He's young, maybe 21 at the most. His clothes look neat and clean, his hair recently cropped. When he gets out of a late-model SUV and crosses a downtown street, a plastic grocery bag in one hand, a woman gets out and follows him. She looks even younger, possibly in her teens, wearing tight jeans and a spaghetti-strap tank top. The man walks up to two other women, Beth and Lynne, who've been sitting on a stoop, and hugs one of them.
"That's 350," he says to Beth, handing her the plastic bag, which is full of containers of dirty syringes. She only has 200 clean ones to give him in exchange, though, and tells the man he now has a 150-needle credit. The teenage girl, who's been hanging back, asks whether the credit should be even higher since a similar thing happened last time. Beth says she'll credit them another twenty syringes, but the man shrugs.
"I'm not picky," he says, with a genuine smile. "I appreciate the service."
Lynne, who's been scanning the intersection, leans in to Beth. "There's an officer at the light behind you," she says calmly.
Beth opens her arms to give the man another hug, and the police car rolls by without pausing. The man and his companion then cross the street, get into their SUV and pull away. The interaction lasts just five minutes, but it could save the man, and those around him, from death or a lifetime of disease.
Beth and Lynne are volunteers for Underground Syringe Exchange Denver, or USED. At its most basic level, the group's mission is to swap injection drug users' used needles for new ones to stop the spread of diseases such as HIV and hepatitis C.
But syringe exchange advocates — and dozens of scientific studies, some of them federally funded — say syringe exchange programs have a far greater impact. For one, the population they protect from disease goes beyond the addicts themselves to their sexual partners and their children. The programs also prevent dirty syringes from being discarded so often in parks and dumpsters, lessening the chances that a child or a garbage man will find them. They can even benefit police officers, by reducing the likelihood that a cop will get stuck by a dirty needle while patting someone down.
Furthermore, supporters say, needle exchange programs serve as a way to educate drug users about safe sex, how to avoid an overdose and how to avoid injection wounds that require expensive — often taxpayer-funded — hospital visits.
Although most needle exchanges don't push drug treatment, they can help when a person is ready to get clean, and often make referrals to detox programs.
Several major cities, including Washington, D.C., Chicago and Portland, have exempted needle exchange workers and participants from laws that typically prohibit the possession of syringes. Boulder has a program through a partnership with local law enforcement that does something similar, and Denver is considering a pilot program.
But needle exchanges, like the one Beth and Lynne carried out — their third that afternoon — are illegal in Colorado. State health advocates have been pushing for years (and as recently as three months ago) to change that, but their proposals have been repeatedly rejected by lawmakers, who believe the programs will make drug use easier.
That's why USED has to operate underground and off the police radar. The members of USED asked Westword to use only their first names — and, in some instances, to change them — to protect their identities.
For Beth, needle exchange is personal.
She was first labeled an "at-risk youth" at age eleven. The youngest of three sisters, she was raised by her mother in northern New Mexico. Despite a loving environment, Beth grew up angry. She hated school, where she had few friends. Although she was bright, she was put in special-education classes for what teachers termed "behavior problems." So she acted up even more.
One night when she was in middle school, Beth stole her sister's car and drove it to a party. A police officer was waiting in her driveway when she came home, and over hot chocolate prepared by her mother, he explained to Beth how she'd worried her family. A court put her on probation for six months.
She kept violating the agreement by skipping school, and her probation period grew longer. When she was fourteen, Beth, who'd been smoking pot for a while, tested positive for the drug and was sentenced to a year in a juvenile treatment facility.
She says she had a great therapist there and excelled in her classes. When she returned to her public high school the next year, her former teachers pulled some strings to get her into an AP English class. Beth was excited, but her enthusiasm didn't last long. On her first day, the teacher snubbed her. When Beth asked about the work she'd missed, the teacher told her to ask her classmates. "She knew that nobody would talk to me," Beth says. "I was a total outcast." It was the last straw.
Beth resolved never to go back, and her mother agreed to home-school her. For a while, things went well: Beth stayed out of trouble and finished school early. When she was sixteen, she moved to Denver to live with a family friend, and later found her own apartment and a job doing market research over the phone.
"I just worked and hung out and smoked pot and drank a little beer," she says of that time. "It was pretty mellow, really."
