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The Washington Needle Depot: fitting healthcare to injection drug users rather than injection drug users… Small, Dan; Glickman, Andrea; Rigter, Galen; Walter, Thia Jan 4, 2010

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ralssBioMed CentHarm Reduction JournalOpen AcceCase reportThe Washington Needle Depot: fitting healthcare to injection drug users rather than injection drug users to healthcare: moving from a syringe exchange to syringe distribution modelDan Small*1,2, Andrea Glickman3, Galen Rigter4 and Thia Walter5Address: 1PHS Community Services Society, 20 West Hastings Street, Vancouver, BC, V6B 1G6, Canada, 2Department of Anthropology, University of British Columbia, 6303 NW Marine Drive, Vancouver, BC, V6T 1Z1, Canada, 3Union of BC Indian Chiefs, 500 - 342 Water Street, Vancouver, BC, V6B 1B6, Canada, 4PHS Community Services Society, 20 West Hastings Street, Vancouver, BC, V6B 1G6, Canada and 5Life is not Enough Society, 42 Blood Alley Square, Vancouver BC, V6B 1C8, CanadaEmail: Dan Small* - dansmall@interchange.ubc.ca; Andrea Glickman - andrea_glickman@yahoo.com; Galen Rigter - galenr@phs.ca; Thia Walter - Lines@thiawalter.com* Corresponding author    AbstractNeedle exchange programs chase political as well as epidemiological dragons, carrying within themboth implicit moral and political goals. In the exchange model of syringe distribution, injection drugusers (IDUs) must provide used needles in order to receive new needles. Distribution and retrievalare co-existent in the exchange model. Likewise, limitations on how many needles can be receivedat a time compel addicts to have multiple points of contact with professionals where the virtues oftreatment and detox are impressed upon them. The centre of gravity for syringe distributionprograms needs to shift from needle exchange to needle distribution, which provides unlimitedaccess to syringes. This paper provides a case study of the Washington Needle Depot, a programoperating under the syringe distribution model, showing that the distribution and retrieval ofsyringes can be separated with effective results. Further, the experience of IDUs is utilized, throughpaid employment, to provide a vulnerable population of people with clean syringes to prevent HIVand HCV.Historical context of needle exchangeSo, so you think you can tell heaven from hell,Blue skies from pain.Can you tell a green field from a cold steel rail?A smile from a veil?Do you think you can tell?Needle distribution programs take place against the back-drop of public health. Public health has been a core partof medicine in Canada since before the establishment ofthe Canada Medical Act in 1912, and can be defined as apreventative approach to improving and maintaining thehealth of a population. The Canadian medical professionhas a long history of protecting innovations in publichealth. The first president of the Medical Council of Can-ada, Dr. Thomas Roddick, initiated a campaign to estab-lish a Canadian public health bureau as early as 1899 [1].Published: 4 January 2010Harm Reduction Journal 2010, 7:1 doi:10.1186/1477-7517-7-1Received: 24 November 2009Accepted: 4 January 2010This article is available from: http://www.harmreductionjournal.com/content/7/1/1© 2010 Small et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 12(page number not for citation purposes)(Roger Waters; David Gilmour)In the first national licensing exam of 7-10 October 1913,Public Health, or Hygiene and State Medicine as it wasHarm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1called then, was a key subject area on which the earliestphysicians had to demonstrate competence in order toobtain their licensure for practicing medicine in Canada[2]. By 1929, the subject of this portion of the nationalqualifications exam was changed to Public Health andPreventive Medicine. Today, public health is still a subjecton which all those individuals seeking medical licensurein Canada are tested. This paper describes the innovationsof a peer-professional needle distribution program, wherepeople with addictions deliver healthcare, under theumbrella of public health.Needle distribution as a response to addiction relatedinfections first came about in response to hepatitis B andC [3]. One of the earliest recorded needle distribution pro-grams was launched by a pharmacist in Edinburgh in1982 in response to an outbreak of hepatitis C [4]. Atabout the same time, a peer based organization of peopleliving with addictions called upon the health authority inAmsterdam to initiate needle distribution to help curb thespread of hepatitis B [5]. Needle exchange in Canada alsobegan in partnership with people who had direct experi-ence in addictions.Canada's first needle distribution program began in Feb-ruary 1989 as a health initiative to control the spread ofHIV/AIDS [6,7]. The program was initially a 10-monthpilot funded by the City of Vancouver during the periodin office of Mayor Gordon Campbell who continued on inpublic service to become the Premier of the Province ofBritish Columbia. A non-profit organization headed byformer addict John Turvey, the Downtown Eastside YouthActivities Society (DEYAS), delivered the service alongwith a local health clinic, North Health Unit, who pro-vided expert input from clinicians as required [6]. Theprogram began with two staff.At the beginning of the program, injecting drug users(IDUs) were limited to two syringes in attempts to preventpeople from selling the sought after needles in order topurchase drugs. In the early stages of the program,exchange, that is, the provision of a used needle in orderto obtain a clean needle, was encouraged but not compul-sory [6]. During the first year of the program, the price ofsyringes for purchase on the street dropped from five dol-lars to one dollar per needle.The injection of cocaine became a major obstacle to nee-dle exchange with daily syringe limits and exacerbated theHIV epidemic in IDUs living in Vancouver. With thearrival of injecting cocaine in the 1990s, enforcedexchanges and low limits on the number of syringes avail-able in a given day, were a recipe for epidemiological dis-increased need for syringes) per day for users. At this time,the PHS Community Services Society (PHS), a non-profitorganization based in Vancouver's Downtown Eastside(DTES), was the only organization in Vancouver, to pro-vide unlimited amounts of needles to IDUs based on needas determined by the addict and not the agency. The PHSpursued this model of syringe distribution in spite ofopposition from DEYAS at the time,In the 1990s, DEYAS had a policy of limiting the numberof syringes that IDUs could obtain in a single day and overthe course of a week. Specifically, IDUs could obtain amaximum of 14 syringes per day, three days per week fora total of 42 needles per week [9]. If an individual wasknown to be living with HIV or HCV, then they wereallowed to double this rate