Do needle exchanges reduce the spread of infectious disease? The research isn't clear.

Correction: An earlier version of this article misspelled Debra J. Endean's last name. It is Endean, notEndeans. Also the AIDS Resource Center of Wisconsin started the LifePoint program in 1994, not 2014.

The numbers are staggering —  233 confirmed drug overdose deaths this year in Milwaukee, with 188 because of opioids, according to Karen Domagalski, operations manager for the Milwaukee County medical examiner’s office.

In Wisconsin last year, there were 829 deaths from drug overdoses — many involving the injection of heroin and fentanyl, Attorney General Brad Schimel said at a recent drug summit in Milwaukee.

“It’s only going to get worse,” he warned, unless a comprehensive approach involving law enforcement, treatment and prevention is taken.

“Without all three, we don’t have any hope to overcome this epidemic."

While the increasing loss of life draws the headlines, opioid use creates other health hazards for users and the community including the spread of infectious diseases.

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And one tool to combat infection is giving users clean needles in exchange for used ones, says Gina Allende, health promotions manager at UMOS, a nonprofit group on the city’s south side.

But there is heated debate — some of it politicized — over whether these programs work, and research in the U.S., at least, is mixed. 

Ten syringes and two cookers

Each Wednesday from 9 a.m. to 4 p.m., Allende and outreach specialist, Naronne Cole Sr., open the front door off UMOS' Mitchell Street office and welcome clients to the Safe Needle Exchange program. The program opened in August to help address increased intravenous drug use in Milwaukee, especially on Milwaukee’s south side.

When users walk in, they receive a starter kit that comes with the tools of heroin use — “a tourniquet, 10 syringes, two cookers, and six alcohol pads and some cotton pellets,” Allende said.

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Clients are encouraged to exchange used needles for clean ones but are not required to do so. They’re given information on safe needle use, local drug treatment programs and detox, and free HIV and hepatitis C testing.

So far, only a handful of the program’s clients have gone into treatment or gotten tested for STDs, but Allende believes those numbers will grow.

UMOS, the Sixteenth Street Clinic and the  AIDS Resource Center of Wisconsin, which offers both mobile and on-site services, offer the only needle exchange services in Milwaukee.

The Centers for Disease Control and Prevention says programs like these lead to more users going into treatment, a reduction of HIV and hepatitis infections and fewer overdose deaths but they remain controversial and have tepid public support.

Public support is waning 

Beth McGinty, assistant professor in the Department of Health Policy and Management at Johns Hopkins School of Public Health, examined support in the U.S. for needle exchange and safe consumption sites. The findings, published in the June issue of Preventive Medicine, found only 39 percent supported needle exchange programs, a decrease from 58 percent in 2000 when the last national survey was conducted. She also found that 29 percent of the public supported safe consumption sites (none operate in the U.S. currently though one is being proposed in California). 

Public opinion of needle exchange programs, like so many other issues, tends to hew closely to party affiliation, with the lowest levels of support coming from Republicans, McGinty said. Stigma about drug use and a negative opinion of users contributes to weak support for such programs, she said.

“If we view people as not deserving of help, or as having a moral failing, such as drug users, we don’t want to devote public policies and resources towards them."

Some states prohibit needle exchange programs, and until 2016, federal funding could not be used to fund them, she added. 

In Milwaukee, the programs have drawn criticism from residents, law enforcement and city officials. Like many other harm-reduction approaches, critics say needle exchanges encourage drug use and other negative behavior.

Nicole Thomas, the mother of an opioid addict in recovery, thinks they do more harm than good. “It is enabling them as if they are getting money from a family member,” she said. 

Debra J. Endean, executive vice president and chief operating officer for the AIDS Resource Center of Wisconsin, which created the state’s first needle exchange program, LifePoint, in 1994, doesn’t agree with the criticism. She believes they are "a proven mechanism to move people into treatment” and also help reduce HIV cases.

Needle sharing and STDs

Intravenous drug users have a high risk of contracting or spreading HIV and hepatitis C because they often share needles and exhibit reckless behavior. Becci Zaddack, a former opioid addict who is now on Suboxone, a drug used to treat opioid addiction, has seen that behavior firsthand.

“I’ve seen people rinse out their needles and hand them to someone else,” Zaddack said. No one will admit having a disease because if they admit to it, they might not get the drugs they need to prevent withdrawals, she said.

“Being dope sick is like being in hell,” Zaddack said.

Heroin addicts often use drugs in a group setting, according to Cole, and can quickly go through the 10 needles provided by a needle exchange. Running out or not being able or willing to get clean needles from an exchange won’t stop them from using, he said.

“They can go buy some at Walgreens, steal some from an insulin user or they’ll just reuse old ones,” Cole said.