When she was seventeen, though, Beth fell in love with an alcoholic, and things got complicated. She wanted nothing more than to be with him constantly, and he wanted nothing more than to hang out with his friends and get drunk. In the midst of the turmoil, she went back to New Mexico and visited some friends. She discovered that they had graduated from taking acid and doing speed to shooting heroin. They invited her to try it, and she did.
Once she saw what heroin use looked like, she realized that her friends in Denver were doing it, too. Beth didn't want to be left out. "That was the beginning of the end," she says.
Beth began using heavily, partly to numb the pain she felt over her breakup. "I didn't want to be present," she says. "I didn't want to be on the planet. Heroin, it lets you be here without having to be here."
Her life soon unraveled. She met another man through her friends in the injection drug world and eventually married him. But they lost their apartment and took to living in run-down hotel rooms they shared with other addicts. They worked day labor, scrubbing toilets and picking up trash, to support their habit. (Beth says she was always too "chickenshit" to steal and too revolted to become a prostitute, common ways that users make money for drugs.) They spent almost all of their money on dope.
"I always say I never worked so hard for nothing in all my life," Beth says.
While she was using, she heard about hepatitis C, a virus that attacks the liver, from other drug users and outreach workers. The Centers for Disease Control and Prevention estimate that 90 percent of injection drug users get infected from sharing dirty needles. Beth was curious and started talking about the disease with other users, warning them about dirty needles and encouraging them to use clean ones and to bleach their injection supplies, or "works." For her, it was a turning point.
"I remember the first time the concept of harm reduction was presented to me, I was like, 'Oh, my God, why doesn't everybody know about this? This is the most beautiful, logical thing I've ever heard,'" she says. "Harm reduction" is industry-speak for ways to keep drug users safer until they're ready to quit. It's based on the notion that every life is worth saving, even that of a junkie.
Three years after Beth started shooting heroin, the consequences of her drug use — homelessness, unemployment, paranoia — grew tiring. She started methadone treatment at 21 and quit using at 22. But Beth, now thirty, didn't stop spreading the message to junkies that clean needles were key; in her spare time, she became an advocate for users.
It was still just talk, however, since needle exchanges are illegal in Colorado, which frustrated Beth. "It was just this conversation, this circular conversation that went on for way too long," she says. "For years and years, I'd sit in rooms...with people and we'd be talking about the needs of the injection drug use community...and, of course, syringe exchange programs would always come up. Every single time, in every single conversation, again and again and again."
Finally, Beth decided to take action on her own. An anonymous person had donated thousands of clean syringes after hearing about her work, and Beth figured out how she could get some grant money from the North American Syringe Exchange Network, a Washington-based organization that supports needle exchange programs. She asked a friend who had experience working with drug users if he wanted to help her start an underground program. They recruited two more people and started holding meetings to figure out the details of how, where and what they would exchange.
On January 12, 2008, USED was officially launched. Since then, it's grown to eight members who are available to exchange syringes for a total of nine hours per week. In February alone, they gave out more than 1,600 clean needles.
Imagine, USED members say, if the law allowed for legal, fully funded syringe exchange programs in Colorado, where the estimates of current injection drug users range from 11,500 to 18,000 people. Denver has a disproportionate share; the city's Office of Drug Strategy figures that there are 4,490 junkies in the city.
So far, USED has exchanged with 27 of them, though their clean needles have reached dozens more through what is known as "secondary exchange": users exchanging with other users. Still, there are thousands more out there.
For a while in the late 1980s and early '90s, it seemed that Colorado was on the cutting edge of harm reduction.
It started with Boulder County. In 1989, the county health department discovered that seven residents, all IV drug users, were HIV-positive. Six of the seven were married couples with children. At the time, Anne Guilfoile was in charge of AIDS prevention for the county. "It was a compelling story. We could diagram out these families and say, 'This is how many kids [are affected],'" she says now. "That was a different picture than what most people had in mind when they thought of drug users, and the consequences of doing nothing were really clear."
Guilfoile came up with three options: teach drug users to bleach their works, which wasn't 100 percent effective; push them into drug treatment, which was typically even less effective; or swap their dirty, potentially HIV-tainted needles for clean ones.