of exchange for a total of 84needles per week. In addition, clients of the needleexchange were allowed to trade an additional five needlesper day at each stop of the mobile needle exchange van.Bulk exchanges (more than one needle at a time) wereonly allowed at the fixed needle exchange and were notallowed at the mobile exchange vans. As well, there was apolicy of "trading" meaning that addicts had to provide aused needle in exchange, or trade, for each clean needlethat they provided through the "exchange". The needleexchange would allow for a single "loaner" syringe perperson in case an IDU did not have a needle to trade.Enforcing a trading system with a one-for-one exchangepolicy and limiting the amount of syringes obtainable wasmeant to obtain three objectives [9]. Firstly, the exchangesystem was meant to maximize the point of contactbetween the needle exchange staff and individuals withactive addictions in order to develop rapport and facilitateopportunities for providing healthcare information aswell as referral to treatment, detox, and counselling. Sec-ondly, the exchange approach was meant to recover asmany used needles as possible. Thirdly, an exchangeapproach with fixed limits was supposed to maximize theamount of clean needles in circulation while minimizingthe amount of dirty needles available for re-use.The end of an era in needle exchangeIn its final years of operation, the DEYAS needle exchangeprogram experienced significant challenges. When DEYASclosed their long-term fixed site needle exchange but didnot have a suitable replacement site, the PHS immediatelyprovided a new needle exchange site and assisted in theacquisition of a municipal permit despite oppositionfrom a local government that was hostile towards needleexchange.After two decades of operation, the DEYAS needlePage 2 of 12(page number not for citation purposes)aster [8]. The relatively short duration of cocaine's effectsmeant an increased quantity of injections (i.e. anexchange program ceased to operate in July of 2009. As aresult, the PHS stepped up its efforts to stretch its existingHarm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1resources to subsume the roles previously undertaken byDEYAS including the retrieval of used needles andincreased mobile syringe delivery to IDUs throughout thecity of Vancouver. Subsequently, the local health author-ity commissioned a review of needle exchange servicesand put all syringe distribution programs delivered bynon-profit agencies, including those operated by the PHS,out to tender.In an attempt to save the most important part of the serv-ices provided by DEYAS (i.e. primarily mobile syringedelivery, outreach, collection of discarded syringes, emp-tying needle boxes that have been deployed in the com-munity), the PHS moved to fill this gap utilizing theexisting infrastructure and capacity of the WND. The pro-gram had the capacity to provide the service immediatelyso that there was no service interruption. The organizationdid not have to purchase or rent a van; they already hadone that was purchased by the health authority. Theymade use of a fully functioning location already fundedfor this very purpose. The existing coordinator at the PHSneedle distribution program assumed the responsibilitiesof supervising the services formerly provided by DEYAS.Today, the program operates 24 hours with a fixed site aswell as a mobile syringe delivery, retrieval and outreachservice. The remainder of this paper focuses on the impor-tance and urgency of keeping needle distributions (asopposed to exchanges) in operation as a public healthmeasure.Out of the healthcare hurricane: context of the Washington Needle DepotThe PHS has been a provider and supporter of syringe dis-tribution for 17 years. The PHS was the first housingagency in Vancouver to operate an "in house", fixed, nee-dle distribution program in 1993, and the first HIV organ-ization to receive funding for syringe distribution in BC.The Washington Needle Depot (WNP) opened as anextension of the organization's existing needle distribu-tion services. The PHS was also the first organization toprovide unlimited syringe distribution without the neces-sity of exchange. This was especially important during theHIV epidemic that exploded in the IDU population inVancouver during the mid-1990's.The organization has been a vocal advocate of the decen-tralization of syringe distribution and the distribution ofclean needles through all community health centres in theregion. The PHS has always argued for a fixed site forsyringe distribution, open 24 hours per day, coupled withoutreach needle distribution and retrieval in the DTES.The WND operates in the Downtown Eastside (DTES)poverty and a concentration of people with active addic-tions. There is a high rate of homelessness and inadequatehousing. Thousands of low-income residents in Vancou-ver live in single room accommodation (SRA) hotels: tinyrooms (e.g. 140 square feet) where they share a bathroomand kitchen with dozens of other tenants. The ethnicallymixed population includes a disproportionately highnumber of Aboriginal residents. Approximately thirty per-cent of the residents of the DTES are indigenous, 10 timesthe national average [10]. Recent studies demonstrate thatyouth and adult aboriginal drug users in the DTES have anelevated risk of HIV infection [11,12].The WND emerged in its present location as part of aresponse to a healthcare and political crisis in Vancouver.On 31 May 2002, the Vancouver Police Department(VPD) shut down a satellite needle distribution programlocated on the corner of Main Street and Hastings Street inthe DTES. This program operated under a tent, equippedwith a humble table and two chairs purchased from alocal department store. People with addictions, peer topeer volunteers, from the Vancouver Area Network ofDrug Users (VANDU) and staff from the PHS sat eachnight to hand out harm reduction supplies (syringes,Band-Aids, condoms) [13,14]. Despite the fact that thehealth authority made needles available at several loca-tions at that time, the needle exchange table was the onlylocation providing service after traditional business hours.The immediate result from the police closure of the needledistribution program was a significant reduction in theamount of needles distributed. Similar experiencesoccurred when the only needle exchange was shut in Vic-toria (the capital city of British Columbia) [14,15]. Theshutting of the Victoria needle exchange resulted in a 23%reduction in syringes distributed. Reductions in theamount of syringes distributed due to closure of healthprograms leads to higher risk of deadly infections (e.g.HCV, HIV) in IDUs. In response to the closure of the Van-couver needle distribution program in 2002, the Centrefor Excellence in HIV/AIDS, a department of St. Paul'sHospital and the University of British Columbia, submit-ted a letter to the Vancouver Police Board requesting thatthe police allow the