Lucy Hunter looks behind the doors of the Dunedin needle exchange
Needle exchange programmes were created to reduce harm and to educate people on taking drugs in the safest way possible. I spoke to Manager Barbara Smith and one of her colleagues Dene Barnes from the Dunedin Intravenous Organisation (DIVO), Dunedin’s needle exchange programme, about the importance of their work and the stigma that still surrounds intravenous (IV) drug use and Hepatitis C.
Before there were needle exchanges, people would inject drugs in very dangerous ways. Dene said in the ‘80s people would break into vet clinics to get new needles and syringes. Sharing and reusing needles was normal. He’d heard an urban legend about a bar in Dunedin that had a syringe on top of the toilet cistern. Patrons would pick it up, sharpen the needle on a matchbox, rinse it off under the tap, inject themselves and leave it for the next person.
DIVO provides a free one-for-one exchange system for 3ml syringes and needles to encourage people to always use clean new equipment, and to bring used ones back to the centre to be disposed of safely.
Peer Service Model
In 1987 the NZ Labour Government authorised New Zealand’s first needle exchange programme in Dunedin. The exchange was set up by drug users and it works under a peer service model, which means some of the people operating the exchange are people who have personal experience with injecting drugs. Barbara and Dene stressed how important this is. Clients need to know the person giving them supplies won’t judge them. New Zealand is the only place in the world with the peer service model.
Barbara, who herself has never used IV drugs, has learned a lot from her staff that she may not have learned if the exchange didn’t use the peer support system. “I’ve always referred to the staff here if something crops up that I don’t understand. They fill me in and educate me.” An example of something she has learned from her staff is what to do if someone comes in with questions about making up a mix for a hit.
Single Use Needles
The exchange looks like a small GP clinic. Every bit of wall space is covered with educational posters about vein health, tips on injecting, Hepatitis C, and other things associated with IV use. But more than anything, the posters emphasise the importance of never reusing needles, syringes, and other equipment.
Needles should never be reused, even by the same person, even if they just accidently stuck it in the wrong way and are having another go. Barbara pointed out a poster on the wall with four images of magnified needle tips. The first was a new needle, and it had a smooth surface and sharp point. The next had been used just once, but already had shards and flakes on the surface of the metal. The third had been used twice, and was looking worse still. The fourth image was a needle that had been used five times. Its surface was jagged and the tip of the needle had bent right over on itself. “You can imagine,” says Barbara, “the damage that would do.”
Medical Stigma
DIVO has a GP who comes in once a week to offer free medical consultation with people who don’t have the resources to go to the doctor, or who are worried or embarrassed to show a doctor what state they are in. Many IV drug users have experienced mistreatment in mainstream health care. People who have or have had opiate habits can be denied pain relief in hospitals. Dene said there could be two people in similar condition next to each other in a ward, one a user and one “straight.” The user may be used to taking 60mgs of morphine a day. The straight person will be given 10mgs of morphine; the user will be given paracetamol.
Dene and Barbara told me how many users will hold off from getting medical attention for as long as possible. “Nobody plans ahead for six months time when their addiction will be out of control,” Barbara said. Someone who has been in good health could suddenly find their body is weaker or they feel a lot worse than normal. “They just don’t go for help,” says Barbara. “We see some desperate things in here.”
Barbara speaks to both medical and nursing students to educate them on the public health aspects and harm reduction programmes with the exchanges. She focuses on the stigma and judgement of IV drug users: “If they don’t take anything else on board, if they go away thinking about their behaviour if they have a client of ours go in there, I have achieved something.”
Dangers of Injecting
“We see some horrible arms and other areas of anatomy here,” says Barbara, “with abscesses from infections, cellulitis, that kind of thing. Basically it’s overuse of a vein to start with, reusing dirty needles, sharing gear, and not filtering.”
Dene explains how scar tissue builds up with long-term IV use. “If you’re not rotating your injection site veins can collapse or block.” The needle exchange encourages people to use wheel filters, which get rid of a lot of the impurities and bacteria in the drugs. They have free pamphlets on “Veintenance” showing the safest places to inject, injection site rotation, tourniquet and filter use, and how to insert the needle and put the shot away.
