A syringe access program participant is handed a bag of safe injection supplies. Photo by Chris Jones/100 Days in Appalachia.

MORGANTOWN — Sasha Crist stood in the waiting room of the Milan Puskar Health Right clinic in downtown Morgantown during a quick drop-in visit on a February afternoon. She was there to pick up safe injection supplies. No more than five minutes after she entered through the clinic’s glass door, she was sitting in a room with a social worker, firing off a list of needs.

Narcan. Needles — a box of shorts and a box of longs. Condoms and cookers, the aluminum spoons used for mixing and heating drugs.

“Do you need a sharps disposal container?” the social worker asked. 

“Yes ma’am,” Crist answered. “I’ll take one of those, too.”

Crist has been getting needles from this syringe access program on-and-off since it first began operating in 2015. Having struggled with a substance use disorder for more than a decade, she used to visit it for her own safe injection supplies. But now, Crist is in recovery and was back at the program to pick up supplies for friends.

“I’ll be honest with you,” Crist told the social worker while sitting in a chair in one of the clinic’s private rooms. “I’m in recovery because of you guys. I’ll be two years clean in May. But I do have friends who are still struggling and I’m doing this for them.”

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“Having the option of being able to get help… that says something in itself,” Sasha Crist said.

Full-service harm reduction programs — often called needle exchanges — exist primarily to prevent the spread of infectious diseases like HIV and hepatitis C among people who inject drugs. They provide clean needles to people who are struggling so that dirty needles aren’t shared or reused. Decades of research shows that these programs work to prevent the spread of disease and increase access to treatment for people living with substance use disorders.

The science is uncontroversial among experts. But for public officials in many places in West Virginia, providing clean needles to people who are struggling with substance use disorders has remained a point of contention. It’s been a subject of debate, for example, in both Huntington and Logan County. 

This has played out especially publicly in Charleston recently, as the capital city faces an HIV outbreak that top U.S. health officials say is the most concerning in the United States. Experts say that increasing access to clean needles for people who inject drugs will be vital to combatting further spread.

But now, in the midst of that outbreak, a state senator last week introduced a bill that would effectively outlaw syringe service programs in West Virginia, even in communities where they’re already operating with local support. 

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Laura Jones, who leads one of the longest-running harm reduction programs in the state, explains the role that these programs play.

A quick glance around the country, but also around West Virginia, provides plenty of evidence that full-service syringe access programs can, and do, exist without the increase of crime, syringe litter or the much-feared community demise that politicians against needle exchanges continue to preach.

Take the program in Morgantown, just 150 miles north of Charleston.

“People are always worried about syringe litter,” said Laura Jones, executive director of the Milan Puskar Health Right clinic in downtown Morgantown, which operates one of the oldest syringe access programs in the state. “The thought of syringes being around where someone might get stuck is very scary. But the reality is that syringe access programs collect many used syringes, and that there would still be syringe litter in the community if this program didn’t exist.”

Laura Jones is the executive director of the Milan Puskar Health Right clinic. Photo by Chris Jones/100 Days in Appalachia.

When the program first started, Jones said that there was some skepticism about the role syringe services would play in the broader community. But with the support of local leadership, the program persisted and is now a vital provider of health care services to some of the area’s most vulnerable residents.

And Jones said that it’s important to remember that the needles, although incredibly important, are only part of a harm reduction program’s offerings.

Beyond preventing the spread of infectious disease, needle exchanges also help lower overdose death rates by providing access to overdose reversal medications to the people who need it most. And research shows that in communities with programs like the one in Morgantown, not only does disease go down but the number of people accessing treatment typically increases.

That’s because harm reduction programs provide isolated people who are struggling with a point of connection and compassion. They meet people where they are and provide non-judgmental care and wrap-around services like wound treatment, disease testing and vaccinations. When a person is ready, and if they choose it, these programs can provide people with referrals to treatment, too.

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Sasha Crist talks about feeling nervous before her first visit to Morgantown’s needle exchange and how compassion helped her to find recovery.

Sasha Crist is a testament to that. After more than a decade of drug use that started with pain pills as a teenager and escalated to injecting heroin just a few years later, she entered a treatment program and got clean. She said she was referred by the harm reduction program in Morgantown in 2019 — three years after she first stepped through the clinic’s doors. 

“If I didn’t have this program, I’d be dead,” Crist said. “Ultimately it was my own strength that led me to recovery. But this program and the people here gave me the tools I needed to get there.”

‘Inclusive community’

When Jones and her team of medical professionals and social workers set out to open a harm reduction program in August of 2015, they did so with little financial support. 

The free and charitable clinic had been operating in central Morgantown for more than 30 years, providing medical and dental services to the uninsured and those who needed care that wasn’t covered by their insurance plans.