Guilfoile chose the third and suggested it to the public health director, Federico Cruz-Uribe, who, she says, took a deep breath and then started a campaign to get health workers, county commissioners, the Boulder Daily Camera and then-district attorney Alex Hunter on board. It worked, and after finding little public opposition, Boulder County started the state's first aboveground (though still illegal) needle exchange program, with Hunter agreeing not to prosecute its participants.
It started out small but grew steadily, thanks in part to a model that trains current and former drug users as volunteers who collect dirty needles and distribute clean ones. Today there are 82 volunteers, and program coordinator Kyla Holcomb estimates they exchanged 40,000 needles with 437 injection drug users last year.
Former public health director Chuck Stout, who replaced Cruz-Uribe in 1990 and retired last year, says that while the needle exchange used up 19 percent of the total spent on the county's drug-user disease-prevention program, "it probably accounted for 90 percent of the success. It was the clear, compelling statement to the injection drug user that I accept you where you are, and my sole intention is to keep you safe."
Stout is frustrated that the rest of Colorado hasn't followed Boulder County's lead. Legislators, he says, are "out listening to constituents' assumptions, beliefs, opinions and attitudes. All of those are against syringe exchange programs. The only thing they're not listening to is the facts."
Stephen Koester, an anthropology instructor at the University of Colorado Denver, helped gather some of those facts in 1989 with a grant from the National Institutes of Health. His goal was to find out why drug users shared syringes. Koester interviewed junkies around Denver and soon discovered that sharing wasn't, as previously thought, part of an "exotic drug-using culture." Rather, it was a necessity: Although being busted in Denver for carrying a syringe with the intent to inject drugs carries only a small penalty — in most cases, a citation and a fine of under $100 — Koester found that most drug users don't risk it because it's a charge that can lead to more trouble. They may be unable to pay the fine, or they may forget about their court date and wind up in jail, which means they're likely to go into withdrawal.
Nationally and internationally, Koester's study made a difference. Municipalities in the United States and even overseas changed paraphernalia laws to allow syringe exchanges. Other researchers cited it, and Koester gave several talks to the CDC.
His study isn't the only one to praise the efficacy of needle exchange. Between 1991 and 2001, seven federal agencies, including the CDC and the General Accounting Office, conducted studies. All showed that needle exchanges help prevent HIV and other diseases from spreading and that handing out clean needles doesn't create more junkies. A 1997 report by the National Institutes of Health concluded that syringe exchange programs "show reduction in risk behavior as high as 80 percent in injecting drug users, with estimates of a 30 percent or greater reduction of HIV."
International research reached similar conclusions. A 2002 study of programs in 103 cities worldwide showed that the number of users contracting HIV in cities with exchanges decreased by nearly 19 percent each year, while the number in cities without them increased by 8 percent. Studies also show that those who use exchanges say they're less likely to share syringes, a sign that the crucial message is being heard.
There are also studies that prove the opposite, though they're few. A 1997 study of drug users in Vancouver, Canada, found that those who used needle exchange programs were more likely to be HIV-positive than those who didn't. Other researchers have countered that it could be because the programs tend to attract high-risk drug users.
Most often, arguments against syringe exchange are moral: Drugs are bad, and needle exchange programs send the message that using them is okay.
Those were many of the arguments heard at the Colorado State Capitol in 1998, the last time lawmakers faced a bill seeking to create a needle exchange loophole.
Paul Simons grew up in Fort Collins in the 1960s, the son of a university professor. When he was eighteen, he moved to New York City for college and found heroin. "It was the late '70s, and I was really into the punk movement," Simons says. "It was a lifestyle choice. I was interested in the effects of chemicals on the body. Heroin was the hardest drug, and I wanted to follow substance abuse to its logical conclusion. And I did."
But Simons, who describes himself as a twenty-year "on and off" heroin addict who's been in recovery for nine years now, also helped found a syringe exchange on the Lower East Side and began working on public health projects.
In 1994, he returned to Colorado to run an HIV-prevention program for Denver Public Health. He applied for federal grant money to start an organization aimed at bringing needle exchange to the state.
His group's first effort failed in 1997, blocked by what was then a Republican-controlled state legislature, so he tried again in 1998. That bill made it through the Senate but hit a roadblock in the House: the conservative Committee on Health, Environment, Welfare and Institutions.