exchange to be re-opened immedi-ately to prevent an increase in risk for HIV and HCV infec-tions due to the closure.On 19 July 2002, the City of Vancouver and the Vancou-ver Police convened a meeting with the funder for the pro-gram, Vancouver Coastal Health (VCH), and the agenciesdelivering the service (PHS and VANDU). Further to thesudden closure and confiscation of the table, tent and nee-dle exchange equipment, the police and city representa-Page 3 of 12(page number not for citation purposes)community of Vancouver, which is a densely populatedand diverse urban neighbourhood. There is a high rate oftives argued that the actual needle exchange table did nothave a municipal permit to operate. The police went on toHarm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1state that they would not allow the peer-to-peer needledistribution program to commence until the VCH com-mitted to re-designing the services available to IDUs at thestreet corner in question. Further, they demanded a writ-ten plan describing the longer-term vision for needleexchange for the City and a direct connection betweenneedle exchange, treatment and detox. By having seizedand closed the syringe distribution program itself, liter-ally, enforcement officials were ironically attempting todictate a specific agenda, arguably outside of their exper-tise, with regard to healthcare services in the neighbor-hood.The meeting had a number of outcomes. The VCH madeit clear that their organization did not want to break thelaw in any way and agreed to cease operating a fixed nee-dle exchange at the corner until such a time that the per-mit was obtained. The City expressed concerns about thelack of a permit for the table. In the spirit of working withthe police, both VANDU and VCH agreed to halt the pro-gram in its current configuration until the demands of thepolice were met. Needle exchange would continue withroaming peer-to-peer workers distributing needles from"fanny packs".In contrast, the PHS was in marked dissention. The citypermit process lays open healthcare programs like needledistribution for public debate in forums as part of themunicipal process. In these cumbersome public forums,healthcare is politicized as opponents to needle exchangeare given an opportunity use the municipal process tovoice their opposition to the syringe distribution in gen-eral. In light of the research evidence presented by theCentre of Excellence in their communications on the mat-ter, it appeared clear that roaming needle distribution wasnot as effective as a fixed exchange coupled with a roam-ing approach. In fact, there was some speculation thatthere would be a statistical likelihood of risk for one pre-ventable HIV infection per night while the fixed site wasclosed at the corner. As a result of these factors, the PHSgave the VPD a deadline of 4:00 pm to return the tableand allow the program to re-commence, or the organiza-tion would erect a new needle distribution table at the cor-ner. Subsequently, several activists were lined up,including a number of public figures, who agreed to vol-unteer at the table and risk possible arrest. At the time, thePHS was forced to seek legal advice regarding possiblecharges such as being arrested for conspiring to save lives.There was, as a result, some tension between the support-ers of the program: the VCH, VANDU and the PHS. Thehard-line approach of the PHS was in direct contraventionof the wishes of VCH and VANDU both of which formallyto the City. The front line city officials in the permits andlicensing department examined the application withhilarity and contradicted the senior City management bystating that no such permit was required or even available.Further, photographs of tables without permits, crowdingthe sidewalks of Chinatown one block away, were pre-sented to the City as part of an argument that no such per-mit was necessary. It increasingly appeared that thedemand for a municipal permit was a charade to maskopposition to syringe distribution.In the end, the VPD missed the deadline. The PHS dis-patched a new table. Shortly after the PHS dispatched thetent and new custom-built table on wheels, without theunobtainable municipal permit, the VPD opposition col-lapsed. Subsequently, the PHS negotiated a contract fromthe VCH to provide a fixed site along with outreachpatrols distributing and retrieving syringes. The programalso while provided healthcare information and referralsto treatment and detox. Condoms were also distributedthat were accessed by a broad population including sur-vival sex workers. The PHS provided a free site for the pro-gram in the Washington Hotel as part of theorganization's ongoing syringe distribution and retrievalservices. The WND was born.Early indicators of the need to move from exchange to distributionCritical examinations of needle exchange suggest thatthese programs need to be decentralized and flexible[16,17]. Early research in Vancouver, Canada suggestedthat needle exchange needed to be a part of a comprehen-sive program to address and reduce HIV and HCV inci-dence [17]. Vital to this comprehensive approach was aneed to switch to a distribution model rather thanexchange. Likewise, decentralization of syringe distribu-tion was critical; needles needed to be available at manylocations.Many exchange programs have a rehabilitative focus: lim-iting the amount of syringes obtainable at one time inorder to force multiple points of contact with people withaddictions and to compel participants to become relianton the programs. Needle exchange, in many cases, is seenas a doorway to referrals and counseling [8].Despite wide-spread cocaine use in Vancouver in the 1990s that neces-sitated considerable access to syringes (cocaine users havebeen known to require more than one dozen needles in asingle day), needles were often limited and exchange pol-icies were employed so that addicts had to provide a dirtyneedle in order to obtain a clean one. In some circum-stances addicts would, presumably, be turned awaybecause they had either reached their limit for the day orPage 4 of 12(page number not for citation purposes)registered their protest to the PHS. Concurrently, the PHSmade an immediate application for the described permitdid not have a dirty needle to trade for a clean one. Earlystudies highlighted the limitations of needle exchange:Harm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1embedding rehabilitative goals in that limit the numberof syringes obtainable by an individual IDU.Difficulty in obtaining syringes is a key risk factor forsyringe sharing [8,18]. IDUs who obtain all the needlesthat they require are measurably less likely to engage inhigh-risk injection practices[18]. In fact, a significant por-tion of individuals who initiate use of syringe distributionprograms report stopping syringe sharing altogether[19].What is required for maximum effectiveness aremore, not less, needles. The difference between needleexchange