Most of the drugs taken intravenously in New Zealand are pharmaceuticals. While heroin can be put into cold water and shaken up in a syringe, opiates in pill form are trickier to inject. The chalk and binding agents in crushed pills needs to be dissolved in other chemicals. There is risk with injecting anything, but substances which need to be heated prior to injecting are especially dangerous; they can cool in the vein and solidify, causing a blockage which can lead to all sorts of health problems. Dene knew a woman who had Temazepam turn back to resin in her arm. She ended up with an open, suppurating wound covering the entire the underside of her forearm.
Different substances present different problems. Some drugs, such as codeine, cause burns. If people enquire how to use drugs the staff have never seen or heard of and ask how to inject it, they’ll tell them not to inject it, and to take it orally if they’re going to take it. Barbara said another problem is proper preparation can be tricky and take patience, which is difficult if a person is hanging out for a fix.
Steroids
The needle exchange is seeing more and more clients needing equipment to inject anabolic steroids, used for muscle gain and performance enhancement in athletics and sports. About a quarter of the exchange’s clients are steroid users. Barbara said they often see themselves as being different to the exchange’s “real” clients, those using opiates and other drugs, and don’t see themselves as doing something illegal. “It’s happening less now but for a while we seemed to have people coming through the door and if one of “our clients,” as they perceive it, was at the counter you could actually see a look of disgust.” She sometimes cautions them for the way they look or act toward other clients at the exchange. They’re breaking the law just the same as the “junkies.” Steroid users are exposed to the same risk of catching Hepatitis C as any other IV user.
Dene explained how steroids need to be injected into muscle, not veins. They require a different technique and larger needles. “If you hit a vein in intramuscular injecting you can get internal bleeding, cause abscesses.” The needles needed for intramuscular injections are very long and thick. DIVO have pamphlets on techniques for injecting steroids that they have tried to make available at Dunedin gyms. The gyms refuse, claiming, “No one uses steroids.” Dene says it’s like the idea that there are no drugs in prison. “Ideally, there would be a needle exchange in prison. But because there are no drugs in prison, there are no exchanges. The needle exchange knows that isn’t true.” I spoke to someone who works at a complex with a gym where they have a sharps disposal box. His workmates have complained that it could “attract junkies,” unaware that their muscle-bound patrons are the ones using the resource.
Addiction
“One of the negatives of addiction is you need to keep upping your dose to feel it or get the stone or whatever,” Dene told me. I asked why people would choose to inject the drugs when they can be taken orally. Dene said, “You get a rush. It’s instantaneous. The rush factor. Especially with morphine. When you inject it you feel it going around your body. It’s a good feeling.” He described a rush going from the feet up to the head. Ingested opiates will have the same effects, but can take hours to kick in. And, Dene said, people get addicted to the needles. He knows people who have gone clean but continue to inject themselves with water. Barbara had seen somebody recently who was desperate to give up because of “diabolical veins,” but who was struggling with the “fixation with the needle.”
DIVO have a good working relationship with the Community Alcohol and Drugs Service (CADS). CADS run the methadone programme, which gives addicts a measured amount of methadone every day to keep them functioning (not going into withdrawal) without getting them high. “Theoretically,” says Barbara, “the needle exchange and CADS shouldn’t mix. In the real world, our clients are their clients.” Though they are supposed to drink the methadone, many people choose to inject it, and so come to the needle exchange. In some places CADS will try to stop the needle exchange from giving users supplies to do this, but the Dunedin branch understand the need to reduce harm before anything else.
Barbara sees similarities between problems with addiction to legal and illegal drugs. “At the end of the day, what’s the difference between alcohol and drugs? Except one’s legal and one’s not. The legal one can cause just as much harm to an individual, and cause as much stress and grief in the world as someone who chooses to use drugs.”
Hepatitis C
New Zealand and Australia were the first countries in the world to set up needle exchanges. Their early appearance may be largely responsible for the low rates of HIV and AIDS in both countries. Unfortunately Hepatitis C, which was not discovered until 1989, is still a huge problem here. One in 100 New Zealanders have the virus. It can be asymptomatic for a long time so many people don’t know they have it. Symptoms can be as vague as feeling lethargic and having a low appetite, and people can live with the disease for decades before being diagnosed. After many years, Hep C often leads to liver disease and occasionally cirrhosis. In some cases, those with cirrhosis will develop complications such as liver failure, liver cancer, or oesophageal and gastric varices.
