Rapid response

Main South activist Billy Breault answers the question, `If not needle exchange, then what?' HIV/AIDS workers, though, don't like his answer.

by Kristen Lombardi

On a recent Thursday afternoon, a crowd in front of City Hall is prepared for another William "Billy" Breault production. The well-known Breault, flanked by Main South activists and city councilors, settles into a rather comfortable position -- beneath the spotlight.

As chairman of the Main South Alliance for Public Safety, Breault's often taken advantage of the limelight to advance his campaign against needle exchange, an HIV/AIDS prevention program that gives intravenous-drug users clean syringes. Today, though, Breault isn't opposing needle exchange or drugs or crime. Instead, he and fellow activists are announcing a pilot program intended to give relief to the very people Breault and company have demonized in the past: needle-using addicts.

Throughout the long, contentious debate around needle exchange in Worcester, opponents, such as Breault's Main South Alliance, have occasionally lamented the lack of drug-treatment services, contending that, if there were no IV-drug users, there would be no need for a clean-syringe program. Now that councilors have rejected the latest proposal -- a unique one-to-one syringe exchange and drug-treatment service -- its most vocal opponents appear to answer a challenge levied at them during the debate: if not needle-exchange, then what?

The pilot program, developed by alliance members, incorporates outreach, treatment, and follow-up methods that are being used in drug-treatment programs throughout the country. But this plan features an experimental, radical technology (known as "rapid detox"), as well as grassroots outreach workers and sober housing. The pilot -- as presented at the press conference -- tries not only to provide uninsured, street junkies with treatment and rehabilitation, but also to help prevent the spread of HIV through shared needles.

Since the April City Hall press conference, the pilot program has been embraced by city officials and residents alike. "People on the street are telling me it's a good idea," Breault says. Even needle-exchange proponents, who bitterly battled Breault and colleagues just months ago, give them credit for not simply winning the syringe-exchange debate then walking away. And advocates look forward to watching as future debate determines the pilot's efficacy -- its efficacy, that is, as a substance-abuse program only.

For needle-exchange advocates have already decided the pilot will have little effect on slowing the HIV disease. "How people are reacting to this is almost comical," one doctor says, referring to city officials' overwhelming enthusiasm. "Except it's not comical because [the pilot] has nothing to do with HIV." Which is exactly what worries needle-exchange advocates the most. If city officials consider the Main South Alliance's drug-treatment plan as an alternative to needle exchange, then the people Breault and friends are setting out to save may end up at greater risk of contracting the virus. Breault insists the pilot isn't meant to be the latest move in his long-standing battle against needle exchange. But the fact that it's being welcomed by those wary of syringe exchange suggests that this drug-treatment pilot could threaten needle-exchange proponents' chances of tackling the HIV/AIDS pandemic here -- especially if Breault succeeds in enticing politicians who were on the fence the last time the council debated the issue.

Throughout the divisive, polarizing needle-exchange debate, both sides have agreed on one fact: Worcester woefully lacks drug-treatment services. It is this common ground that Main South Alliance for Public Safety seized when it developed a "three-prong" pilot (based on outreach, treatment, and "after-care" models) for the city's intravenous-drug users, particularly homeless, uninsured ones.

Perhaps the most intriguing aspect of the pilot is the detoxification treatment. Rather than rely on conventional methadone, Breault and colleagues have turned toward a controversial, cutting-edge procedure called "rapid detox," a one-day procedure accelerating detox for people addicted to such opiates as heroin and narcotic pain killers.

Normally, physical detox can take as long as a week and is characterized by extreme, mind-numbing pain (vomiting, chills, diarrhea) -- a brutal, but typical reaction when the body is deprived of the addicting drugs. The new technique, also known as "anesthesia-assisted detoxification," speeds up the process and thus spares patients from the most painful moments of withdrawal.

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Despite needle-exchange proponents' reservations, they give Breault and colleagues credit for attempting to address the city's drug problem. But, they maintain, the pilot will not curb the spread of HIV, not to mention hepatitis B and C.

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Rapid-detox patients sleep under general anesthesia while a powerful, heroin-blocking drug is pumped intravenously into them. The IV medication, nalmefene, essentially flushes out the opiate. After six hours, patients wake up no longer physically addicted.

