naloxone, a medication approved by the Food and Drug Administration (FDA) to prevent overdose by opioids such as heroin, as he helps members of the Utah Harm Reduction Coalition as they exchange needles on 500 west between 200 south and 300 south in Salt Lake City, Thursday July 27, 2017.

Utah Harm Reduction is the state’s first and largest exchange provider, founded by former meth addict, drug-court graduate and licensed clinical social worker Mindy Vincent.

Three years ago, Vincent lost her sister to an opioid overdose and her brother is in recovery. She paid “thousands” to operate the program out of her own pocket before being awarded federal funds. She‘s since hired two staffers.

“We’ve lived on blood, sweat and volunteers,” she said.

Compromise, too. The coalition no longer distributes two materials that seemed to be farther left on the enabling/harm reduction spectrum: citric acid powder, which breaks down cocaine and black tar heroin for injection, and pieces of Brillo Pads, which can be repurposed as filters in crack pipes.

And in Carbon, Emery and Weber counties, Vincent has offered to distribute syringes only if law enforcement will agree to leave Utah Harm Reduction and its clients out of their crosshairs.

Carbon and Emery county sheriffs Jeff Wood and Greg Funk believe Vincent may be guilty of distributing paraphernalia — a class A misdemeanor. Utah law prohibits delivery of anything, other than sealed syringes, to “inject, ingest, inhale, or otherwise introduce a controlled substance into the human body.”

Eliason’s statute vaguely allows for a “syringe exchange program,” but that’s open to interpretation. A court could decide that means syringes only, or it could accept a broader definition understood by most health professionals (and intended by Eliason) that includes other materials that can help prevent the spread of disease.

The Carbon County Commission passed a resolution in May that gives Wood the green light to arrest and prosecute Vincent if she tries to deliver anything other than syringes. Vincent and former Republican state Sen. Steve Urquhart, an exchange ally, plan to plead their case before the commission at its Aug. 16 meeting.

And then there’s Hughes, who has set up a temporary office in Salt Lake City‘s Rio Grande district so he can marshal an effort to defeat “lawlessness at its unimaginable worst.” Advising Hughes is the DEA’s Besser, who says he’s had bad experiences with other exchanges.

“I don’t see how you can argue in some form or fashion that this is not encouraging intravenous drug use,” Besser said. “We’re giving everything you need to be a heroin addict except for the heroin and the thumb that you need to push down on the plunger.”

Hughes, something of a firebrand himself, said he admires Vincent’s tenacity. But “I don’t believe that a ‘starter kit’ with drug paraphernalia is a way to get someone closer to recovery,” he said. When he met with Vincent recently over breakfast, his message was clear: Get out of the Rio Grande neighborhood.

Vincent said that suits her — she’d prefer an office a couple miles south — and asked Hughes to give her until Sept. 1 to find a new spot. Hughes said he’s not going to set a date: He wants to act quickly, and it behooves Vincent to do likewise.

(Rick Egan | The Salt Lake Tribune) Greg Hughes, Speaker of the Utah House of Representatives, says he's not sold on needle exchange and wants the Utah Harm Reduction Coalition to move out of the Rio Grande area of Salt Lake City, where he's set up an office to crack down on lawlessness.

‘The point is the point’

Preliminary state data shows that from the beginning of December 2016 through June, 188,000 needles were distributed and 71,000 collected at exchanges.

Heather Bush, the Utah Department of Health’s viral hepatitis prevention and syringe exchange coordinator, said there are important factors to consider before forming an opinion about those numbers.

At inception, the state didn’t have funds to buy sharps containers — 1-quart tubs with sealable plastic lids — and many drug users had to collect used syringes in plastic bags, or socks. From Dec. 1 to March 30, the ratio of needles going out to needles returned had been 4.2 to 1. Since, it’s been more like 2.2 to 1.

Some drug users discard syringes because they fear police will cite them for paraphernalia, sharps container or not. They are also prohibited from bringing contraband into the shelter at 210 S. Rio Grande St. by its operators, The Road Home.

Eliason said that, besides, his bill was purposefully written so that it didn’t limit exchange, based on best practices that have been vetted over decades. The North American Syringe Exchange Network found that in 2013, 82 percent of the nation’s exchanges allowed for more syringes to be given out than collected.

UTAH’S SYRINGE EXCHANGES



Utah has had three syringe exchanges that distributed a preliminary total of 187,783 syringes and collected 70,528 between Dec. 1, 2016, and June 30 — most of them on 500 West near the homeless shelter at 210 S. Rio Grande St.



Only four months of data was available for the individual providers, from Dec. 1 to March 30. Utah Naloxone suspended its exchange June 9.



Both Utah Harm Reduction Coalition and One Voice Recovery distributed so-called “safer injection kits” — including other materials associated with drug use and disease prevention, like cookers and cottons. Utah Naloxone did not. All three have distributed naloxone, an overdose reversal drug.



• Utah Harm Reduction Coalition • Founder Mindy Vincent; Rio Grande and Tooele County; 1,141 encounters (350 unique individuals); 34,952 syringes distributed; 9,406 syringes collected (1,334 reported disposed of elsewhere).



• Utah Naloxone • Founders Jennifer and Sam Plumb; Rio Grande; 914 encounters; 37,147 syringes distributed; 6,975 syringes collected.



• One Voice Recovery • Founder Patrick Rezac; Salt Lake County outreach; 40 encounters; 1,190 syringes distributed; 1,017 syringes collected.

Since June, Utah’s exchanges also gave out more than 2,500 naloxone kits and more than 22,000 referrals for various health and social services. Providers have also picked up an additional 8,000 syringes during regular cleanups that began March 1.

