The drug treatment program in Baltimore, the Institutes for Behavior Resources, operated a DEA-licensed van and a backup van to dispense methadone to hundreds of patients for about 10 years, and then purchased new vans and used them for another 10 years before parking the vehicles and letting their licenses expire.
Two years ago, Behavior Resources leased one of those vans to another nonprofit program, the Behavioral Health Leadership Institute, which is using the vehicle to provide buprenorphine instead of methadone. Although the DEA also has authority over buprenorphine, it has not banned licensed prescribers of the medication from working out of a van.
Equipped with a bathroom and private counseling rooms, the van allows Behavioral Health Leadership to offer low-income residents drug screenings, addiction assessments, counseling and pre-paid prescriptions for buprenorphine.
Nowhere to Go
WILMINGTON, N.C. — Until the opioid epidemic began seeping into nearly every city and town in the country, the idea of a Main Street storefront offering free needles, alcohol wipes and small metal cookers for heroin users was unthinkable in a conservative Southern city like this one.
But these days, most of the roughly 100,000 residents of this historic port on the Cape Fear River are painfully aware that their community has a serious drug problem. Syringes carpet sections of public walkways, drug users congregate in vacant lots, and an increasing number of residents are attending the funerals of friends and family members who have died of an opioid overdose.
As a result, many police officers here fully support syringe exchanges, places where drug users can go to dispose of used needles, pick up fresh ones, get health exams, and maybe find out about treatment options. They say they’re willing to overlook the fact that possessing drug paraphernalia, including syringes, is an arrestable offense.
But even in North Carolina, where the state Sheriffs’ Association helped a grassroots harm reduction organization enact the most liberal syringe exchange law in the country in 2016, many cops still insist that giving free supplies to heroin users simply enables their drug use.
“Police officers are just like the rest of the public,” said Capt. Lars Paul of the Fayetteville Police Department. “Until I got educated on harm reduction, I questioned why we were giving drug users all kinds of free supplies too. It was just a matter of taking the time to talk to folks and learn about the public health benefits of syringe exchanges.”
Kendra Williams, a recovering addict who works part-time for the Wilmington syringe exchange, said some cops in the drug unit there still don’t take the law seriously. “They’ll take away ID cards proving they’re syringe exchange clients and tell them it doesn’t mean anything. If they want to arrest you, they’ll find a way.”
Last year, a poll in Ohio — among the nation’s hardest-hit states — found that half of adults in that state favor syringe exchange programs. Politicians are listening.
Nationwide, at least a dozen states legalized syringe exchanges in 2016 and 2017, said Daniel Raymond, policy director of the Harm Reduction Coalition, a New York-based national organization that advocates for syringe exchanges. And nearly all of the new laws were signed by Republican governors and approved by GOP-led legislatures, including in Ohio.
That’s not surprising, Raymond said. Many Republican leaders’ constituents — particularly middle-income white males — are among those who have suffered most in the opioid epidemic.
Even so, most of the lawmakers and governors who ultimately approved the laws resisted until they received endorsements from law enforcement groups, Raymond said. Otherwise, they would have risked appearing soft on crime.
A dozen states — Florida, Indiana, Kentucky, Louisiana, Montana, New Hampshire, North Carolina, North Dakota, Ohio, Tennessee, Utah and Virginia — enacted laws in 2016 and 2017 that protect the employees and clients of syringe exchanges from existing state drug paraphernalia laws that otherwise could be used to prosecute them for possessing a syringe, according to Raymond.
Five more Republican-led states, Alabama, Arizona, Georgia, Iowa and Missouri, are considering similar legislation this year, he said.
An Old Idea
Syringe exchanges, also known as needle exchanges, first came into being in the late 1980s in places such as New York City and San Francisco and in liberal states such as Massachusetts, Minnesota and Washington. Once it became clear that the HIV/AIDS epidemic was spreading through needle sharing among injection drug users, public health officials took up the cause.