"What takes place over days is compressed into hours," says Alan Stoll, founder of UniQual Network in Framingham, which has been picked to run the pilot's treatment. UniQual administers several rapid-detox programs at area hospitals, including Worcester's AdCare Hospital.

Though rapid detox appears a magical, pain-free way to kick the heroin habit, experts warn that withdrawal symptoms linger. "People think they'll wake up and feel great," says Dr. Scott Gonzales, an anesthesiologist and UniQual's medical director. "It's not true." A "light" addict who injects a few bags' worth of heroin on the weekend will probably be okay. But a hard-core addict who injects 10 or more bags daily, Gonzales says, "will feel like [he] has a serious flu for a couple of days."

What is exceptional about rapid detox is its medication, not its time frame, he adds. Patients undergoing this method, rather than methadone, are given pills of the heroin-blocking naltrexone to take each day for six months. Naltrexone, like nalmefene, attaches to the brain's opiate receptors, the specific area of the brain that reacts to drugs. As a result, naltrexone curbs the physical cravings that recovering addicts almost always experience. Even if they relapse and take drugs, naltrexone prevents them from actually getting high.

"If a conventional-detox patient slips and uses heroin, he will get high and will be addicted all over [again]," Gonzales says. "Because of the medication, our patients detox faster; they cannot get high; their cravings decrease faster -- all of which leads to better long-term success."

Maybe so. But right now, rapid detox is still considered experimental, and doesn't come without substantial risk. Patients are anesthetized for the whole procedure -- a must, Gonzales says, because the body goes through severe withdrawal in a compressed time -- so the dangers are almost entirely associated with anesthesia. Patients need a tube inserted down their wind pipes to prevent asphyxiation. Some who underwent the six-hour procedure have suffered low blood-oxygen levels; others have had seizures, which is extremely dangerous while under anesthesia.

UniQual, unlike some providers, employs anesthesiologists and addiction specialists to increase patient safety. It runs its programs out of hospitals, instead of independent clinics, because hospitals are better equipped to handle anesthesia's potential side effects. Further, it screens possible patients for heart, kidney, and lung ailments. "You have to be relatively healthy," Gonzales allows.

You also have to fit a certain psycho-social profile. Indeed, UniQual gives possible patients a psychological test, examining factors like employment status and severity of addiction, to make sure candidates are likely to respond to treatment -- and this may explain why rapid detox is considered extraordinarily effective. Close to 70 percent of the 50 patients whom UniQual's treated so far remained heroin-free for six months, Stoll says, compared to 10 percent of conventional-detox patients.

The impressive success rate is what caught Breault's attention. After further research, Breault says, he found the rapid-detox promise of less pain appealing as well, since the physical agony of withdrawal could deter addicts from getting clean. Insurers, however, won't cover the innovative technique, and few addicts -- street addicts, anyway -- can afford it. UniQual charges $6000 for its detox program, which includes a few days' hospital stay and six months' worth of naltrexone.

That the cost is so prohibitive is exactly why Breault and other Main South activists included rapid detox in the pilot. "Conventional detox is already funded," says Beacon-Brightly activist Barbara Haller, who supports and helped draft the proposal. "UniQual needs to be funded. . . . We want to move this cutting-edge technology to the streets."

Stoll, who says that UniQual's trying to "become more known in the marketplace," views the alliance's proposal as a way to reach addicts who cannot afford rapid detox. But because UniQual recognizes that rapid detox ignores the emotional aspects of addiction, it also requires patients to sign up and pay for follow-up visits.

Breault, Haller, and others, then, have put forth a component, which would consist of counseling, "life skills" education -- such as how to balance a checkbook -- and sober housing. In short, the follow-up is intended to help the recovering addict, as Haller puts it, "break the whole cycle of being a marginal person."

Of course, before detox and rehabilitation can take place, addicts must be identified and then pushed into seeking treatment. To this end, the pilot calls for aggressive outreach, based on the "indigenous leader outreach intervention model," created by University of Illinois public-health professor Wayne Weibel. Weibel developed a model after studying the effectiveness of former addicts living in Chicago who acted as outreach workers, hitting streets, visiting IV-drug users' haunts (abandoned homes and parks) to encourage them to change risky behavior like needle-sharing.

