Johnny is the exchange coordinator for the syringe exchanges run through Outside In, a free clinic and service agency near downtown Portland. Outside In specializes in working with homeless (and often transient) youth.

I started out as an EMT working in an ambulance in Albuquerque New Mexico. I worked, I ended up doing that for about four and a half years. By the time I left New Mexico I was moonlighting as a waiter in a café one summer waiting for school to start and I developed a relationship with some customers of mine who used come in every Tuesday for a meeting that they would have at the café. After getting to know them, I realized they were an outreach team for a HR outreach program in Albuquerque. The leader of the team who has done a lot of amazing and good things for harm reduction asked me what I was doing with my life and I told her I was an EMT and waiting for school to start back up and she got excited about that and said I could volunteer. She asked me if I would do blood draws for them. SO I started with Healthcare for the Homeless which started their needle exchange program in 1997.

They had a really interesting program. After volunteering there for a while I got to know their program pretty well and a position became open and Maureen offered me the position. I took it but still worked with the ambulance at the same time. That lasted about six months and out of pure exhaustion I decided to work with Healthcare for the Homeless and just work every once in a while as an EMT.

At the time I joined, the program went from exchanging 45,000 syringes to a quarter of a million. The year I left we exchanged 420,000. We were doing great work. That was about the same time Governor Johnson came out in support of decriminalization and legalization. It was a very sexy idea at the time so we got a lot of publicity. NPR came down and did a ride along with us. The governor came out to the exchange as well.

That was the breeding ground for my introduction to harm reduction philosophy.

I went from that tiny program to a huge program two years later doing needle exchange up and down the drug corridor in Albuquerque. We opened up an entire HR center with syringe exchange 9-5 everyday, showers, acupuncture, detox, a garden program. It was really an amazing time. After I left, I decided to go back to school to finish my degree and went back to working ambulance full time. I had a whole different perspective on injection drug use and Harm Reduction.

Growing up and learning the EMT skills you have a certain mindset to injection drug use. I remember my first call as an EMT was a heroin overdose. It really impacted me at the time because I was a young 20 year old kid who didn’t know anything. I was really moved by watching this woman die with her children there and realize it was totally preventable. Then I had the privilege of one of the last calls I worked before leaving New Mexico for Portland, while with Healthcare for the Homeless we had put together overdose prevention classes- we would take popular opinion leaders from the community and train them how to do overdose prevention and rescue breathing, with naloxone and that sort of thing. One of the last calls I worked was a heroin overdose. I walked in and it was like a man hunched over another man administering rescue breaths. We walked over and the guy looked up and I recognized him as one of our peer educators. He said, Johnny, I did exactly what you told me, I keep giving him breaths. We administered naloxone and the guy was fine. The guy’s overdose was reversed. That’s when I really squared my faith in Harm Reduction- when it solidified and I realized the work we were doing really affected people. That was March of 2002.

I had come here for a syringe exchange conference in 2000 and fell in love with the place. It’s beautiful and progressive and all of that. After I decided to move to Portland I figured there was two things I could do- do EMT or syringe exchange. I wanted to do syringe exchange.

I became the syringe exchange program coordinator at Outside In. The list of qualifications was basically my resume. I was perfectly fitted for it.

We administered naloxone, but what had happened was that the woman hadn’t been using for several months and her tolerance had adjusted. Well, she naively administered her regular dose from when she was using a lot.

I was so affected by the call that I read her obit. I probably got way too emotionally involved with it. It is such a strange thing to watch someone die. She was the first person I ever saw die. Just being a kid, it was really wild. Her whole family was there, there were a couple of kids, she was a young woman. We did administer naloxone, but she had been down too long. She used alone, she had locked herself in the bathroom and used, which is a rule that we teach people in the HR classes- to try not to use alone, and if you do, call someone to check on you. Watch your dose… There’s so many rules we teach people in the classes that she never got an opportunity to learn.

Q Differences between Albuquerque and Portland

Our program is super busy. We saw a lot of people back in NM, but we had two components. The stationary exchange and a mobile unit that would go out and do exchange. Here we just have the office- so we see 100-120 people a day inside of five hours. So that means we have less one on one time with folks, which has been a real challenge for harm reduction. Back in New Mexico I had plenty of times when I talked to folks, I could do an intervention. Here, there’s just way more people, the volume is higher.

We are in the back of what is perceived by the community pretty much as a medical clinic which has it’s positive and negative points. IT is a little sterile for a lot of folks in our target community. The positive is that being part of the clinic, we get the medical care when they need it which is a really positive thing. Basically our clients here have medical care on demand. Whether they have illness related to injection or not- foot issues, internal health, eyes, women’s issues, we can refer them to the clinic and they can see a doctor within minutes.