There’s no shortage of them, explained Zaddack, who recalled picking up hundreds of needles while cleaning out the house of an addicted friend who died.

Advocates see a growing need

From June 2017 through May of this year, the AIDS Resource Center provided 1.4 million clean needles to about 15,000 clients in Milwaukee, a 16 percent increase from the previous year, Endean said. Since 2013, the program has distributed 5.5 million clean needles in Milwaukee. Even though the rate of needle drug use has gone up, the rate of HIV has remained stable, she said. Still, 18 percent of new HIV infections are the result of injection drug use, she said. 

In fact, the majority of hepatitis C cases in America are the result of needle use, according to Stephen Davis, assistant professor at the West Virginia University School of Public Health. The explosion of the heroin epidemic in West Virginia and other rural areas and the increase of hepatitis C infections among users, prompted Davis and other researchers to conduct a meta-analysis, published in 2017, that looked into the effectiveness of needle exchange programs at reducing the spread of the disease in the U.S.

The findings, published in the Harm Reduction Journal in 2017, were inconclusive.

“From an empirical standpoint we can’t know how effective they are in reducing hepatitis C,” Davis said.

Some of the studies reviewed found the programs were helpful; others showed they might be harmful, he said. Studies examining the ability of such programs to reduce HIV infections show a stronger correlation, he said. 

Are police tactics affecting the programs?

There were many limits to needle exchange programs that could explain why the findings were not definitive, Davis said. One problem: injection drug users are a hard population to track and study and many of the studies required self-reporting, which can skew data.

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But research in Europe has shown needle exchanges are effective, which is why he believes that structural barriers — including policing tactics and paraphernalia laws that discourage people from using the programs — are limiting their impact in the U.S. 

“There is an abundance of evidence that there is a fear of arrest in using a needle exchange program and carrying needles, especially those with drug residue. People won’t go because they are scared of a police encounter and of getting arrested,” Davis said.

Endean believes the programs have been proven effective but she acknowledges fears among users about confidentiality and run-ins with law enforcement. The AIDS Resource Center and others design delivery systems with those concerns in mind, she said, which is one reason the Lifepoint program uses mobile units.

“The vans allow people to be met where they are,” Endean said. The organization continues to work with law enforcement and politicians so they are aware of the barriers faced by users and the needle exchange providers.

The Milwaukee Police Department has no formal policy that would prevent a user caught carrying paraphernalia — whether headed to a needle exchange or not — from being in trouble with the law, acknowledged Heather Hough, a lawyer in the city attorney’s office assigned to District 2’s Community Prosecution Unit.

“Each situation is taken on a case-by-case basis,” Hough said.

Police and the DA’s office are working with community groups to find creative solutions to the problem of increased heroin and needle use, she said.

But there is one major problem that undercuts public support: Users throw away their used needles in public spaces where children and others can find them. 

A challenge for exchange programs

“Time and time again the community cries out to us about the waste and what they are exposed to. Kids are finding and being exposed to needles,” Hough said.

There is no way to know whether needles found in backyards or church lots are from needle exchanges, Hough said, but the concerns about discarded needles prompted the district attorney’s office, Ald. Jose Perez, Milwaukee Police Chief Alfonso Morales and representatives from needle exchange programs to sit down in September to figure out how to reduce the number of residents being exposed. Several ideas were discussed. 

Allende understands the frustration but worries that changes could affect whether users feel comfortable making an exchange. “They have to feel safe or they won’t come and they can’t bring in their used needles,” she said.

In fact, she argues, exchange programs are needed now more than ever.

“We need people to keep coming back through our doors so that we can keep encouraging them to get treatment.” 

Edgar Mendez is a free-lance writer who lives in Milwaukee. Email: edgarmilwaukeenns@gmail.com

How I reported the story

Reviewed:

Needle exchange programs for the prevention of hepatitis C virus infection in people who inject drugs: a systematic review with meta-analysis

Qualitative case study of needle exchange programs in the Central Appalachian region of the United States

Public support for safe consumption sites and syringe services programs to combat the opioid epidemic

Language Matters in Combatting the Opioid Epidemic: Safe Consumption Sites Versus Overdose Prevention Sites

Interviewed:

Debra J. Endean, executive vice president and chief operating officer, AIDS Resource Center of Wisconsin

Gina Allende, health promotions manager at UMOS

Naronne Cole Sr., outreach worker, Safe Needle Exchange program at UMOS

Heather Hough, assistant city attorney, City of Milwaukee

Stephen Davis, assistant professor, West Virginia University School of Public Health

Beth McGinty, co-deputy director, Center for Mental Health and Addiction Policy Research, Johns Hopkins Bloomberg School of Public Health

Data used for the story was obtained from the Centers for Disease Control and Prevention (CDC), AIDS Resource Center of Wisconsin and the Milwaukee County medical examiner’s office.