REACHING OUT TO THE FRINGES

Baltimore's Needle Exchange Program Has Been Deemed An Overall Public
Health Success. But Most Younger Drug Users Aren't Participating, And
The City's Worried.

The young redhead with the stylish black backpack and heart-shaped
earrings had come a long way to be standing at Monroe and Ramsay
streets in Southwest Baltimore, waiting her turn outside the big
white van. For years, she'd put off this moment: signing up herself
and her husband for the city's needle exchange program.

The couple -- their street names are Pebbles and Bam-Bam, a nod to
the Flintstones television characters -- have been injecting heroin
since they were 17, she said. They've been sharing used syringes with
others and attempting to clean them with water and bleach between
uses, rather than coming to the exchange for new ones, even though
they were aware of the serious health risks in sharing.

"I always think, 'I'm going to get clean, so I don't need to [join
the exchange],' but then we don't get clean, and we don't accept the
fact that we're using," said the 21-year-old woman, who is from
southwestern Baltimore County. "So just today, I said, 'We're going.'
I've been thinking about getting clean, but if I'm going to keep
living this lifestyle, then I ought to at least do this."

At a time when heroin remains Baltimore's leading drug scourge, city
officials wish more addicts like the couple would make use of the
exchange program -- a key tool in efforts to curb the spread of HIV.
But despite growing up in the shadow of AIDS, or acquired immune
deficiency syndrome, most younger drug users are not participating, a
problem especially acute among whites in their teens and 20s.

A recent study by researchers at the
(http://www.baltimoresun.com/entertainment/visitor/college/bal-hl-hopkins,0,3324446.story)Johns
Hopkins University Bloomberg School of Public Health found that only
10 percent of people who started injecting drugs in the past five
years rely on the exchange as their main source for syringes. An
additional 18 percent of the 294 users surveyed, most of whom were
interviewed in Southwest Baltimore, said they were mainly obtaining
their syringes from pharmacies, where a 10-pack costs about $2.50.

But most users said they bought needles on the street -- a risky
practice because they can't be sure the needles are new -- or shared them.

While the study found that addicts were more likely to visit the
exchange as they grew older, Susan G. Sherman, the lead author, said
"it's really important" to attract users soon after they first start on drugs.

"Habits get established very early," she said.

There are no reliable statistics for what proportion of drug
injectors of all ages rely on the needle exchange, which the city
instituted 11 years ago after overcoming opposition from some state
lawmakers and other critics who argued it would encourage drug use.
The exchange has registered more than 15,000 people since it began
and has about 325 visitors a week, many of whom are believed to
distribute or sell the needles they obtain to other users.

Overall, the program, which costs just under $500,000 a year, has
been deemed a public health success: Every week, the exchange's two
vans distribute about 6,500 syringes and other injecting equipment
(swabs, cookers, bottles of water and bleach) in exchange for dirty
needles at a dozen sites around the city. The vans also offer HIV
tests and drug treatment information. Since the program's inception,
the rate of new HIV cases attributed to intravenous drug use has
dropped by a fifth, to about 40 percent of cases.

But Monique Glover Rucker, the city Health Department's senior
adviser on HIV/AIDS and harm reduction programs, acknowledged the
problem identified by the Hopkins study. Only 6 percent of those the
program has enrolled since it began were younger than 25, she said,
and the number of younger addicts registering with the exchange has
remained flat even as the program has expanded its number of sites.

To address that, the city is applying for a $25,000 grant from the
Tide Foundation to improve the exchange's reach among younger users,
Rucker said. The grant money would be used to pay younger addicts who
use the exchange to do outreach work among other younger injectors
and to pay for a new weekly exchange time that would be dedicated to
users younger than 30.

The hope is that such measures could increase the comfort level that
younger addicts, particularly younger white addicts, feel toward the
exchange, Rucker said. Previous studies have shown that heroin
addicts in their teens and early 20s in Baltimore tend to be white,
whereas blacks tend to start using hard drugs later, in their late
20s and 30s. The exchange's staff is all black, which Rucker
speculated could deter some white addicts from using it.