and needle distribution is significant, two dis-tinctly different healthcare initiatives, a topic that isaddressed in the remainder of the paper.Effectiveness of needle distributionHIV and HCV can be transmitted via infected bloodtraveling from one person to another through a sharedneedle. The basic approach to needle distribution is toprovide IDUs with clean needles so that a new needle isused every time to avoid transmission of infectious dis-eases. As part of the program, drug users are educatedabout dangerous injection practices: (e.g. sharing nee-dles). There is persuasive scientific evidence that needlesyringe programs reduce the risk of HIV and HCV consid-erably. Further, credible data of any harmful conse-quences of these healthcare programs do not exist [3,19].Syringe distribution is supported by a myriad of main-stream medical, scientific and government bodies includ-ing United Nations, the World Health Organization,United Nations Office on Drugs and Crime[20], theAmerican Academy of Family Physicians[21], the Ameri-can Medical Association[22], the U.S. Centers for DiseaseControl (CDC)[23], the U.S. National Academy of Sci-ences Institute of Medicine[24], American Society ofAddiction Medicine[25] and the U.S. National Institutesof Health [26]. There is widespread consensus in the med-ical and scientific community regarding the effectivenessof distributing clean syringe equipment as made evidentby an open letter written to the Office of National DrugControl Policy by Ranking Member Henry A. Waxman onbehalf of the Congress of the United States House of Rep-resentatives Committee on Government Reform on 25May 2005 (see additional file 1).In response to the AIDS pandemic, the United NationsGeneral Assembly unanimously adopted an imperativeResolution to address AIDS on 2 June 2006. In this reso-lution, the United Nations General Assembly unani-mously and publicly declared the importance of harmreduction and needle distribution by reiterating that:"...prevention of HIV infection must be the mainstayintensifying efforts to ensure that a wide range of pre-vention programmes that take account of local cir-cumstances, ethics and cultural values is available inall countries, particularly the most affected countries,including information, education and communica-tion, in languages most understood by communitiesand respectful of cultures, aimed at reducing risk-tak-ing behaviours and encouraging responsible sexualbehaviour, including abstinence and fidelity;expanded access to essential commodities, includingmale and female condoms and sterile injecting equip-ment; harm-reduction efforts related to drug use;expanded access to voluntary and confidential coun-selling and testing; safe blood supplies; and early andeffective treatment of sexually transmitted infec-tions;"[27] (p. 4).Psychosocial EngagementThere is a difference between the cost of a needle that isdelivered in the alleyway at 3:00 am and a needle that isavailable at a health clinic during business hours. Needlesservices that are delivered from 9:00 am to 5:00 pm as anadjunct to a given program are relatively easy to deliver asthey are simply added onto to existing facilities. However,syringe distribution and retrieval that occur between 5:30pm to 9:00 am are more challenging. These servicesrequire staff to be available at more challenging hours andin more challenging areas (e.g. the alleys and SRA hotels).It is precisely in these more difficult times and places thatthe WND operates and flourishes at a much lower costthan could be provided through a higher threshold, pro-fessionally based, healthcare institution. (See Figure 1)Impediments to acquiring syringes are the prevailing riskfactor for dangerous injection practices that can lead toinfectious diseases HIV and HCV [18,28]. Needle distribu-tion can have a dramatic impact: IDUs who receive alltheir syringes from a NEP are considerably less likely toshare syringes [18,19]. By engaging street level IDUs inservice provision through syringe distribution andretrieval, the WND represented a fundamental shift in thecentre of healthcare gravity. Rather than simply receivingservices, vulnerable IDUs could be actively involved indelivering them. This went one step further than beingconsulted about how to best deliver services to drugaddicts to actually paying IDUs to deliver service. Addi-tionally, this meant recognizing that their experiencesprovided them with a unique insight and ability to deliverpeer-based harm reduction services, including being easyto approach for IDUs seeking services. IDUs often reportseeking services at the WND because of familiarity andcomfort with the peer workers.Page 5 of 12(page number not for citation purposes)of national, regional and international responses tothe pandemic, and therefore [we] commit ourselves toPeople who still inject drugs can be involved in the pro-gram. In a "work-first" approach, traditional rehabilita-Harm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1tion models are turned upside down: rather than forcingpeople to be "in recovery" before obtaining work; thisprogram gives people work immediately as part of theirrecovery. In an "employment first" approach, work is apart of the initial recovery process. Rather than being theend destination in their recovery, involvement in salubri-ous activities like harm reduction services becomes one ofthe first steps in the road.The WND provides a 'safe place' where people who havebeen barred from other service locations regularly attend.Discussions on politics, jail, and childhood happen regu-larly, along with conversation around harm reduction.People come and go all night, and sometimes disappearaltogether, often seeking recovery, before returning againpublic education on a variety of other public health issues.The WND outreach workers, by way of example, placeeducational materials about treatment, detox, healthcareprograms, referrals and harm reduction in alleyways fre-quented by IDUs (see Figure 2) The use of posters is aneffective way to reach people who live below the povertyline who do not read newspapers or watch television.The WND provides a range of low, medium and highthreshold employment opportunities that range from pre-vocational skills training stipend positions all the way tofull time employment in delivering harm reduction serv-ices. As of July 2009, there was a total worker pool ofapproximately 70 members, with varying levels ofinvolvement. Some are solely dependent on the WND astheir only source of income, and for some it is purelyabout giving back to their community. For many peerworkers it is a four-hour relief from their daily struggle forsurvival, a place to socialize with peers and take a breakfrom the street. The WND is also one of the only places toobtain work even for those who are physically or educa-tionally challenged. Several workers are amputees, somehave serious weight and heart problems, and some cannotread or write; all