In New Mexico our mean participant was between 35 and 45, male, Hispanic. That’s who we mostly served. Here, our target population is younger, our average person is between 25 and 35, he’s white and male. We see about 65-70% male. As far as the substance use here, it’s much different. In New Mexico it was 90% heroin. Here, it’s about 65% heroin. There’s more methamphetamine in Portland than there was in New Mexico. There’s a lot of transient population in Albuquerque- it is the biggest city, but that is even more so here- we are the only big city between Seattle and San Francisco. We get a lot of super young people coming in which we rarely saw in New Mexico. We see people 18-20, 21, 25. Self identified as “gutter punk.” That was novel for me when I came- to see young people using.

I would like to think that we are capturing a lot of the street culture. Outside In is identified as a homeless youth service agency. We get a lot of homeless youth here using the exchange. But the young, disenchanted punk scene is just very big here.

I think there is a bigger, younger population that is using here and they are definitely accessing our program.

Q: What is the HIV prevalence among IDU’s in this area?

That’s really hard to nail down. We did a study with a HIV testing company. We randomly picked 100 of the people coming in to the exchange and we had a 2% sero-prevalence rate. That’s the closest we’ve had here to a study.

The only other data that we have is when people self-disclose. Another slim sliver is how many people we test who actually test and come out positive- that is less than 1%. Self-disclosure isn’t recorded though. Anecdotally though, it is very rare that we find people who are HIV-positive. My best guess is 2-5%. Which compared to New York City or New Jersey or even San Francisco is really amazing. But one historical fact is that we have had syringe exchange a really long time here- since 1989. That’s one of the differences in having a low sero-prevalence rate. We were one of the very first exchanges. HIV had a lot longer time to settle in those communities.

Q What is the street price of a syringe?

I have heard anecdotally they go for around $1

The state decriminalized syringes- declassified as paraphernalia- back around 1989. So there is no penalty for having a syringe on your person. That doesn’t cover residue though and we have some police confiscating syringes and sending them to the lab and trying to press charges, but clients have told me that usually doesn’t stick because they have to be tested three times and their usually isn’t enough for that. But some cowboy cops around here have tried to issue citations for attempted possession of controlled substances- those never stick, but they are a huge nuisance.

Q: How many syringes do you exchange in a given year?

As simple as that should be to answer, it has gone up so much it is hard to answer- last year we did about 465,000. This year we are on par to do over 500,000. We’re growing which is really strange because we plateaud in the mid-90’s. We have about 22,000 interactions this year with people- up from 19,000 from last year. We also really emphasize secondary exchange.

Q: Is treatment available around the Portland area?

Like most places, treatment is pretty sparse. We average about 20-25 treatment referrals a month. We also average about 30-45 medical referrals for folks that come in and actually get to be seen by a doctor. Treatment referrals are one of those things we don’t offer until people ask. Once people self-identify as interested then we offer, otherwise we just support them. We did 226 drug and alcohol referrals last fiscal year.

If you don’t have insurance, and the state of our Medicaid program in this state is pretty bad. OHP just cut more than half of the people enrolled. OHP cut medical coverage for all low-income Oregon citizens- it cut over half of the roster. That being said, treatment options for people aren’t that great. There are a couple of detoxes people can go to for a week or so. There are 4-10 week waiting lists for in-patient detoxes. So the MO now is go to Hooper Hospital’s detox for 5-6 days and then try to find a place to stay while you do intensive out-patient and you try to prove yourself so you can get into in-patient treatment. There are a few residential facilities where you can actually live in an apartment with medical staff on site. It’s not great here.

Where people fall through though- most of our folks are homeless or near-homeless. So first of all, you have to go to Hooper by 7am, so people need to line up by 530am to even have a chance of getting in. It is far away and hard to get to. People tend to have to wait for 4-5 days to get in. After the week of detox people get kicked out and can go back to their camping spot, but there are a lot of people using there and there is nowhere for them to go. Nine of 10 people fall back into use. There is just nothing for them in between. People need long-term, in house rehabilitation, often with mental health services. Old habits die hard. There’s a huge gap of treatment, it’s very discouraging for people.