"Ideally, the [exchange's clientele] would be completely
representative of [the addict population], but it's not. The users
are changing, and we need to make sure we're reaching all of the
population," Rucker said

Increasing the program's reach among younger users won't be easy,
however. Interviews with about 20 addicts who recently visited the
city's exchange site at Monroe and Ramsay revealed a variety of
reasons that others stay away.

Some clients said younger addicts were in denial about their
addiction or were hiding their drug use from their families. The same
feelings of shame, they say, keep many younger addicts from buying
syringes from pharmacies, which several years ago were allowed to
sell syringes over the counter. (The law gave pharmacists discretion
on sales, but addicts say it's not difficult finding stores that sell needles.)

Clients at the van suggested a dedicated exchange site for young
people be located in a building or another more secluded location,
not at a well-trafficked street like Monroe.

"They're scared that somebody walking by will see them and will tell
their family, 'I seen so and so by the van,'" said Chris Morcek, a
36-year-old construction worker in a black T-shirt from Arbutus who
recently visited the van.

Devon, a tall, blond 26-year-old prostitute raised in Essex and
Middle River, said an outreach effort by younger addicts who use the
exchange would also be a good idea because many young addicts, some
of whom hail from outside the city like herself, didn't necessarily
know about the exchange sites. Just that day, she said, she had
persuaded a friend to come with her to the exchange for the first
time because the friend had tested positive for hepatitis C.

"I'm not letting her use my tools," said Devon, who, like some others
interviewed, would not give her full name because she didn't want to
expose her addiction.

Several younger addicts who use the exchange program said it took
them a while to start coming simply because they were too busy
"running the streets" looking for drugs and money to pay for them and
not thinking clearly enough to get themselves to the site on time.

A 23-year-old addict, a West Virginia native who gave only her first
name, Amy, came rushing up to the van with her black purse full of
syringes to exchange, just moments after it had closed for the
afternoon -- the second time that had happened to her, she said.

"I didn't realize what time it was," said the rail-thin brunette, as
a middle-aged man waited for her in a car across the street. She said
he supported her $75-a-day heroin habit. It took her about a year of
injecting before she even started coming to the van at all, she said.
"It's being lazy about it. I had the time, but I didn't want to take the time."

To some older addicts who have been coming to the van for years, the
reluctance of younger users is just another sign of the foolhardiness of youth.

"They think, 'It can't happen to me.' That's the way they are," said
Mark Bartlett, a native of Southwest Baltimore who has used heroin
since his teens and looks much older than his 32 years. "To them,
[the exchange] is a waste, a joke. Anything dealing with their health
is a waste of time. It's, 'I'm young; I'm going to live forever.'"

A related recent Hopkins study of a similar population of addicts
found that more than 90 percent of younger addicts interviewed knew
about the risks of contracting HIV or hepatitis C from shared
needles. (In both studies, about 5 percent of addicts interviewed
tested positive for HIV, while the rate of hepatitis C infection
ranged from a third in one study to more than half in the other.)

But Sherman, the author of both studies, said addicts' awareness
about disease risk doesn't always translate into prudence when users
are craving heroin.

"By 11 o'clock in the morning you're very sick, and you're not
thinking about what's going to happen [from sharing]. Your boyfriend
shoots up and there's only one syringe, and so what are you going to
do? They're not thinking," she said.

Pebbles, for her part, said she and her husband weren't so reckless,
even before they decided to come to the exchange. They tried, she
said, to clean shared syringes by dipping them repeatedly in water
and bleach, which, if done right, can greatly reduce the risks of
disease transmission.

But it got to the point where she deemed even the risk left after
cleaning to be too big.

"Who knows? It might be too late," she said. "I might have already
caught something."