Conscientious Injectors (Part II)

The enforcement of drug laws should be less hurtful than the dangers inherent in drug use itself, say the "harm reductionists" at Prevention Point, who practice what they preach by distributing 1.5 million needles to the city's drug users.

The Webster Exchange
On another sunny Tuesday night, two white guys stand in front of any empty, cyclone-fenced lot on Webster Street just north of Eddy, solidly in the Western Addition. Charles Pearson and Alex Kral, volunteers for Prevention Point, stand there with several hundred syringes that resell on the back market for between 50 cents and $2 each. They've got the de riguer small steel table with all the trimmings, a biohazard buxket, and a small portable radio playing KMEL. Nobody hassles them. Ever.

Webster Street's low volume - averaging one client every three or four minutes - allows time for casual talk, which volunteers at the high-volume sites can't afford. Most passers-by know Kral and Pearson by sight; the needle exchange is pure human contact for marginal people in a marginal community.

"Free condoms?" Kral offers a young woman pushing a stroller.
"No, thanks, I already have some," the woman replies, embarrassed.
What possesses the two to volunteer to help junkies, er, IDUs?

Kral spends his days crunching IDU numbers for Watters' Urban Health Study. He says, "I believe in knowing more about the topic, knowing more about the people. I want to see how the system works ... I think it's really important to have some kind of direct-service thing, just for the psyche. If you work in the world of numbers and writing papers and stuff, you don't often see any finished products, you don't get any thanks, you know?"

Pearson also mixes the personal and the professional: As an ethnographer with the San Francisco Urban Institute, he researches the lives of homeless heroin addicts.

"It's a direct application of public-health activism," Pearson says. "You somehow get more involved in more people's lives that way."

Webster Streetis mellower than Duboce, 14th Street, or the Tenderloin site with its reputation for chain-reaction alcoholic fistfights. Typically, there are 35 exchangers per evening, generally men in their 40s. Kral says younger kids tend to either snort heroin rather than inject it, or they smoke crack or abstain from drugs. The needle volume is still high, though, up to 1,800 a night, or about 50 a person, as many IDUs turn in their friends' points for them.

Pearson and Kral started the site in April 1994 after working at a site in the lower Haight and realizing the Western Addition was exchangeless. Prevention Point offered to provide needle and other goodies, so the two scoped out Webster Street.

After making inquiries of some people in the area, they settled on a site just around the corner from what Pearson calls "the drug stroll" on Eddy Street, a sedate-looking block of row houses that during the day is the local Crack Central. It's a block from the Plaza East project, nicknamed "O.C." for "Out of Control."

They also talked to local church groups, the cops at Northern Station, and tenant associations. And talked and talked. The tenant associations were hesitant; they said, "Just what we need, now the cops will know who to bust for having paraphernalia." Pearson says he took this concern to a lieutenant at Northern Station, and the lieutenant got Capt. Richard Carnes to write a letter saying his officers wouldn't stake out the exchange or bust people without cause. Good enough. In April 1994, the Webster Street site went into business.

It's a drive-through site par excellence as folks pull up, leave the engine running, jump out with their points, grab a fresh set plus some alcohol wipes and cotton, and drive away.

It's also a bike-through; a bike messenger comes by every week around 6:30 just to get condoms, and on my second visit I am dumbfounded by an immense bag of pot protruding from his shoulder bag.

"Uh," Kral says, "you should make sure your bag's closed."
"Nah, it's OK," the messenger replies, happily riding off with a fistful of lubed rubbers. Prevention, prevention, I think.

The site's driveability can cause problems. One strung-out-looking guy pulls up in a cab and falls in line behind a man who is counting out his points into the biohazard bucket just a little too slowly.

"Hey, I got a cab waiting, man."
"We've all got to wait, brother," says the gentleman ahead of him, turning briefly from his count to touch the speaker's shoulder.

"Don't touch me. I'm not your brother," the first guy snaps.
The slow guy sighs, stops counting his points out, and steps aside for Mr. Civility. By this time, the cab driver has gotten out of his car and is looking on, wondering what's up. His fare is counting maybe 20 used hypodermic needles into a bucket and arguing with a bunch of guys standing, for some reason, in front of an empty lot.

"You feeling OK?" asks a nurse practitioner who also is visiting the site that night.

"Yeah, yeah, feeling fine," says the guy, avoiding eye contact as he ans the stoic cabby return to the car and drive away.

"He probably here from another part of town," says Pearson.
The outreach of needle exchange has brought many stigmatized IDUs in contact with officaldom for the first time. The nurse practitioner at the Webster site is doing a "needs assessment" to determine how the Department of Pubic Health can help the city's addicts. The Haight-Ashbury's Women's Needs Center attends to women at the 14th Street site every other week, and UCSF routinely sends its docs down to check on the Sixth Street clientele.

