Walking down a wash toward a homeless camp near an entrance to Las Vegas’ vast storm-drainage tunnel system, Robert Hoey is clad all in black. On his feet, combat boots. On his head, a black bandana. He carries a military-style backpack and a holstered gun. A patch covers his left eye, the arm on that side decorated with molecule tattoos.
Hoey looks more like a soldier than a social worker, and by most definitions he is neither. In this makeshift homestead in the shadow of the Strip, he is simply known as Fox. And he’s here to help.
After a bit of small talk, Hoey opens his backpack. It’s full of packaged syringes. “Need some?”
After giving the man as many needles as could fit in his scooter’s cup holder, Hoey moves on to the next inhabitant. This man has painful abscesses on his feet from working all day in wrong-sized shoes with no socks. Using a discarded box, Hoey has the man elevate his feet while he puts on gloves to clean the wounds.
“What’s your shoe size? We’ll get you some socks.”
“Can you get me some ’83 Air Jordans?” The man laughs at his own joke before accepting some fresh bandages to use later.
After a few hours with Hoey, a cardboard box and 2-liter bottle are filled with hundreds of used needles that might have been discarded in tunnels, alleys, parks or swaths of undeveloped land where homeless drug users congregate. He has checked out some physical ailments and referred several people to free clinics.
For Hoey, this is a typical Friday. Over the past six months, he has made weekly deliveries to various camps, bringing bottled water, food, clothing, shoes, even tents. For those who inject drugs, he has supplied clean needles. It’s a project five years in the making, with Hoey slowly building rapport.
He’s not the only one who wants to help. On April 12 the Southern Nevada Health District (SNHD) unveiled what it’s calling the first needle-exchange program in Southern Nevada. It comes in the form of three $15,000 vending machines, filled with kits containing clean syringes and other supplies injection drug users might need.
These parallel efforts showcase a fundamental divide in approaches to helping those who are struggling. Bureaucracy meets boots on the ground in an effort to curb a potential public health crisis.
• • •
Deaths from opioid overdose have quadrupled since 1999. The Centers for Disease Control and Prevention classifies the issue as an epidemic, pointing to the dramatic rise in doctors prescribing oxycodone, fentanyl and methadone to treat pain. One CDC study found that three out of four new heroin users first abused prescription opioids.
Each day, related overdoses claim the lives of 91 Americans, but preventable deaths aren’t the only consequence. The practice of addicts sharing needles has resulted in outbreaks of HIV, hepatitis C and other blood-borne diseases.
In 2015, Indiana health officials announced an outbreak of HIV in the state’s southeastern region. Infections had increased about 25 percent, with rates of hepatitis C up by about 30 percent. The cause: shared needles to inject Opana, a powerful opioid painkiller.
Nevada thus far has avoided such outbreaks, but state and local officials are aware of the potential. Nevada has one of the highest rates of infection for HIV in the country, and approximately 9 percent of those diagnoses in Clark County occur in people who inject drugs. That’s where the new vending machines come in.
“Needle-exchange programs are model public health programs,” says Dr. Joe Iser, SNHD’s chief health officer. “Providing clean needles and supplies is a proven method for limiting disease transmission in a community.”
Needle exchanges emerged in Europe in the early 1980s. The concept arrived in the U.S. later that decade, and while Congress initially banned the use of federal funding for outlets, health officials made the case for their necessity. Acceptance on that level hasn’t eliminated the concern that giving away clean needles enables or encourages drug use and addiction.
“It does not promote drug use,” says Dr. Jerry Cade, director of UMC’s Wellness Center. He added that the notion was refuted by nearly 100 academic studies. “There are zero downsides from a clinician or medical perspective.”
Exchange programs often are a first step toward recovery, Cade asserts. They connect injection drug users with people who can point them to substance-abuse counseling, treatment centers and other services. If it’s a gateway, Cade says, it’s a gateway out of addiction.