A lot of folks eventually realize they are not going to get any help. The option is to continue using or try to quit cold turkey. It is an extremely difficult situation. People have nowhere to go and these are folks who are genuinely interested in getting clean. One side effect of the DW is creating this whole mystery around drug use, demonizing drug users, the people who come in my doors are not demons, they are broken, they are shattered, they need help and the entire world is treating them like they’re monsters, like they are garbage. There is nowhere for me to tell them to go. There is no system in place to help them. Oftentimes we can just offer an encouraging word, or basic medical help. But people need long-term completely supportive medical mental health treatment. People here are very discouraged, suicidal. They are dejected. People are in their 40’s looking like they are in their 60’s because the lifestyle is so difficult. It’s the lifestyle, not the drug use that makes people age so quickly. Heroin is fairly innocuous as far as the body goes- it’s not like other drugs like methamphetamines. But the social and legal implications are totally destructive. We are dealing with broken souls everyday.

Q: If someone is genuinely interested in entering treatment, what keeps them from getting a job and using that money to pay for a private program?

Not only is there no system for treatment, there is no system to help people transition out of homelessness. The systems in place are inadequate. When someone does express and interest in getting a job, what is the first thing people ask for on a job application? A home address. That something so minimal as having a place to receive mail or get a call is a very difficult thing. People who have been living on the street also show the wear of the road. It is very tough to pull off a good interview. They lose some of those marketable skills. Vocational and educational rehabilitation programs in this city just don’t exist. They aren’t many programs where people can walk in and say, “Hi, I’m homeless, I am missing most of my teeth, have no address or phone number, can you help me get a job?” There are a lot of issues there.

While it might seem simple to say, “Pull yourself up by your bootstraps, make your way” it just doesn’t work. It’s not realistic in our society- that ethical/egoist approach that each person is responsible for their own destiny. We have to help people and people often need the help and assistance from their community to make meaningful changes in their lives.

Those programs are just not in place and those that are, are too stressed to do a lot of effective work. Can you imagine someone who is haggard and who has been beaten down by the road for years, with drug use and prison terms, can you see them coming in and asking for an application? It’s just not reasonable. A lot of our folks have gotten facial tattoos, some are missing extremities from being on the road, it’s just not practical.

Q: Has their been an impact on the ground because of the cuts in OHP?

Absolutely. In March 2003, OHP went through several changes. I think it’s over half now- March was the first big shift, they cut a majority of ancillary services including methadone coverage for people who had been on methadone for years.

Folks started showing up at the exchange who had been on methadone for 5, 6, 7 years. They started chipping and their habit kicked back in or they were using methadone and involvement in that program was the backbone of their sobriety and it got kicked out from underneath them. We saw significant numbers of people who hadn’t used in a long time before that.

Consequently, OHP took several other belt-tightening measures. They were ultimately forced to reduce membership to 25,000 for the entire state within six months of now. They have left a lot of people off. The only people who can sign up now have to be underage and pregnant, or some other extreme qualifications.

At the clinic we are busting at the scenes because of it- they can’t get seen anywhere else, but we are a free clinic.

CODA opened 30 slots for people who had been kicked off from methadone- somebody found a little bit of money somewhere, but that is a drop in the bucket, the vast majority are going without it.

Q: How many injectors are in Portland?

Someone from the State of Oregon once estimated to me in private that there are 15,000-20,000 injectors in the state, but that is not an official number. I would guess between 5,000-10,000 regular injectors.

We have seen around 2,500 unduplicated participants in a given year, but that is a very rough count.

Q: What public don’t understand about NEX? Misconception?

I think what I alluded to earlier, the demonizing of injection drug users-

Reexamine what we have been fed about who drug users are. The fact is that most injection drug users in America are fed and housed. I would really challenge people to do some real deep thinking about stereotypes that we hold for injection drug users and homeless people in general. It was an eye-opening experience for me starting as an EMT in the medical field- there is a lot of prejudice, institutionalized prejudice against homeless drug users, because especially emergency medicine folks, we deal with homeless people constantly. I had bought into that prejudice for a long time. I realized doing this kind of work that what motivates people to use, what sorts of issues people are having, organic issues, experiential issues they’ve had in the past that leads them to use- was an epiphany- that there’s such a thing as really good people who use drugs.

I was raised in the Reagan era- the Just Say No era. Question your stereotypes about drug users before you decide that someone out of fear is a bad person. If people can overcome that, then perhaps we can go to the next level of institutionalizing helping people. Making an institution out of the treatment system. A more effective system. A system less focused on punishing people for addiction and more interested in helping them through addiction.

I would really challenge people to be more human, especially law makers. Some of them have really stepped up to the plate- Larry Campbell, the mayor of Vancouver with Safer Injection Rooms.

I would really hope that we look critically as citizens at our policies.