For the past five years, the IDEA Exchange has operated on the front lines of Miami's fight against drug addiction, overdoses, but also the spread of infectious diseases such as hepatitis C and HIV, the latter of which affects nearly 30,000 people in Miami-Dade, which has the highest rate of new HIV infection in the country. But last March, the exchange had to face a new public-health crisis: COVID-19, which according to the U.S. Centers for Disease Control and Prevention can leave people affected by homelessness and substance-abuse disorders at increased risk of severe illness compared to the general population.
Nationally, about 375,000 people died from COVID-19 in 2020. But the opioid crisis is linked to a record 93,000 fatal overdoses last year. It’s estimated that deaths due to drug overdoses rose 30 percent in 2020. Of the 258 drug-overdose deaths logged in Miami-Dade during the first half of 2020, 188 were from opioids. As one epidemic surged, so did the other. Here, at this modest campus of shipping-container offices, is where these two epidemics collide in Miami.
IDEA physicians and staff were worried about COVID-19 and their patients. Many of the people in recovery work in the service industry. Some lost their jobs and started using again, says Dr. Hansel Tookes, an associate professor of medicine at the University of Miami and the founder of IDEA Exchange.
"People would lose their jobs, their insurance. How does anyone cope with stress?" Tookes explains. "It was really heartbreaking to see people doing so well in their recovery return to the program. But I'm grateful the needle exchange was there for them as a safety net."
"To do the work that we do, you have to love people who inject drugs," Tookes says.
IDEA Exchange is rooted in so-called harm reduction — policies and programs that aim to reduce the stigmas, barriers, and negative consequences associated with drug use. Handing out clean syringes would violate state drug paraphernalia and possession laws. Yet, without access to clean needles, drug users would share dirty syringes, and potentially spread infectious diseases intravenously. Though the clinic sought to eliminate that possibility, the concept remained contentious.
For years state legislators fought the Infectious Disease Elimination Act — legislation that would legalize a pilot program for the needle exchange. Miami-Dade leaders attacked the program with ignorance and bad-faith arguments. Critics contended that giving away needles would only enable and perpetuate drug use.
But Tookes kept up the fight for more than four years and ultimately won during the 2016 legislative session when he was granted permission to run IDEA Exchange for five years as a pilot program. In June 2019, a law that would legalize needle exchanges in the entire state was passed by Florida's conservative legislature and signed into law by Gov. Ron Desantis.
"Withholding syringes from a vulnerable community knowing that providing clean syringes can save lives is a human-rights violation," Tookes contends. "I'm happy I was able to advocate to change that."
The IDEA Exchange opened in December 2016, and more than 1,700 people have visited the facility since then. Some patients are homeless who live nearby and walk to the clinic, but others hold jobs, drive cars, live in houses. So far, the clinic has removed an estimated 900,000 needles from Miami's streets. The program is estimated to save Jackson Memorial Hospital $11.4 million a year by lowering infection rates and routing drug users into rehab. Moreover, IDEA physicians and staff are caring for some of the most vulnerable, stigmatized and hard-to-reach patients in Miami.
Before COVID-19, IDEA participants could walk in freely to the exchange on NW Seventh Avenue and 17th Street. They'd count their used needles, drop them in a sharps disposal container, and receive an equal number of clean syringes in return. Some got treatment for injection-related wounds or infections. While they waited to be seen for tests or treatment, they'd hang out in the air conditioning, chat up the doctors and social workers, and watch television.
But in March 2020, when the first coronavirus cases were confirmed in Florida, employees started working from home, and non-essential businesses closed. IDEA halted some of its in-person operations for about two months, but staff never stopped showing up for the needle-exchange program. Doing so would have put people who inject drugs at risk of reusing or sharing needles. Wearing N-95 masks, staff resorted to handing out syringes through a window, cafecito style, a practice that continues today.
"It was hard because harm reduction is a smile and a hug, and all of a sudden we could not do those things," Tookes says. "But we had to do that to remain well. The needle exchange never closed and I'm proud of that. We adapted to the new world."
So on a scorching afternoon, the woman in the pink sleeveless blouse stepped up to the needle-exchange ventanita and emptied several sacks full of used hypodermics on the ground. She counted them one by one, and then five by five, disposing of them in a sharps container as she went. An IDEA staff member and peer addiction-support specialist, a tattooed man who goes by Arrow and requested not to give his full name for privacy reasons, counted along with her: 1…47…102…200.