As the overdose crisis devastated communities across the state, Jones and her staff became more aware of the prevalence of disease among the people who relied on their clinic, and they set out to open what would become one of West Virginia’s first syringe access programs.

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Laura Jones talks about launching Morgantown’s harm reduction program in 2015.

“In the first year we had over 300 people,” Jones said. “It’s grown from there.”

The harm reduction program run by Jones and her team is needs-based. That means that in order to receive clean needles, the people who rely on the program are encouraged, but not required, to return syringes. It’s the model that’s endorsed as best-practice by the U.S. Centers for Disease Control and Prevention.

The program is also low-barrier. While some programs require a valid ID, a physical examination or time with a recovery coach in order for participants to receive safe injection supplies, the program in Morgantown does not. Rather, there is an intake process that is encouraged but remains optional. 

With the participant’s permission, volunteers — often people in recovery, themselves — ask questions about housing and medical needs, family planning, “the whole nine yards,” Jones said. That happens alongside questions like  “what supplies can I get you today?” and “do you need any Narcan?”

It’s quick, casual, private and judgment-free. For the most part, people are more than willing to partake.

If a person wants to stay and talk with a recovery coach, the option is there. If they need additional medical care, the option is there. If they want to be tested for sexually transmitted diseases, hepatitis C or HIV, the option is there.

And if they just want to come in, get the supplies that they need and leave without further interaction, that’s fine, too. They’re handed a bag of supplies with a smile and as quickly as five minutes later, they’re on their way. 

“Be patient with patients who are not patient,” reads a sign in the Milan Puskar Health Right. Photo by Chris Jones/100 Days in Appalachia.

The program gets results. While there have been HIV outbreaks in both Cabell and Kanawha counties in recent years that rival case numbers in metropolitan centers more than 20 times their size, Monongalia County, where Morgantown’s program operates, averages fewer than five new HIV cases linked to injection drug use a year. It is one of the least vulnerable counties in the state to the spread of rapid hepatitis C.

Despite distributing the most  syringes in the state annually for the last five years, the program has received little pushback from the community. Businesses in the county remain open and unscathed — leaders in Charleston have suggested the distribution of syringes would be devastating to downtown —  and some local businesses even offer their support. 

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Laura Jones explains reason why needs-based programs are best-practice.

On a Wednesday night in February, a worker from a local bakery stopped by the Morgantown clinic with a bag full of rinsed and emptied plastic bottles — those which used to hold laundry and dish detergent — that could be used as syringe disposal containers.

“We heard you guys needed plastic containers so I wanted to bring these by,” said the woman from the bakery. “We saved what we had. Hope it helps!” 

“This is awesome,” said the nurse who answered the door. There had been a back-order on syringe disposal containers; the clinic’s staff posted a call-out on Facebook looking for alternatives that could be used in their place. The call was answered.

In addition to help from Morgantown businesses, medical and pharmacy students volunteer to help with syringe distribution and medical care. Local churches have rallied behind the program, too, volunteering and donating snacks and clothes for participants. Just last month, a downtown church was vandalized in the night. Instead of asking for help to repair the damaged building, the congregation asked for donations to be sent to the needle exchange.

Jones said that she’s thankful for the community support. It was essential for the program’s success, and it’s one key difference between Morgantown and Charleston, right now. 

But Jones said that gaining that support begins with local leadership. 

“We, in Morgantown, have a huge sign as you roll into town that says this is an inclusive community,” Jones said. “And if we really mean that, it means including people that you’re frustrated with, or afraid of, or concerned with their behavior.”

A syringe access program participant speaks briefly with a social worker about safe injection supplies during a harm reduction clinic at the Milan Puskar Health Right. Photo by Chris Jones/100 Days in Appalachia.

After the program launched back in 2015, Jones and her team spent a lot of time educating local leaders. They spoke with the city council, with local business people, and explained the science behind their program and why it was necessary. The leaders listened.

The program also had the support of the city police chief, as well as the county health department.

“County health departments are required by law to protect the public, prevent disease and promote public health,” said Dr. Lee Smith, who has served as executive director of the Monongalia County Health Department since 2015. 

Smith said that if officials follow those mandates that are obligated by law, supporting syringe access programs is the obvious and ethical decision.

Although the health department does not run or oversee the syringe access program operated by Milan Puskar Health Right, Smith said the program works alongside the health department’s Quick Response Team to help combat the opioid epidemic by offering compassion and support to residents who are struggling.

And while syringe litter has yet to ravage the city, overdose deaths are lower because people who are struggling have access to lifesaving services. Jones said because the program was embraced in Monongalia County, she and her team were able to focus on expanding services to other counties in the region, too.