Simons describes the hearing before that committee as "tearjerking and harrowing." Among those who testified in favor of the bill were state health officials, doctors, nurses and a woman who had gotten HIV from her former fiancé, who was a secret injection drug user.
But it was Bill Ritter, then Denver's district attorney, who was the star witness. In an even, rational tone clearly audible on a tape recording of the hearing, Ritter told the committee how, as a new district attorney in 1993, he was asked not to prosecute people participating in needle exchange programs. He'd refused, he said, but his interest was piqued. For four and a half years, he studied the topic, even visiting a program in Chicago. There, he stood in a van for hours and watched as drug users traded dirty needles for clean ones and chatted with outreach workers. He also spoke with a state attorney who told him the police supported the effort because it decreased the likelihood that they'd get stuck with a dirty needle while searching someone.
Ritter was firm on one point, though: As long as needle exchange programs were illegal in Colorado, he'd prosecute their participants. That said, he told the committee members they had a chance to change that, and to change lives.
"I don't see a downside," he said. "I don't see that it dilutes our message if we stay strong on the message. I don't see that people who participate in needle exchange programs started their drug use — their heroin use, specifically — because a needle exchange program existed. I just don't see that." (For more of Ritter's testimony, log on to the Latest Word blog at westword.com.)
But other law-enforcement officials did. Several testified against the bill, suggesting that the availability of free needles would attract riffraff and make it tough for police officers to do their jobs. And in the end, the committee, anchored by Republicans, killed the bill on a 7-4 party-line vote.
Simons was disappointed but not surprised. "There was no way we were going to get through that committee," he says. "We could have had babies dying in the front row and that committee would have been as hard-hearted as they were." Simons, who has since moved out of Colorado, partly blames the political climate at the time.
Things should be different today, he and other advocates say. There's eleven more years' worth of research and a new president who has said he supports lifting the ban on using federal funds for needle exchange. Democrats run the state legislature, and it's not an election year. Most important, Ritter is now governor.
That last development is what prompted Monique Whalen to start the Public Health Awareness Task Force in 2007. Whalen runs a small nonprofit in Denver called the Drop-In Center that educates injection drug users.
She says she's frustrated that she can teach drug users about the importance of clean needles until they're encyclopedia-grade experts — but she can't actually give them any because it's illegal. Sometimes, she adds, "I feel like what we do is almost pointless."
So when Ritter got elected, Whalen — who has worked on aboveground syringe exchange programs in Europe and the U.S. but is not affiliated with USED — and other public health folks set out to change that. For two years, they worked toward drafting legislation that would legalize syringe exchange, and last fall they hired a lobbyist: Jeff Thormodsgaard of Mendez, Steadman & Associates in Denver.
Thormodsgaard says he worked for months with the governor's staff to craft a bill that wasn't too risky or too broad and would provide for local control. Representative Claire Levy, a Democrat from Boulder, signed on to be the sponsor.
But in early January, just days after the start of the 2009 legislative session, two top officials in the state Department of Public Health and Environment — executive director Jim Martin and chief medical officer Ned Calonge — said they wouldn't support the effort. Given the promise of opposition — and the fear of a veto from Ritter — those behind the bill decided to pull it.
"I felt that even though it's a very good idea and good policy, I didn't want to put legislation out there that wasn't going to be signed into law," Levy says. "It would be a waste of resources."
Calonge says the bill was last-minute and contained too many unanswered questions, including how to ensure that syringe exchange programs wouldn't "invite other criminal activities from around the edges." He says he was bothered by the fact that those pushing the bill hadn't gotten the go-ahead from law enforcement, something Thormodsgaard says he was working on.
The governor's spokesman, Evan Dreyer, deflected several inquiries from Westword about Ritter's position, referring all questions to the public health department.
"I don't speak for the governor," Calonge says. "I don't want to get in trouble." But he will say this of Ritter: "Our advice was that this was not ready for prime time, and given our other priorities, we needed to address the economy and jobs. Had he disagreed, had he wanted us to push this forward, we would have taken a different tack."
As long as lawmakers and bureaucrats continue to fumble with Colorado's drug paraphernalia laws, USED will continue its work underground in Denver.