Prevention Point is working its own needs assessment, says the organization's chief, Roslyn Allen, so "injectors can tell us what, when, and where" to do exchanges. Allen, with a master's in clinical psychology, has headed the group since January. She says Prevention Point is establishing a program to screen active injectors and teach them proper injection techniques, with the goal of having them teach their comrades - in a phrase, peer-group education. But this program requires funding that Prevention Point has not yet received, she says.

The exchanges are also "a conduit for all kinds of information," Sheigla Murphy, a researcher for the Institute for Scientific Analysis. "People are able to access information about social services [and] drug treatment programs," she adds. ISA is completing a three-year qualitative study on how needle exchanges work or don't work. Key among the successful programs are those that teach people the correct way to self-inject, as well as overall safety tips, she adds. The information is getting to IDUs, Murphy says, to the point that "you're really seeing people, especially the younger users, who wouldn't even think of sharing [a needle]." And if they do share, she adds, they know to disinfect them with bleach.

There's time to observe people's routines at Webster Street. A couple of guys walk up and one starts counting points out. Kral notices that each one has a little X,C, or O on it.

"Hey, what's your system? I always like to ask," Kral says to the client, who makes a response I don't catch, gets his fresh points, and walks away.

I ask Kral what was up. He tells me that sometimes when people live in a house with several users, they mark their needles so that no one shares a needle with anyone else.

Good system, I remark.
Sure, Kral says, they love that. He maintains that heroin users are very ritualistic, and part of doing the drug is doing the ritual. Lay things out just so, in this order, cook things, mark things, clean things. It's part of the process, he says.

Like a superstitious baseball pitcher? Yup, Kral says, saying that one reason the "Bleachman" ad campaign was so succesful a couple of years back - with its cartoon-superhero bleach bottle and no-nonsense safety instructions - is that addicts were open to adding another intricacy to the heroin ritual. Ah-hah. Now we flush each point with Clorox, then with water. That's the drill. Got it.

A clearly wacked citizen pulls up in a mid-' 70s Mercury to exchange his points. I mentally note that his motor control is impaired, which is a polite way to say he's reeling. On what I have no clue.

"Hey, the car!" Pearson says.
"That's the car," the client slurs.
"We've been hearing about this car, and here it is," Pearson says to me. "How's it running?"

"Coils, man. Coils keep burning out."
Pearson, the client, and the nurse practitioner commence a Guy Car Talk that's indistinguishable from any other conversation guys have about cars. The needles are almost, but not quite, an aside.

"Universally Reviled"
Prevention Point must be doing something right to keep attracting IDUs but what do heroin users themselves think about needle exchange? It's hard to tell from just talking with them. THe dozen or so IDUs I spoke to acknowledged that the needle exchange makes their lives a little easier, but they are so "universally reviled," in John Watters' words, that they keep a low profile in the face of the System, including reporters, and talk only reluctantly.

One night at an exchange, a pale, unshaven man in jeans and a sweat shirt approaches. He turns in his points, and while he does so I ask some questions. He says he does injectable amphetamines rather than heroin. How often, I ask? "Maybe twice a week," he explains, clearly ill at ease, then walks away. A volunteer asks me what the client said, and then seems impressed that he has maintained a consistent story from week to week. I remark that twice a week seems like too low a number to require 20 syringes, until the volunteer explains that those two episodes could be two - to three-day binges or injections at 30-minute to one-hour intervals.

While there are no hard and fast numbers on heroin-related crime or mortality in San Francisco, needle exchange isn't making a dent in those statistics. The SFPD does not parse heroin arrests from other opiate arrests; its figures show that total opiate arrests have crept upward since 1990 when there were 5,157 arrests for crimes relating to opiate drugs. Last year there were 6,363 arrests.

Heroin-related deaths are on the rise in San Francisco, reports Donna Allison, forensic lab manager at the San Francisco medical examiner's office. During fiscal year 1990-91 there were 48 heroin-related deaths in the city compared to 113 in 1993-94. But it would be a mistake to link the increase in heroin-related deaths to the much-ballyhooes increase in heroin purity. SFPD Capt. Greg Corrales reports that over the last two decades, the purity of street heroin in San Francisco has only gradually risen from the 3 percent range to an average 35 percent purity.

But potency is only one of the variables in a heroin-related death, as researchers reported in Science in 1984 and later in the Journal of Forensic Sciences (1989). Studying heroin-related fatalities in Washington, D.C., they were unable to establish a relationship between heroin purity and death-by-overdose or nonfatal overdose. The primary risk factors discovered were intermittent or post-addiction use of heroin, and the deadly combination of alcohol and heroin, a fact that harm reductionists across the country preach to their IDU populations.

The Dry Doc
From political middle to far-right, stopping just before Barry Goldwater-style libertarianism, the cries of "Wrong!" still ring out against drugs. One quotable naysayer is former Reagan administration drug czar William Bennett, who co-wrote a recent series of inspirational drug-war editorials in the Washington Times.

"The cornerstone of national anti-drug efforts," Bennett and his co-author write, "is to give force to the principle that drug use is wrong, harmful and will not be tolerated. This principle should be embodied in the institutions of society, which, in turn, should be organized to give force to that principle."