Through mobile distribution, the syringe access program now provides safe injection supplies and medical care to West Virginians living in Preston and Upshur counties. When they first introduced the services to those communities, Jones said there was some initial pushback, but that settled down.

“We persisted and the health departments [in those counties] persisted with us,” Jones said.

‘When I’m ready’

In a presentation given by the CDC to Kanawha County’s HIV task force, members of city council, members of the Kanawha-Charleston Board of Health, and Charleston Mayor Amy Goodwin last week, the agency highlighted the need for the quick implementation of needs-based syringe access programs — like the one in Morgantown — in order to contain the HIV outbreak in West Virginia’s capital city.

“We’re seeing a decline in the progress that we have made since the 1990s in HIV diagnoses linked to injection drug use,” said Dr. Demetre Daskalakis, the head of HIV prevention for the CDC. “This is a rapidly increasing outbreak. [There is] a need for enhanced urgency.”

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Dr. Demetre is the head of HIV prevention for the CDC.

Daskalakis said the work of syringe access programs in response to the crisis comes in two forms. The first is making sure clean and sterile syringes are widely available. The second is providing increased access to testing for HIV and hepatitis C, and connecting people who are positive with medications that help suppress the diseases.

If lawmakers pass Senate Bill 334, programs following CDC recommendations would become illegal and could face thousands of dollars of fines. That, according to experts, would be devastating to communities across West Virginia and beyond.

“This matters to the whole country, not just West Virginia,” wrote Gregg Gonsalves, a professor of epidemiology at Yale University’s School of Public Health, in response to the bill. “We have to be serious about ending epidemics, not perpetuating them with bad policies… What a disaster.”

Gonsalves, who is a world-leading expert in HIV prevention and has received a MacArthur “genius grant” for his work, has called for the bill’s retraction. 

The bill was introduced by Sen. Eric Tarr (R-Putnam), who did not return a request for comment.

But while debate in the Capitol is ongoing, back in Morgantown, the Milan Puskar Health Right continues to serve as an example of the good that can happen when communities make public health decisions driven by experts rather than fear. 

It was through that program that Sasha Crist’s journey to recovery began.

A reflection of Sasha Crist as she stands in the lobby of the syringe access program in Morgantown. Crist, who is a person in recovery, was referred to treatment by the program in 2019. Photo by Chris Jones/100 Days in Appalachia.

Crist had visited the syringe access program in Morgantown periodically since it opened in 2015. But circumstances in her life kept her from using it routinely, and as a result, she still ended up sharing and reusing needles from time to time.

“I was in a really dark place,” Crist said. “Drugs fade you. You don’t understand it until you’ve been there, but I’ve been to the point of using toilet water [to help inject] before. That’s not something I would ever do in my right mind.”

At some point she contracted hep C. Initially, she didn’t show symptoms of infection. But when Crist stopped by the clinic in 2019, her leg was two times the size that it should have been. 

She wasn’t at the clinic that day to seek medical care; she was there to pick up some Narcan and a bag of clean syringes so she wouldn’t have to reuse needles when she injected heroin later on. But when a nurse recognized the swelling — the result of a blood clot brought on by infection — she helped Crist get to Ruby Memorial Hospital. 

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“In May of 2019, I was dying,” Sasha Crist said.

There, she got treatment for endocarditis, an infection of the heart’s lining caused by bacteria entering the bloodstream and not uncommon among people who share or reuse needles when injecting drugs. She also got treatment for the hep C. The doctor told her he was glad that she had made it there; if she hadn’t, she would have died. 

“My family had just lost my mother not even two years prior. I didn’t want to put my family through another death,” Crist said. “I got the drugs out of my system and I was like, wow, I don’t want to go back to that. I want this for me now.”

Crist completed a six-week recovery program and she’ll be two years clean this May. She said if it hadn’t been for the harm reduction program offering clean needles, she wouldn’t have ever made it to a clinic or been connected with care.

“It took me almost 15 years of using before I was ready for help,” Crist said. “It’s up to the user when they want to quit, but having the option of being able to get help like what Health Right offers, that’s something in itself.”

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“It’s sad that there are places in West Virginia that closed down needle exchanges,” Sasha Crist said.

On the February day that Crist came back to the program to pick up safe injection supplies for her friends that still use, she couldn’t help but smile as she chatted with the worker who helped her get supplies.

“It’s crazy. I used to come in here and I was usually high,” said Crist, her choppy blonde hair falling over her right eye. She was sitting in one of the private rooms.

The worker smiled.

“At the end of the day it’s my strength, but you guys led me to it,” Crist said.

“That’s what we’re here for, hon,” the worker replied.

She handed Crist a white paper bag. Simple and full of life-saving supplies.

Lauren Peace is a Report for America Corps Member who covers public health.