Ten minutes before intravenous drug users began walking through the door of the Allegheny County Health Department building in Oakland on a recent Sunday, Ron Johnson of Prevention Point Pittsburgh was arranging syringes. "Browns," the biggest needles, sat next to "pogos." Nearby were cotton balls, alcohol wipes, cookers, where drugs are dissolved, and tourniquets, which ease vein access.
By the end of the day, 65 users had visited Prevention Point Pittsburgh to exchange their dirty syringes for clean ones. PPP, the only needle exchange program in Western Pennsylvania, works to reduce the transmission of blood-borne diseases like HIV and hepatitis C by giving addicts clean needles to use in place of shared, dirty ones.
"The only time [addiction] is gonna stop is when the man upstairs cuts the lights out on the planet," Mr. Johnson said. "We're helping people so they don't lose their bodies."
But even as Mr. Johnson, 65, watched users begin to arrive, he said his mind was on the people he couldn't help. An Allegheny County rule prohibits new needle exchange sites from being established within 1,500 feet of schools, day-care centers and drug treatment centers. According to maps drawn by PPP, the rule is sufficiently restrictive that almost no new needle exchanges can open under it. (The organization's current sites in Oakland and the Hill District were established before the 1,500-foot rule went into effect. They are open for a combined five hours a week.)
Scott Burris, professor at Temple University School of Law, studied needle exchange laws in 19 major U.S. cities and said none of those cities had laws as restrictive as Pittsburgh's.
Now, PPP is moving to have the rule eliminated. Its representatives argued at a July 11 presentation before the county Board of Health that the rule keeps them from serving vulnerable populations struggling with rising rates of heroin abuse. The Board of Health agreed that the rule should go, and plans to vote Sept. 5 on an amendment that would then be sent before the Allegheny County Council. PPP also proposed a new location in Homewood.
"We have to be in the communities, not hidden," Mr. Johnson said. "Right now there's no place for us to go but into the river."
Neil Capretto, medical director at Pittsburgh's Gateway Rehab, remembers a 19-year-old girl who came to his center for help kicking her heroin habit. She eventually worked her way through rehab, reconnected with her family and settled into a new life. Soon she was dead of a blood infection she'd contracted from a contaminated needle she used before entering treatment.
"There are thousands and thousands of IV drug users," Dr. Capretto said. "Most of them do not want to be IV drug users." He continued: "You can't help a dead person."
Samuel Friedman, director of AIDS research at the National Development and Research Institutes in New York, said the medical evidence is unambiguous: "It shows in basic terms that needle exchange reduces HIV transmission. In New York it basically broke the back of the epidemic among drug injectors, and having needle exchanges around tends to reduce the number of dirty syringes that are left on streets or parks."
But the politics are more complicated, especially on the question of location. Evidence shows that needle exchange pushes more users to seek treatment, but it is hard to avoid the perception that the services enable drug abuse. County Councilman Vince Gastgeb, R-South Hills, remembers getting emails and phone calls from parents and teachers when the 1,500-foot rule was written in 2008. (It was written as part of a broader affirmation of needle exchange services in the county.) Parents recoiled at the prospect of allowing syringes near their children.
"They said they're just tired of seeing needles around schools," he said. "I don't know why [PPP] would want to push the issue and all of a sudden bring light to something they should let alone."
County Councilman Michael Finnerty, D-Scott, who backed needle exchange services as chair of the health committee in 2008, said the council was likely to be reluctant to allow PPP free rein to choose its sites.
"It maybe could be less than 1,500 feet, but I think there should be some type of buffer there."
Others, though, contend that a robust location vetting process already in place will protect sensitive community spots from needle exchange. PPP must receive approval from the county health board and city of Pittsburgh for any new site it wants to open. Lee Harrison, chair of the health board, said after the July 11 meeting that those requirements were integral to the board's support.
Public health officials are also concerned that rising heroin abuse is pushing more and younger users into the IV drug world. Rates of prescription drug abuse tripled between 1998 and 2010. Westley Clark, director of the Center for Substance Abuse Treatment at the U.S. Department of Health and Human Services, said that trend may have led more users to heroin as people substituted cheaper injections for pills. In 2010, heroin was the most commonly cited drug among drug treatment admissions in Pennsylvania. Nationally, the average age at which recent initiates started using heroin went from 25.5 years in 2009 to 21.3 years in 2010.
