Bryan Arnold bent at the waist to talk to the woman who sat half-curled in a chair in the Kanawha-Charleston Health Department's waiting room, her dark hair tied in a loose bun at the base of her neck.
He told her about her options; she listened quietly, and asked him whether she would have to say she was suicidal to get a spot at Prestera, where he works.
"No," he told her, while her friend looked on, concerned.
Like other recovery coaches who volunteer for the KCHD, Arnold does most of his work in the health department's lobby each Wednesday, talking to the intravenous drug users who come in - sometimes every week - for clean needles.
Arnold had seen the woman at the clinic at least four times before. He'll likely see her a few more times before she really considers treatment, he said. He knows this from experience - when he finally sought help for his addiction, it was because he was ready to recover.
"I've seen her from when she's come in, and I can see she's trying to make an effort, she just ..." he trailed off. "She's trying to straighten up, but she can't get away from it. She just ain't ready to quit communicating with [other addicts]."
Despite this, Arnold said he's successfully directed about a dozen addicts into recovery since he began volunteering at the health department.
"I don't try to push them - I give them my business card, my name and who I'm with and tell them if they ever want to talk, to know about treatment options, to give me a call," he said.
Treatment referrals are just one facet of the health department's weekly harm reduction clinics, which have expanded to respond to increased demand for services among intravenous drug users in the Kanawha Valley.
The clinics, which have been held every Wednesday from 1 to 3 p.m. since December, will now operate from 10 a.m. to 3 p.m., according to the health department. Visitors to the clinic can access free HIV/STD testing and counseling and can exchange used syringes for clean ones.
"We see people from all walks of life, and we see a lot of different drug combinations," said Tina Ramirez, prevention and wellness coordinator for the health department. "It's grown immensely."
Since the clinic began, Kanawha's clinic workers have distributed 45,193 syringes and accepted 21,584 used needles. Among regular patients, the return rate for used needles hovers around 70 percent, Ramirez said, and the clinic sees an even mix of new and returning patients. The KCHD's first clinic saw eight patients; its July 20 clinic saw 101 patients, and 682 unique patients have visited the harm reduction clinic, according to the health department.
"We knew that eventually it would get to a point where we couldn't handle the amount of patients coming in; we typically have three exam rooms running, and to get through 100 patients in two and a half hours was too much. We're volunteer-based, so it was really taxing our volunteers."
Although the Kanawha health department does not perform primary care, its health officer, Dr. Michael Brumage, has referred at least three patients to the emergency room, Ramirez said.
"One person came back in the next week and said 'I was septic and didn't have a clue,'" she said. "Essentially, he helped save that person's life by saying 'You need to go to the ER right now.'"
Visitors to the clinic are anonymous, and can request rapid HIV testing, STD testing, hepatitis B vaccinations and referrals for outside services - at least five women have been referred to other providers for intrauterine devices, Ramirez said. The clinic also has an in-person assister from First Choice Health Systems to help patients sign up for health insurance.
"We have a lot of patients who are homeless or uninsured, and we felt like that was another valuable service - not just for harm reduction patients, but for anyone who comes into the health department," she said.
Needle exchange programs offer free sterile syringes and collect used syringes from injection-drug users to reduce the spread of blood-borne pathogens, including HIV, hepatitis B and hepatitis C. Multiple studies have documented that they reduce the risk of HIV infection among injection-drug users and their partners.
In West Virginia, the biggest existing threat to intravenous drug users is hepatitis - there were 14.7 cases of hepatitis B per 100,000 people in the state in 2015, well above the national average of 1 case per 100,000 people, according to the West Virginia Department of Health and Human Resources. In a 2015 study, the Centers for Disease Control and Prevention found that hepatitis C cases in four Appalachian states - Kentucky, Tennessee, Virginia and West Virginia - more than tripled between 2006 and 2012.
Cabell County has also seen a surge in need for its own harm reduction clinic, which has treated roughly 1,660 unique patients since it launched in September. Cabell-Huntington Health Department distributed more than 150,000 needles between its launch and June 30, Kilkenny said, and has collected roughly 120,000 used needles in that same time frame.
What's more, drug overdose rates from Cabell County are down 25 percent for the first half of 2016 when compared to last year, Kilkenny said - likely due in part to increased education and referrals from both the health department and local government agencies, as well as the department's naloxone training program. Since it began training the public in February on how to use naloxone, an opioid antagonist that reverses overdoses, 35 people have reported using free kits from the health department to revive users who have overdosed.
"Our best story in terms of recovery is that one of our clients got that naloxone training and reversed a friend's overdose, and the effect of experiencing that was so profound on him that he entered treatment and stayed in treatment, and returned last month as a recovery coach for us," Kilkenny said. "We get a lot of encouragement when we see someone who turns their life around and rejoins the community. That's what this is really all about."
The Kanawha-Charleston Health Department's harm reduction clinic is entirely volunteer and donation based, Ramirez said. For more information on the harm reduction clinic or upcoming naloxone trainings, call 304-344-5243.
Reach Lydia Nuzum at
lydia.nuzum@wvgazettemail.com, 304-348-5189 or follow
@lydianuzum on Twitter.