The COVID-19 lockdown has reminded David Galorath how painful it can be to inject heroin with a dull needle.
"It sucks," he said. "That hurts. It hurts your body."
So in early April — with his supply of fresh syringes for his heroin use dwindling as needle exchange sites closed due to staff shortages — he attempted a dangerous do-it-yourself way to sharpen his old ones at home.
"A buddy of mine said, 'You can do it on a nail file, one of those big ones,'" said the 41-year-old former waiter who said he perfected the technique through trial and error. "I started sharpening one, and that thing was like sandpaper."
"It was all because the place closed," Galorath said of the state-funded exchange site.
Government-funded needle exchange programs — such as the Community Outreach Intervention Projects' storefront that serves Galorath — have cut services and closed exchange sites due to staff shortages and safety concerns as the virus sweeps the nation, so far killing more than 70,000 in the U.S.
In fact, the amount of needles exchanged by the Chicago program in March plummeted by more than 78% from the year before. It has left hundreds of high-risk users to fend for themselves — more likely to reuse or share needles and unable to get the help on which they have come to rely.
"Am I worried about it? Yeah," Galorath said of the COVID-19 outbreak. "But I'm not like, overstressed because we're all going to die of something, right?
"Hey, I'm a drug addict, dude."
That needle exchange programs — established decades ago specifically to slow the spread of the HIV epidemic — would now cut back in the face of yet another deadly disease is an irony not lost on public health experts who said drug users are at higher risk to themselves and others during the pandemic.
Staff reductions at COIP prompted it to close two storefront locations, in South Chicago and Humboldt Park, and reduce hours at three other storefronts, while also halting daily mobile efforts on the South and West sides. The Chicago Recovery Alliance, a mobile needle exchange and delivery operation, cut visits to two of its less-frequented sites and stopped providing supplies to another exchange in Edgewater, which also closed.
The programs — which together supply more than four million clean needles every year to the more than 10,000 injection drug users in the Chicago area — reported significant declines in the number of people the exchanges have served so far during the pandemic.
A newly published study from New York University revealed about half of 173 addiction aid organizations responding to a nationwide survey decreased their services due to COVID-19. This is sparking concerns of increases in overdoses as well as future HIV and Hepatitis C outbreaks caused by needle sharing and the absence of testing for these diseases, which are typically performed by the organizations.
One of the study's authors said in an interview that drug users left to fend for themselves during the pandemic could also become a "real reservoir" for COVID-19.
"There is a real concern that this could be a population among a bunch of other low-income populations where COVID could potentially have a very drastic effect and that the coronavirus would not stay contained within these high-risk populations," said NYU epidemiologist Don Des Jarlais.
Des Jarlais said that drug users are more at risk of an HIV or Hepatitis outbreak without clean syringes. They also have a difficult time social distancing and may be more at risk of contracting COVID-19.
Des Jarlais' study found one in four of the organizations surveyed reported shutting down sites for safety precautions and a lack of staff, and most reported a decline in the number of clients served since social distancing measures took effect.
In Chicago, directors at two of the region's busiest needle exchange programs said they were forced to scale back their workforces because many of their employees are in high-risk groups for COVID-19.
Some are older, having played an instrumental role in establishing needle exchanges during the AIDS and HIV epidemic of the 1980s. Others have auto-immune disorders or are recovering drug users themselves as both organizations make a practice of hiring people who can identify with clients because of their shared understanding of street life.
Brandie Wilson, Chicago Recovery Alliance executive director, said that maintaining pre-COVID-19 staffing levels during the outbreak is "non-negotiable."
"We deeply care about the people who built our organization and help build our movement and we value their lives and so do they," she said. "So we all agreed we would act as leaders and take the proper precautions to not impact health care as well as to prevent potential life loss within CRA."
Her program, funded with more than $1 million in state and city grants each year, has been operating with half the regular staff since March, but CRA officials said their services have been largely uninterrupted. Wilson said the number of clients CRA has served is down 18% from the same period last year, while the number of overdose medications it distributed was up about 11%.
At COIP, which is affiliated with the University of Illinois at Chicago, staff is down about 80% to only eight employees, according to program officials. COIP also receives about $1 million in city, state and foundation grants annually.
COIP exchanged only 5,062 needles in March, down from 24,086 in March 2019, according to program officials. Secondary exchanges, where a person deposits and collects needles on behalf of themselves and another person, fell by 40%, from 410 to 246. Overall, the number of COIP's clients plummeted nearly 70%, from 252 to 76.