But until recently, syringe exchanges were nonexistent in rural towns and cities in the rest of the country, except for informal underground efforts organized by advocates.
In North Carolina, syringe exchanges now are cropping up in office parks, pawn shops, church basements, fire stations, hotel parking lots and treatment centers throughout the state, and the state health department is tracking their progress. So far, 26 syringe exchanges have opened, and the coalition is working to open more.
“Until the law was enacted, people were afraid they’d be arrested if they came to pick up supplies,” said Robert Childs, director of the North Carolina Harm Reduction Coalition. “And we were afraid to advertise.”
North Carolina’s law made it simple for a syringe exchange to open its doors, he said. For underground groups already supplying drug users with sterile supplies, it simply meant registering with the state health department and providing a plan to ensure the privacy of clients. For new groups, it meant finding funding and a base of operations, even if it was a private vehicle in a parking lot.
A Rural Problem
Unlike the AIDS epidemic of the 1980s and previous drug epidemics, which were spawned and largely defeated in urban areas, this opioid epidemic is ensnaring people who live in far-flung small cities and rural communities. In addition to mounting overdose deaths, these rural communities are experiencing unprecedented surges in hepatitis C infections and increasing threats of HIV/AIDS outbreaks.
Despite nearly 200 people testing positive for HIV in Scott County in 2015, Indiana’s then-Gov. Mike Pence, a Republican, was reluctant to allow a syringe exchange, because of his moral opposition to drug use. But among those whom Pence sought for counsel, according to The New York Times, was the local sheriff, who told him: “I believe the only thing we can do … is to get clean needles out there.” Pence declared a public health emergency and allowed a syringe exchange to open to curb further infections.
That exchange has since closed because of lack of support.
Even so, Pence’s emergency declaration marked a turning point for other Republican governors, said Gary Tennis, president and CEO of the National Association of Model State Drug Laws, a research group supported by the federal government. It made it easier for conservative politicians to support syringe exchanges.
But if states want to attack their long-term drug problem, Tennis said, it will be essential to nurture grassroots coalitions like North Carolina’s and build political will, particularly with law enforcement. Without that local support, standing up and maintaining syringe exchanges in affected communities will be impossible, he said.
According to Paul LaKosky, executive director of the North American Syringe Exchange Network, which helps fledgling groups launch syringe exchanges, that’s already starting to happen in dozens of places, including Native American tribal lands and small rural communities across the country.
Nationwide, LaKosky said, the list of syringe exchanges, both official and unofficial, has grown by about 15 percent a year for the past three years, with the fastest growth in Kentucky, North Carolina and Ohio.
“We’re seeing the greatest growth in rural areas, where there’s been an historic lack of access to health services of any kind,” LaKosky said. “The opioid epidemic is shining a light on those places.”
West Virginia, which has by far the highest opioid overdose death rate in the country, has not yet enacted legislation to authorize syringe exchanges. But a proposed opioid response plan released by the state health department in January lists harm reduction, including syringe exchanges, as a top priority.
Even without statutory authorization, at least 10 West Virginia municipalities have started exchanges, including eight with affiliations to county health departments.
In Charleston, the state’s new director of the Office of Drug Control Policy, Dr. Michael Brumage, said the police department there fervently supports the city’s syringe exchange. But just a few miles outside of the city, he said, the attitude among police officers is very different.
Dr. Michael Kilkenny, who as Cabell-Huntington public health chief runs a syringe exchange an hour’s drive away in Huntington, said the lack of state authorization makes him nervous.
The city’s drug control director when the exchange opened in 2015, Jim Johnson, said he also worried whether the police department would continue to support it without a state law. “All you’d have to do was stick a policeman outside the office on Monday and you’d have to close the doors on Tuesday.”
In Philadelphia, which has also been hit hard by the epidemic, Scott Burris, director of Temple Law School’s Center for Public Health Law Research, said Kilkenny’s concerns are warranted. To be effective, he said, syringe exchange laws must affirm that distributing syringes is a legitimate public health function that should be funded with public money. At the same time, any new laws must remove syringes from the definition of illegal drug paraphernalia, so that anyone can possess one without fear of prosecution.
