In January 2008, an elderly chaplain, a public health advocate, and a registered nurse were picked up by patrol officers for distributing narcotic paraphernalia on the streets of San Antonio. The trio, who worked out of St. Mark’s Episcopal Church, each faced a $2,000 fine and up to a year behind bars for doing what they believed to be crucial social work: distributing clean syringes to chronic drug users in exchange for their dirty needles, which they would safely discard.
In doing so, the group hoped to keep addicts from catching fatal diseases like HIV or hepatitis C, while also removing dirty and infected needles from public parks, streets, and trashcans. But law enforcement didn’t see it that way.
“When we were picked up, the police were only interested in the clean syringes we were distributing, they didn’t care that we were picking up the dirty ones,” says Melissa “Mo” Lujan, the arrested nurse. “It was clear what their directive was.”
The three volunteers were treated like drug dealers instead of do-gooders. Then-Bexar County District Attorney Susan Reed saw their work as drug promotion rather than disease prevention — and made an example of the trio with their arrests.
“It was personally detrimental,” says Lujan, who lost her job over the arrest. “But it brought the conversation out of the shadows: it started a public dialogue about needle exchange. That was a victory.”
By now, countless studies have shown how syringe exchange programs slash infectious disease rates and have often become the first step of an addict’s path to recovery. These programs have become staples of every major metropolis in the United States. That is, outside of Texas, the only state in the country that hasn’t legalized needle exchange.
Nearly a decade has passed since the group’s failed attempt at a needle exchange, and Bexar County is still without a safe program for its rapidly-growing community of IV drug users. But change could be on the horizon. The county has a new DA sympathetic to drug addicts, a new city health director with a background in drug treatment, a longtime county judge fed up with arresting away a public health crisis, federal money coming in to fight the opioid crisis, and a hepatitis C rate double the national level. In other words, the county may finally be ready to lead the state.
“We’re now poised in a special place,” says Neel Lane, the San Antonio lawyer and public health advocate who originally represented the three volunteers distributing needles. “If the county is committed, this could finally come together.”
Needle exchange in the U.S. was born out of necessity
, not novelty. In the late 1980s — at the height of the country’s AIDS epidemic — more than half of all IV drug users
in New York City tested positive for HIV, likely transmitted through shared needles. Community health advocates desperate to keep people from dying turned to Holland’s new syringe exchange model for relief. The result: The Lower East Side Needle Exchange.
“I watched the program emerge from the very beginning,” says Jill Rips, who worked at St. Clare’s, the first hospital in NYC to treat only AIDS patients.
By the time Rips moved to San Antonio in the early 2000s, she was certain syringe exchange was a crucial piece of comprehensive public health care. Especially in a county where heroin and morphine overdose deaths had nearly tripled in the past four years — and the HIV rate had remained steady throughout the past decade.
“With all the heroin use, it was so clear needle exchange was needed here,” says Rips, who was San Antonio AIDS Foundation’s deputy executive director. An exchange wouldn’t erase addiction, but it would keep more drug addicts alive — hopefully long enough to enter a recovery program.
In Rips’ eyes, needle exchange is just another form of what medical professionals call “harm reduction,” like wearing a seatbelt in a car. Yes, sitting in a vehicle going 70 mph is dangerous, but wearing a seatbelt makes the chances of you dying in a crash a little less likely. The same goes for injecting illegal, powerful drugs into your body: Yes, it’s dangerous, but using a clean needle will make the chances of you dying from a fatal disease a little less likely.
But Rips’ efforts to destigmatize syringe exchange programs in Bexar County went unrecognized. That meant she and the rest of the SAAF staff only had one place to send people in search of sterile syringes: the local tack shop.
“They sold syringes to use on farm animals. It was the only place you could buy them without a prescription,” Rips says.
Less than a decade later, during the 2007 Texas legislative session, a needle exchange program tucked into a sweeping Medicaid bill surprisingly made it past Governor Rick Perry’s desk. The measure specifically allowed Bexar County health officials to start a pilot program that “may include...the anonymous exchange of used hypodermic needles and syringes.”
