A bag of heroin goes for around $10 on the streets of New York. Though they contain one of the most dangerous recreational drugs on the planet, these bags are snatched up by hordes of men and women, of all ages and socioeconomic class. Whether folks are looking for a cheaper alternative to oxycodone, trying to get another hit of the drug they tried the night before, or have been injecting drugs for 20 years, they’re all contributing to one of the worst heroin epidemics the country has ever seen.

According to the Centers for Disease Control and Prevention (CDC), more than 8,200 people died from heroin-related overdoses in 2013 — nearly quadruple the amount reported in 2002. We’ve seen heroin and all the public health risks that go along with it before, and we’ve seen it withstand harsh drug laws and public condemnation. The most notable manifestation may be The War On Drugs, a largely ineffective attempt at combating drug use through prosecution and incarceration. When this effort proved unsuccessful,  researchers, clinicians, and lawmakers were forced to go back to the drawing board.

The 21st century may be experiencing déjà vu in terms of heroin, but it seems government officials have learned from its earlier mistakes. This is clearest when considering the unprecedented plan to focus more on rehabilitation, de-stigmatization, and needle-exchange programs that wouldn’t have been considered, let alone implemented, the last time the country faced an epidemic of this proportion.

Arresting Addiction

As if heroin itself wasn’t enough of a public health concern, the way it’s administered can lead to a myriad of other consequences. Using a hypodermic needle and syringe to inject heroin intravenously is a huge risk factor for HIV/AIDS. In fact, Aids.gov reported intravenous drug use is responsible for approximately 10 percent of HIV cases every year. Heroin has also been ranked as the number one recreational drug to cause social harm, or the harm caused to others in the community due to intoxication, health costs, and other problems caused by drug use. So heroin, really, is everyone’s problem.

“If someone was using a needle to inject [the drug] and they’re between two cars at night so the police don’t see them, there are two things that could happen in the community,” Dr. Ellen Tuchman, an associate professor of social work at New York University and chair of the Lower East Side Harm Reduction Center (LESHRC), told Medical Daily. “They can throw that used needle on the ground and a kid, or a dog, or a person can step on it and get hurt. The other thing it does is — well, you don’t really want to have people doing drugs in your neighborhood.”

This was certainly the case for New York City in the late 1960s, what many consider the epicenter of this decade’s heroin epidemic. The high rates of heroin addiction and the increased crime rate that came along with it prompted the state government to take action. Officials tried a variety of different legal approaches in an attempt to halt the problem. These efforts came to a head in 1973, when then-Governor Nelson Rockefeller proposed the most aggressive drug laws in the nation. He called for punitive measures against heroin users, the most glaring example being mandatory, life-time incarceration for the sale of any amount of heroin greater than one ounce.

The city tried to prosecute away addiction and squelch the community’s fear by incarcerating people until prisons were overflowing, but it didn’t work. Instead, the 60s epidemic burned out on its own, only to come roaring back everywhere from inner cities to white, middle-class suburbs.

Now, with a second crisis fueled in part by higher rates of addiction to prescription painkillers, the government is beginning to look at addiction and its associated issues as more than a punishable offense, but as a public health crisis.

How Do You Solve A Problem Like Addiction?

Lawmakers had to recognize two things before they could draft an effective treatment plan: One, addiction is the underlying cause of the heroin epidemic, and two, punishment is rarely an effective cure. So how could a city pull millions of people back from the clutches of one of the most addictive substances on Earth?

Many cities’ first attempt at rehabilitating heroin addicts was centered on a simple philosophy: abstinence. Abstinence-focused treatment programs maintain individuals can only recover from addiction if the addictive substance is completely gone from their life. Without an understanding of the chemical-based processes underlying addiction, however, abstinence is rarely effective.

“It’s punitive and unrealistic to expect an IV drug user to stop their IV drug use cold turkey,” Dr. Paul Hokemeyer, an addictions therapist and senior clinical fellow at Caron Ocean Drive in Florida, told Medical Daily in an email. “It sets these men and women up to fail and re-enforces their negative self concept. This in turn drives them deeper and deeper into the clutches of their disease.”

White-knuckle sobriety is rarely the answer for those willing to try. And yet, the bigger problem may be some don’t even want to.

Dr. Tuchman recalls New York in the 1990s, when addiction was still primarily approached with abstinence-based treatment. Working as a social work supervisor in a hospital and supervising a detox center, Tuchman noticed many people who came to detox weren’t ready for or interested in abstinence-type treatment. Some users had no intentions of stopping at all, but even those who gave abstinence their best shot often went right back to using.

“When I was working in abstinence, trying to help people find ways to stop, I was so unsuccessful,” Tuchman said. “I said, ‘If I’m this unsuccessful and frustrated, then my clients must be that frustrated, so what am I doing wrong?’”

Tuchman had familiarized herself with an alternative approach to addiction therapy, called harm reduction, by working on a study with female injection users at a (then) relatively new facility on the Lower East Side. The LESHRC worked with a different philosophy called harm reduction, and after spending two years working with participants, Tuchman realized that if abstinence is the goal from day one, many people will get lost on the way to recovery.

“Most people who come in asking for help are not ready to go from using drugs for more than 20 years to just stopping,” she said. “Harm reduction’s eventual goal is abstinence. We would love that. But that’s not the goal when people come in — we start with ‘what does this person need, what do they want right now?’ Do they want clean syringes, do they want housing, do they want clothes, do they want food?”

