Does Indy Need A Needle Exchange Program?
IU Emergency Medicine’s Dr. Krista Brucker is on a mission to change the way patients who overdose on opioids are treated, ensuring they receive the same level of care as a gunshot wound victim or heart attack survivor. Along the way, she’s gained respect as one of the city’s most serious opioid fighters. Now, she’s trying to convince city officials to set up a needle exchange to avoid deadly—and costly—HIV and hepatitis C outbreaks. Will they listen to her before it’s too late?
Pale blue lips and fingertips haunt her—almost every hour, of almost every shift. Amid the sterile and omnipresent whites of the Sidney & Lois Eskenazi Hospital Emergency Department near IUPUI, those hues consume Dr. Krista Brucker’s attention. They’re the telltale physical signs of an opioid overdose, as a patient’s oxygen uptake slows to a trickle. On duty in the high-acuity area, Brucker has treated those patients night in and night out for nearly two years of the state’s opioid crisis. On certain days, the 35-year-old might see as many as a dozen overdoses come through her department in one eight-hour shift. If police and emergency medical services save the lives of overdosed drug users—injecting them with life-saving opiate antidote Narcan on the scene, knocking the drugs out of the brain’s opiate receptors—Brucker’s job is to keep them alive.
But on a Monday night in October, statistics, not colors, were on her mind, as she walked into the Indianapolis Public Library Services Center to brief citizen members of the Marion County Prosecutor’s Office Community Justice Academy. Brucker, a respected IU professor of emergency medicine, had been invited to discuss the opioid surge. The number of deaths from drug overdoses since 1999 in Indiana has skyrocketed 500 percent, and Marion County leads the state in both overdose deaths and emergency room visits due to overdoses. From 2007 to 2016, opioid-related overdose deaths shot up 135 percent, with 275 lives claimed last year. Worse, the same indicators that predated the largest outbreak of HIV in the nation’s history—in the spring of 2015 in Scott County, Indiana—are popping up in Marion County. From 2016 to 2017, incidents of hepatitis C were expected to double from 30 to more than 70, according to the Marion County Public Health Department.
Brucker trundled through her PowerPoint slides, delivering bleak news in a world-weary manner: Unless hospitals and the city changed their response to the emergency, the tide of opioid overdoses and deaths would not be stemmed, and the cycle of addiction would remain unbroken. Project POINT, founded by Brucker last February, is a unique pilot program that aims to put opioid users revived by lifesaving Narcan on a path to long-term recovery. An acronym for Planned Outreach, Intervention, Naloxone, and Treatment, POINT goes further than a typical emergency room’s response to an overdosed patient, providing them with a range of services, including HIV and hepatitis C testing, transportation, housing, and financial counseling.
“This is really scary. I’m sure many of you have heard about what happened in Scott County,” Brucker told the group. There were, she said, “almost 200 new cases of HIV in 2015 and 2016, 90 percent co-infected with hepatitis C. That’s devastating to a community. It’s also a financial disaster.”
For every new HIV case, she explained, the lifetime cost to treat a patient would total as much as $400,000. Tack on another $80,000 for hepatitis C. “There are estimates from the health department that if that happened in Marion County, because of the density of our population, it would cost a half a billion dollars,” she said. The figure equaled nearly half of Indianapolis’s $1.1 billion budget for 2018. “If for no other reason than you’re a tax-paying citizen of Marion County, there’s a good reason to care about this stuff,” she told the audience.
In Indiana, policymakers and politicians have a mixed record in confronting its opioid crisis. When the Scott County outbreak began to peak in March 2015 and state lawmakers on both sides of the aisle renewed calls for a syringe exchange, then-Governor Mike Pence said publicly that he would “pray” about how to respond. For months beforehand, hepatitis C rates had spiked in Scott County, an indication to public health officials that dirty needles were in rotation among opioid users. Since then, dozens of innovative programs designed to combat opioid abuse, such as Brucker’s Project POINT, have sprung up.