Susan Sherman, a professor at Johns Hopkins’ Bloomberg School of Public Health, has extensively studied needle exchange and the consequences of added exchange restrictions in Baltimore that were lifted a decade ago.

Pushback to exchanges is “not uncommon at all,” Sherman said. “In the early days of needle exchange, people got arrested. People have a very hard time reconciling that you’re enabling drug dealers.”

Many exchanges give out cookers and cottons for the same reason they give out the syringes, Sherman said: because clean supplies prevent the spread of disease.

“Would you rather people be using filters from cigarettes, which has a ton of fibers and glass in it?” Sherman said. “What’s the point? You’re going to punish them just a little bit? If you’re going to provide sterile equipment, you’re going to provide sterile equipment.”

Where Utah’s two largest exchange providers get $370,000 per year in federal funds — plus a small amount of “use-or-lose” state funding — the CDC’s Division of HIV/AIDS Prevention says the average lifetime cost of a single HIV infection is $380,000. Nationwide, about 1,800 AIDS diagnoses in 2015 were attributed to intravenous drug use, according to the CDC — or 10 percent of all new diagnoses.

Carbon, Emery and Beaver counties are among the top 5 percent of U.S. counties most poised for an HIV outbreak, according to a 2016 CDC report. Such an outbreak in Indiana’s Scott County drew national attention in 2015 when more than 200 cases led then-Gov. Mike Pence, despite his reservations, to legalize syringe exchange.

The two leading hepatitis C drugs cost Americans more than $11 billion in 2015. In Utah alone, Harvoni and Sovaldi accounted for nearly 10 percent of a $103 million Medicaid budget.

(Steve Griffin | The Salt Lake Tribune) Rep. Steve Eliason, R-Sandy, passed legislation that made needle exchange legal in Utah and has worked behind the scenes to defend its merits to critics who say there's too many needles and other associated materials going out, and not enough coming back.

The trick now for the Utah Health Department’s Bush is to demonstrate a reduction in bloodborne illnesses by October, when statute says she must address a legislative committee. Eliason’s bill allocated her no funding to do so, and she’s reliant on volunteer support, she said.

Bush also must show “the impact of the programs on the number of individuals receiving treatment for a substance-abuse disorder,” even as publicly funded treatment has monthslong wait lists.

An exchange can be a useful bridge between addicts and services, Sherman said, but “the point is the point.”

“The point is the syringe, with no strings attached.”

Dirty needles

The battle was won by the time Dina Walton-Kirklen spoke last July 27.

Salt Lake County health officials had begun a public hearing by announcing they would go back to the drawing board after proposing a ban on materials like cookers and cottons. Exchange proponents no longer had anything to object to. But the Oakley resident addressed them, anyway, while choking back tears.

Walton-Kirklen first learned about One Voice Recovery after finding their business cards strewn among her son’s belongings.

The syringe exchange had given him the materials to use heroin without contracting disease, naloxone he’d used to save somebody’s life, and a regular influence that shared her desperate hope: to end his addiction.

Though her son relapsed after inpatient treatment that he was referred to by One Voice, exchange founder Patrick Rezac is working to line him up another bed.

“I’m hoping that the needle exchange is keeping him alive until he chooses to get better,” Walton-Kirklen said to a roomful of supportive smiles.

Gary Edwards, the Health Department’s executive director, said the proposal resulted from conversation with Salt Lake City officials about community cleanup, in which they heard anecdotal evidence of an increase in illegally discarded needles.

“I said that if we’re seeing more needles, that’s kind of a success for syringe exchange, because people are using clean needles,” he said. “They’re not having the need to hang onto dirty needles. But from a public-health perspective, we also don’t want a lot of dirty needles around.”

(Al Hartmann | The Salt Lake Tribune) A hypodermic needle used for shooting heroin is lodged in a tree well along 200 South and 500 West in Salt Lake City on Wednesday, July 19.

City officials had simply relayed constituent complaints, said Salt Lake City Community Relations Director Jennifer Seelig. Needles had been found in small parks and along the Jordan River, and parents worried their children might step on them. Three syringe drop boxes have been purchased by the county and delivered to the city for placement.

Seelig said she also observed a 500 West exchange for an hour in an unmarked police car and “it did not appear that people were exchanging. They were just taking.”

“I am, personally, a huge proponent of harm reduction, and so is this administration,” Seelig said. “It works — it works when it’s done correctly.”

Neither city nor county officials have specified how exchanges should be improved. Eliason doubts they have the standing to impose further limits, anyway.

The greater danger to exchange may be at the Capitol, even though just two state senators voted against the authorizing legislation in the 2016 session. Sheriff Wood, for one, urges an amendment that would allow counties to opt out of the exchange, or at least clear up the “gray area” about exchange ratios and allowed materials.

In the meantime, Rezac wants to help fill the void left by Utah Naloxone’s decision to suspend its Friday exchanges on 500 West. He’s devised a setup that he hopes will be more palatable to policymakers: a syringe-only exchange (like Utah Naloxone) with separate tables advertising treatment options and naloxone administration that clients must pass before they re-up.

He’s a former drug addict and is HIV positive, owing to a syringe he shared while staying at a weekly rate motel in San Francisco.

Were it not for access to clean syringes after a later relapse, Rezac believes he likely would have contracted hepatitis C, which wreaks extra havoc on the livers of people with HIV.

Sometimes other drug addicts approached his sharps container in search of a syringe — even knowing he was HIV positive. It didn’t matter: “At that point, you hate yourself.”