That is reflected in the almost 200 programs operating in 36 states. Beyond personal benefits, needle exchanges are touted as a way to reduce long-term costs to communities. A 12-week hepatitis C treatment can cost $70,000. That is far more than it costs to provide clean needles, even over a drug user’s lifetime.
Southern Nevada’s take on the model is a collaboration between the SNHD, Trac-B Exchange and Nevada AIDS Research and Education Society. Here’s how it works: Drug users register with Trac-B, either at its walk-in clinic or at a partnering agency. They receive a card or personal identification number to swipe or type into one of the Impact Exchange machines. These brightly colored kiosks offer boxes of new syringes and disposal kits, as well as safe-sex and wound-care kits.
The delivery method is unique. According to Trac-B program director Rick Reich, it is the first exchange of its kind in the country and possibly the continent, though the model already has seen success in Europe.
“Most (needle-exchange programs) are storefronts and good operations, but the problem is there can be a built-in bias,” Reich explains. “A machine takes away the bias.”
The only identifying information on the registration form is the first two letters of a person’s first and last name, and date of birth. Program manager Chelsi Cheatom says these details are used to enforce the cap of two needle boxes per week. The rest of the questionnaire asks what substances a person is injecting, if he has open wounds, and whether he wants information about drug rehab programs or getting tested for sexually transmitted diseases. It also asks for a ZIP code in hopes of determining where future vending machines might be needed. Reich says people wary of giving out information need not worry. “They can just put an X.”
While the vending machines debuted last week, the Trac-B storefront has been functioning in earnest since January. It’s open four hours a day, Monday through Thursday. According to Cheatom, it has been averaging eight or nine visitors daily. And she expects that number to rise now that the vending machine component is out there. She thinks word of mouth will be the primary driver of new clients, though Trac-B hasn’t identified any target goals for this pilot program.
Cheatom says, “We’ll see.”
• • •
Clark County is trying to do something positive, but Hoey sees an essential flaw: lack of accessibility for homeless addicts. The way he sees it, they are the ones who need the most assistance. They are the ones whose ER visits, jail stays or other needs cost taxpayers the most money. He thinks a needle-exchange program without a built-in element of mobility is ill-conceived.
Shadows of Hope study
This data was given voluntarily by 370 people over seven months, collected every Friday for 31 consecutive weeks. Most of the subjects were homeless individuals concentrated in three areas of Clark County.
Drug of choice: All 370 users admitted to using multiple types of drugs. Meth, 335. Prescription opiods, 161. Heroin, 151. Marijuana, 210. Crack/cocaine, 32
Exposure risks: Of the 370, 194 (52%) admitted to regularly sharing needles, and 169 admitted to regularly exposing themselves or others to risk by using/sharing dirty needles with those they know or suspect have some type of communicable disease.
Instances of infection: Of the 370, 73 had a confirmed diagnosis of either hepatitis C or HIV, or at least suspected they had been carrying the disease for some time.
Details: The largest segment of the surveyed group — 72 people — had been using drugs for 21 years or more. The majority of users were between the ages of 31 and 40 (193), while the smallest number were between the ages of 14 and 20 (11). Men outnumbered women by more than 100, and the racial makeup was predominantly white (314).
All three Impact Exchanges are within a 7-mile area, inside centers with traditional business hours, meaning they won’t be accessible at night or on weekends. Hoey worries that some of the most vulnerable people won’t be able to get to the help being offered.
Hoey generally sees a disconnect between the idea of aid work and concrete results. It drives him to do independent humanitarian missions in almost 30 countries around the world through the nonprofit he founded, Shadows of Hope. It was between overseas stints that the EMT/combat medic heard about the people living in the tunnels around Las Vegas. After connecting with the so-called “mole people,” Hoey began collecting supplies and giving them directly to the homeless.
That brand of DIY aid work has been discouraged in the past. In 2006, the Las Vegas City Council passed an ordinance making it illegal to provide food to the homeless in city parks, though a federal District Court found it unconstitutional. And in 2015, the city put out PSAs urging residents to donate to organizations rather than taking matters into their own hands. One argument is that independent efforts can’t be regulated for the safety of either party. And that compounds when you add in biohazardous materials.