But there was a catch: It didn’t explicitly safeguard officials from being prosecuted under the state’s Controlled Substances Act, which deems possession or distribution of drug paraphernalia illegal. Bexar County then-DA Reed, who thought a needle exchange program would only encourage drug use, warned health officials that they didn’t have “any kind of criminal immunity.” She promised to prosecute anyone distributing needles to the full extent of the law. In 2008, she proved her word by arresting the St. Mark’s volunteers.
San Antonio Senator Jeff Wentworth, a Republican, appealed her decision to then-Attorney General Greg Abbott’s office, requesting an opinion on whether or not she was allowed to treat health providers like narcotics dealers.
Abbott gave a non-answer
, ruling that “prosecutorial discretion may be exercised in evaluating the facts and evidence of possession of drug paraphernalia to determine whether a criminal violation of the Texas [CSA] has occurred.” In short, Reed could do whatever she wanted — meaning the pilot program never had a chance.
Lane, who took Reed to court over her ruling, says Abbott took an “inexcusable position” in handing the DA this power.
“People were threatened with persecution for doing good deeds,” he says. “That ground things to a halt.”
Lane and fellow needle exchange supporters testified in each subsequent legislative session in support of the program, but it never got much traction.
Then, the opioid epidemic hit.
While heroin still remains the most popular illicit substance in San Antonio, the White House’s August decision to declare a state of emergency over the spike in opioid overdoses in the U.S. sent $27.4 million in federal funding to Texas. A slice of that has allowed Bexar County to jumpstart an “Opioid Task Force,” a group of representatives from the medical community, drug rehabilitation organizations, county courts, and city leadership tasked with curbing opioid overdoses in the region. It’s a massive undertaking, since opioids include any kind of opium derivative — including heroin, synthetic drugs like fentanyl, and prescription drugs like oxycodone, hydrocodone, codeine, and morphine. All of these can be injected with a syringe.
Bexar County Judge Nelson Wolff sees an opportunity in the task force to break a pattern he’s watched play out for decades.
“It started in the ‘80s with crack cocaine, then heroin, and now we have these synthetic drugs and opioids,” Wolff says. “You run these cycles trying to put everybody in jail and,
damn it, it just doesn’t work.”
With a county jail packed with nonviolent drug offenders, Wolff says the opioid task force he helped put together will be looking at addiction as a health issue, not a criminal issue. He supports a needle exchange program, as long as the staffers encourage addicts to eventually get into treatment. Plus, it’ll save the county thousands — if not millions — in health care costs.
According to data from 2015, HIV treatment alone costs the county around $4 million annually. A clean needle? Around 10 cents.
HIV isn’t even the worst of Bexar County’s troubles linked to IV drug use. A 2012 study
of UT Health San Antonio patients found that Bexar County residents born between 1945 and 1965 — Baby Boomers — are more than twice as likely to have hepatitis C than the rest of the country.
Hepatitis C has no obvious symptoms and often goes undetected for decades — until a person starts showing signs of liver disease or liver cancer. Unlike HIV, hepatitis C can be treated and cured, if a person knows they should get tested.
Delia Bullock, an infectious disease doctor at UT Health, calls hepatitis C “the
redheaded stepchild of virality.” According to Bullock, it’s the virus most transmittable through IV drug use (HIV is the least), meaning a needle exchange program could significantly curb this skyrocketing rate.
With federal funding trickling in and an obvious need for prevention coming out of the medical community, Lane believes it’s perfect timing to give the 2008 pilot program a second shot.
“The law’s still on the books, it’s just ready and waiting. And now, there’s one big thing that’s changed,” Lane says. “We have a new DA.”
Nico LaHood has made it his job to be an unconventional District Attorney for Bexar County.
Since entering office in 2015, LaHood’s used the story of his 1994 arrest
for selling Ecstasy to a cop as proof that people deserve “second chances.” He has been featured in documentaries for his strong belief that vaccines “can and do cause autism,”
punctuates his press conferences with scripture quotes, and has been accused of making closed-door threats to defense attorneys.