“If you are wondering if you’ve been exposed to it, you have to think, have I ever been exposed to anybody else’s blood?” says Allison Beck from the Hepatitis C Resource Centre in Otago. Hep C is spread through blood-to-blood contact. You can catch Hepatitis C off all sorts of things. As well as needles and syringes you can catch it off toothbrushes, razors, the notes and straws people snort drugs through. Tattoos, piercings, rough sex, fighting, even getting your legs waxed at a beauty parlour - anything with the tiniest chance of having come into contact with blood is a risk. You don’t know who could have Hep C. The virus can live outside of the body for six weeks, even in dried blood. “You’ve got to do a really thorough clean. You can’t just spray some Dettol and think it’s fine.”
Allison told me about the social attitudes surrounding the disease in New Zealand. She told me people think ‘junkies’ when they think of Hep C. “The stigma at the needle exchange, that’s our stigma too.” The stigma can stop some people seeking treatment “because they don’t want to tell their parents or their employer the reason they’re sick and their hair is falling out.”
Treatment
The current government funded treatment for Hep C is a 24-48 week course of the drugs pegylated interferon and ribavirin, and dependent on genotype, a third drug called boceprevir. It is a form of chemotherapy. Allison said they’re “particularly nasty drugs,” with horrendous side effects and only a 20-50 percent chance of curing the illness. But a new treatment (daclastovir, subfostbovir and ribavirin) has been developed which can achieve remarkable results in 12 weeks of treatment for 98 percent of people that have Hep C, and Pharmac in NZ won’t fund it. If people want it, they have to pay around $100,000. The Hep C centre facilitates access to an Australian a “buyer’s club” to help people get access to the medication from China or India via Australia, who have made it available to all Australian citizens. Through this channel the medication costs $2000-$4000 – far cheaper, but still a lot of money for many people with the disease.
Allison’s friend Chris Heazelwood is in the middle of a course of the new medication he got through the buyer’s club. On the morning of publishing this article Chris wrote a Facebook status:
“I wanted to say that my course of meds is booting the door in on my viral load...from the very first day I started taking these pills I felt amazing and that hasn’t stopped. Which really just tells me how very sick I was; constantly nauseous legs like concrete..mind like a sieve..mood swings psychopathic...real mental confusion....now I am clear headed energetic focused calm even relaxed....so once again huge shout out to everybody who helped and continues to help...thank you so much....and if you are unfortunate enough to have this disease go sort it out...you will be truly amazed what good health feels like..xxc”
Allison has lost many friends to Hep C, one only a few weeks before I interviewed her. Dying from liver failure is slow and gruesome. When I asked her why the government won’t fund the new medication, Allison said she believes it had to do with the stigma around the disease. “I get the feeling it’s easier just to let them die.”
Worse still, the current government has failed to renew the Hep C Centre’s funding for another year, so sufferers may lose the little support they have in Dunedin. It only costs the government around $45,000 a year, including Allison’s salary, to keep the Centre open. Since the announcement Allison has been getting dozens of phone calls with people saying “Hey, now we have the buyer’s club we need you to help facilitate getting the meds. If you close, what do we do?”
Support
Both DIVO and the Hep C Centre provide emotional support for people who may not have other places to talk openly without judgement. The Hep C centre can help people get aid from WINZ or Housing NZ during their gruelling treatment. DIVO can get people into detox programmes and help them get proper medical treatment if they need it. Dene told me “We don’t judge people – that’s a really important thing. We listen to them when they choose to talk to us.”
For friendly, non-threatening advice on IV drug use:
DIVO Needle Exchange Dunedin:
Address: 405 Princes Street, Dunedin, 9016
Phone:03-479 2300
Opening hours: 9am-6pm Monday to Wednesday,
9am-7pm Thursday and Friday
10am-4pm Saturday
ED/vending machine for after hours access
For advice and support for Hepatitis C sufferers:
Address: Commerce Building, Level 2, 2 Dowling St, Dunedin 9016
Email: otago@hepcnz.org
Phone: (03) 477 0407
Hours: 9am to 4pm Mon-Fri