So have needle exchanges, a so-called harm-reduction method endorsed by the Centers for Disease Control and Prevention, the National Academy of Sciences, and the National Institutes of Health. The NIH has argued that the programs can curtail HIV cases by 30 percent. At press time, seven Indiana counties maintained or had announced plans to create their own exchanges. A new law signed by Governor Eric Holcomb gives counties and cities freedom to launch such programs.
But syringe exchanges remain controversial. Indiana’s Republican attorney general, Curtis Hill, opposes them, arguing that they encourage drug addiction. “[Hill’s] lying at this point,” says Chris Abert, a social worker and recovering IV drug user who now works for the Indiana Recovery Alliance. “Or he’s being willfully ignorant.” The same month as Brucker’s presentation, Lawrence County, situated in Southern Indiana, shut down its exchange. “It will result in people dying,” says Abert. “Some of our most vulnerable community members will be abandoned, and be pushed back into the shadows.”
Before voting to shut down the Lawrence County program, county commissioner Rodney Fish quoted 2 Chronicles 7, a Bible verse: “If I shut up heaven that there be no rain, or if I command the locusts to devour the land, or if I send pestilence among my people; if my people, which are called by my name, shall humble themselves, and pray, and seek my face, and turn from their wicked ways; then will I hear from heaven, and will forgive their sin, and will heal their land.” Prior to its closure, proponents of the exchange credited it with decreasing cases of hepatitis C by 50 percent.
Under pressure from Hill, Madison County shut down its exchange earlier this year, too.
Mayor Joe Hogsett—despite revealing in October his intentions to file lawsuits against six opioid makers and distributors—has remained relatively quiet regarding needle exchanges, allowing the Marion County Public Health Department to take the lead on the issue. In announcing the suits from the 25th floor of the City-County building, Hogsett said, “We have fought back as best we can, only to find this epidemic untenable.”
But there’s one thing Indianapolis officials haven’t tried. Marion County hasn’t established its own needle exchange, despite a 339 percent increase in the number of cases in which Indiana Emergency Medical Services administered Narcan on overdose runs from 2012 to 2016. Prosecutor Terry Curry, a Democrat, whose office invited Brucker to speak, has yet to take a position on establishing a needle exchange. “We’ve been trying to get the prosecutor on board with a needle exchange for at least a year,” Brucker told me a few days before her presentation. “The sheriff and the prosecutor say the health department doesn’t want it. The health department says the prosecutor doesn’t want it.”
This month, the City Council is expected to take up the issue of establishing a needle exchange. Dr. Virginia Caine, the director of the Marion County Public Health Department, told me she would bring a resolution before the City-County Council by year’s end. (Privately, Hogsett aides say the mayor would be unlikely to oppose the creation of a needle exchange.) But in the absence of a locally sanctioned program, at least two underground exchanges are believed to be in operation in the city,
organized by churches and drug users—one, according to a source, has been running for nearly 25 years, keeping a portion of the city’s addicts outside the boundaries of proper care.
All of which puts Brucker in a bind. As a doctor, she is trying to save lives. But on the front lines of an epidemic, she finds herself crossways with a conservative, law-and-order town where people still flinch at the idea of providing addicts with free needles. At several points throughout her talk, Brucker shadowboxed with invisible critics, having heard from them so frequently over the last two years. As she speaks, her voice cracks several times. “Sometimes we get pushback, like, ‘Oh, you’re just teaching people how to use drugs,’” Brucker told the room. “No, no, no. We’re teaching people how not to die.”
Brucker grew up near Minneapolis, spending time on her grandparents’ farm in a rural area of the state. She attended a strict Evangelical Christian high school, a milieu that to her seemed armed with easy answers to complicated issues like addiction. Brucker bristled at these but internalized the parts of the faith that seemed to explain the suffering she saw at a Honduras clinic, where she did menial work after graduating from DePauw University in 2004. “I believe that we are all broken in different ways,” Brucker says of the forces that lead to addiction. “There is something in all of us that wants to address that brokenness.” Those two years taught her that “people who seemed vulnerable and suffering aren’t helpless,” she says, and she resolved to become a doctor. When she got into Harvard Medical School, Brucker’s grandmother, who lived in a small, insular farming community outside the city, told her, “My neighbor told me nothing good came out of Harvard.” Brucker understood this sentiment as endemic to the culture from which she came.