COIP director Antonio Jimenez said the public health crisis also has spurred COIP to give its clients extra needles and overdose medication to try to keep them safe and at home.
A lack of access to clean needles can contribute to viral outbreaks, especially as more people become addicted to powerful prescription painkillers and shift to heroin, experts say. One recent example was in Scott County, Indiana where a state prohibition on needle exchanges — and a slow effort to rescind the prohibition by then-Gov. Mike Pence — contributed to an HIV outbreak beginning in 2014 that infected more than a hundred people, according to an academic study and news reports.
"If they don't get their needles, they're going to share," said Keith Adams, a COIP client. "They need the needles and that keeps them from sharing. It's going to happen because they get that craving and they're going to share needles. The craving is real strong."
Adams is homeless. At night, the 49-year-old who dropped out of high school as a sophomore sleeps on a couch in an enclosed gangway near the COIP site. For the past three months, he's been visiting the COIP site to obtain prescriptions for Suboxone, an opioid addiction replacement drug he takes instead of heroin, a drug he had used for 30 years.
"With me being a drug addict, I need these people to help me because I'm a heroin addict and they give me Suboxone to keep the cravings of heroin away from me so I won't pick up and use," said Adams.
Anticipating a possible disruption in the heroin supply chain, workers at COIP have encouraged clients to switch to Suboxone, typically administered through a strip or pill.
According to news reports, COVID-19 has already disrupted the street trade of synthetic opioids because many of their ingredients are manufactured in Wuhan, China, where COVID-19 is thought to have started. The sudden absence of heroin could have calamitous repercussions.
"You may have people going through severe withdrawal symptoms and a lot of desperate circumstances call for desperate measures," said longtime COIP employee Tryce Johnson, who works at the Austin site after the location in South Chicago closed due to the pandemic.
For now, Chicago's narcotics black market is alive. Chicago Police have set up multiple checkpoints on the West Side due to gang activity and drug sales, and workers with COIP and CRA said they have witnessed hand-to-hand drug deals and drug users congregating on their way to work.
According to records obtained by the Better Government Association, more than a quarter of all 311 calls that were referred to Chicago police in March 2020 — the first major month of the Gov. J.B. Pritzker's stay at home order — were for drug use and sales.
While millions of people shelter in place, many heroin users cannot.
"They're up against it on every front right now," said John Gutenson, a senior outreach worker with CRA. "You have to have a whole sh--load of money to stock up on the things they need. That's not generally how it works. They don't have the big ATM card and the big bank account because of their situation."
COIP's clientele has gone through a dramatic transformation since it opened in 1986 to fight the HIV and AIDS epidemic. Increasingly, the people who are stopping by the site to exchange needles are white and suburban as opioid use skyrockets outside the city's borders and suburbanites commute into the city to buy drugs.
Basmattee Boodram, a UIC epidemiologist whose research is conducted in collaboration with COIP, has spent years studying the changing social networks of heroin users. Her work focuses on the shift of first-time users from urban to suburban, and the spread of disease.
"People initiating injection right now are not likely to be urban or black," Boodram said. "That's a major shift from the '90s and '80s. That geographical shift had some impact on disease and transmission as you spread out into different geographies where it's harder to reach people.
Nick Litrento commutes to the COIP site from his home in the suburb of Roselle, west of O'Hare Airport.
At 36, he has been using heroin for seven years. He switched to the street drug after getting a prescription for Percocet due to a back injury incurred at his shipping and receiving job. Litrento has taken basic COVID-19 precautions such as wearing a facemask when he commutes into the city.
Programs designed to reduce risks for those with heroin addictions, such as COIP and the CRA, are a last ditch safety net for many people, he said. In early April, he stopped by to exchange syringes and to have an onsite doctor examine his swollen leg.
"Once these people are out here and they are out on the streets, they literally don't care," Litrento said. "There's no support system. Why care? They are going to die out here anyways, probably alone. If these places close, it will make sh-- really hard for them."
Galorath doesn't sharpen his old needles at home now, since he discovered the exchange is still open on limited hours and days.
That's where the BGA caught up with him as he dropped off a paper bag of old needles at COIP's storefront in Austin for a fresh supply.
"I eventually called and found out the new schedule. Now I try to get enough for the new week," said Galorath, a drug user for more than two decades.
He explained how when he tried sharpening the needles himself, he filed too much the first time, the needle split, and the liquid shot out in three directions.
"I did use one that I filed down, but I learned from the first one," Galorath said. "I did get it correct. I am pretty sure."
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