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A man walks into the needle exchange.
Sounds like the start of a joke, doesn’t it. A man walks into the needle exchange, and says.
It’s usually men who walk into the needle exchange. Women are much rarer.
What they usually say is ‘Give me X number of long oranges, Y number of 2ml barrels, or 1ml completes. Some citric, swabs, filters, spoons. A small bin please. No, I haven’t got any used pins this week. I’ll bring them next week.’ (A lie. They hardly ever do.)
A man walks into the needle exchange who doesn’t look like you.
A typical exchange goes like this: a user comes in. The drugs worker asks their date of birth, looks them up on the system. They ask their name. They read the notes to see if there’s anything to be following up on.
There are different needle gauges on offer, following a loose hierarchy of injection site and stage of use: inner elbow, hands, legs, feet, groin. Neck, though you can’t give any advice for that. The only advice is Don’t do it. If anything goes wrong, you can amputate a leg. You can’t chop off your head.
A man walks into the needle exchange who doesn’t look like you. He looks so little like you, in fact, that it slips past me at first, how much he reminds me of you, or even that he reminds me of anyone at all.
Fine needles for areas like hands and feet, where the veins are thin and closer to the surface. Long needles for groin injection. Thick needles for veins where a lot of scar tissue has formed. We always encourage clients to use the smaller and thinner needle possible.
If the user is injecting only heroin, the thinner needle, 29G, will do. If it’s heroin and crack, go one up, 27G. The crack gets gloopy when dropped into the warm heroin solution: it would block a 29G.
what should I have done what should I have done what should I have done
what would you have done differently
Things to be following up on: has the client been feeling low, have they just come out of prison, are they sleeping on the streets? Have they mentioned feeling unsafe, suicidal? Have they overdosed recently? Does anything in their file suggest they’re an overdose risk, and if so have they been given Naloxone?
Sometimes you won’t check these things. Sometimes you’ll check some and not others. Sometimes you’ll be conscious that a long queue is forming outside the exchange, you’ll be conscious the person you’re talking to is withdrawing. Clucking. Rattling. Sometimes you’ll be overwhelmed, distracted, in a hurry. Sometimes you’ll forget.
A man walks into the needle exchange. He’s vivacious, he smiles a lot, more than I’ve ever seen any client smile during an exchange. He talks a lot and smiles the entire time, and I find myself laughing at the joke he just made, even though I have no idea what the words that came out of his mouth were. And I think This must be what people mean when they talk about contagious laughter.
Most users will have gotten their advice from whoever injected them first, and it will probably have been bullshit. It’s surprising, how set in their ways our clients become, for people with such chaotic lives. They heard something once, from someone older who’s been doing this as long as they’ve been alive, who told them the wrong thing like it was god’s own gospel and they believed it. Flushing, swabbing all over, groin injecting.
You can give advice about where to inject, how, with what needle. Don’t ever assume you know better than the clients. Don’t assume they know better than you, either. Don’t assume anything. This is good life advice, too.
He says I have nothing to hide.
Many people are, if not squeamish about needles, at least wary of them. We counter that wariness by associating needles with a certain level of hygiene, a certain care. We think nurses or, at a push, tattoo artists. We think hospital wards. Sterilized surfaces, gloved hands, brief swabbing with alcohol before the needle is inserted.
We don’t think: a piece of land fenced off with corrugated iron, full of trash, a riot of decay and germs. We don’t think: dark doorway, semi-hidden stairwell, obscured telephone box. We don’t think: dirty top of a discarded fridge, bottom of a coke can, a needle picked up from a gutter on the way over. We don’t think: trousers pulled down in a hurry in the corner of a park, hands caked in dirt. We don’t think.
whatcouldIhavedone whatcouldIhavedone whatshouldIhavedone
‘Remember’, my supervisor says, ‘for many of our clients, we’re the only people who will show them some kindness today.’
A man walks into the needle exchange who doesn’t look like you. Except he does. Except he doesn’t. He doesn’t look like you but he feels like you, by which I mean he makes me feel like you did, which I don’t realise at the time but much later, when I’ve spent the first twenty minutes of my end-of-shift debrief weeping and my supervisor asks-
Any bumps, lumps, or scrapes? you ask casually, as you input the number of needles, barrels, and paraphernalia the user picked up that day. Anything you’re worried about? What you mean is, Any abscesses, ulcers, other horrors you’ve been ignoring that could cost you a limb or send you into septicemic shock?
What you mean is, Tell me. I’m here to listen. I’m here to look.
Something was severed when you died. The world went deaf, so I stopped talking. Or I went mute, so the world stopped listening.