such challenges are approached withrespect and a willingness to adapt and be creative. ThePHS Program Coordinator oversees the service delivery,maintains delivery and retrieval statistics. They focus onremoving barriers to service for marginalized IDUs whilesupporting and engaging a range of street level IDUs asparticipants in the program.People with active addictions are recruited from the streetlevel to engage in low threshold positions in syringe dis-WND educational posterFigure 1WND educational poster. A poster placed in the allies in Vancouver describing the services of the WND.Educational poster in an alleyFigure 2Educational poster in an alley. A poster placed by the WND in the allies in Vancouver describing a safer place to Page 6 of 12(page number not for citation purposes)to the WND as a point of connection with the community.The outreach component of the program also allows forinject drugs under the supervision of medical personnel.Harm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1tribution and are signed up on a daily or weekly basis.Many people decide to volunteer after using the servicesthemselves. A person can commit to one shift on a partic-ular given day and be paid the same day. Jobs are distrib-uted at bi-monthly meetings at the WND. Names arechosen by a lottery draw and work amounts on average tothree or four, four-hour shifts per individual in a two-week period. These shifts currently operate between 8 am-12 pm and 10 pm-2 am, 7 days a week and are paid out ina cash stipend. These shifts are flexible as to when theyshould be deployed.Higher threshold opportunities, though still within thelow threshold continuum, are available for those individ-uals who have undergone a probationary period in thelow threshold category. The Peer Supervisor position isavailable to a peer recognized for his or her hard work.Promoted to this position, the peer takes on more respon-sibility following which coordinators regularly observenoticeable improvements in the self-esteem of workers.The Peer Supervisors earn a liveable wage and receive aregular cheque. This has resulted in several peers whohave been able to become independent of income assist-ance and to make significant life changes. Using this "lowbarrier" approach, virtually any IDU who wants a full-time job and is capable of performing one, is able tosecure employment as long as a position is available.The valued collective knowledge of the peer workers isparamount to the success of the program. They are theeyes and ears, the heart and soul, and are always willing toshare their experiences in hopes to improve the program.They are the first to know, for example, if there is a "bad"batch of drugs on the street, if there is a new hotspot forused syringes, and what the specific needs are for them-selves as users and for their peers.Low threshold and inclusiveThe WND is an essential service in promoting harm reduc-tion because it is the only "low threshold" needle distribu-tion program in Vancouver. This means that the programis designed to be completely accessible to all people, bothreceiving and participating in service. Rooted in publichealth, in harm reduction the focus shifts from drug useitself to the effects or consequences of addictive behav-iour. Harm reduction accepts the fact that many peopleuse drugs and engage in other high-risk behaviours, andthat idealistic visions of a drug-free society are unlikely toactually happen. Harm reduction advocates endeavour toreduce the harm associated with drug use, with the possi-bility of ceasing drug use all together [29].A low-threshold environment provides opportunities formany individuals who are not able to participate in serv-ice delivery in other programs for a variety of reasonsincluding active addiction, psychiatric or physical healthbarriers. In addition to creating a diverse service deliveryteam for the WND; this has the benefit of psychosocialengagement for often marginalized individuals. The WNDattempts to create a sense of membership and belongingwhile promoting safe injection practices.Many individuals dealing with active drug addictions inthe DTES experience daily exclusion based on gender, eth-nicity, class, and lifestyle. In this context, VCH strives toprovide a continuum of services that meet a wide range ofneeds in addiction services. To this end the WND is anexample of a service that promotes inclusivity as an activecomponent of addiction services. The WND offers paidwork for participants regardless of gender, levelling thefrequently unequal field of work that regularly findswomen and transgendered individuals performing sexual-ized work in order to pay for their addiction. Because thework is designed to be low threshold, there is no room forexclusion based on ethnicity, class or lifestyle among thepaid volunteers. Ethnicity matters, and health care is often'racialized', meaning that the process of racialization canshape how health providers treat clients or patients [30].Because the peer workers at the WND come from theDTES and are not discriminated based on ethnicity, theyare typically representative of the service population.While there are regular disagreements as in any work-place, generally the WND is able to offer a workplace freefrom discrimination that respects equally both workersand those receiving service.From exchange and centralization to distribution and decentralizationDuring its first decade of operation from 1988 to 1998,Vancouver's first needle syringe program at DEYAS oper-ated using an exchange model. At that time, the needleexchange program was centralized, that is, ostensibly con-trolled by one agency. There were set limits on the syringesthat were allowed by people recovering from addictionand the process of distribution and retrieval were closelylinked in each interaction with IDUs relying on the pro-gram. The syringe distribution program of the PHS wasthe only exception.In 1999, the health authorities in Vancouver began a proc-ess to decentralize needle distribution with a plan to makesyringes available through a variety of government clinicsand non-profit agencies serving active drug addicts. By theyear 2000, the health authority for Vancouver was super-vising the distribution of syringes through health clinics,peer support groups, homeless shelters, non-profit agen-Page 7 of 12(page number not for citation purposes)virtually any individual wishing to become involved. Pro-gram Coordinators in the WND report working withcies and housing providers. This took place against a back-drop of a widespread attempt to place needle disposalHarm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1boxes in healthcare, housing and public settings. Thisprocess of expanding retrieval points for used syringes inpublic places for needles is not unique to Canada. Today,needle retrieval boxes are located in many public placessuch as the bathrooms at the famous San Diego SeaWorldattraction (see Figure 3).In