In 2014, Brucker finished her residency in emergency medicine at the McGaw Medical Center of Northwestern University in downtown Chicago. “I chose emergency medicine because I like the acuity of the problem, that we can help people very immediately,” she says. “We are the true safety net of healthcare.” A newly minted MD, fresh out of Harvard in 2010, she knew how to treat victims of gun violence, car wrecks, heart attacks, and dozens of other ailments that brought people to the ER. She was skilled in administering traumatic resuscitations, intubating patients, and treating life-threatening hemorrhages. But outside of Chicago, in opioid-torn Indiana, she would confront a different scourge, one that was perhaps more insidious and intractable. By the time she arrived in Indiana in 2014, she entered a state where you’re more likely to die of a drug overdose than in a car wreck. That’s according to 2011–2013 data from Trust for America’s Health and the Robert Wood Johnson Foundation. While that’s the most current data available, it’s now years behind a problem that has only become worse. Back in 2010, opioids led to roughly 20,000 deaths nationwide, according to the CDC’s National Center for Health Statistics. In 2015, when Brucker started working at Eskenazi and the Indiana University School of Medicine, that figure mushroomed by 75 percent to nearly 35,000.
“That year was a really sad year for ER docs,” Brucker says. “We spend a lot of time training to learn how to respond to motor vehicle deaths, gun deaths, and gun homicides. We spend almost no time learning how to respond to people who overdose on heroin. This was a wake-up call for emergency rooms across the country, including ours.”
Almost 90 percent of IMPD officers have seen an overdose. From October of 2016 until October 2017, the average number of IEMS overdose runs was 21 and the most was 43, a particularly busy day on September 15. Many of these patients end up seeing Brucker at some point in their addiction cycle. The prescribed treatment for an opioid overdose, once the patient is revived with Narcan, is to monitor them for four to six hours, ensuring that they don’t need more Narcan and watching their respiratory rate. Close to 20 percent of patients she treats are receiving naloxone (the drug branded as Narcan) for at least the second time. Some of the patients have received the drug as many as 12 times. Multiple incidents of naloxone administration increase the likelihood of death by 65 percent.
After a year of experiencing the onslaught firsthand, Brucker couldn’t in good conscience continue what seemed like passing patients through a revolving door. In a conversation with a colleague, she pondered the question, What if we treated an overdosed patient in the same way we treated a heart attack or gunshot wound survivor?
In February 2016, Brucker launched Project POINT, a partnership among IEMS, Eskenazi Hospital’s Emergency Department, and Midtown Community Mental Health, with the goal of doing exactly that. The Richard M. Fairbanks Foundation awarded Brucker and her team a $700,000 grant set to expire at the end of 2018. With the funds, Brucker and her team hired two recovery coaches, former addicts who conduct a bedside intervention with each patient, and help them navigate housing and health-insurance issues. The program also provides patients with free HIV testing, hepatitis C testing, and mental health assessments. Since then, Brucker and POINT have serviced 319 patients.
In many cases, addicts are desperate for this kind of help. In the first 10 months of her program alone, 89 percent were interested in treatment referral, and 50 percent of patients engaged in three or more follow-up visits. Once, a couple in their 20s came to the hospital, the girlfriend having just been revived from an overdose. A Project POINT recovery coach conducted a bedside intervention, promising a range of services to the patient. Her boyfriend asked the recovery coach whether he could get the same help. The coach had to tell him no, that the services were only for patients resuscitated from an overdose. Within hours, the boyfriend had arranged to meet his opioid supplier in the parking lot and had injected drugs on the site—all so he could access Project POINT.
