Four or five times a week, Patty Pastore, 70, and her team of volunteers scour Port Angeles’ 40 blocks, six creeks and half dozen parks for every needle they can find.

They’ve picked up almost 700 this year, and Pastore is having trouble getting rid of them. She has nearly a thousand in her garage, in coffee cans and salsa containers. She can take them to the regional transfer station, but they have to be in soda bottles for the safety of sanitation workers, and she doesn’t drink enough soda to hold all the needles.

But needles don’t frustrate Pastore as much as this: If she were a user, she could dispose of the needles for free at the local syringe exchange. Pastore thinks there’s something fundamentally wrong with the exchange.

“Why don’t they just hand the addicts a gun and let them shoot themselves? Because that’s what they’re doing,” Pastore said. “No citizens in this town were ever given a right to vote on something, yet our taxpayer dollars were used for the syringe exchange.”

Syringe exchanges, once seen as an answer to the public health crisis of AIDS, are coming under criticism from elected officials in parts of Washington who believe they are making a new public health crisis — opioids — worse.

Syringe exchanges were born in Washington in the ’80s. Today, 39 states have them, and the practice has been endorsed by the national Centers for Disease Control and Prevention. In response to the opioid epidemic, hundreds of syringe exchanges have opened across the country in the past two years, according to Dr. Paul LaKosky, who helps run the North American Syringe Exchange Network.

The Seattle Times’ Project Homeless is funded by BECU, The Bernier McCaw Foundation, The Bill & Melinda Gates Foundation, Campion Foundation, the Paul G. Allen Family Foundation, Raikes Foundation, Schultz Family Foundation, Seattle Foundation, Seattle Mariners, Starbucks and the University of Washington. The Seattle Times maintains editorial control over Project Homeless content.

But as more and more needles have appeared in public parks and streets, there’s growing fear and frustration that the syringe exchange is partially to blame.

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In the Tri-Cities, the county evicted a syringe exchange from its Pasco location, resulting in the exchange moving twice in two months. Grays Harbor’s syringe exchange has been teetering: County commissioners voted to end it in December before one commissioner changed her mind in April and voted to continue it. Cowlitz County defunded its exchange in 2017, though it’s still operated privately.

And in Kitsap County, after pressure from the health board, public health officials are working on a plan to move an exchange out of a mobile van and into health-care centers. It is a compromise to focus more on treatment, which those who do syringe exchange work say isn’t realistic.

Public health officers around the state are worried about this shift, said Dr. Allison Unthank, Clallam County’s public health officer and a family doctor. Officials warn that ending syringe exchange raises the risk of hepatitis, HIV or other bloodborne pathogens infecting a community. North Seattle saw an outbreak among 17 homeless men and women earlier this year.

“I think that’s put some fear in the rest of us that if we do anything too ‘out there,’ we could get closed,” Unthank said.

There is little evidence that syringe exchanges bring more needles to a community; in fact, a 2012 study found eight times more needles in Miami, which didn’t have a needle exchange, than San Francisco, which has had one for a long time.

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“I don’t like seeing used syringes in the street either,” said LaKosky. “But there’s a good way to prevent that from happening — it’s to provide a space for people to get rid of those used syringes.”

The pushback to syringe exchanges in Washington spotlights a divide between the “keep them alive” philosophy of public health officials, and the longstanding public conceptions that making drug use safer enables users and makes it harder to quit.

First in the nation

The first needle exchange was started by a biker and drug counselor in Tacoma in 1988. Dave Purchase began with a TV tray, a folding chair, cookies, and needles he bought with his own money. The public health department started picking up the bill a few months later.

Today in Washington, there are at least 27 programs the state Department of Health (DOH) is aware of; two-thirds are operated by local health departments. Seven of those are in King County, where around 8 million needles were exchanged in 2018. Many exchanges also hand out naloxone to reverse overdose and test strips to detect potentially deadly fentanyl in drugs, as well as giving referrals to treatment.

Syringe exchanges have been shown to decrease infections and help people get into treatment. A 2000 study from Public Health – Seattle & King County found new users of syringe exchanges were five times as likely to enter drug treatment as those who don’t use exchanges, and those who use exchanges regularly were three times as likely to inject less.

Nonetheless, syringe exchanges often operate in the shadows. In Clallam County, where opioid deaths increased 64% from 2002 to 2017, critics more brazen than Patty Pastore sometimes gather outside the exchange, taking pictures of people who go in, according to Unthank.

The local health department quietly opened a syringe exchange in Forks last year, but only a handful of people use it per month on average; more than 30 others drive to Port Angeles instead, according to a health department survey. Unthank thinks people in Forks are afraid of being recognized walking in.

But more moderate critics think there’s simply not enough focus on treatment at syringe exchanges.

I think that’s put some fear in the rest of us that if we do anything too ‘out there,’ we could get closed.” — Allison Unthank, Clallam County public health officer.

Poulsbo Mayor Becky Erickson, one of the members of the Kitsap Public Health District board, said in a public meeting in January she felt the practice was “supporting drug addiction,” according to The Kitsap Sun. In May, she walked out of a board meeting while a representative from the People’s Harm Reduction Alliance, which runs the syringe exchange, was speaking about the program, according to the group.

Now, instead of shutting it down, Kitsap County plans to move its mobile exchange into health-care facilities, at least in urban areas of the county. Erickson said needle exchanges were opened to fight one disease, but today, there’s another disease of epic proportions.

“It’s called addiction,” Erickson said. “It’s called heroin. That’s a disease too, and we can’t not focus on that.”

Needle exchanges are already referring people to treatment: In 2018, Kitsap County’s needle exchanges referred 500 people out of the almost 5,000 visits to the exchange.

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And it’s unclear if drug users will actually come to health-care facilities. A University of Washington survey of people who use state exchanges found that 59% of drug users knew they should have seen a doctor in the last year, but they didn’t because of how they’d be treated by health-care providers.

That syringe survey did not include Kitsap County, county health officer Dr. Susan Turner pointed out, although Kitsap’s neighboring counties did participate and found similar results. Turner stressed that the hope is to have more access points for syringes, not fewer, and to have them in places where getting into treatment is easier.

But Caleb Banta-Green, principal research scientist at the UW’s Alcohol and Drug Abuse Institute, believes the new approach will be counterproductive.

“Most people with substance-use disorder don’t want to have substance-use disorder and don’t want to be using dangerous drugs in dangerous ways,” Banta-Green said. “But they’re not accessing services because it turns out most services don’t want them. What do you do for those people who don’t want to stop their use? Do you give up on them?”