fact, a culture change in terms of our understandingabout the process of retrieving syringes has occurred in thepast ten years in Vancouver. Rather than linking theretrieval process to the point of distribution, the addict,we were separating the process of recovering used syringesfrom distributing new ones. It has become clear thatretrieval of used needles is a practical matter of sanitationand public safety rather than something that has to be tiedto needle exchange. This process was taking place at manylevels. The City of Vancouver, for example, installed a nee-dle receptacle, in the artful shape of a daisy, in a park adja-cent to the Downtown Eastside during this period (seeFigure 4). In analogy, if there is a problem with too muchgarbage in public parks, then it is a suitable publicresponse to install more garbage cans. Similarly, with agoal to recover as many used syringes from the publicspaces as possible, there can be increasing resources dedi-cated to this issue with a practical response: more recepta-cles for dirty needles and more people paid to pick themup with gloves and tongs. Needle receptacles were placedthroughout the public spaces wherever addicts mightrequire them and roving teams called "needle sweeps"were created. The VCH began to keep track of each area ofthe City of Vancouver as a separate zone to determine "hotspots" where more attention to needle pick-up might berequired. Today it is also the standard of practice to installand maintain receptacles to retrieve used syringes withinsocial (government funded) housing in Vancouver.Underlying the disconnection between distribution andretrieval was a change in our understanding with respectto the ineffectiveness of straight exchange. The reality isSyringe receptacle at SeaworldFigur 3Syringe receptacle at Seaworld. A photograph showing a syringe receptacle in the bathroom at the Seaworld public Daisy receptacleFigure 4Daisy receptacle. A repository for used syringes installed in a Vancouver park.Page 8 of 12(page number not for citation purposes)that people who are injecting drugs in unsafe and uncleanplaces are often very wounded people, as indicated byattraction.Harm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1their willingness to purchase illicit substances and injectthese substances into their bodies in very unclean andunsafe conditions. This is not to say that personal respon-sibility cannot be encouraged in the community of drugusers, but to highlight the fact that they are at the edge ofpersonal survival, in a kind of "fight or flight" modality.Like most people, their centre of gravity, per se, is notalways located around an elaborate planning process formaintaining personal health. If not able to meet the rulesof a needle exchange program in order to get sanitaryinjection equipment, some drug users are more likely totake on additional personal risk (sharing syringes).The effectiveness of disconnecting distribution andretrieval can be objectively measured. The process is sim-ple: count how many needles were distributed and howmany were retrieved? This can be expressed as a percent-age sometimes referred to as the "recovery rate". In fact,the recovery rate for the WND is often at 100 per cent (orhigher). This is due to the fact that roving teams recoverlarge batches of needles when an IDU drops them off orwhen a needle retrieval outreach worker pays a visit to theSRA room of an IDU to clear out a large batch (sometimeshundreds) of needles in a single visit. Although the WNDsometimes gives out more needles than are returned, thereare months where the number of "found" needles com-bined with the number of "returned" needles surpassesthe number of needles that are given out. This highlightsthe effectiveness of separating retrieval from distribution.The Division of Needle Distribution and Retrieval in the 21st CenturyNeedle exchange and needle distribution are two very dif-ferent approaches to addressing the spread of HIV andHCV. They are healthcare worlds apart. Needle exchangeinsists that IDUs exchange dirty needles in order to obtainnew needles. There are variations in this approach rangingfrom strict one-for-one exchange rules to more flexibleapproaches that allow pre-set amounts of "loaner"syringes. In a one-for-one approach, IDUs simply are notallowed to have a clean syringe unless they have a dirtyone to trade. In a more flexible exchange approach, IDUsmust, overall, exchange dirty needles for clean ones, butthey are allowed, within pre-set limits to borrow cleanones, as "loaners" as long as they return a dirty one at thepoint of exchange at a later point. These approaches alsoplace limits on the amount of needles that a person canobtain within a given period and, as a result, significantlyreduce the impact of NEPs [13].Various rationales are at the base of exchange approachesto needle programs. The first is that the belief that theretrieval of needles must be embedded within the verytaneously engage in the process of salvaging the sameamount of needles. The process of exchanging syringes ismeant to enforce a kind of personal responsibility for peo-ple with addictions. This would not be unlike making analcoholic bring a wine bottle back before they could pur-chase another bottle of wine. Or, taken out of the addic-tion realm, it would be like enforcing that each time aperson wanted a container of milk, they would have toreturn an empty milk carton, as opposed to current pro-grams that separate the distribution and recovery of recy-clables such as milk cartons and wine bottles.Secondly, this approach aims to enforce the practice ofappropriate disposal of used needles. By providing a kindof "value" to dirty needles, it is expected that people withaddictions will keep them in order to obtain new needles.This model is meant to create a kind of positive economyin dirty needles. People with addictions keep the needlesin their pockets and rooms so that they can use them as acurrency to trade for new needles, despite the obvioushealth hazards that this entails.Thirdly, limitation on the number of needles in theexchange model is meant to promote a kind of closenessor rapport between the person that needs the needle andthe person that is paid to provide the needle. Compellingthe addict to engage the needle provider numerous timesevery day of every week of their life is meant to provide alink to healthcare services such as detoxification, treat-ment or counseling. As such, it is a kind of "forced" prox-imity between healthcare provider as a source of supportand referrals and the person in need. In analogy, thisapproach is similar to a religious organization providingfood to the starving but insisting on some participation inreligious activities in order to obtain the food. The needleexchange provider becomes a healthcare missionary sav-ing healthcare souls as a condition for receiving the gift:the life saving needle.In contrast to these three rationales at the base ofexchange