Brucker’s not here to tell glossy stories about Project POINT. Despite incremental successes, the program has been fraught with setbacks, too. Earlier this year, a patient who had put his life back together after six overdoses in eight weeks missed an appointment with Brucker. When Brucker first met him after his sixth overdose, he looked at her and said, “If I hadn’t met you today, I was going to die.” Brucker coaxed him into treatment. Over months, he rebuilt a relationship with his son. He made plans to become a recovery coach, helping other addicts. He volunteered to film a video about Project POINT. She set a Google alert for his name. Soon, his obituary popped up in her email. “The patients’ stories are sad,” Brucker says, “but what makes me most want to scream is there’s all this talk about an emergency and an epidemic, and I get it. Everyone likes to have news conferences. But then it just feels like there’s this disconnect between this hoopla, and this reality that there were four patients here today who deserved to have all their options available, and they got the scraps of what I could put together. That’s bullshit.”
One crisp October Friday evening, Brucker settled in at her station for an eight-hour shift that would more than likely span 10 hours, and promised to bring a deluge of patients. Perhaps unsurprisingly, overdoses seem to spike on Friday and Saturdays, when opioid users receive checks. The first of the month is particularly brutal to ER docs such as Brucker.
Most overdoses happen to patients who were recently clean, and relapsed. One of her first patients on this night was 67 days clean. As a result of his relapse, he could lose his bed in a sober living environment. Because of his housing situation, Project POINT would have to work over the weekend to find him a place to live. “That overdose moment is filled with a lot of shame and guilt and feeling like a failure. Part of our work with POINT is to try and help people kind of reimagine what that overdose experience can be—less full of regret and more full of opportunity.”
In a white lab coat, Brucker sits behind a computer in the middle of the emergency department. She scans a color-coded screen called a trackboard, based on where patients are in the process. Green, for example, means a patient is ready for discharge or admission to the hospital. All of the overdoses come to the high-acuity area, where they can be placed in shock rooms, the kinds of huge ER rooms you might see on TV medical dramas such as Grey’s Anatomy. By 6 p.m, three hours into her shift, the trackboard included a gunshot victim, a possible stroke, and two opioid overdoses. “That’s pretty typical for a Friday afternoon,” she says. One opioid overdose patient, a 19-year-old, was just discharged, bringing the total number of overdoses to four that day. Compared to most nights, this one actually seemed slow to Brucker.
Her phone rang. She answered. It was a pharmacy calling to check the veracity of a recent painkiller prescription coming out of the ER. Brucker passed the phone off to a resident. “Yeah, I prescribed that,” the resident told the pharmacist on the other end of the line.
“That’s good news,” Brucker told me. But even as doctors and pharmacies are more careful about over-prescribing opiates, that has had an unintended consequence. From 2009 to 2016, Indiana led the nation in pharmacy robberies, tallying 651. For Brucker, that statistic illustrates the crisis’s seeming intractability, one that we can’t arrest or prosecute our way out of as a city. “My experience in medicine is the more sure you are about a solution, the less science there is behind it,” she says, referencing the Indiana attorney general’s opposition to needle exchanges.
At 6:48 p.m., Brucker scanned her trackboard again. She couldn’t believe another overdose hadn’t popped across it since the last discharge. “It’s too good to be true.”
In a too-rare reprieve, she had time to reflect on the news of the week. A drumbeat of local headlines chronicled major efforts to confront the opioid epidemic, including Hogsett’s plan to sue manufacturers and distributors, as well as a $50 million landmark plan put together by IU, which includes more than 70 researchers over the next five years. The researchers will focus on data collection, law and policy, education, the science of addiction, community engagement, and workforce development. But already-operational programs such as Brucker’s won’t receive that money. “The state just put however many millions of dollars into care, and people are going to ask, ‘What did you do with it?’” Brucker says. “And there’s going to be a lot of looking around, trying to find patients that you can point to.”
Brucker is also dubious about Hogsett’s lawsuit gambit. “There are other ways to bring drugmakers to the table and provide relief more quickly,” she says. “It’s frustrating for me to see this process that everyone knows is going to take 10 years to play out. I think there’s an argument to be made for laying out what we need, saying (to drugmakers), This is how much it’s going to cost and Hey, can you pay for this? Lawyers stand to make a lot of money in the next 10 years. All that money could be used to fund programming,” she says, like POINT.