Hoey’s effort to collect and dispose of needles is legal. While the state regulates needle exchanges, the law changed in 2013 to allow government entities, nonprofit agencies, public health programs and medical facilities to create programs. Hoey’s falls under Shadows of Hope, and he drops the contaminated “sharps” at local hospitals for proper disposal.
“When you bring providers to the frontline, you reduce costs in the long run,” argues Sam Scheller, a paramedic and owner of Guardian Elite Medical Services who volunteers his time and company resources to Hoey’s endeavor.
In his line of work, Scheller has seen homeless people call 911 for nonmedical emergencies because they couldn’t find transportation to a hospital and because it’s simply an accepted practice. He has treated severe injuries that he knows could have been avoided early on with antibiotics or other interventions. He has seen these cases bog down the emergency response system and wanted to be part of a solution.
“That’s the idea behind community paramedicine. It’s just shifting the funding,” he says. “We know we’ll lose money, but we’ll only lose a bit of money on the front end. Then we keep people out of the ER.”
The scope of the work isn’t focused, and that is by design. Hoey says they stay flexible to take advantage of available resources and meet the most needs. One week, they’ll have a lot of food. Another, clothes. Another, a volunteer lawyer. For the past few months, they’ve had a private donor give them hundreds of clean syringes, which volunteer and pharmacist Khanh Pham says the homeless may not be comfortable or able to buy in a pharmacy, or to find a way to an Impact Exchange.
Hoey and Pham heard about the county’s pilot program during a meeting of the Harm Reduction Alliance, a SNHD-organized group of service providers and related organizations that meets monthly. Both are active in it; Hoey leads the medical committee. They’d hoped the county program would adopt some of the spirit of their efforts, which they shared with the group. “Look at what we’ve done with very little funding,” Hoey says. “We’ve barely started trying, and we’re five times ahead of the health district with all their resources and funding.”
Pham says she walked out of one alliance meeting because it was “all talk, no action. … They just sit and wonder, ‘How do we get rid of the stigma?’”
Her answer to that question: Go spend time at a homeless camp and hear about their needs. Then find a damn way.
Jess has been homeless for more than two years. She once was in college training to be a medical assistant, so she understands the risks of using dirty needles. Still, the mental hold of meth, her drug of choice, is strong. And she says many local pharmacies won’t sell syringes unless the buyer shows a prescription, especially if a person looks like a homeless drug user.
Jess’ regular camping spot is miles from the nearest Impact Exchange, and she rolls her eyes at the thought of having to visit one once a week. “It’s always on their terms,” she says. “There doesn’t seem to be any program willing to work on the homeless’ terms.”
So Jess has become Hoey’s on-the-ground point of contact. She collects dirty needles from the tunnels or nearby camps and hands out clean ones. She says it gives her purpose, and that it has gotten her thinking about how she might improve her life.
“One day I’ll want something different,” she says. “It’s not a matter of rock bottom. If this isn’t rock bottom, what is? … I’m just stuck in a rut.”
Jess knows she needs to become unstuck, but she doesn’t yet see a clear path. Every day she calls her son back home in Colorado. Her eyes tear up as she recalls a recent conversation where he asked her, “Mom, why are you making bad decisions?”
“I don’t know,” was all she could say.
• • •
Asked to compare the county’s needle-exchange program to Hoey’s approach, Reich defended the structure of Trac-B, saying consistency and permanency are especially important in building programs that can scale up and help more and more people. “It’s great to go out and do one-on-one outreach, but are you going to be there the same time every week, in the same place?”
He doesn’t dissuade rogue outreach, but Reich believes it to be less effective.
Hoey isn’t so sure.
“What they need is to know that the world doesn’t treat them like sh*t,” he says. “If the world treats you like sh*t, do you have a reason to rejoin society? You don’t. You need to see that someone cares.”