Soon after they began exchanging syringes in early 2008, USED's four original members realized the demand was greater than their capacity. Within months, they added four more members. They have a few things in common, like their ages — late twenties or early thirties — and chosen professions, since many work for liberal-leaning nonprofits. But the members joined the group for different reasons. A few, like Beth, are former injection drug users. The rest are not. Some are compelled by the statistics and the logic. Others are drawn in by the users and their stories.
Jessi, a 29-year-old who works for a nonprofit, says she's never even seen heroin. She joined USED because it feels like an organic and effective way to make sure the needs of everyone, even junkies cast aside by society, are met.
"There are reasons people got addicted, and they're really terrible reasons," she says. "The more you get let in to their lives...it starts to become very clear how people got where they're at, and it's not always their fault."
"Every user is somebody's child," Beth says. "They're somebody's brother and sister. They're not just a user. They had lives once. They have talents and dreams and things to offer. They're people."
To that end, USED also hands out other items aside from syringes. Since diseases and bacteria can also be transmitted through other paraphernalia, they distribute five-milliliter tubes of clean water to mix with dry drugs and clean metal soda caps in which to cook the mixture. They give out new tourniquets and tiny sterile cotton balls to use as filters, as well as alcohol pads to sterilize the injection site.
Most Denver drug users inject heroin, cocaine or methamphetamine. Depending on their choice, they could inject anywhere from two to ten times a day. USED recommends they use a clean needle each time.
It's legal in Colorado to buy syringes at pharmacies, but actually doing so is often complicated and unsuccessful. A 1999 study by CU's Koester showed that metro-area pharmacists were hesitant to sell to injection drug users because they worried about encouraging drug use. Plus, Beth says, even though it's legal to buy needles, it's illegal to possess them with the intent to inject a controlled substance. Once users leave the pharmacy, there's a chance they could get arrested.
That's a chance many junkies aren't willing to take. But the members of USED are. They believe that if they were arrested and prosecuted, they'd be able to show that the good they're doing outweighs the fact that exchanging needles is against the law.
"We're literally saving people's lives," says Jordan, a 28-year-old member who does social justice work and has never used IV drugs. "Really, literally. Not like saving their lives in a dull, these-people-will-turn-over-a-leaf-and-find-Jesus or something way, but like, we're saving their lives in that we could really prevent them from getting HIV."
When statewide efforts to legalize syringe exchange failed this winter, advocates turned their attention toward the City of Denver. And Andrew McClure, a tall 26-year-old with dreadlocks and arms wrapped with tattoos, took the lead.
McClure sits on the Denver Drug Strategy Commission, a 27-member board that advises Mayor John Hickenlooper on drug-related policy. In late February, the commission voted 16-1 to recommend to the mayor that Denver look into starting a pilot needle exchange program.
McClure proposed the vote. Like Beth and Simons, he's a former heroin user.
For him, it started with marijuana when he was eleven. "The first time I smoked weed, I loved it," he says. "And something just happened. I believe that I reacted abnormally to it, because it set off this chain reaction of always needing more."
McClure's family had recently moved from Five Points to suburban Greenwood Village to escape growing street violence, and he was having a hard time adjusting. By thirteen, he was drinking, doing meth and taking acid. His straitlaced parents didn't understand his drug use, and it caused turmoil at home. So McClure began sleeping on the streets and eventually left home for good, traveling around the country following bands and playing music. At eighteen, he ended up in San Francisco, where he put a needle in his arm for the first time.
"It was like I found home," he says. "Like I'd lost home when I was a teenager because I couldn't be there, and the first time I did heroin on the beach in San Francisco, it was like I started sweating and I puked and I found home, and I just wanted to stay right there forever, just like that first time I got high. So I chased that from there on out."
The chase, however, had devastating consequences. McClure grew sickly thin, and in his early twenties, he suffered a stroke and barely survived a bout of endocarditis, a heart infection caused by bacteria from dirty needles. He was beaten up, arrested, and revived by hospital staff at least once.
At some point, he also contracted hepatitis C. He thinks it was in San Francisco, soon after he started using. He was with a small group of people; they had heroin and a needle, but they also had full-blown hepatitis. McClure says they drove around for two hours looking for the city's needle exchange but couldn't find it. He struggled with what to do, he says, but in the end, he decided he needed to get high. "It wasn't a question of saying no," he says. "It was, 'Fuck, all right.'"