All of these resources may seem like a broad net to cast in order to address the specific problem of addiction. But, Tuchman says, substance users often need many different services, and cannot focus on getting clean if they’re struggling with several other issues (like hunger or housing) as well. She considers harm reduction a holistic approach that has two main goals: Reduce the harm a person does to themselves with a substance, and reduce the harm done to communities where people inject or sell drugs.

The main draw for users to the LESHRC is its syringe exchange program: A simple, anonymous process designed to suppress the spread of HIV and other bloodborne viruses like Hepatitis C. The exchange gives out “the works” — clean syringes, tourniquet, cotton balls, alcohol bags, and the “cooker” to heat up drugs — that potentially come into contact with blood, and consequently spread viruses in the real world. The exchange is a win for both users and communities, and all users need is a photo ID with no name.

“We’re getting [used] syringes off the street, out of the communities, and people aren't reusing them,” Tuchman said.

The numbers favor these syringe exchanges: In New York City, government officials reported the rate of new HIV infections plummeted from 5,684 in 2001 to 2,832 in 2013 after needle-exchange programs were introduced. Studies have shown syringe exchanges have been successful in getting used needles off the street, and the World Health Organization (WHO), among many other international public health organizations, believe “there is compelling evidence that increasing the availability and utilization of sterile injecting equipment for[…]drug users contributes substantially to reductions in the rate of HIV transmission.”

The WHO also noted how integral facilities like the LESHRC are to addiction recovery, pointing specifically to how needle- and syringe-exchange programs“involving face-to-face contact have helped  reduce the “rate of HIV infection among injection drug users, including an increase in recruitment into drug-dependence treatment and primary care services.”

The LESHRC doesn’t stop at harm reduction therapy and syringe exchange, but it offers additional free services and goods for drug users. It makes fact sheets, condoms, and dental dams available to those who want or need it, in addition to syringes, pregnancy tests, STD tests, vaccinations, and even primary health care. There are counseling groups available for those who have experienced trauma; women’s groups; transgender services; and even psychotherapy.

“One of the very special things we do is harm reduction psychotherapy by the social workers,” Tuchman said. “It’s pretty unheard of because most people who are substance users don’t really get that type of treatment. This is harm reduction psychotherapy — it’s absolutely non-judgmental.”

Any one of these services or free goods have potential to draw in a drug user, which is the first step in getting that person to use drugs more safely, and eventually not at all. Tuchman said representatives from the LESHRC will travel all over downtown to make sure users know about it.

The center does a huge amount of outreach, going to parks where there are substance users and injectors and trying to bring them to the syringe exchange. They’ll even give users syringes right there in the park. LESHRC social workers most often rely on sandwiches, condoms, and fact sheets as ways to engage users who may have previously had no intention of visiting the center.

“Giving that person a meal engages them, and they come back to us,” Tuchman said. “That’s when we start working — when someone is ready.”

Tuchman acknowledges the patience necessary for the harm reduction philosophy to be successful, and that it’s not something every clinician can spare.

“You have to be able to sit with someone who is continuing to use drugs, and still work with them, still help them. And that’s hard for some people.”

A New Future For Treating Injection Drug Addiction

Despite all science, statistics, and research, many still struggle with the idea of willingly allowing drug users to inject on a moral level. Wouldn’t handing out free needles essentially be handing out passes to do more drugs? Wouldn’t this cause more people to start injecting drugs? What’s next, letting people actually inject in a legally sanctioned building?

Actually, that’s already happening.

Safe injection facilities (SIFs), also known as supervised injection sites, have cropped up in Europe, Canada, and Australia, totaling 92 around the globe. The U.S., however, hasn’t been on the same page.

“The underlying philosophy is: ‘We accept drug addiction, we accept the state of affairs as acceptable,” Bertha Madras, deputy director of demand reduction for the White House Office of National drug Control Policy, said in 2007. She was attending a symposium the San Francisco health department co-funded in an effort to explore the idea of a safe injection facility being used to help resolve the city’s issues with public drug use. Madras looked at SIFs as “a form of giving up.”

This may be too progressive for the federal government, who only just lifted its ban on needle exchange programs in 2009. According to Tuchman, however, the 2010s could be a fresh start for SIFs.

“It’s happening now. There’s a very big movement by the harm reduction coalition and all syringe exchanges for SIFs,” she said. “The first SIF in North America was in Vancouver…it’s incredibly successful. All of the research shows that it reduces all of the harms people do to themselves with their drug use and their syringes…you’ll see it in the news now.”

Dr. Hokemeyer adds that he hopes this is the case.

“It’s time to stop isolating heroin addicts by criminalizing their behavior and sending them off to prison,” he said. “Safe injection sites will provide men and women who are suffering with their addiction a clean and safe place as well as a nurturing community that will hopefully move them out of the darkness of their disease and into the light of recovery.”

As for those who believe syringe exchanges, SIFs, and the whole de-stigmatized philosophy of harm reduction isn’t going to get people to stop doing drugs, Tuchman has an answer for them.

“I would say, you’re probably right. That person may not want to stop using drugs,” she said. “But I don’t want to step on a needle that person has used. I don’t want that person getting high on my doorstep. I’d rather them go into a place where they’re going to inject in front of a nurse…then they’re going to stick their syringe in a waste disposal, they’re not going to throw it on the ground, or throw it into my car if I leave the window open. They’re going to be injecting in a safer place, they’re not going to be outside. That person is going to get medical care there, they’re going to get substance abuse treatment there.”