Keep your tone light. Keep your voice steady and your face straight, and carry on keeping it straight when they drop their trousers with no warning, even as they’re saying Actually yeah, could I show you quickly? After all, you asked. Don’t bother covering it friend, I’ve already seen everything.
Breathe through your mouth.
‘What would you have done differently?’ my supervisor asks. The drugs worker’s mantra. The answer is ‘X, Y, Z’, so now you know for next time. Or the answer is ‘Nothing’, so you get to finish the day with an unburdened conscience.
The aim is to not take anything home. To not carry the burden of having been caught short. We can’t save everyone. In fact, we can’t save anyone. All we can do is try to keep people safe while they’re killing themselves. Recognise the limits of what we can do, or face burnout.
Heroin addicts we meet carry that special kind of tiredness around the eyes, one that hasn’t got to do with lack of energy. It hasn’t got to do with being homeless, with sleeping rough. It hasn’t even got to do with the weight of traumatic experience they live with, the violence and assault, sexual or otherwise, that most of them have witnessed or endured.
Needle exchange clients don’t make an awful lot of eye contact, and when they do it’s furtive, and they often look vulnerable. Beaten down.
It wasn’t the wrong needle that killed you, I know this. It wasn’t the lack of a swab, a dirty filter, it wasn’t citric instead of VitC.
Nobody dies, my friend used to say when I was a young waitress stressing over the job. We serve drinks. Nobody dies if we get it wrong.
He says These days I wake up clucking.
Users come in at different stages of withdrawal. Sometimes they’ve already scored, heroin and crack is the preferred combo of this city, and we’re the last port of call. Although that’s not how they see us: not the last haven but the last storm, the last wave to ride before they reach their tranquil heroin ocean. You can tell even with little experience who’s at that stage. They’re dripping with sweat, they don’t sit, they don’t want to talk. They don’t check whether you gave them the right gauge needles, that you included swabs, or wait for a bin. ‘That’ll do, love,’ they say, bunching up the white plastic bag you haven’t finished putting their equipment in, thank you as they rush out, not looking back.
He says Maybe I should just end it all.
Some will appear like that at first. They’ll be impatient and gruff and deflect your questions, the gentle prodding you’re meant to do if you think a user is at risk or needs to talk. And there are two things that might happen: you might decide to drop it. Leave it for another day, another worker, another exchange. Hope they’ll be in a better mood next time.
Or, you might decide not to.
I should have said I should have done
A man walks into the needle exchange who isn’t you. You’ve already died, and no matter how many people I meet who look like you or act like you or feel like you, no matter the level of situational resemblance, they won’t be you. You, I’ve already lost.
‘It’s easy to think we’re a big cog in their lives. But we aren’t. We’re a very small cog.’
And then I start noticing how much eye contact he’s making, how unflinchingly, and as he leaves he says Thank you for putting a smile on my face I hope I put a smile on yours.
And then it hits me, what we do, what he does, the reality of what happens after he goes out our door, what he’ll do, where he’ll do it and how. We’ve thrown him a lifeboat, for now. But the wave he’ll be riding crests high and what’s the likelihood he’ll survive it when it crashes?
‘You need to learn to distance yourself, if you’re gonna do this longterm.’
You might decide to keep prodding, risk being snapped at, shouted at, dismissed. You might decide to still try to push the Naloxone, which is no panacea but might just pull someone back from the abyss of overdose, keep them alive long enough for the paramedics to arrive.
‘Remember, some of our clients have been doing this for years. They can take care of themselves. To a point. They’re more resilient than they look.’
It isn’t bravado. It’s not that they don’t think it’ll happen to them: it’s that they don’t care whether it does. Otherwise why refuse the Naloxone, the simple injection that could make the difference between life and death. If it happens, it happens. What have I got to live for anyway? What have I got to lose?
It isn’t bravado. It’s pragmatism.
It was different, I was different, I couldn’t have known. I didn’t know anything, then. I didn’t even know you, not really. It wasn’t me who let you die.
You died, I felt nothing for months. Years. I heard nothing, saw nothing. I knew no one.
We judge no one for their choices. We do this work because we believe people should be safe when entering whatever heaven or hell they think they deserve, without judgment from each other.
I don’t judge him but I do fear for him, I sense on every inch of my skin the danger he’s in.
I know some of our clients have been doing this for decades, for quarter of a century. I also know that the likelihood of a fatal overdose increases in proportion to the length of time someone has been using for. I know most heroin users we see will have overdosed at least once. I know a recent overdose puts them at a higher risk of overdosing again. And I know how little our clients value their lives.
And I really, really hope he will come back. The next day, or the next week, or the next month, or the next year. I really, really hope he will come back.