McClure, who's been sober since 2005 and now works with homeless youth, has since "cleared" hepatitis C on his own, which the CDC says happens in 15 to 25 percent of cases. But there is no medical cure or vaccine. Health experts estimate that 76,000 Coloradans, many of them injection drug users, are infected. That's seventeen times the number of Coloradans with AIDS.
McClure has signed on to work with other commission members and advocates to hammer out the details of what a pilot Denver needle exchange program would look like, a model they will eventually present to the mayor. Ideally, he says, it would have a fixed site as well as a van that could travel to different neighborhoods. Volunteers and participants would have photo ID cards allowing them to carry clean syringes that they could show to the cops, and he estimates they could serve up to 1,000 people in the first two years.
But in order for that to happen, they first need to untangle some confusing state laws and city ordinances and to get law enforcement on board.
Denver police lieutenant Pete Conner also sits on the city's Drug Strategy Commission. He was one of two members to abstain from the pilot-program vote. Conner says he didn't have enough information to vote it up or down. One of his chief concerns was Ritter's apparent change of position: "This is a governor that was once in favor of it as a DA, and now he's not. I didn't know why."
As for Denver's current DA, Mitch Morrissey, spokeswoman Lynn Kimbrough says he hasn't been directly involved in recent discussions about needle exchange. Morrissey must uphold state law, Kimbrough explains, and that currently prohibits such activity. "Denver's district attorney cannot selectively choose which of the laws he's going to enforce and which laws he's not going to enforce," she says.
Advocates figure that if they can get Hickenlooper on board, other government officials will follow.
But the mayor hasn't yet made up his mind. Commission chairman Jamie Van Leeuwen, of the Denver Department of Human Services, says Hickenlooper's office has been "unbelievably supportive" of efforts to examine the issue and has asked for more specifics, which the commission is likely to deliver in the next few months. Spokeswoman Sue Cobb says the mayor "looks forward to learning more about the commission's analysis and reviewing its supporting data and research."
Beth hopes Hickenlooper sees it their way.
"It's our last chance," she says. "If we don't get a pilot program in Denver, if we don't get the mayor's support...I don't know if it'll ever happen."
She and other USED members think Denver-specific data will be key in convincing lawmakers that a program is needed here. So for several months, they've been silently collecting it. In December 2008, USED gave out 1,292 clean syringes, which means it collected about the same number of dirty ones, since they typically exchange on a one-to-one, clean-to-dirty basis. (They take the dirties to a local facility, where they're incinerated.) In January, they gave out 1,349, and in February, they distributed 1,670.
If they keep up that pace for a year, they'll exchange close to 16,000 needles annually, less than half of Boulder's volume.
But that's pretty good, considering their constraints. For starters, USED doesn't have much money. Last year, the group got a $4,500 grant from the North American Syringe Exchange Network, which they use to buy clean needles and other supplies. But that cash is running low, and they don't know where their next pot of money will come from. They're also small; they have just a tenth of the number of volunteers that the Boulder County program does. And the need in Denver is arguably greater. According to state data, there are 252 people with HIV in Boulder County and 3,654 in Denver County. Nearly 17 percent of those cases can be traced to injection drug use.
On the streets, those numbers turn into faces, and that's what will keep Beth and other members of USED going.
After exchanging syringes with the young man and woman in the SUV, Beth and Lynne walk a few blocks and sit down under the shade of a tree. A few minutes later, their phone rings. It's one of their most frequent clients; he wants to hop a bus and meet them in half an hour.
He's a white man in his thirties, wearing a sweater and a baseball hat. He meets them on a corner, and as Lynne watches the street, Beth exchanges one bag for another. She asks him how he's doing, and he opens up about the trouble he's had finding an apartment. He keeps getting turned down because his criminal record shows an arrest for a drug crime he was never charged with. His current living situation is no good, either.
Another cop car rolls by, and the three decide to walk and talk. The man tells them about how he and his roommates let another user stay with them because he had a good drug connect with better shit. But the situation became a hassle; the kid invited tons of people over, calling attention to the apartment. Once, he stole everybody's cell phones.
Beth tells him to lie low, to work on getting his own place. "Any kind of connect, whether it's good or not, isn't worth that trouble," she tells him.
When they get to the end of the block, she hugs him. "Take care of yourself," she says.
After all, that's the point.
