The Controversial Answer To America's Heroin Surge
With heroin use at epidemic levels, harm reduction — a bold, long-contested approach to treating addicts — is gaining political traction. But are we ready to make it easier to shoot heroin even if it means fewer deaths?
On a chilly Monday morning in mid-March on Coney Island, down Surf Avenue from the famous Wonder Wheel and Cyclone, a parked Dodge van blasts its heater. Stuffed with all manner of injection-drug paraphernalia — needles of different gauges, cookers, ties, pearl-sized cotton balls, alcohol wipes — as well as plastic bags of nonperishable food items called “pantry” and thousands of condoms and lube packets, it's a clinical stockroom meets therapist's office on wheels. The van has these supplies to make using drugs safer, all for free — though getting high in the van is not permitted.
Ian, 60, sits in the back of the van, rubbing his hands to keep warm. “I used for over 45 years. Last 25 years was basically crack,” he says. He suffered what he calls “three minor strokes” that doctors said should have killed him, but kept getting high. So when someone slid a flier under his door for something called harm reduction — an approach to combating drug use that allows the person to continue to get high, but in a safer way — he was interested. Slowly, he decreased his use from daily, to weekends, to monthly — until he could finally quit. Now he works for FROST'D (Foundation for Research on Sexually Transmitted Diseases) — one of New York City's harm reduction programs and the organization that runs this mobile unit — as a peer educator, a paid, part-time position that serves as a bridge between the staff and the communities they serve.
Next to him, Scott Spiegler, 28, flips through a binder of anonymized client information. Scott is one of FROST'D's outreach workers, and delights in explaining safer sex practices to anyone who enters the van, which is parked here every Monday and Thursday — and regular corners throughout the boroughs other days of the week. Later this afternoon he'll tell one woman, a new client named Brooke, that flavored lube for blow jobs “is like dinner and a movie: You can give head and eat a peach.” When she tells Scott she's never heard of a female condom, he lights up. “I love telling people about the female condom,” he says. “It’s, like, my jump-off.”
Around 11 a.m., the first client of the day shows up. Willy, late forties, knocks on the van's sliding door and hops inside. In limited English, he says he's homeless and has been sleeping a few blocks away on 22nd Street with his wife. Scott offers to connect him with their housing program, but Willy doesn't like shelters. “Too many people stealing,” he says. He's been using heroin for three years (including this morning) and has cirrhosis of the liver.
He's come to the van today just for the pantry — pasta, cans of beans — and he’s already taken home plenty of clean needles. “Do you know about alternating veins?” Scott asks. Willy does, but he says he has trouble finding others. After showing him (with a capped needle) the 15-degree angle he'll want to aim for if he decides to shoot up in his hand, Scott warns him about the powerful, fentanyl-laced heroin that's going around — the type that Philip Seymour Hoffman was initially thought to have used when he overdosed. Willy wants nothing to do with it. “No, no, I don't want to die,” he says with a smile.
Willy is one of the approximately 669,000 people in the United States who used heroin in 2012, a 65% increase from rates in 2002, according to the most recent National Survey on Drug Use and Health. Other trends also show heroin use and availability is increasing at alarming rates. The same survey found that people “with heroin dependence or abuse in 2012 (467,000) was approximately twice the number in 2002 (214,000).” According to DEA numbers, heroin seizures at the Southwestern border “increased 232 percent from 2008 (558.8 kilograms) to 2012 (1,855 kilograms).” Drug overdose is now the leading cause of accidental deaths, eclipsing car crashes, though pill abuse far outpaces heroin use. More than 12 million people in 2010 abused painkillers, according to the Centers for Disease Control and Prevention, and data supports the much-repeated narrative that many newer heroin users got started on pills.
But Willy, and many of the people who use FROST'D's services, are not the kind of people the media has put forward as representatives of the endlessly touted heroin crisis. The face of the new crisis is a familiar one: the white, middle-class kid who should never have become a junkie. Whether the story is in Time, any number of local reports from major cities, or small-town Wisconsin, the takeaway is always the same: Heroin use among young, middle-class users in the suburbs and rural areas is increasing. And that number will undoubtedly rise as pain pills continue to get more expensive.