What makes this brand of outreach effective is the outreach worker's knowledge of addiction's cycle, as well as its powerful emotional dependency. "The outreach worker isn't trying to be a best friend," Haller says, "but is giving doses of reality."

Ultimately, the outreach, treatment, and follow-up combination makes for a sound, sensible proposal, Breault says. What seems to separate this program from the city's existing services is neighborhood involvement; the program designers, in fact, plan to include residents on a future advisory board.

But while all of this looks promising, questions abound concerning administration and, equally important, funding. "Other than being a good idea," one city official comments, "the pilot is kind of vague." What observers are especially wondering, it seems, is just how alliance members will convince city, state, and federal agencies to fund an experimental detox procedure that a privately owned company operates.

Breault and fellow activists, though, claim that such concerns will be resolved. After all, they expect to take advantage of several recommendations put forth by the Public Inebriate Program (PIP) task force, now trying to relocate the PIP shelter out of Main South because of neighborhood pressure. In its January report, task force members suggested setting up an emergency access center and post-detox housing to serve PIP's clientele, which includes many homeless, IV-drug users, as well as alcoholics. "We hope to fold the pilot into the PIP report," Haller says, adding that she has "every optimism" the PIP report will be implemented. So the pilot's outreach phase, for instance, could be run under the emergency center, while UniQual might be administered as part of the post-detox.

As for funding, Breault and colleagues are reviewing state and federal drug-treatment grants -- specifically, funding available through the state departments of public health and health and human services, along with federal criminal-justice dollars. They say they're meeting with Community Healthlink and AdCare Hospital to discuss possibly incorporating the follow-up phase into existing services. And Breault, Haller, and others are trying to mobilize local support to attract private foundations.

"You can do anything that's grounded," Haller concludes, "if you have support of the community behind you."

Even if the logistics were to fall into place, it hardly guarantees the pilot's success. And, perhaps not surprisingly, needle-exchange proponents (many of them medical and public-health professionals) doubt that it would substantially benefit the city's IV-drug users.

Take, for example, the pilot's outreach phase. Addicts need caring, committed outreach workers, for sure; but, needle-exchange advocates note, the likelihood that homeless, street-bound junkies will listen, let alone be so motivated as to quit drugs, is close to nil. "Most addicts run from outreach workers," says Jonathan Heins, a former IV-drug user who often steers addicts toward help. "This is the problem with harm reduction," he adds. "It assumes addicts want to change their lifestyles."

Another, even bigger concern of needle-exchange advocates centers on the rapid-detox method -- a method, they contend, that isn't at all geared toward the very people the pilot supposedly targets. Consider the fact that insurers decline to cover the technique. This means only those who can come up with $6000 in cash, then pledge to participate in follow-up, have completed rapid detox. In the words of one local physician who treats both substance-abuse and HIV/AIDS patients, "The procedure works well for wealthy, motivated addicts, of which there are surprisingly few."

Precisely because rapid detox caters to closeted junkies -- those who still have jobs -- its success rate is astronomically high, adds the physician, a syringe-exchange supporter. "They end up pre-selecting a group of addicts who are likely to succeed." This, coupled with the medical/psychological screening, suggests to him that rapid detox, albeit fast, doesn't meet the needs of homeless addicts.

It's a suggestion that UniQual officials dismiss, but not without certain concessions. Stoll, for instance, acknowledges rapid detox isn't for everyone, yet he points to self-determination, not socio-economics, as the reason. "Addicts have to be willing to recover," he says. Gonzales, who thinks the procedure will "find its place in the patient spectrum," views an "ideal" patient as someone hooked on methadone -- who is not on heroin, and has found stability in a job and family life. But Gonzales says rapid detox can also work for street addicts.

Especially, he clarifies, "those [street addicts] who are new to heroin and have good support systems."

Whether Worcester's homeless, uninsured addicts will benefit from rapid detox and from the overall pilot remains to be seen. And despite needle-exchange proponents' reservations, they give Breault and colleagues credit for attempting to address the city's drug problem. But, they maintain, the pilot will not curb the spread of HIV, not to mention hepatitis B and C.