Brucker has a particular ire for politicians who trot out campaign-ready rhetoric and solutions: “This is not a political issue. This is about saying to a patient, ‘I know you’re using heroin, and I know you’re using heroin because there’s a lot of brokenness, and providing this service to you—which is evidence-based, financially sound, has everything going for it—is not a political act.’ It’s a way of saying, ‘I care for you and I want you to engage in care so much that I’m going to do this thing—which maybe feels a little off to a lot of people—because I’m on your side.’ Politicians have made it into this thing about crime. But I would like to ask them, ‘Have you ever met a person who was injecting heroin every day, using a dirty needle? Have you ever had to look in their eyes, and say, No?’ Because I have to everyday, and that feels wrong.”
Brucker maintains a dizzying schedule. She attends conferences on opioids. Increasingly, she’s in demand with community groups who want her to speak about her experience. “She’s top drawer,” says State Senator Jim Merritt (R-Indianapolis), who has met with Brucker to discuss opioids on several occasions. “She understands that this is an illness, not a character flaw.” She would address the prosecutor’s office days later, in an effort to sway their opinion on a Marion County needle exchange.
Flummoxed by moral opposition to exchanges, Brucker makes a counter argument, one partially influenced by her time at a conservative Evangelical high school. “I don’t think the Bible has opinions on needle exchanges,” she says. “It’s like a seat belt. The evidence is there.”
In the meantime, Brucker has considered taking measures into her own hands: “I’ve thought a lot of times about giving out clean needles, because you can just write a prescription for them, but as long as people are going to continue to be arrested for possession of a syringe, I’m not going to hand them out to people. I feel like it’s unfair.”
Brucker has gone so far as to use her own money to purchase bus passes and Uber rides for patients to get to and from treatment, says Dan O’Donnell, an ER doctor who is chief medical officer for IEMS, which partners with POINT. “She would kill me for telling you that,” he says. “It weighs on her. It’s difficult.”
By 10 p.m., two more overdosed patients had arrived. This time, though, they were taken into what’s called a holding room, a locked section of the emergency department staffed by at least two Marion County Sheriff’s deputies, meaning they have been arrested at the scene of their overdose or were found to have an open warrant at the time. The holding room is visibly darker than the rest of the department. Brucker made her way there to check on the new patients. As she surveyed them from behind protective glass, Gloria Haynes, a POINT recovery coach, knelt beside the bed of one. Haynes asked her about her drug usage, while softly stroking her hair. The woman, who looked to be in her 20s, writhed in pain. “She’s dopesick,” Brucker said. “Imagine the worst flu you’ve ever had in your life, times 10.” The woman continued to seize on the gurney, as Haynes sat there, holding her. “To me, that is an image of healing,” Brucker said, looking at the patient. “She is clearly uncomfortable. You can see how she’s looking away. She’s not making eye contact. But if you watch this interaction long enough, you’ll see her slowly start to come down and make more eye contact. I bet no one else here has even touched her.”
But by then, it was nearly 11 p.m. In the first seven hours of her shift, she would see eight overdoses. Sleep was still far away. Even when she got home, to her husband and her 14-month-old son at their home on the near-east side, she would struggle to turn off her whirring mind. “I can’t get to sleep right away,” she said. “I spend a lot of time trying to figure out what just happened.”
With an hour left in her shift, she had a bigger problem to deal with than a stern sheriff’s deputy. While still in the holding room, her phone buzzed with a message that a victim of a major trauma was hurtling to the emergency department. Details were fuzzy. She made a beeline to one of the trauma bays, where she met 15 to 20 other doctors and nurses, along with a care coordinator and a chaplain.
“You have all of these people standing around right now, and that’s what should happen with an overdose,” she said. In Brucker’s perfect world, a heroin victim would be met by the same phalanx of staffers, and, at the very least, three people: a financial counselor, a recovery coach, and a care coordinator. For the next year, Brucker will have to make do with what she has, and hope for POINT to prove itself worthy. With that in mind, as she looked around at the medical team assembled, she sighed, and her eyes narrowed. “It means I have a lot of work left to do to change the response to an equally life-threatening illness.”