"I have a lot of them," the woman admitted.
Altogether they counted 220 used syringes. Arrow gave the woman the same number of clean ones in return. She thanked him before walking out of the small IDEA complex and onto NW Seventh Avenue. Though no one said it, it’s implied that she’d later inject herself with heroin or fentanyl, but proponents of harm reduction consider it a victory that at least she won’t risk catching hepatitis C or HIV or transmitting it to another person via a dirty syringe if she's already positive.
Arrow, he of the airbender tattoos on his wrists and bald scalp, says he understands that the woman in the pink blouse wants to get clean, but living on the streets — surrounded by other drug users and without access to rehab programs — makes that so much harder. Arrow should know; he was addicted to drugs for decades and met most of the people who come to the exchange back when he used to sell cocaine and fentanyl.
As he tells it, Tookes and the IDEA program saved his life. Arrow says he went into treatment for drug use and HIV. He says he's been clean since 2018 and has persuaded more than a few drug users to go into detox or long-term care facilities.
He tells them that if he can do it, they can, too. He tells them how awful the withdrawal process feels but encourages them to continue because it gets better. And if they're not yet ready to go into treatment, he tells them to come see him when they feel ready to take that step.
"I get to give back to this place," Arrow says.
Taking care of people who use drugs during a pandemic hasn't just been about providing clean needles and testing. During the dire first months, it was about providing for people's most basic needs.
"Some feedings stopped because of COVID," says Dr. David Forrest, the IDEA Exchange's program director. "A lot of people went hungry very fast. This is not our usual thing, but we started making sandwiches and packing them up with a drink so people had something to eat."
COVID-19 also forced the IDEA Exchange to change the ways it operated. The staff shut down HIV and hepatitis-C testing for a couple of months, then resumed using the ventanita model. They also incorporated telemedicine into their visits, all while protecting themselves and each other against mounting coronavirus cases and hospitalizations.
Forrest, a lean, bearded man wearing jeans and a plaid, long-sleeved button-down, says the exchange had a goal of providing mobile healthcare to the people they serve, even if the person lives under a highway overpass. The pandemic propelled that vision and forced staff to innovate. IDEA staff would go out to the places they knew they'd find people who inject drugs. The people would step into a mobile unit and have their blood drawn for HIV and hep-C tests. They would then have a telehealth visit with a doctor via a wireless hotspot and tablet. IDEA staff would even pick up and deliver medication to people who were under HIV or drug-use treatment.
"This is the kind of engagement we were shooting for," Forrest says. "This very high-level goal we had, COVID really pushed that. It became a necessity not to make this happen in a few years, but to make it happen as much as possible right now. We developed a lot of capability for telehealth participation with IDEA members. In that sense, the pandemic really pushed things forward."
Tookes' work, as well as the way he and his team revolutionized the way they care for drug users during the COVID-19 pandemic, earned him one of the 2021 Avenir Grants, awarded by the National Institute on Drug Abuse to support projects run by doctors who study HIV/AIDS and substance abuse.
"The list of people who have won this award are some of the biggest powerhouse researchers, and I can't believe this is where I am now," Tookes says.
Tookes received a grant of $2.3 million for a research study he's spearheading with 360 participants from Miami, West Palm Beach, and Tampa. It will analyze the differences between HIV patients' rate of viral suppression (the amount of HIV in the blood) when being treated in an on-demand, virtual setting versus in a traditional healthcare setting. Tookes hypothesizes that the group receiving on-demand, virtual care will include more patients who are undetectable for HIV compared to the group being seen in person in a standard medical setting.
If Tookes' hypothesis is correct, the study will demonstrate that harm reduction and removing barriers to care for people who inject drugs is a successful model.
"We know that meeting people where they're at, physically and emotionally, actually works to treat HIV, hepatitis C, and addiction," he says.
IDEA Exchange's success in Miami has opened the door for other clinics to open across the state. IDEA Tampa opened earlier this year. FLASH Exchange in Palm Beach County is also up and running. Broward, Alachua, Manatee, and Leon counties have passed resolutions to establish needle exchanges.
IDEA Miami, meanwhile, is on for the long haul.
"What's alarming is that the 93,000 people who died [in 2020 from overdoses] were all preventable deaths," Tookes says. "We have work to do."