approaches, needle distribution approaches focusprimarily on stopping the spread of HIV and HCV trans-mission by providing as many clean needles as arerequired. This is achieved by providing IDUs with as manyneedles as they need so that they have brand new needlesand injection equipment for each "fix." This approach iscoupled with educating IDUs on HIV and HCV transmis-sion via shared needles so that they are empowered to (a)never share needles (b) return all their used needles todepots or needle disposal boxes, and (c) educate theirpeers about dangerous injection practices. The distribu-tion approach recognizes that it may not always be possi-ble for IDUs to return every single needle to the locationPage 9 of 12(page number not for citation purposes)practice of distributing needles. Each time an addictreceives a needle or a portion of needles, they must simul-it was dispensed from (e.g. perhaps the mobile van is notnearby). Instead, importance is placed on using needlesHarm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1once only, and on their safe disposal to prevent transmis-sion of disease. This approach does not condone injectiondrug use; rather the aim is to respond to a public healththreat in an effective and respectful manner. A key advan-tage of this approach is that IDUs are treated with equalitythat ideally builds trust in the system and allows this vul-nerable population to freely access health care servicesthat will save their lives.It is our experience, through the WND, that the majorityof people with addictions will dispose of their syringesappropriately. They do not, by way of example, have todispose of them through exchange. Many IDUs share thesame concerns about community safety as people withoutaddictions. As such, they concern themselves with makingsure needles are put into appropriate repositories and thatthey are not left in public places (such as playgrounds).This is not to say that there are not exceptions, "badapples" that discard their needles without concern for oth-ers. But, these people, consumed by their own needs at theedge of survival, are not the majority. Retrieving needles isa key component of the WND but retrieval is not con-nected, directly, to dispensing syringes.Sometimes, health authorities embed an exchange ethosinto distribution programs. For example, the monthly sta-tistics form for needle distribution from the VCH carriesan official "performance target" of 90% written at the topof the form. The separation of syringe retrieval and distri-bution through the WND results in the retrieval rate (thenumber of needles collected) relative to the total amountdistributed has remained at over 100% over the past fiveyears of the program operation. That is to say, moresyringes are retrieved than distributed, on average, by theWND. This illustrates that a high "retreival percentage" ofused syringes can be reached without relying on a strictexchange model.The Washington Needle DepotThe WND is innovative in several ways. Firstly, it is a nee-dle distribution program rather than a needle exchange pro-gram- a crucial distinction that goes to the very heart ofhow needle supply programs are delivered. This paperpresents an argument for needle distribution, rather thanneedle exchange, as a standard of practice. Secondly, theprogram makes use of a partnership with professionalswho work alongside "peers," thus drawing on the experi-ence and street level rapport of people with active addic-tions while ensuring the service is delivered at optimumlevels. Thirdly, the program provides immediate jobs forpeople who are actively addicted, many of whom arestreet entrenched. People do not have to go through alengthy training period or program to participate. Theyrecovery process by providing paid employment and vali-dation of peoples' direct life experience in the area whereservice is being delivered. By providing work immediately,in some days on the very same day that a person shows upto a job meeting directly from the street, the programinverts traditional vocational models that demand thatIDUs be living an abstinence based lifestyle before obtain-ing employment. In essence, rather than getting peopleready for work and then eventually giving them employ-ment, the WND gives people a chance work immediately.Work at the WND has a great deal of "symbolic capital" inthat its primary purpose is to save lives as opposed to themore menial jobs typically offered to people with long-term barriers in finding employment [31].The WND draws heavily from the experiential resources ofpeople with active addictions from the community. In itsearly stages, the program was operated in partnership witha peer support organization for people with addictions(VANDU). Ms. Thia Walter, a feisty activist, advocate andelderly mother whose son struggled with addiction, sub-sequently volunteered to assist with the recruitment andengagement of street entrenched injection drug users(IDU) as participants in the program.The involvement of people with active addictions in theprovision of harm reduction accomplishes two goals.Firstly, it validates the experience and humanity of anextremely marginalized group of citizens who face multi-ple obstacles to their social tenure. People with addictionsare welcomed into an entry-level role providing life savinghealthcare. They have access to a range of "low threshold"vocational opportunities that range from being paid forthe day to full time employment. Secondly, the programmakes use of the rapport and credibility of people withactive addictions to reach extremely marginalized peoplewho live in the shadows of the community. Programswith a peer component can be very effective at reachingmarginalized and high-risk IDUs [13,19].Politics and PoliciesIn our view, needle exchange needs to be replaced by nee-dle distribution in every possible instance. Policy makersand professionals are often complicit in all of this, insist-ing on an exchange to somehow make addicts accounta-ble and forcing points of contact with professionals whosometimes feverishly promote the virtues of treatmentand detox [32]. Needle exchange, from this perspective, isa kinder, gentler, approach to enforcement (of commu-nity will with respect to how needles are discarded) andtreatment (referrals to the healthcare system). Yet, thistype of forced exchange would not be tolerated in otherhealthcare realms outside of addiction. Imagine a situa-Page 10 of 12(page number not for citation purposes)can, in many cases, start the very same day that they arrivefrom the street. The job is simultaneously part of thetion, for example, where a heart patient or person withcancer had to exchange their chemotherapy pill bottleHarm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1before receiving a refill. Forced exchange has virtuallynothing at all to do with preventing the spread of infec-tious diseases; it as attempt at imposing the wider com-munity's will upon already