SALT LAKE CITY — The Carbon County Sheriff's office will now allow the nonprofit Utah Harm Reduction Coalition to bring needle exchanges into the county under an agreement reached late last month.
The breakthrough comes after protracted negotiations with the Carbon County Sheriff's Office over a 2016 Utah law that legalized needle exchanges to limit the spread of HIV and hepatitis C, as well as deadly infections.
The standoff centered on whether the new law legalized only sealed syringes, or whether it also included critical preparation materials such as clean cotton, sterile saline, adhesive bandages and clean bottle caps used to cook heroin.
Mindy Vincent, executive director of the Utah Harm Reduction Coalition, said she was “ecstatic” at the compromise the allows the distribution of needles but not to distribute related paraphernalia in a county that has the highest rates of opioid deaths in the state.
“Basically, both sides have agreed to follow the law as written,” said Rep. Steve Eliason, R-Sandy, who sponsored the 2016 law that legalized needle exchanges and helped broker the agreement with Carbon County.
Still unsettled are differing views of the health and public safety risks in making needles and related sterile materials available to drug users. While Carbon County Sheriff Jeff Wood has agreed to enforce the law, he says he's convinced that providing needles and related sanitary supplies both serve as a “trigger” to drug users who are trying to stop substance abuse.
Most public health experts, however, argue that syringes are part of a continuum of infection that can just as easily be contracted by sharing or using other dirty materials used to prepare the injection.
"There is no evidence that needle exchanges increase crime, recruit new users or increase levels of use," said Monica Ruiz, a professor of public health at George Washington University in the District of Columbia. In fact, Ruiz says strong evidence to the contrary has been accumulating for decades.
"Allowing clean needles but barring clean preparation equipment would be like distributing condoms to fight HIV, but poking holes in them," Ruiz said.
Eliason now faces the difficult decision of whether to try to tweak the law in the next legislative session. Acceptance by local officials and the general public of legalizing needle exchanges remains tenuous, and many advocates fear that an effort to tweak the language could backfire, leading to opt-out provisions that will further isolate vulnerable parts of Utah.
Wood says he hopes that the law will be adjusted to allow counties to opt out entirely. Eliason hopes that doesn't happen, but he understands the fears behind resistance to needle exchanges.
“This is a hard one for people," Eliason said. "It was hard for me.”
A hole in the law
The matter seemed less controversial in 2016 when the law passed legalizing needle exchange. House Bill 308 unanimously passed the House on a 72-0 vote, and a nearly unanimous Senate, 23-2.
Eliason says he pitched the proposal not just as a lifesaving measure, but primarily to protect the public purse. Over 40 percent of those who have hepatitis C, or HCV, which is frequently contracted from dirty drug paraphernalia, are on Medicaid, Eliason said. Powerful drugs are now available, but treating the disease costs around $90,000 per case.
And the state is on the hook for that. “Some states are spending tens of millions of dollars on HCV treatment,” Eliason said.
The public has become accustomed to the idea of needle exchanges preventing the spread of infectious disease, Eliason notes, but the other paraphernalia of drug use remain troubling to many.
Bowing to political reality, Eliason’s 2016 bill focused strictly on needles. It did not extend to related materials. The problem, health experts and advocates say, is that those materials, shared or merely dirty, can be just as dangerous as a shared or dirty needle.
The Centers for Disease Control and Prevention states that "the best way to prevent hepatitis C is to use new, sterile syringes and equipment with every injection."
The medical consensus, multiple experts confirmed, is that there is zero risk difference between the needle and the equipment used to prepare for the injection. Anything that touches the drug or the needle presents an equal risk of infection.
This bifurcation in both policy and the public mind between equipment and needles has resulted in odd paradoxes.
For one, federal policy is now the polar opposite of Utah’s law. Except for a brief interlude during the Obama administration, the federal government has for decades barred use of federal funds for so-called syringe services programs. That changed in 2016, allowing states to use federal grants to support those programs, but not to directly purchase needles.
Under federal law, states may use federal funds to purchase and distribute the "kit," including cotton, saline, bottle caps and bleach — but not the needles. But in Utah state law, programs may distribute needles — but not the kit.
Creating further confusion, local jurisdictions like Carbon County can make their own rules within the state law, which makes it illegal to “deliver, possess with intent to deliver … any drug paraphernalia, knowing that the drug paraphernalia will be used to … inject, ingest, inhale or otherwise introduce a controlled substance into the human body in violation of this act.”
In Carbon County, possessing anything related to illegal drug use — including the bottle cap used to cook the heroin, the sterile saline used for mixing and the tourniquet strap used to find a vein — with intent to distribute is treated as a class A misdemeanor. The only exception is sealed needles, which are legal under state code.
Those same materials are legal in the view of the Salt Lake City Police Department, said detective Greg Wilking. “As long as there is no evidence that the materials have been already used for drugs, then they are just common items,” Wilking said.
At the Fourth Street Clinic in Salt Lake City, a free triage clinic kitty-corner from Pioneer Park, medical director Michele Goldberg pulls out the kit they distribute to addicts. It contains two metal bottle caps, two vials of clean water, a rubber tourniquet, two adhesive bandages, two small pouches of sterile saline, two cylinders of cotton, an antibiotic packet and a vial of bleach with visual instructions.
People are so focused on exchanging needles, Goldberg says, they can easily miss the dangers of dirty materials that are never shared, or of sharing materials other than needles.
"Cooking in dirty water is a huge problem," Goldberg said. "If there is any bacteria, fungi or even bits of glass, all of those things can cause infections." The water needs to be sterile, she said, which means not even using tap water. And residue on the cooker can be just as hazardous. Hence, the sterile saline packets in the kit.
Political realities
Eliason is attuned to concerns from both sides of the issue but is moving very cautiously, recognizing the critical role for education and persuasion before big policy changes are possible.
The truce in Carbon County, Eliason says, is really just a matter of both sides agreeing to obey the law as written. "We may or may not try to modify the law," he said, "but in meantime, stop (distributing the other items.) These items are really helpful, but they are not allowed under the statute."
Eliason says he is considering proposing a clarification of the law in the next legislative session. But like other health officials supporting needle exchanges, he fears that opposition from Carbon County and other sources could lead to a weakening of the existing law if it is opened up for revision.
Dr. Jennifer Plumb, a professor of pediatrics at the University of Utah School of Medicine and the co-founder of Utah Naloxone, sees the experience of gaining acceptance for naloxone as a model for widening the needle exchange law. In 2014, Utah passed laws widening access to the life-saving treatment for drug overdoses. But passing the law was only half the battle, she said.
Plumb emphasized the need for buy-in from local officials. With naloxone, she said, there was initially a great deal of misunderstanding and it took months to get law enforcement to fully embrace the program. Now, naloxone is routinely carried and used by law enforcement throughout the state, and is uncontroversial.
"The last thing you want to do with something that seems edgy or taboo is to tell them what you are going to do because they have to do it," Plumb said. "We want this to be something you want to participate in, rather than just saying this is the law."
But Wood in Carbon County can't imagine any more education on the topic will change his mind. "I can't think of any evidence that would convince me that this is good public policy."