“Authorizing exchanges to distribute syringes still leaves drug users vulnerable to arrest, which means fewer will come,” he said.
South Carolina wants to replace aging school buses. Colorado plans to electrify Denver’s bus system. And Washington wants electric ferryboats for Puget Sound.
As part of a 2016 federal court settlement after Volkswagen admitted programming its diesel vehicles to cheat on emissions tests, the automaker agreed to pay $2.8 billion to states to be used to reduce diesel pollution. And with money arriving as early as June, states are already deciding how to spend their share of the funds.
The infusion of money comes at a time when states are struggling to meet air quality standards and believe they won’t be able to do it without widespread adoption of low- and no-emission vehicles, from the Nissan Leaf in someone’s driveway to propane-fueled city buses and electric freight locomotives in public and corporate fleets. The VW funds — ranging from $8 million to $423 million per state, depending on the number of diesel VWs sold — could jump-start a viable market for alternate-fuel and electric vehicles, clean energy experts and state officials say.
“The hidden value of the VW settlement is creating an interest and appetite [among] agencies that might not otherwise have been participating in clean-vehicle technologies,” said Dan Welch of the Center for Climate and Energy Solutions, a nonprofit that advocates for clean energy.
Under the settlement, negotiated by the U.S. Environmental Protection Agency and the California Air Resources Board, states can spend the VW money on grants to both public agencies and private businesses. Each state has named a lead agency — whether environmental, energy or transportation — to oversee the projects, and 11 states (Arkansas, Connecticut, Colorado, Delaware, Maine, Nevada, Oregon, Pennsylvania, Virginia, Vermont and Washington) have already released draft plans outlining their proposed grants to replace engines that spew nitrogen oxide, or NOx.
States can spend as much as 15 percent of their payout to subsidize construction of public charging stations for electric cars. Most states are likely to spend the full amount, said Nick Nigro of Atlas Public Policy, a transportation electrification consulting firm: 17 states have already said they will do so. (Under a separate part of its court settlement, Volkswagen is spending $2 billion to build electric car charging stations and $10 billion to buy back diesel cars from consumers.)
Clean-energy advocates say public transit and school buses are likely targets for state programs for diesel replacement. Parents like the idea of getting rid of diesel fumes at the school bus stop. And the VW funds are arriving at a time when transit systems around the country are increasingly trying out electric and hybrid buses.
“There’s an enormous amount of public interest on the school bus side,” said Will Toor, transportation program director at the nonprofit Southwest Energy Efficiency Project, a regional advocacy group.
In New Mexico, a group of voters rallied in November to demand the state devote its $18 million settlement to zero-emission school buses to protect children with asthma. In South Carolina, the Department of Education wants to use all of the state’s $34 million payout to begin replacing the state’s 5,600 diesel buses, which average more than 15 years old.
In July, the Los Angeles Metro public transit system pledged to convert its fleet of 2,200 buses from compressed natural gas to electric power by 2030; the first purchase of 95 electric buses, to be on the road beginning in 2020, will cost $138 million. In Seattle, King County Metro has committed to buy only electric buses after 2020.
Still, just over half of the 71,000 transit buses in the U.S. remain diesel-powered, according to the federal Alternative Fuels Data Center.
In Colorado, the state’s proposed plan calls for about one-quarter of its payout, or $18 million, to subsidize new electric and compressed natural gas transit buses.
“What this [VW settlement] can do is make it easier for more transit agencies to try more electric buses on a greater number of routes, and become familiar with them and see that they really work for them,” Toor said.
In California, which has perhaps the nation’s most extensive, and complex, air quality mitigation programs, much of the $423 million in VW settlement money will likely go to existing programs to reduce diesel emissions in neighborhoods near warehouses, industries and seaports, said California Air Resources Board spokesman David Clegern. Those programs include vouchers to offset costs of businesses buying hybrid and zero-emission trucks and buses, and demonstration projects for electrification of forklifts, refrigeration units and yard trucks at freight facilities.