marginalized IDUs.Needle exchange may have been a necessary political stopalong the road to adequate harm reduction to address thepandemic of HIV and HCV. In some jurisdictions, evenneedle exchange is not sanctioned. In the United States, orinstance, federal funding for NEPs is not allowed [13]. Butnow that the evidence base has shown us the effectivenessof syringe distribution programs, we need to eliminatemoral and political values that are a barrier to life savinghealthcare in this area. We need to acknowledge thatenforced and restricted needle exchange is, at its founda-tion, public policy formed on the basis of the exceptionrather than the routine, responding to emotive imagessuch as the ever elusive and rare needle that might behypothetically found (or imagined) in a playground.Antagonism towards NEPs can lead to increasing restric-tive operating policies such as strict exchange policies,daily limits on syringes and reduced hours of operation.Yet, there is a powerful association between high-riskbehavior (needle sharing) and problems with adequateaccess to syringes for IDUs [13]. For instance, enforcementinitiatives can have a significant effect on the core opera-tions of NEPs [13,28]. Specifically, police presence candramatically impact the number of syringes that are dis-tributed through a NEP. Even in places where syringes arelegally accessible in Canada, such as pharmacies, therequests of IDUs for these life saving items are oftenturned down [33]. As obstacles to syringes for IDUs ele-vate the risk for the spread of infectious diseases likeHIV[13], these barriers need to be removed wherever pos-sible. One of the areas where service providers can be apart of the solution is to remove barriers associated withmore rigid exchange policies (syringe for a syringe).ConclusionsThis paper provides an overview of the WND, a programoperated by the PHS Community Services Society in Van-couver, British Columbia that shows that the distributionand retrieval of syringes can be separated with effectiveresults. Needle exchanges tend to focus on exchangingclean syringes for dirty ones. However, it is not essential,or necessarily effective, to link clean syringe distributionand the syringe retrieval at the point of contact with IDUs.The WND makes use of the experience of active addicts,through paid employment, to provide an extremely vul-nerable population of people with clean syringes to pre-vent HIV and HCV.relieving pain or prevent deadly diseases like HIV orHCV). The WND makes healthcare contact with anextremely hard to reach population of IDUs. To date,there have been over 2 million syringes distributedthrough the WND and close to 100,000 points of health-care contact over the six-year span of the program. Inorder to achieve this, a number of innovations have beenbuilt into the program. It is a professional and peer part-nership that brings together professional quality assur-ance and peer-to-peer expertise to reach a difficult targetgroup (those IDUs unconnected to healthcare in anyother way). Further, it operates during the most difficulttimes (between midnight and 10 am) and in the most dif-ficult of places to reach with traditional healthcare (e.g.alleyways and SRA hotels). Unlike more institutionalmodels where IDUs are expected to come to healthcarecentres and wait patiently for service, the WNP bringshealthcare to IDUs. The program is a decentralized needleexchange (providing needles from a specific location aswell as through roving patrols of harm reduction work-ers), and, equally important, separates the functions ofneedle distribution and retrieval while removing syringelimits.The WND is available when, where and how addicts needthe program, and is flexible in meeting new needs thatarise out of the context of addicts' real, and not imaginedlives, where illness and the risk of it exist in the life worldof the IDU rather than the clinic. The program operates 24hours a day with a critical coverage during the late nighthours in difficult to reach parts of the inner city. It reachesthe most vulnerable addicts, immediately, with healthcare(e.g. clean syringes, referrals to detox and treatment, peersupport and first aid) as well as entry-level work opportu-nities. The WND recruits active addicts directly from thestreet to be a part of delivering harm reduction servicesthat draw on their skills and experience. The programbuilds on the experience and rapport of people with activeaddictions in order to reach a vulnerable populationwhile maintaining high levels of quality assurance withprofessional oversight. The centre of gravity for syringedistribution programs needs to shift from politics to epi-demiology. In order for this to be accomplished, needleexchange needs to be replaced by a needle distributionmodel (unlimited access to syringes). The WND providesa case study for a needle distribution program with thefundamental goal of fitting itself to injection drug usersrather than forcing injection drug users to fit to a program.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsPage 11 of 12(page number not for citation purposes)Throughout their history, needles have been employed inhealthcare in order to alleviate suffering (e.g. to assist withDS wrote the first draft and AG collaborated on subse-quent drafts. GR and TW drew on their considerable expe-Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Harm Reduction Journal 2010, 7:1 http://www.harmreductionjournal.com/content/7/1/1rience with syringe distribution and retrieval programs toprovide observations that strengthened the final versionof the paper. All authors read and approved the final man-uscript.Additional materialAcknowledgementsNo funding was obtained in association with the writing of this paper.References1. Vodden C: Licentiate to Heal: A History of the Medical Council of CanadaOttawa: Medical Council of Canada; 2007. 2. 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Bluthenthal RN, Kral AH, Gee L, Erringer EA, Edlin BR: The effectof syringe exchange use on high-risk injection drug users: acohort study.  AIDS: Epidemiology and Social 2000, 14:605-611.20. WHO: Evidence for action on HIV/AIDS and injecting druguse, Policy Brief: Provision of Sterile Injecting Equipment toReduce HIV Transmission.  2004.21. Syringe Exchange Programs   [http://www.aafp.org/online/en/home/policy/policies/s/substanceabuse.html#Parsys0020]22. AMA: Report 8 of the Council on Scientific Affairs (A-97):Reduction of the medical and public health consequences ofdrug abuse.  American Medical Association 1997.23. Syringe Exchange Programs   [http://www.cdc.gov/idu/facts/aed_idu_syr.pdf]24. NAS: Preventing HIV Infection among Injecting Drug Users in High RiskCountries: An Assessment of the Evidence National Academies of SciencePress; 2006. 25. ASAM: American Society of Addiction Medicine Public PolicyStatement on Access to Sterile Syringes and Needles.  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