Thumping beats of hip-hop and reggaeton blast out of cars on Kensington Avenue in Philadelphia. It's 11 in the morning, and people lie prone on park benches or hunched over on stoops under the elevated transit line. Inside an old church on the street corner, dozens of people—men, women, old, young, black, white, and Hispanic—fill a small room. One by one, they receive bags of needles, ties, and medical supplies, everything they need to fulfill an opiate addiction short of the drugs themselves.
"Do you have pipes?" someone asks. "No glass today," employee Sam Sitrin says.
Sitrin, 36, greets participants with warmth. She's provided syringes to many of them for years. "Test before you fly," she advises, reminding them their tolerance might be down if they haven't been using for awhile.
Another staff member walks through the room, shouting out an offer for free HIV and hepatitis C testing. While handing out supplies, Sitrin receives a phone call and sprints out of the church to assist someone who overdosed on a nearby street. The line in the room backs up with people eager to collect their needles.
"It's a little slow today, actually," employee Shawn Westhahl says as he hustles to keep up with the demand.
The syringe exchange takes place at Prevention Point Philadelphia, a services center in the city's Kensington neighborhood, which is home to what is commonly referred to as the largest open-air heroin market on the East Coast. The center operates on a harm-reduction model, offering clean syringes in addition to medical treatment, Narcan (overdose antidote) training, legal services, meals, and even mailboxes for people with no other address. "We're not here to tell people they shouldn't be doing drugs," says executive director Jose Benitez. "We're here to help them stay safe, and when they're ready to stop, provide them with the resources they need."
At the epicenter of an opiate crisis that has wrecked communities across the nation, the number of people using the exchange program has doubled in recent years, Benitez says. In 2016, he says, the program handed out 2.4 million syringes and collected 2.2 million back. The program relies on city money and private donors.
To prepare for the rush when the doors open at noon, Bernard Guy, 68, tall and bald with a gray beard and gravelly voice, fills paper bags with medical supplies. "These are wound care kits," Guy says, stuffing in gauze, band-aids, pink saline water, and other items.
He packs another bag with two ten-packs of 27-gauge needles, tie-off bands, and small metal caps used as cookers. The center also offers bigger needles for people who inject steroids or hormones, and smoker kits for crack. "Where there's a need and we can help, we're gonna help," Guy says.
When the exchange kicks off, participants bring in old needles and drop them in collection bins by the door, receiving a ticket so they can receive the same number of clean syringes in return. They present a card or ID number so staff can track demographic information, but the program is otherwise anonymous.
In 2016, the program handed out 2.4 million syringes and collected 2.2 million back.
Prevention Point was founded in 1991 based on the efforts of AIDS activist group ACT UP to distribute needles out of the back of cars, at a time when the city saw around 1,500 new AIDS cases per year, nearly half spread via injection drug users. The following year, the city issued an order effectively legalizing the program, though syringe exchanges are technically prohibited under Pennsylvania law. By 2015, new HIV or AIDS diagnoses were down to 538, with only 5.5 percent suspected of transmission through needles, according to statistics compiled by the city's AIDS Activities Coordinating Office.
Even as the risk of AIDS has diminished, a wave of deaths by overdose is currently menacing people who inject drugs. Nationally, there were more than 40,000 lethal overdoses caused by heroin, prescription painkillers, or synthetic opioids like fentanyl in 2015, more than the total deaths from gun use or car crashes. Philadelphia saw 900 overdose deaths in 2016, a 30 percent increase from the previous year, including 35 over a five-day period in December
In response, Prevention Point is emphasizing training people in the community to use Narcan, or naloxone, medication that can stop an overdose almost instantly. Benitez says the program has spurred nearly 750 reversals so far.
Staff say a rise in additives supplementing or replacing heroin altogether is a major cause of the overdoses. "You just say, go get me a blue bag," Guy says. "You don't even know what's in it. Fentanyl, numerous tranquilizers, everything but heroin."
Nationally, syringe exchanges are still controversial—only 17 states plus Washington, DC, explicitly authorize the programs. There were 288 active syringe-service programs in the United States as of 2015, according to the North American Syringe Exchange Network. A federal funding ban on the programs was lifted last year, which in theory could supply additional support, although no extra money was allocated.
To many who work in public health, the programs are common sense. "The theory of harm reduction is, since these certain kinds of practices are going to exist whether we like them or not, let's try to deal with them in a realistic way," says William Martin, director of the Drug Policy Program at Rice University's Baker Institute for Public Policy. "Zero tolerance, prohibition, these aren't going to work."
Preventing the spread of communicable diseases, he notes, doesn't just protect the people using drugs; it protects family members, sexual partners, and others in close contact. Bringing needles off the street helps prevent children and other passersby from accidentally getting pricked.
From an economic perspective, spending a few cents to provide a clean needle can save hundreds of thousands of dollars in treatment costs, often born by public insurance like Medicaid, if someone contracts HIV or hepatitis C, Martin says. "There's the public health measure," he adds, "the compassion measure, and the economic measure."
For the people using opiates, the costs are personal. "You don't take it one step at a time, you don't make it," says June Paige after picking up a bag of medical supplies. Paige, 60, leans on a cane as he speaks. His forearms are pink with scars.
He says he used drugs starting at age 13 up until he nearly died from an overdose on his 57th birthday. He's been coming to Prevention Point for two decades, and while in recovery, still uses their medical services for diabetes and other health problems.
"I wouldn't want to see no one go out the way I did," Paige says. "That's the way things are. That's life."
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