Needle exchanges: When the perfect is the enemy of the good

Between 7:30 and 10 a.m. on a glacial late November morning, a tall white van lingers at a street corner in Boston’s South End. I consult my iPhone one more time to confirm that I’m in the right place and knock on the vehicle’s glass-paned door. Ritchie, with his oversized Las Vegas baseball cap and faint smell of cigarettes, ushers me inside and I settle in across from him on one of the grey-upholstered seats to await the van’s more typical visitors.

Ritchie joined the Needle Exchange Van more than six years ago – after a midlife career change from furniture sales that was brought on by watching two friends and fellow Marine veterans start using, contract HIV, and die. My morning with Ritchie, part of a required residency rotation on addiction, offered a rare glimpse into patients’ lives outside hospital walls and the important, if unsettling, work that complements our efforts as physicians.

The Boston Department of Public Health has funded this mobile unit since 1993 as part of an outreach effort to encourage safe intravenous drug injection for active users. The van offers safety supplies to 2,000 or so users each year, says Sarah Mackin, the chief coordinator of Harm Reduction Services/AHOPE Needle Exchange at the Boston Public Health Commission who arrives just after me. Its services target some of the greatest dangers of opioids like heroin and other injected drugs: overdose and the needle-to-needle transmission of HIV and Hepatitis B and C. Here and across the country, these efforts run parallel to programs that connect users to detox centers and help them maintain sobriety.

Ten minutes into my visit, the first client enters with a barked hello and finds the sharps disposal to deposit his grocery bag of used needles. He’d like to replace them with some of the big needles please – the 27 gauge ones. He turns to the right wall and starts to rifle through bins of alcohol swabs, matchsticks with CPR instructions, tourniquets, bleach kits, and condoms. Once he leaves, Ritchie shows me another popular van offering – a booklet on safe drug injection co-written by users that includes diagrams of veins on the arm and distinctly street-credible language.

In 2006, Massachusetts legislators made it legal for any adult to buy needles from a pharmacy without a prescription. But the van still serves an important role, says Ritchie: you get the needles for free without the stigma that would come with public acquisition and you can get tested for HIV and other blood-borne infections. Beyond needle exchange, overdose prevention has become a major focus of the van, particularly in light of rising rates of opioid-related death. A recent report from the Massachusetts Health Council, Inc found that in 2011, the greater Boston had the most emergency room visits involving illicit drugs among the 11 largest U.S. cities. Ritchie and Sarah teach clients how to rescue fellow users with intra-nasal Naloxone – a medication that reverses the deadly breath-slowing effects of opioids In the past five years, Sarah estimates that these trained opiate overdose responders have saved 1,500 lives in the Boston area.

Twenty more minutes pass and several clients enter at once, so Ritchie and Sarah split up to go through the intake questions and record the answers on an anonymous, trackable form. Have you shared a needle in the past year? No one has. Are you homeless? Most are. When was your last HIV test and what did it show? Ritchie and Sarah’s tones are remarkably nonjudgmental. One client tells Sarah she loves her. Sarah says it back.

I wait for a question about getting clean or sober but it doesn’t come up for any of the ten-odd clients who pass through during my hour and a half in the van. Sarah tells me they always try to assess if their clients are interested in drug rehabilitation but they must strike just the right degree of intervention – they don’t want to make the visit so long and burdensome that the clients won’t come back.

Needle exchange is a polarizing issue along the political spectrum, among those who differ on whether addiction is a choice or a disease (I’d argue it’s overwhelmingly the latter) and on the role played by socioeconomic circumstance (I’d argue huge). But as I sit in the van I feel conflicted along another axis. Harm reduction is the purview of public health workers and is decidedly uncomfortable for the doctor trained to target individual patients. When each client comes in, I want to tell them to stop using, to block the door and prevent them from leaving just to get high. But Ritchie, Sarah, and the many others doing this work know what they are doing. These sorts of interventions have shown more benefit and life-saving potential than plenty of things we do in within hospital walls. Sarah later wrote to me in an E-mail, “…we are a harm reduction centered program, and thus celebrate any positive change an individual makes in their life…”

It takes a lot of patience and wisdom to recognize that perfect can be the enemy of good – I’m glad I got to see how it’s done.

Ishani Ganguli is a journalist and an internal medicine-primary care resident who blogs at The Boston Globe’s Short White Coat, where this article originally appeared. 

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