The people who care: How harm reduction strategies for those who use drugs bloomed in the region

Daryl Hams saw a discolored bandage poking out from the man’s sleeve. The bandage covered a festering abscess. A wound from a contaminated needle. The man had had it cleaned at a hospital but hadn’t yet picked up antibiotics prescribed for him. Daryl, who had never met the man before, handed the stranger fresh bandages, cleansing packets, and urged him to get and take all the antibiotics.

Still, Daryl could not stop thinking about the young man.

A nurse, Daryl bought wound-care supplies and carried them in a kit for three weeks, hoping to see the man again.

Quick look:Harm reduction history in Greater Cincinnati

Then one day, at the Hamilton naloxone-giveaway site: “Are you the guy with the wound?” Daryl asked a man in a cloth mask. “I was worried about you.”

The man proudly showed off a wrist no longer bandaged, the abscess healed. He started to walk away. Then stopped and turned back.

“It’s been a long time,” the man said, “since anybody worried about me.”

----

Molly B. True was a 19-year-old college student in the late 1990s when she started using heroin. This was before the epidemic settled into the region. Heroin chic was fashion. Kurt Cobain, idolized.

Now 41 and living with her boyfriend in Bellevue, Molly has seven broken-off needles in her body – arms, groin, neck – scarred over, there forever. It makes it tough to get an MRI. Tough to forget that she once had no place to go when she wanted to protect herself from infections.

Molly had always tried to use safely. She tried, after getting hepatitis C, not to spread the virus to others. She’d buy syringes when pharmacists would sell them to her.

She cared about her health. She says she was addicted to heroin but wasn't ready to get treatment.

Molly knew of places across the country where people who injected drugs could get sterile syringes, no judgment.

“I remember thinking, ‘Gosh, that’ll never happen in Cincinnati,’” she says.

Because, in the late 1990s through the early 2000s you were on your own.

Today, you are not.

Today, there are Daryls.

---

It has taken Greater Cincinnati something like two decades to understand what Daryl and people like him offer. It’s called “harm reduction,” a host of strategies to minimize negative physical and social outcomes from drug use. It's that place between prevention and treatment, where people who use drugs simply are.

With the heroin epidemic grew the understanding that addiction is a health issue. And fixing a health problem by locking it in jail, or even by scolding it, was not terribly effective. That maybe fixing it, or starting to, requires being there. Being kind. Helping people stay safe.

The epidemic grew. Understanding grew. Life got better for the Mollys of the world.

Not everyone understood.

Syringe exchange – trading used syringes for sterile ones – still feels wrong to a lot of people, who think it enables drug use.

But there is no scientific evidence to suggest that people who inject drugs will stop using because they can’t find sterile syringes. They will use what is available.

“I remember using needles to inject my drugs that … were bent and it looked like something you’d pulled out of a garbage can, really,” Molly says.

Scattershot needles back then led to a groundswell of complaints from neighbors who’d find the syringes in playgrounds, grocery store parking lots and even their own lawns.

The hepatitis C virus can live in the barrel of a syringe for up to six weeks. People started to realize they, or their children, could get the bloodborne disease.

It was this threat to the general public that led some to begrudgingly accept the idea of the harm reduction strategy syringe exchange.

“Everybody (who used), pretty much, had hepatitis,” Molly says. “A few people had HIV.

“But your life is in such shambles from addiction that you don’t care.”

---

Dr. Judith Feinberg, an infectious disease expert who at the time was a professor at the University of Cincinnati College of Medicine, cared.

She is the pioneer of harm reduction in Cincinnati. She saw hepatitis C cases rising and, by 2006, thought it was time for syringe exchange.

Feinberg gathered research to point to the positive results of harm reduction elsewhere. Syringe exchanges had been going on for years, most notably after the AIDS crisis evolved in the 1980s and ‘90s. Feinberg took that evidence and met with public health officials, city leaders, neighbors. Steadily, she pushed for syringe exchange.

Her analysis showed what newer studies amplify: Syringe services have been associated with a 50% reduction in HIV and hepatitis C. They cost less than $2 a day per person, research shows. Compare that to the lifetime cost of HIV treatment which is about $350,000 per person. The annual cost of hepatitis C treatment? About $84,000 per patient.

That, and this: “People who use drugs are five times more likely to enter treatment” if they use harm reduction, Feinberg says, noting U.S. Centers for Disease Control and Prevention data.

In 2014, Feinberg got the go-ahead to start a needle exchange. The first attempt failed from community pushback, but The Cincinnati Exchange Project was operating a few months later, outside Church of Our Savior in Mount Auburn. The Cincinnati health board approved the exchange. UC College of Medicine covered major costs. Interact for Health supplied a grant.

And as the mobile exchange expanded into several Cincinnati neighborhoods, Molly caught wind of it. “I’m like, ‘Impossible,’” she recalls.

“I did a little investigating, because that’s what I do,” the former Northern Kentucky University journalism student says.

 “I went,” Molly says. “And I met some of the greatest people that I’ve met in years.”

---

The exchange was a place to get things: sterile syringes, drug-cooking devices and clean wipes, naloxone, HIV and hepatitis C tests, condoms.

