By Cathryn Domrose
“Show me how you scrub,” Mark Freeman, RN, FNP, instructs his patient, a 49-year-old man with HIV who has been injecting illegal drugs since he was 26. Freeman works at a needle-exchange center at a storefront in San Franciscos Skid Row district. His patient has stopped in to pick up clean syringes and injection supplies and to see about an infection that Freeman treated on a previous visit.
Skin infections, including abscesses and cellulitis, are a common complication of injection-drug use and often are caused by bacteria getting into the injection sites. The man’s leg, covered with shiny scabs, seems to be healing, but Freeman wants to make sure it doesn’t happen again.
The patient rolls up his sleeve and swipes an alcohol wipe about 20 times across a vein in the crook of his elbow where he sometimes injects heroin.
”That’s pretty good,” says Freeman, a nurse practitioner who is on loan twice a week from the city-run Tom Waddell Health Center to the needle-exchange center run by the San Francisco AIDS Foundation.
Most injection drug users swipe two to five times, Freeman says, which does little to prevent infection. He recommends 100 wipes before injecting never after.
Since the height of the AIDS epidemic, needle-exchange centers across the country have been helping a neglected segment of the population care for themselves. These programs set out to discourage needle sharing - which can transmit HIV and other blood-borne illnesses – by exchanging used syringes for clean ones. Multiple studies have shown their success in lowering HIV rates and risky behaviors among drug users.
In recent years, nourished by state and local funding, an increasing number of these programs have expanded beyond providing clean needles. They have blossomed into community health and social service centers that offer vaccinations, screening, education, referrals to treatment programs, health assessments, and help with basic needs such as food and housing.
A hook-up to healthcare
Needle-exchange centers operate on a philosophy called harm reduction, which recognizes that substance abuse exists and seeks to minimize its harmful effects to individuals who abuse and the community.
“We don’t need to tell people how to live their lives, but we certainly can engage them,” says Keith Hocking, director of volunteer-based programs at the San Francisco AIDS Foundation, which runs one of the largest needle exchanges in the country. ”We’re giving people a place to consider changes in their lives.”
Many studies have shown needle exchange does not increase drug use, crime or drug trafficking. Some evidence suggests those who use a needle-exchange program are more likely to seek out and stay in treatment than those who do not. Nurses who work with needle-exchange programs instruct their clients on how to:
- Inject drugs as safely as possible
- Train them to prevent overdose deaths
- Educate them about the dangers of reusing needles
- Provide basic, preventive healthcare
“A big part of what we do is try to hook people up to primary care,” says Freeman, who treats problems such as abscessed wounds, fungal infections and colds and allergies, but refers serious health problems to a county clinic or hospital. “I don’t think we should be doing primary care in the back room only one or two days a week.”
A needle-exchange program may be the first contact with health providers for many injection drug users. Drug users historically have had poor relationships with medical providers, and they are jaded by that, says Narelle Ellendon, RN, HCV director and speakers bureau coordinator for the Harm Reduction Coalition in New York.
”People say that drug addicts don’t take care of themselves, but that’s not true,” says Freeman, who has worked with injection drug users in various environments for nearly 20 years. “They also take care of each other.”
He and other nurses tell of clients who make sure friends and relatives use clean needles, pass along health information, and have saved friends’ lives by giving them naloxone hydrochloride (Narcan), which rapidly reverses opioid overdose- all things they received from needle-exchange programs.
As of November, about 185 needle exchanges operated in 36 states, the District of Columbia and Puerto Rico, according to the U.S. Centers for Disease Control and Prevention (CDC). Although the number of programs has stabilized in recent years, increasing amounts of funding are enabling programs to expand their services, according to reports from the CDC and Beth Israel Medical Center in New York.
The San Francisco program exchanges about 2.3 million needles per year at more than a half-dozen mobile and permanent sites. Although clients are anonymous, Hocking estimates the program reaches some 12,000 adults - about three-fourths of the city’s estimated injection drug users. Nearly 80% are men, just over half are white, and about a third are African American. The program receives about 80% of its $857,000 budget from city coffers, Hocking says. The average budget for needle-exchange programs nationally in 2006 was about $130,000, according to the unpublished Beth Israel report.
”A lack of [public] funding can lead to a program’s demise or chronic instability,” the report states. “Adequate funding, on the other hand, can lead to longevity and the expansion of important services beyond syringe distribution.”
Nationally, services vary from program to program, depending on funding and the population served. Most offer education about hepatitis, HIV and sexually transmitted disease protection, as well as HIV testing. Many offer information about overdose protection, and some distribute naloxone. Some offer hepatitis A and B vaccinations and hepatitis C testing, tuberculosis testing, wound care, general health assessments, and mental health therapy. A few offer acupuncture and herbal remedies.
They also give referrals to substance abuse treatment programs, mental health programs, medical care, soup kitchens, housing services, and support groups.
Most needle-exchange programs started in the mid-1980s and early 1990s in response to an HIV/AIDS epidemic that spread rapidly through communities of intravenous drug users.
Small groups of independent activists distributed clean syringes illegally to encourage injection drug users to stop sharing needles and spreading HIV. Concern about AIDS led many states to change laws about syringe possession, and state and local governments began to fund and oversee grass-roots programs.
Syringe exchange is supported by the American Nurses Association, the National Association of Nurses in AIDS Care, and many state nursing organizations, as well as the American Medical Association and other health groups.
But the programs remain controversial. Despite evidence to the contrary, opponents still fear needle exchange encourages or enables drug use. Congress banned using federal funds for needle-exchange programs in 1988.
“Federal government funding for [needle exchange] has often been withheld on the grounds that the public will perceive such funding as official sanction of illicit drug use,” wrote Holly Villarreal, RN, BSN, and Catherine Fogg, RN, MS, ARNP, in an article for the American Journal of Nursing published in May 2006.
The AJN report cites numerous studies supporting the effectiveness of needle exchange and recommends nurses advocate lifting the federal funding ban.
There are some indications needle exchange is gaining wider political acceptance. Congress recently lifted a ban on needle-exchange funding for Washington, D.C. New Jersey recently became the last state to ease restrictions on access to syringes.
At least two states - New Mexico and Hawaii - have laws mandating harm reduction programs, including needle exchange. In New Mexico, 40 public health offices and 13 community-based programs exchange syringes, says Bernie Lieving, LMSW, director of the states Harm Reduction Program, which oversees needle exchange.
The need for nurses
Nurses work directly with many of the needle-exchange programs, providing education, screening, wound care and harm reduction counseling, as well as prescribing naloxone, Lieving says.
But not all programs can afford to hire nurses or other healthcare providers to do the medical piece.
Chicago Recovery Alliance, one of the country’s largest programs, relies solely on volunteers, supervised by physicians, to give vaccinations and do testing.
“We would love to have nurses at our sites,” says Dan Bigg, director of the Chicago program. ”There’s no question that it would improve the work we do, but it’s a question of resources.”
Cathryn Domrose is a staff writer.