Knox County is highly vulnerable to HIV and Hepatitis C outbreaks, according to the Tennessee Department of Health. State statistics show that in 2020, Knox County experienced 845 new cases of Hepatitis C (HCV), 38 new HIV diagnoses and 342 overdose deaths. 

According to the CDC, new users of syringe services programs are five times more likely to enter drug treatment compared to non-participants.

The numbers have grown since then. HIV diagnoses increased to 84 in 2021. The Knox County Regional Forensic Center’s numbers for drug overdose deaths have soared — to 533 in 2021 and 544 last year. 

To address individual and public health risks associated with injectable drug use, some medical providers have focused on having candid conversations with historically stigmatized drug users. These candid conversations begin on a foundation of trust.

Five years ago, Choice Health Network’s harm reduction program started building that trust from a truck parked at downtown Knoxville’s Volunteer Ministry Center. While mobile clinics still visit Campbell and Cocke counties, the service now has a permanent home in a small clinic off Ailor Avenue where people who use drugs can find resources and exchange used needles for sterile ones.

“The need was massive in 2018 when we started and the need is massive now,” said Genoa Clark, Choice Health Network’s harm reduction program director.

Harm reduction is an evidence-based public health strategy that minimizes the negative consequences of drug use, while empowering people who use drugs to take incremental steps toward living healthier, self-directed, purpose-filled lives, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

Inside the Ailor Avenue clinic, clear bins of wound care supplies, sterile cookers, naloxone, fentanyl test strips and condoms line the wall behind a big round table that holds boxes of sterile syringes.

A team of registered nurses and counselors greets visitors. They can treat wounds, teach safe injection practices and perform HIV and HCV tests. When individuals test positive, clinic staff link them up with medical providers next door.

Opening the Door

Nearly 30 years of Centers for Disease Control and Prevention research shows that harm reduction and syringe services programs (SSPs) such as those at Choice Health Network’s clinic do not increase drug use or crime, but play a crucial role in reducing the transmission of infections like viral hepatitis and HIV, and protect first responders and the public by facilitating safe needle disposal.

Furthermore, CDC studies show that new users of SSPs are five times more likely to enter drug treatment and three times more likely to stop using drugs compared to non-participants.

That’s Jay’s goal. He’s been coming to the clinic for nearly a year. In that time, he has taken steps toward a safer, healthier lifestyle. (Editor’s note: Compass is not using the last names of program participants.)

“I used to get sores, staph infections a lot, but this program has helped me develop clean, better habits to take a better step on my way to getting clean,” he said. “I’m at the point where I won’t use anything that looks unsafe and I use a lot less, where I used to not even care.”

Jay is on a methadone regimen, but he said his dose wears off too quickly.

“I’m really trying to get off of everything, but when (the methadone) wears off, I fall back on drugs to get through the day,” he said.

Drug metabolism varies greatly among individuals, which is why SAMHSA declared dose-capping “contrary to the current state of the medical literature and the principle of individualized treatment” more than 16 years ago.

While Tennessee regulations don’t enforce a methadone dosage cap, they do require providers to get state approval for doses greater than 120mg, according to Tennessee Department of Mental Health and Substance Abuse Services spokesman Matthew Parriott.

State regulations don’t require methadone treatment programs to immediately discharge patients who actively use drugs or participate in SSPs either, but they must “intensify services,” for those patients, Parriott said.

When a patient tests positive for drug use, medication-assisted treatment providers must immediately terminate the patient’s ability to take home medication, and enact more frequent counseling and dosing appointment requirements, according to the state’s minimum program requirements. 

Upon a fourth positive drug test, providers must enroll patients who can’t or won’t comply with increased appointment requirements in medically supervised detoxification and discharge them from treatment. 

“I’m still proud of what I’ve been able to change so far and that I’ve been able to better myself a little with the resources I have right now,” Jay said. “I know that it’s still bad, but it’s not as bad as it could be or as bad as I could allow it to be. I still have the monkey on my back, but now I’ve got it on a leash.”

These may seem like small victories, but to Choice Health Network’s harm reduction team, they’re huge. At its core, harm reduction uses practical and compassionate intervention to mitigate the negative public health consequences of drug use by “meeting individuals where they are,” Clark said. By destigmatizing conversations about drug use and sexual activity in the clinic, harm reduction providers can help their clients stay safe, while leaving the door open for conversations about recovery.

“Sometimes we see some folks once and they ask for a referral to treatment and that’s it,” Clark said. “For people that want to go to treatment, we want to support them — but it’s not as easy as a lot of people think.”

Barriers to treatment include expense, lack of insurance or underinsurance, family care needs and the inability to take time off work due to employer policies or household income loss. Getting into a recovery program can also be a lengthy process, Clark said.

“We don’t push it; we just leave the door open for that conversation and follow their lead and it works,” she said. “Nearly every single day we have someone come in and say, ‘Hey, I’m really interested in going to treatment,’ and we will spend as much time as they want to spend talking about it.’”

Saving Lives

Harm reduction is not without its critics. Dr. Darinka Mileusnic-Polchan, the Regional Forensic Center’s chief medical examiner, questioned the effectiveness of harm reduction in an introduction to the center’s annual operations report for 2022.

“It may be time to reevaluate more seriously many of the programs and measures that have been instituted to combat drug-related deaths such as medication-assisted treatments, accessibility of naloxone, and needle exchange programs,” Mileusnic-Polchan wrote. “All of these approaches appear to be ineffective bandages to deeper societal woes.”

Clark acknowledged that the harm reduction approach can be challenging for a lot of people, but she said the program measures success through the connections built with participants.

Since the program began, about 20 percent of participants tested for hepatitis C have been antibody positive, meaning they were exposed to hepatitis C at some point in their lifetime, Clark said. 

The HIV positivity rate across the organization has increased by 3 percent since 2020, raising concerns for community-wide positivity.

“I’ve seen people sharing needles and cookers and getting these big sores that spread,” said Shannon, who has been coming to the clinic for five years. “The stuff I get at this clinic helps me stay safe and help others too.”

Shannon said she tries to teach others about the safer drug use and needle disposal practices she’s learned at the clinic. She also frequently uses naloxone from the clinic to save people’s lives.

“People see us struggling with addiction and think that because we keep (using drugs) we don’t value our lives, but we do,” she said.

Between October 2017 and March 2023, naloxone distributed by programs like Choice Health Network’s harm reduction clinic saved at least 60,000 lives across the state, according to the Tennessee Department of Mental Health and Substance Abuse Services.

Clark said she hears about clients using naloxone to treat people who have overdosed nearly every day. But overdose deaths still happen. Bulletin boards on the clinic’s walls display hand-written memorials for clients and their loved ones who have died.

Harm reduction staff serve on Knox County Health Department’s Overdose Fatality Review (OFR) team, which creates case narratives to identify drug intervention strategies.

“We really do get to know people’s paths, their families, their stories and their work,” Clark said. “We get a lot of information that helps with case building, but it’s been hard for our team because we have a much more personal relationship with many people who have died.”

While statistics for measuring lives saved by naloxone against lives lost to fatal overdoses are available, it’s harder to tally up the effects of all the small, incremental steps harm reduction clients like Jay make toward a healthier lifestyle.

“When people trust us enough to tell us really intimate details of their lives to try to get some resources and help, that takes a lot of vulnerability,” Clark said. “When we build that trust and make sure people know we care about them, they keep coming back.”