"There are more IV-addicted individuals in our community than at any time ever," Dr. Capretto said. "I see that trend getting worse before it gets better."
Renee Cox, Prevention Point Pittsburgh director, said her concern is not only that PPP is failing to serve enough drug users, but also that it's failing to reach certain groups of drug users. Seventy-five percent of its clients are white. With bus service being cut and many users old, sick or without a car, she said her current sites reach only those who can afford to drive. She said a new site in Homewood is critical to easing access for African-American users who want clean needles but can't travel to get them.
A study in New York City found that 81 percent of drug users living within a 10-minute walk from a needle exchange site used the services, compared with 59 percent of those who lived farther away. Dr. Friedman, of the National Development and Research Institutes in New York, said that elevated HIV infection rates in African-American communities will persist until groups like PPP begin correcting service disparities: "There's a great need for more exchanges in African-American areas."
It's a need that Mr. Johnson knows better than most. Mr. Johnson grew up in Homewood and contracted hepatitis C there as a frequent heroin user. Needle exchange wasn't around then, and he said most of his friends got hepatitis C from sharing needles, too. Every once in a while an old friend who is still using calls about the syringe exchange program. But he rarely sees them at his sites.
"That's why I need Homewood. This is a population that doesn't come."
Michael Robinson, 59, a former heroin addict who used PPP's services, then entered treatment and got clean in 2008, now serves on the organization's board. He said trust and familiarity helped him get healthy, opportunities he worries aren't available to those whose age or disabilities keep them from accessing needle exchange sites.
"Ron is my best friend," he said. "The person who supplied me with clean syringes is also my best friend whom I can talk to about things that I can't talk to anyone else about."
Mr. Johnson said those relationships depend on being in communities, day after day, and treating addiction like a disease.
"I don't use, but I don't judge."
Derrick Lopez, president of Homewood Children's Village, is one of many who support a new needle exchange site in Homewood and think the 1,500-foot rule should go.
"We have this huge fear in some ways that our children are going to be affected by drug use by osmosis," he said. "But in reality every day our children walk down the streets of Homewood they see drug dealing taking place right in front of them."
Tamesha Bottoms, 30, a Homewood mother of two, said that as long as drug use afflicts the community, it's time to stop assigning blame and make help available. She said she trusted PPP to pick a safe location.
But for as much emphasis as the organization places on its community outreach efforts, there remain holes in how it represents its community support. At the July 11 health board meeting, Ms. Cox announced PPP's preferred Homewood location and said "we have the support of the YMCA in Homewood, Jerome Jackson of Operation Better Block and the Center for Spirituality in Twelve Step Recovery in Homewood. All parties are comfortable with the chosen location."
But Ricardo Williams, director of the Homewood YMCA, and Mr. Jackson of Operation Better Block said they had never been informed of the chosen location. Told that the exchange would sit at the intersection of North Dallas and Hamilton avenues, Mr. Jackson said he couldn't support it; he worried that the spot is two blocks from Homewood Park and close to a building being converted into an indoor bike park. He said the 1,500-foot rule "does make a lot of sense."
Mr. Williams said he had only one conversation with PPP representatives before being listed as a backer. He thinks the 1,500-foot rule "sounds appropriate" and said he was not told of the location. "Communication should have been better."
Ms. Cox ascribed the error to a miscommunication with Mr. Johnson, who handles community outreach, and said it is "something we take seriously." Mr. Johnson said PPP would move the proposed site to the intersection of Frankstown and Homewood avenues, a corner of known drug activity a few blocks farther from Homewood Park.
But the new site still concerns Magdeline Jensen, CEO of YWCA Greater Pittsburgh, which runs a day-care center three blocks away. She said in a statement that her group recognizes the value of needle exchange programs but hopes PPP "can identify another location in Homewood."
Others said that those fretting over locations are simply trying to push messy solutions to difficult problems into the dark.
"They're not complaining about drug activity and prostitution. Why would they complain about help coming in?" asked Gina Hickman, director of Homewood's Center for Spirituality in Twelve Step Recovery. "I think it's one of those 'shhh' moments."
Speaking at Homewood Park, Florence Macklin, 67, mother of three and a grandmother, said Homewood residents had to be vigilant in making sure PPP addresses their community's concerns. But she said as uncomfortable as free needles make her, drug users are battling addiction and need help.
"They need someone to care, even though they sometimes don't care themselves."region
Benjamin Mueller: firstname.lastname@example.org, 412-263-4903