That’s more immediate if you meet them where they are, eat what they eat and don’t pity them for how they’re living. Hoey recalls taking a nonprofit worker to the tunnels and watching her cry over the conditions. “How would you feel if Bill Gates came to your house and cried over your lifestyle?”
Gerard Schmidt, president of the Association for Addiction Professionals, says many factors influence a person’s decision to step into recovery. Organizations of whatever structure can be ready with resources and offer various points of entry, but results will always come down to something that isn’t clinical.
“The biggest thing is the person’s own internal motivation to create change,” he says.
Since Shadows of Hope began giving out needles in December 2016, Hoey estimates his team has distributed almost 7,000 to more than 370 people. Many, like Jess, now rely on them, and several people camped near the tunnels said they were reluctant to try the machines.
With a Shadows of Hope operation happening overseas later this year, Reich’s question about consistency looms large. Hoey is aware that the amorphous nature of his work in Las Vegas means it hinges on him — a bit of a loose cannon with a nontraditional life that makes him uniquely able to meet the people where they are. He believes that with additional resources he could set up something more permanent that maintains the philosophy of flexible, bare-knuckles assistance.
“I’d like to see a complete overhaul,” he says of the established ways most care is delivered. “I think things are too structured. The resources are there. The people are willing. We just need to be willing to play and be flexible.”
THE ISSUE ON A NATIONAL LEVEL
Heroin use has increased nationally by more than 60 percent in recent years, and by 114 percent among whites. The rise is tied to increased use of prescription opioids including oxycodone, morphine and fentanyl. Data published in the New England Journal of Medicine reflected a sharp increase in the availability of such drugs in the 1990s through 2010.
The CDC states that overdose deaths involving prescription opioids have quadrupled since 1999, as have sales of these drugs. In the 16 years since, more than 183,000 Americans have died from related overdoses. And every day, more than 1,000 people are treated in ERs for misusing prescription opioids.
Four out of five new heroin users started out by abusing such prescription painkillers.
1 in 4: Number of injection drug users who reported receiving all of their supplies from sterile sources in 2015.
Approximately one-third of injection drug users between the ages of 18 and 30 are believed to have hepatitis C.
The CDC estimates there are nearly 200 needle-exchange programs in the United States, spread across 36 states.
WHO INJECTS DRUGS?
The CDC’s National HIV Behavioral Surveillance Data show changing demographics for injection drug use.
2005: 38% White; 38% Black; 19% Hispanic/Latino
2015: 54% White; 19% Black; 21% Hispanic/Latino
About 46% of new white users shared syringes, compared with 32% of Hispanic/Latinos and 28% of blacks. Data also show that white injection drug users started at younger ages than other ethnicities and races, and that younger people are more likely to share syringes.
THE CASE FOR NEEDLE EXCHANGES
Early 1980s: The first needle-exchange programs launch in Europe.
1986: The first legal needle-exchange program in the United States debuts in New Haven, Connecticut.
1988: Congress prohibits the use of federal funds for such programs.
1995: The U.S. Institute of Medicine recommends Congress lift the ban, citing growing medical and public health research finding such programs effective at reducing rates of blood-borne diseases. Congress does not act.
2009: Newly elected Nevada Sen. David Parks identifies the decriminalization of hypodermic needles as a goal but meets resistance from other elected officials.
2013: The Nevada State Legislature removes used syringes from the list of illegal drug paraphernalia, opening the door for needle-exchange programs. They also pass legislation requiring the state health department to establish guidelines for legal needle-exchanges and allow pharmacies to sell needles over-the-counter without a prescription.
2014: Nevada’s first legal needle-exchange program opens in Reno.
2015: In response to the national opioid epidemic and outbreaks of HIV, Congress lifts the ban on using federal funding for needle-exchange programs. Under new guidelines, federal funds still cannot be used to buy the needles themselves, but can be used for staffing and support programs.
2017: The Southern Nevada Health District and partners launch Impact Exchange vending machines — the first program of its kind in the United States.
IMPACT EXCHANGE VENDING MACHINES
Trac-B Exchange, 6114 W. Charleston Blvd.
