The Dangerous New Disease in Needle Park
With risks like addiction, HIV and hepatitis C, the last thing street junkies need is another disease to ward off. But that's just what they have—and almost no one is paying attention.
Annie’s sad story is increasingly common on the streets of Philadelphia. A young heroin user from the suburbs coming into the prime of her addiction, she moved to North Philly, the center of the injection drug scene. There, her life commenced the downward spiral of typical street-level addicts: at first funding her habit through boosting, she got booked for retail; then turning to sex work, she got booked for prostitution. Outreach attempts by her family were rebuffed; social workers tried to get her into treatment after her arrests, but she refused. Her startlingly quick fall seemed bottomless—until a microscopic organism nearly killed her.
Annie got an abscess from injecting in her hip. Left untreated as she continued to run the streets, the infection spread until she was unable to walk and was finally brought to the hospital. By that point the infection had become systemic. It took eight surgeries and months of inpatient treatments to get the infection under control. At the age of 22, Annie is now clean and sober, but it’s not really a happy ending; she lives in a nursing home, where she receives around-the-clock care. Maybe she’ll walk again, maybe she won’t. Her family is grateful that at least she’s alive.
Since the start of the AIDS epidemic in the early 1980s, public health professionals have made impressive progress in developing prevention programs that stop HIV and hepatitis C in injection drug users; thousands of lives have been saved. But there’s a less recognized—and growing—danger with the potential to wreak havoc on the bodies of drug users and to burden the healthcare system with steep financial costs: bacterial infections like abscesses and cellulitis that can be debilitating and, in rare cases, fatal.
The numbers are startling. A 2010 study by Dr. Vivian Hope of the London School of Hygiene and Tropical Medicine found that in major cities in the developed world, bacterial infection rates can be as high as one-third of all injecting drug users; a steady 5% to 10% rate is common. Other recent research shows that needle users are more prone to acquiring more severe infections, like the so-called super bug, MRSA, which is resistant to many antibiotics.
Annet Davis-Vogel has watched the bacterial infection crisis unfolding in real time. A registered nurse, social worker and the project director of the University of Pennsylvania’s HIV Prevention Research Division, she’s been on Philly’s streets and in its shooting galleries advising addicts on safe injection practices since the 1990s. In the course of her career, she’s noted that while HIV infections have come under control among injection drug users, bacterial infections have remained widespread and largely unaddressed by public health measures. On a recent trip to North Philly with Davis-Vogel, I watched as she counseled a pair of homeless, middle-aged African-American men in an open-air injecting space behind an abandoned building in the city’s heroin district.
Annie's startlingly quick fall into heroin addiction seemed bottomless—until a microscopic organism nearly killed her.
We followed Davis-Vogel along a dirt path that veered from the sidewalk, through scrub and tall grass littered with garbage and drug detritus, to a narrow alleyway where—amidst empty liquor bottles, dirty needles, discarded crack straights and used condoms—a picnic bench was propped against the crumbling wall of building. This hidden corner is one of countless secret places in the neighborhood that addicts can duck into to get high after buying dope. One of the men we found there was on the brink of getting an infection.
“You’re going to get an abscess here,” Davis-Vogel said gently, pointing to a raw, bleeding hole on the back of the man’s hand into which he had just emptied a syringe of heroin. “If you don’t start using a different vein, it’s going to get infected,” she told him. "Do you have another vein that you can use? Do you cook your dope? I’m not trying to sound like your mom, but it’s really important to do these things if you don’t want to get an abscess.”
The men nodded before wandering off on dope-wobbly legs.
After we left the men, Davis-Vogel explained to me what she had seen that so concerned her. “The vein on the back of his hand was elevated, hard and bruised, which means it’s becoming calloused,” she said. “It was basically an open wound, a portal for bacteria. That’s why you need to rotate sites, to give each a chance to heal.” She also pointed out that the men were using alcohol pads incorrectly, applying them after injecting to clean up the blood instead of before inserting the syringe to clean the site.
Bacteria enter overused injections sites in many ways. The unsanitary conditions where Philly’s often-unwashed heroin addicts hang out and shoot up is one way. Contaminated drugs and water supplies are two other routes. (Injection drug users, when necessary, use water from rain puddles, public bathroom toilet bowls, even a half-empty bottle of Snapple on the sidewalk.)
There are also the ubiquitous metal bottle tops that addicts use to prep their shots. “That’s why they're called ‘cookers,’” Davis-Vogel said. “You cook your dope because cooking kills bacteria.”
Unfortunately, unsafe injecting is still a widespread practice on the streets. Supplying public health information to isolated addicts operating on the fringes of society is only part of the battle to prevent bacterial infections. Even addicts who know better may make risky injecting decisions in an effort to save time and evade the law-enforcement presence that hangs over drug users and sellers.
In addition to a non-sterilizing quick stir of their drugs with a syringe plunger, the pressure to get off fast, ditch their works and walk away clean of drugs and paraphernalia so they don’t get pinched for possession can also push addicts to overuse a single injection site. “Guys will tell you, ‘This is my best vein’ or ‘this is my special vein’—the one they can always hit so they’re reluctant to rotate,” Davis-Vogel said.
The harm reduction organization Prevention Point has for years, through its Street Side Health Project, provided Philly addicts with prevention information and street-level treatment of abscesses. Clayton Ruley, Street Side’s program coordinator, said that once a week an addict will come to their office or one of their mobile syringe exchange locations asking for help with an abscess. But the extent of the bacterial infection problem among needle users in Philadelphia remains unknown. “There is no database that collects this information,” Ruley said. “It’s a hard problem to map—many of the people at risk live underground and off the grid."
Gus Grannan, who runs Prevention Point’s syringe exchange program, said that after recent severe budget cuts, the organization is struggling to meet priorities like supplying enough clean syringes in order to prevent HIV and hepatitis C, let alone doing skin infection prevention. Could Prevention Point make an impact on the growing bacterial infection problem with more resources? “Definitely,” Ruley said.
The need for such intensive outreach could be averted through opening a supervised safe injection site along the lines of Vancouver’s celebrated Insite, according to Gus Grannan. “An Insite-style facility in Philadelphia is our dream goal,” he said. But the politics of such a risk-reduction sanctuary remain prohibitive.
What is the dollar cost of treating these infections? With little data, it’s anybody guess. But having an abscess lanced and drained is a costly outpatient surgical procedure when performed in a hospital. If the infection becomes systemic like Annie’s, the costs can soar to mind-boggling heights to cover days or weeks of inpatient hospital treatment for multiple surgeries. Most street addicts lack private health insurance, so taxpayers foot the tab. As usual, prevention efforts make fiscal sense.
For now, Prevention Point’s Gus Grannan advises users to use their alcohol swabs before injecting, not after, and use a fresh sharp every time you inject. Pass it on.
Jeff Deeney is a Philadelphia social worker and a writer who is in recovery. His column, "Street Beat," runs regularly in the The Fix. He is also a contributing writer at The Daily Beast.