While the state has made strides in making cars cleaner, trucks haven’t reached the same standard, Clegern said. “There’s just a lot of trucks there, and a lot of trucks that sit and idle. If you’re at a port and your truck is moving six inches every 30 minutes, you’re putting out a lot of stuff.”
Clean Diesel or Zero Emissions?
One difference in states’ approach to diesel replacement has already emerged: how hard to push private and public fleet owners to replace old diesel engines with electric, rather than newer “clean” diesel, engines. (VW’s “clean” diesel engines were the ones that got it into trouble.)
“There’s a tension in a way between wanting to get the most immediate thing for your buck by going for the low-cost diesel, the newer diesel vehicles, and going all the way to zero emission,” said Max Baumhefner of the Natural Resources Defense Council, an electrification advocate.
New diesel vehicles cost less than electric or alternate fuel vehicles, and don’t require charging infrastructure or new fueling stations. But zero-emission vehicles are cheaper and cleaner long-term, said Nigro of Atlas Public Policy. “It’s clearly a lot of work up front. It’s a lot easier to swap out an old diesel bus for a new diesel bus. But that’s not going to move the needle on emissions, particularly NOx emissions.”
Colorado, which will receive $69 million from the VW settlement, will only offer subsidies for truck and bus owners to replace old diesel engines with alternate-fuel or electric vehicles. For private businesses, it plans to pay $100,000 toward the cost of a new electric dump truck, or $36,000 for a dump truck powered by propane. For government-owned fleets, subsidies are higher: $200,000 for an electric heavy-duty truck or $50,000 for a propane-powered one.
Only small businesses with fewer than nine trucks can apply for reimbursement for replacing old diesel trucks with newer “clean” diesel. In all cases, the old diesel-powered trucks must be scrapped.
Connecticut, which is eligible for $56 million, will allow public and private fleet owners to replace old diesel engines with newer, cleaner diesel engines without restriction.
“We’re not limiting ourselves in any way shape or form,” said Paul Farrell, assistant director of air planning for Connecticut’s Department of Energy and Environmental Protection. “We want to see what the projects are out there.” Connecticut also plans to subsidize new electric vehicles at a higher rate than replacement with new diesel.
But proponents of electric transportation say allowing new diesel engines at all is a poor use of mitigation trust money.
“If you spend your money on buying new diesel to replace old diesel, five years from now you’ll never know the settlement happened,” Toor said.
Electric vehicle technology is evolving quickly with improved reliability and battery life. Electric automaker Tesla, for instance, recently introduced an electric tractor-trailer truck with a 500-mile range and a price tag of $180,000. School bus makers Blue Bird and Thomas Built Buses have both introduced electric models.
“If this was five years ago, we wouldn’t even be having this conversation because there weren’t electric options even on the horizon’’ for medium- and heavy-duty trucks, Toor said.
The swift evolution of alternate-fuel transportation is partly why Colorado plans to put 18 percent of its settlement money — $12.2 million — in a “flex fund,” to be allocated after it becomes clear which programs will be most successful, said Chris Colclasure, deputy director of the air pollution control division of Colorado’s Department of Public Health and Environment.
“We didn’t want to decide everything up front and lock ourselves into spending everything in a certain way,” he said.
States’ money from the Volkswagen settlement may be least effective at combating nitrogen oxides from long-haul trucking, a major source in many states. A tractor-trailer heading through Pennsylvania and Ohio on Interstate 80, for instance, may be owned by a company headquartered elsewhere and not eligible to take part in either state’s diesel replacement program.
“While significant, the VW money is not enough to tackle all of the sources of diesel pollution out there,” Baumhefner said. “The good news is that there’s still plenty of bad air to go around. There’s no shortage of opportunities here to get dirty diesel off the road.”