Bennett would have the government secure our borders and the inner cities, decapitate domestic trafficking organizations, and administer piss tests.

Clintonian wishy-washiness isn't much friendlier to the needle-exchange concept. Drug czar Lee Brown ducks needle exchange in a written statement, saying his job is solely to "reduce the use of illicit drugs in America," adding, "We must ensure that approaches used to confront one epidemic do not compromise our efforts to confront the other."

One needn't agree with Bennett or Brown to have mixed reactions to harm reduction. Darryl Inaba, doctor of pharmacology and perennial force at the legendary Haight-Ashbury Free Clinic, says that sometimes harm reduction doesn't mesh well with 12-step programs, which focus on cold-turkey approaches. The two should be kept separate, he says, because they can be "too conflicting with people who are trying to get off drugs. ... We deal with then walking wounded," who don't need the additional stress of being around mixed messages. Besides, he remarks, the studies he's seen indicate that "95 precent-plus" of the people who try to merely manage their addictions are "not able to keep it al the controlled level."

It's not that Inaba totally opposes harm reduction; the Free Clinic was one of the first organizations to dispense bleach and condoms to IDUs incapable of getting off the hard stuff.

But he prefers "continuous abstinence. All the research on the addictive process ... has shown that the part [of the brain] addicted is the old brain, not the new brain. It's not the conscious part of the brain that's being impacted, it's the instinctive or subconscious part." In other words, addiction is not so much a monkey on your back as an ancient reptile on your cortex.

Prevention Point leans in the other direction, only referring clients to methadone, counseling, and 12-step programs if the client first asks.

"We don't ever suggest it to people without their first showing interest. It's a completely nonjudgemental program," says Fernando Aguayo-Garcia, Prevention Point project coordinator.

An Ounce of Prevention
It is 6:36 at the Taylor Street needle-exchange site one recent Wednesday night, and Prevention Point's royal-blue Grumman delivery truck is six minutes late. The clients and volunteers are antsy, lighting cigarettes and forming a ragged line where the steel cart-tables usually atand between two trees in the middle of the block. Every five seconds or so, the clients scan the horizon toward Turk and Market, where the truck must come from.

Taylor Street is where the run-down Tenderloin borders what travel agents optimistically call the "Union Square area." The Tenderloin's teeming masses abut the enormous Hilton hotel at the corner of Taylor and Ellis and the holy edifice of Glide Memorial Baptist Church. Armies of European tourists head south to Market from the Hilton, white American prostitutes head east toward Union Square's fringes, choral singers of every stripe walk to Guilde for evening practice. It is the Asia Minor of needle exchanges: Everyone has to go by to get somewhere else.

Except that damned truck. Volunteers Rosie, Elissa, Bob, Mike, Marian, and Kelly talk amongst themselves about why the truck could be - check watches - 10 minutes late now, while the waiting line turns into a crowd and the crowd into a 50-person throng. It's going to be standing room only.

Finally, at 8:42, the truck appears way down Market Street. It spends another agonizing minute at the stoplight at Eddy, and then it's here. There's now a neat queue, which in turn has blossomed into a zigzag three people wide as those farther back attempt to see around the people in front of them. The volunteers start exchanging needles at 8:44, and for the next half-hour they may as well be working at a high-speed assembly line for all the time they have between exchangers.

"This is the bulk line, folks," says Bob. Taylor Street is so busy it has an "express" line and a "bulk" line for volume exchnagers (30 or more points). Meanwhile, the German tourists go by, surprisingly nonplused and possibly wondering why a needle exchange would be on a dirty street instead of a clean lighted building, with nurses and shooting rooms, like at home in Germany.

Faced with long waits in the bulk line - one 20-year-old waif counts out 222 needles, five by five - conversation turns to the state of city services and library hours.

"Hey, come over to my place before we go to the library."
"You come over to my place."
"Well I don't know where you live."
"I'm in the book."
"Well, I got a fractured foot."

A can of whipped cream makes the rounds, not just as a yummy topping for the two pints of ice cream being vortexed, but as a convenient source of nitrous hits. Emptied of its precious fluids, the can is carefully set down by a city tree.

A black man of about 45 enters the line with his 3-year-old son, who immediately sets to work rattling the parking lot's cyclone fencing. I say that the kid will soon be climbing over the fence instead of just rattling it.

"Yes," the man agrees, "they're smarter now. TV helps. Sometimes it helps in the wrong way."

He gets to the head of the line and starts counting out his points; his hands shake slightly, enough that he breaks off the orange protector caps covering the needles. The bright caps fall to the sidewalk in a way that mesmerizes the little boy, but only for a moment. He's had it with standing around waiting.

"Daddy, I want to go play in the park."
"OK, just a minute. Sixteen, 18 ..."
"Daddy."

"Well, just wait a minute until I get done. Go wait over by the fence." He tops out at 54.

"Gimme half shorts and half longs." That done, the two walk downhill holding hands, to find a place where Daddy can shoot clean.

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