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San Francisco drug users bring harm reduction to the streets

Under CC license from Flickr user TedsBlog

There’s a plan circulating in San Francisco to make using crack cocaine safer: give away free crack pipes. It might sound farfetched, but it’s supported by science.

Many cities offer a number of health services that target people who use drugs. For example, there are methadone clinics and substance abuse recovery programs. One of the programs that came with the most controversy is needle exchange, which came to San Francisco back in 1992.

Needle exchanges typically involve city health departments teaming up with nonprofits. They give away clean syringes to people who inject drugs. Used syringes can spread infectious diseases like HIV or Hepatitis C. New syringes eliminate that risk, so needle exchanges have drawn the support of organizations including the Centers for Disease Control and the American Medical Association.

In San Francisco there are about a dozen locations where people can pick up a brand-new syringe at no cost. In 2012, the city spent about $1.2 million on needle exchange — or about 75 cents per needle.

Needle exchange is just one of many services for people who use drugs — services that don’t try to get a drug user to quit. Instead they take a different approach, known as “harm reduction.”

“Harm reduction is anything we’re doing to take an activity that could be harmful and reduce that harm so it’s safer,” says Laura Thomas of the Drug Policy Alliance, an organization that works to reform drug laws. Thomas says harm reduction means treating substance addiction with the understanding that some addicts won’t quit for many years. And some never will. But even if they can’t stop using substances, they can still be healthier substance users.

“Once you start engaging with people as human beings,” she says, “and understanding that they’re trying to take care of their health by using a sterile syringe – that’s often the first step to getting someone to come back, get an HIV test, maybe see a doctor about their abscess and start the process of engaging with services that can meet their needs.”

Thomas says that San Francisco has been a leader in harm reduction – but now it’s falling behind; because there’s an effective, inexpensive and humane measure the city should enact right now for drug addicts – and it’s refusing to do so.

Free crack pipes

It’s a windy afternoon on Turk Street in the Tenderloin. People cluster on corners, smoking cigarettes, and drinking beers from paper bags. Stroll down the street, and you’ll be offered Xanax, Oxycontin, pot, speed and other drugs. On the corner of Turk and Jones, there’s a man called G.             

“I don’t know how representative I am of typical crack user,” he says. “But I don’t know if there really is such a thing.”

G – and that’s not his real name – is a white guy with curly gray hair in a baseball cap. He says it’s hard to be a person who smokes crack.           

“I feel like I lie about my use pretty habitually. I mean I can’t even begin to tell you how much would change in my life if I told everybody everything about what I’m doing,” he says. “I do think that there is more stigma attached to crack smoking than any other drug that I know of.”

Advocates say this stigma has created a gap in San Francisco’s harm reduction policies. People who inject drugs have needle exchange – where they can get information and supplies. But there are few services specifically directed at people who use crack. And that means they are more likely to do things that make a risky behavior even riskier, like having unprotected sex, or smoking out of a broken pipe.

“I use a broken pipe, every day.” says G. “I cut up my hand actually. I had a whole bunch of little cuts in there, that were deep enough from the broken end of a pipe that I was pushing a screen through.”

Picture this: at one end of the pipe, there’s a screen, usually made out of a Brillo pad. Broken up crack rocks are sprinkled on that screen and lit and inhaled from the other end of the pipe. This leaves a resin, which can be smoked again.

“They were definitely deep enough cuts that if somebody besides me had been smoking from there, there would seriously be a possibility for infection,” says G.

He’s talking about an infection like HIV or Hepatitis C. Research has shown that crack smokers have higher rates of both diseases, and sharing pipes, especially broken pipes, is one possible cause. Crack users sometimes burn their lips on pipes, and when those injuries bleed, it creates another way to spread infections. G says he doesn’t know why he uses a broken pipe. He understands the risks. He could get a replacement for about a dollar at the corner store. But he keeps his broken one.

“I think that for so many people the urge to just get high is so overwhelming that people don’t care if they’re putting their freaking lives at stake,” he says.

People who use drugs are prone to making impulsive, dangerous decisions. Programs like needle exchange try to reduce the harm those decisions cause. So an intravenous drug user has a clean needle right there when he or she wants to inject. Harm reduction advocates say smart policies can make smoking crack safer too. And they have a proposal for how to do this.           

San Francisco’s about face

San Francisco has a commission called the HIV Prevention Planning Council. In January, members of that commission who were also advocates for drug users proposed a plan to give away free crack pipes. Several groups give other harm reduction materials away, like mouthpieces and alcohol wipes, but not pipes. Giving away crack pipes is illegal. The HPPC voted unanimously to study the plan.

But before it could conduct study, something happened. A reporter who’d attended the meeting wrote a story about the proposal to distribute crack pipes. And that story got a lot of attention.

Blogs picked up the story. Many mocked the idea. Mayor Ed Lee publicly opposed the measure, and privately, he encouraged the Department of Public Health to distance itself from the proposal. But other cities, such as Seattle, have already embraced the idea.           

“I really feel like it’s one of our most successful programs,” says Shilo Murphy. He’s the founder of the Urban Survivor’s Union, a network of drug users who lobby for alternative drug laws. He also runs the People’s Harm Reduction Alliance in Seattle, which offers free Hep C testing, safe injection advice, needle distribution, and, since 2010, crack pipes.

“We have homeless people who are cocaine smokers, who are now part of running our program,” he says. “People who are in housing, whose lives have changed because of our program. We have made a generation of people carry knowledge. That can only be a positive thing. And the stigma is starting to wash away a little.”

Murphy says he has more than anecdotes to back him up. Two Canadian studies found that distributing crack kits decreased risky behavior like sharing pipes and using broken ones. A Vancouver non-profit has installed crack pipe vending machines, which sell the devices for a quarter. It’s unlikely that such innovations will come to San Francisco. But local activists are taking matters into their own hands.

The underground exchange           

It’s evening in the Tenderloin. A police SUV idles nearby, its lights flashing. A crowd watches it suspiciously but Isaac Jackson pays it no mind. He’s the founder of the San Francisco chapter of the Urban Survivor’s Union, and tonight he’s giving away free crack pipes.

Jackson and a couple other group members stand on the sidewalk along a chain link fence bordering an empty lot. They’ve given away pipes, alcohol swabs, and mouthpieces every week since early March.           

“This is way of telling people, ‘Hey someone cares about you,’” he says. “We want people not to get sick.”

Jackson and his team offer the kits to anyone passing. Within five minutes they get their first taker, a man who wants one for himself and one for his wife.

“Sorry, it’s one per person,” Jackson says.

Soon, people are coming in twos and threes. And, for an activity that’s illegal – it’s a mellow affair. People show up, ask for a kit, say, ‘Thanks,’ and walk away.

About half an hour into the distribution, a church group approaches, offering free Doritos and Jesus.           

One of the members, a girl in her late teens or early twenties, introduces herself to Jackson and asks how his day is going.

“Okay,” he says.

“What’s okay about it?” she asks.

“We’re giving away free crack pipes,” says Jackson. He chuckles. “Want one?”

The girl declines and asks if there is anyone Jackson wants her to pray for.

“Pray for drug users,” he says. “Pray that they live happily.”

Jackson says he’ll keep distributing the crack kits until the city takes over. But, that doesn’t look likely. The proposal made by the HIV Prevention Planning Council to give away crack kits is on ice at the Department of Public Health. So giving away pipes is still illegal. Jackson points out that needle exchange started the same way, as an underground activity. In cities around the country, activists broke the law, until the law changed.

Crosscurrents HealthSan Francisco