"It will be totally ineffective in preventing HIV," says Joseph McKee, spokesperson for the Harm and Risk Reduction Coalition, an activists' group that put forth the comprehensive syringe-exchange proposal, which city councilors rejected this past January. If anything, he maintains, the pilot's very nature reveals a "clear misunderstanding" about the disease and about the people most at risk.

A vast number of addicts, for one, are already HIV-positive by the time they enter detox. (Considering the medical stipulations, it's questionable whether anyone with HIV could undergo rapid detox.) Also, addicts rarely go through detox without ever relapsing. "There is a process to recovery and, during that process, addicts can catch HIV," McKee explains. And finally, there are addicts who refuse to stop using and will keep refusing until they die.

For McKee and fellow advocates, all of this boils down to the pilot's failure to tackle the central issue in battling HIV: addicts share needles -- as evidenced by the 75 percent of HIV/AIDS cases in Worcester directly related to contaminated syringes. "Addicts are playing Russian roulette with needles," Heins exclaims. No doubt, it's good and necessary to examine drug abuse. But while trying to curb the city's substance-abuse problem, he reasons, hand out clean needles to IV-drug users at constant risk of contracting then spreading a deadly disease.

Without recognizing this, the pilot, he insists, "is like Nancy Reagan's `Just Say No.' . . . Until we attack HIV at the point of infection, which is the dirty needle, we're not slowing the spread of HIV."

Breault and colleagues, however, are equally convinced the pilot deals with the HIV/AIDS issue. Because of the trustworthy, give-and-take relationship the so-called indigenous leader outreach model promotes, Haller says, it's helped motivate street addicts to stop sharing needles. She and Breault point to a 1996 study of the Weibel method, which evaluates its success by measuring how many Chicago junkies became HIV-positive. More than 600 IV-drug users were tracked for four years; eventually, it was determined that HIV rates among them declined.

"It's statistically valid," Breault says. "Outreach will make a difference in reducing the spread of HIV."

But their own supporting data doesn't entirely prove their argument. In the same '96 study, Weibel himself writes that the intervention of outreach workers might have contributed to the HIV drop, but, he stipulates, "the study's research design precludes any such conclusive findings. . . . Alternative explanations for observed declines must be considered."

It is this sort of uncertainty that troubles needle-exchange proponents, especially when, they say, rates of hepatitis B and C are skyrocketing. A recent city report shows that hepatitis B has increased 928 percent in the past three years (from 14 to 144 local cases). Meanwhile, hepatitis C has risen 2700 percent (eight to 224 local cases).

Even more troubling is the immediate support the pilot's received so far, needle-exchange advocates say. Now pending in the city council health committee, it's expected to advance swiftly. The city administration has vowed to help search for funding. And Worcester residents concerned about HIV/AIDS yet frustrated by the lack of action seem to be latching on to the pilot as an easy alternative to needle exchange.

As one resident laments, "It's better than doing nothing."

Such statements alarm McKee and colleagues, leaving them more resolved to push their agenda, rather than settle for what they see as a less-than-viable option. Besides, they acknowledge a deep skepticism over motivations behind the pilot. "These opponents didn't suddenly become altruistic," one syringe-exchange advocate declares. "They're just trying to answer the question, `If no needle exchange, then what?'"

To his credit, Breault is upfront about the role the issue's played in developing the pilot. "If there were no debate on needle exchange, would we be discussing this?" he poses. "Probably not." Still, he's quick to specify that he's not trying to preempt another syringe-exchange proposal; he's not even trying to provide an alternative.

"We believe we have something valid that doesn't include needle exchange," he concludes.

No matter that proponents doubt aspects of the pilot, they aren't about to thwart it. After all, they say, more power to anyone wishing to extend a hand to the city's most vulnerable, addicted population. "If they want to help addicts get off drugs, we won't stop them," Heins says. "But then, don't get in our way when we want to help addicts stay alive."

It's a request Breault won't likely entertain -- considering, in his estimation, the needle-exchange debate in Worcester is history. As he puts it, "Needle exchange is politically dead. Period."

Kristen Lombardi can be reached a klombardi[a]phx.com