AID For AIDS of Nevada, 1120 Almond Tree Lane
Community Counseling Center, 714 E. Sahara Ave.
WHAT DIFFERENT APPROACHES COST THE COMMUNITY
Providing needle exchanges
Impact Exchange: $5-$8 per box (containing 10 syringes and a rubber tourniquet, alcohol swabs, bandages and a sharps container)
Users are entitled to two boxes a week. That’s $10-$16 per person per week. Multiply that by 52 weeks and it’s $520-$832 per person per year. If a person used the needle-exchange program for 50 straight years, the total expense would be $26,000-$41,600 — still way below the one-time cost of most hepatitis C or HIV treatment courses.
Reich compares needles to condoms. He recalls his days working in public health back in the 1980s: “We never thought about condoms. We never gave them out. We were in public health — we just treated people.” Over time, attitudes shifted. Prevention is now seen as a key component of public health. Reich thinks needles should be seen in the same light and notes that the wholesale cost of needles and condoms are similar.
There is an economic argument to be made for needle-exchange programs, but there’s also an unquantifiable human element. “Everyone deserves a level of dignity,” pharmacist Khanh Pham says. Even if the numbers weren’t in favor of assisting people struggling with addiction, Pham says it would still be the right thing to do. “It’s a forgotten group of people. But they’re people. Drug addiction is a disease.”
Treating blood-borne diseases
$379,668: Estimated lifetime cost of treatment for HIV
$70,000: Estimated cost of a 12-week treatment for hepatitis C
Some chronic drug users may not have the resources for health insurance and rely on urgent care in hospitals, which are federally mandated to provide it. Those unpaid bills fall mostly on taxpayers, as the government subsidizes the uninsured with tens of billions of dollars each year. And costs may roll to Americans with insurance, whose premiums rise as hospitals may charge higher fees to compensate for losses.
THE ISSUE IN NEVADA
In the fall of 2016, Nevada Gov. Brian Sandoval received a report from a task force he had mobilized to advise the state on combating addiction to prescription painkillers. Details that came out of the State of Nevada Plan to Reduce Prescription Drug Abuse (and other materials from the CDC and Trac-B) included:
• Nevada has some of the nation’s highest rates of prescription painkillers sold. Per units prescribed per 100,000 patients, Nevada ranks: No. 2 for hydrocodone and oxycodone, No. 4 for methadone, No. 7 for codeine.
• In 2013, 5.5 out of every 1,000 ER visits by Nevadans resulted from heroin/opioid dependence, abuse or poisoning (4,539 visits).
• In 2014, about 2 million Americans abused or depended on prescription opioids. About 14,000 died from prescription drug overdoses that year, including 382 Nevadans.
• Nevada’s has the nation’s fourth-highest overdose death rate, at 20.7 for every 100,000 people. The national average was 12.4.
• The number of drug-overdose deaths — the majority involving prescription drugs — in Nevada has increased dramatically since 1999, when the rate was 11.5 per 100,000. “There has been a substantial increase in heroin-related deaths in Nevada between 2009 and 2013, with over double the number of cases between those years.”
RELATED BLOOD-BORNE ILLNESSES
1982: Year the first HIV infection in Nevada was diagnosed, in Clark County. According to the 2016 Southern Nevada Community Health Assessment, the number of people living with the disease has since increased steadily, while the number of new infections has decreased.
Between 2008 and 2014, the annual rate of new HIV infections in Clark County was between 16 and 20 people per 100,000.
383: New HIV diagnoses in Clark County in 2014. About 9% occurred in people who inject drugs.
413.1: Southern Nevadans per 100,000 living with HIV in 2014
98: Number of related deaths in 2014
0.1: Cases of hepatitis C per 100,000 people in Clark County in 2014. The rate has remained “relatively low and steady” over the past decade. “The only spike was observed in 2007-2008, when incidence increased to 0.5 cases per 100,000 persons. This was traced back to an outbreak at an endoscopy clinic.”