After watching his uncle return from the Vietnam War addicted to heroin, leading to a life spent behind bars, LaHood says he’s open to a change in the way the county addresses drug addiction.
“My uncle was a carpenter. He was a good man. Wasted talent is the saddest thing I see in the justice system,” he says.
More importantly, LaHood says that he supports a “responsible needle exchange program,” and has no intention of prosecuting people involved. A responsible program, he says, means one that is calculated, that uses successful programs as a model, that’s “vetted out.”
LaHood says the county has to actively engage with the community before rolling out a drug program heavy with stigma. It has to be more organized than previous underground movements.
Bexar County District Attorney Nico LaHood
“Can we make sure we’re stopping the spread of disease? Do we have a chance of getting people help?” LaHood asks. “If we do the same things, we’re going to get the same results.”
Fortunately, syringe exchange programs have been up and running long enough in other cities to prove they can solve LaHood’s concerns.
A 1999 study in Baltimore found an increase in clients enrolling in a drug treatment program after regularly participating
in a syringe exchange program. Other research has replicated these results. Exchange staffers have found that the trusting relationship they create with repeat clients is the first step in getting an addict into recovery — it’s proof that someone cares about them. No studies have linked exchange programs to an increase in crime
, as some critics assume.
Research has also estimated that 33 percent of U.S. HIV infections
could be averted as a result of creating a national network of syringe exchange programs, and would result in the U.S. health care system saving somewhere between $361 to $796.5 million.
With such certainty in its success rate, it seems all a local needle exchange program is missing is a leader.
In July 2016, the Republican-majority North Carolina Legislature did the unthinkable:
green-light the use of syringe exchange programs in the state.
NC’s Orange County Health Department, led by Colleen Bridger, was one of the first to roll out a program — staff had been planning for months in preparation
for the bill’s passage. It was a health department of firsts when it came to harm reduction — it backed the use of e-cigarettes
(keeping smokers from inhaling tar and soot) and was the first county
in the state to distribute free naloxone (the drug used to reverse opioid overdoses) to addicts and their families.
So, it only seemed natural that when Bridger was appointed as director of San Antonio Metro Health Department in March 2017, harm reduction was one of her top priorities. Bridger, who co-heads the opioid task force, says her first goal is getting all San Antonio police officers armed with naloxone.
City of San Antonio
Dr. Colleen Bridger
Naloxone can be either injected or inhaled, and acts as an instant detox for someone experiencing an opioid overdose, jolting them out of a narcotic fog. It’s not an instant fix, since people still need to get to a hospital within 90 minutes, but it’s a harm reduction tool in that it keeps users from dying. Which is Bridger’s top priority.
“Our goal is to decrease the number of intentional drug overdose deaths. How are we going to reduce those deaths?” Bridger says. “Naloxone. We know it works.”
Texas officials seem to agree. On October 4, Texas Attorney General Ken Paxton issued an opinion
officially allowing state law enforcement to carry naloxone. Paxton’s nod is a sign that the state is slowly warming to the idea of harm reduction. Could syringe exchange be next?
“I’m confident that here in San Antonio, we’re not going to go backwards,” Bridger says.
Her background in harm reduction will hopefully get the rest of the city up to speed. Councilwoman Shirley Gonzales has been the most vocal on San Antonio’s City Council about tackling opioids in the city. Gonzales said she often sees people “looking like zombies” exiting known drug houses in her District 5 neighborhood. In a June interview, she told the Current she was unsure who to call to help people struggling with opioid use — aside from the police. Gonzales said she isn’t familiar with syringe exchange programs and would have to “investigate further” to see if she supports it.
Rips, who saw the same resistance and unfamiliarity in New York City decades ago, believes needle exchange is more than just a smart public health tool. It’s a social justice issue.
“It’s saying that people who access drugs — their lives matter. Instead, we punish them for what they do and keep the tools they need away from them. We don’t hold back treatment from someone with diabetes for eating sugar. Are we just not supposed tohelp ‘bad’ people in society?” Rips says.
“The biggest question here is: Are you going to address this problem by punishing people or by helping people? We have to reach them where they are."