But it was not just about things. It was about treating people with dignity – an underpinning of harm reduction strategy, says Feinberg.

“You have a totally supportive, nonjudgmental rapport so that if, or when, they are ready (for treatment), you are there.”

For Molly, that support had a name: Billy Golden.

Billy Golden – everyone calls him Billy – prefers to stay out of the spotlight and just do his job.

When he worked for The Cincinnati Exchange Project you might find him on the streets, picking up used syringes, at the van or working at a table in some alley. Always, he made sure the exchange was a safe space for people who use drugs. If a client was there for three minutes, Billy says he made sure, “for three minutes of the day, that person was more than their drug addiction."

“That that person can come and just breathe.”

Once, when Billy was working in a Walnut Hills alley, his 100-pound German shepherd mix Wylie in tow, a woman asked if she could brush his dog.

“She stayed for the whole shift and just brushed him and brushed him,” Billy says. “When she left, like, there was this lightness. Like, this break.”

Sometimes Molly brought her dog, Fiona, to play with Wylie while she and Billy talked.

“And, no matter what kind of mood I’d be in, he would always ask how I was doing. And it wasn’t about, ‘Are you clean yet?’ It was about, ‘Are you OK today?’ And that just felt right.”

“I mean, my whole life it was like, my family and my friends and my ex-boyfriends were all like, ‘are you clean yet?’” Molly says. “I would always be ashamed.”

Billy was different. “He knew that I was strung out and was just offering me help for what I needed at that moment.”

Billy helped Molly get a doctor who understood addiction. He laughed with her, listened to her. Once, when she was overwhelmed, Billy sat at a picnic table with Molly, offered a notebook and pen and stayed while she thought through her priorities.

But Billy says now it never occurred to him that Molly felt so strongly about his help.

In 2018, Hamilton County Public Health took over The Cincinnati Exchange Project with sure funding. It was a signal to the region: County leaders believe in harm reduction. The service winds through Cincinnati, Hamilton County and even reaches into Butler and Clermont counties.

Molly has been in methadone treatment since September 2020. She manages her drug use, using maybe twice a week instead of what used to be several times a day. She still stops at the Exchange Project, as it’s now called.

One sunny Wednesday, Molly drove to the van at McMicken Avenue in Over-the-Rhine. Masked clients filed in and out. A man carried a foot-tall, red plastic tub filled with used syringes. From a parking lot, Molly pointed out the van to a first-timer.

Then she walked over, disappeared behind the door and returned with two small bags. They held syringes, stretchy blue tourniquets, a plastic case for used syringes, disinfecting wipes and a plastic zip bag with more odds and ends. She would use some and provide some for a friend who has no transportation.

But for Molly, the most comfortable place to spend time and find help is Caracole, in Northside.

Molly used to volunteer at the nonprofit, but it suspended volunteer work when the COVID-19 pandemic started.

Billy is there, working as a harm reduction coordinator.

One recent evening, he parked his pickup in the lot and beelined to folding tables set up outside where co-workers stood. He’d come straight from a Northern Kentucky exchange, where he’d given clients HIV and hepatitis C tests. The Caracole exchange runs 5-7:30 p.m. Thursdays. Billy grabbed a clipboard, smiled through his mask and waved over cars that were idling in the lot.

About 25 miles north of Caracole, Daryl is project director of the Regional Harm Reduction Collaborative. Funded through the Butler County Mental Health and Addiction Recovery Services Board with a state opioid response grant, it hosts harm reduction services, some new, in Butler, Warren, Clinton, Brown and Clermont counties. And just south of the Ohio River, in Northern Kentucky, Campbell, Kenton and Grant counties have syringe access programs and advocates are ready with naloxone for anyone who asks for it.

Daryl says he looks to Billy and other Caracole workers as harm reduction role models.

“The people we see aren’t used to being seen,” Daryl says, tearing up. He learns clients’ names. He asks them about them. He advocates for them.

The art and science of harm reduction and its menu options are evolving in Greater Cincinnati. Sometimes a city won’t allow needle exchange but officials will say OK to naloxone giveaways.

Daryl hands out cards for Never Use Alone, a toll-free number that offers safety by phone. Rob Goeller from Caracole offers messaging on You Tube for how to use safely during the pandemic. Alexis Deatherage and Beth Bullock walk Clermont County streets checking on people and handing them water bottles, naloxone and snacks. There are myriad services with multiple funding streams, sometimes consisting of just donations.

Molly embraces it all, though she no longer can keep track of everything available. She is excited for others who will benefit from harm reduction. Like she has.

“My life is exponentially better,” Molly says. “I am a different person. I buy Christmas presents. I have a bed now.”

“My ultimate goal (is) to continue to volunteer, and maybe it will lead to some actual, real job in harm reduction,” Molly said. “I feel like that’s where I belong.”

In mid-January, Molly was unanimously appointed to the Harm Reduction Ohio board of directors.

Her position is indicative of another pillar that the National Harm Reduction Coalition advocates: Ensuring that people who use drugs and those with a history of drug use routinely have “a real voice” in programming and policy designed to serve them. 

“We’re going to use Molly's knowledge and talents to make the world a better and safer place for people who use drugs,” says Dennis Cauchon, the nonprofit’s founder.

She can’t wait.