And even though a 2013 study shows that people with an annual household income of less than $20,000 were much more likely to begin using heroin than those in higher income brackets, the perception that the crisis is primarily affecting middle-class America seems to have had an effect on the potential for political action. There's the just-passed plan to have New York City police officers carry a heroin "antidote" to reverse overdoses, part of a $5 million program; the state legislature passed a Good Samaritan law to protect users who call 911 if they witness an overdose and another law that decriminalizes heroin residue in used needles. At the federal level, Attorney General Eric Holder has endorsed first responders carrying similar kits, and a spokesperson for the Drug Enforcement Administration echoed support for the programs. But a significant reason for the shift in lawmakers' attitudes is the advocacy work done on the national level by groups like the New York City-based Harm Reduction Coalition, and the local organizing that groups like Brooklyn's VOCAL-NY are doing on the city and state level.
Over the next five hours on Surf Avenue, 10 more clients will come to the van and request condoms and needles and cookers, as well as phone numbers for detox and rehab programs. One young Ukrainian woman was clean until she ran into friends and had a party weekend. One guy just got out of a 30-day bid in Rikers for having a cooker, and despite the methadone they gave him in jail, the withdrawal was terrible.
Some of their bodies will show signs of drug use — scabs, bruises — and some will not. Some will express disgust at their habit (“I'm fucking sick of this shit,” one guy spits, standing outside the van), while others will say they want to keep using heroin. But all of them will walk away with tools that, for today at least, workers at FROST'D say make it less likely they'll contract HIV, hep C, or any other communicable disease from reusing needles or having unprotected sex. And that idea — meeting people where they are without judgment — is at the heart of harm reduction, a philosophy that, after decades of false starts, is finally finding political traction, and not a moment too soon.
Harm reduction — as opposed to abstinence models — is not a new idea. Needle exchanges go back to the 1970s, and a drug called naloxone that reverses overdoses from heroin and opiate painkillers was created a decade earlier. Naloxone (also known by its trade name Narcan) works by blocking opioid receptors in the brain and sending the overdosing person into withdrawal almost immediately. It doesn't get a user high, is nonaddictive, and doesn't negatively affect someone who isn't OD'ing on opiates — the only downside is that it’s a temporary fix, and if the survivor doesn’t get to the ER, the person could fall back into overdose. Still, it requires a prescription, which makes it harder to get in the hands of drug users and their families.
Seven states have what's called a “standing order” provision for naloxone, which means a medical professional doesn't have to be on site to write individual prescriptions, similar to a flu shot. In the vast majority of states, however, if a parent comes to a needle exchange and asks for a drug that could save their child — unless a doctor is on site at the moment — it's illegal to give them a take-home kit.
New York isn't alone in adopting new, more liberal drug policies. At least 17 states and Washington, D.C., have Good Samaritan laws, a number that seems to get larger almost every month. States and cities from Massachusetts, to Ohio, to Wisconsin, to California, and beyond have created pilot programs to equip EMTs and cops with naloxone. Even Paul Lepage, the governor of Maine who came out against giving naloxone to family members of drug users, has softened his position. (His office didn't respond to a request for comment.)
The efficacy of the new laws and policies remains to be seen, however, as some advocates worry beat cops either won't be aware of the changes or won't follow them. Similarly, the naloxone pilot programs in New York and New Jersey are funded through asset forfeiture, a controversial policy that allows the police to seize property they believe was connected to illegal activity — even without securing a conviction. “There's probably not a single better potential use of civil asset forfeiture funds, but it's a corrupt system,” says VOCAL-NY Policy Director Matt Curtis.
And despite the new laws, advocates say decades of drug-warriorism isn't going anywhere any time soon. “I'd characterize the embrace of naloxone — coupled with the framing of the opioid epidemic in public health terms, and the repeated mantra from law enforcement that 'we can't arrest our way out of this problem' — as a partial validation of harm reduction but not a full paradigm shift,” says Daniel Raymond, the policy director at the Harm Reduction Coalition. “The urgency of the overdose epidemic is translating into greater access to naloxone, but we're unlikely to see European–style harm reduction strategies such as heroin prescription or safer injection facilities.”
To see those strategies in action, you don't have to cross the ocean. But you do have to leave the U.S.
There is only one safer (sometimes called “supervised”) injection facility in North America: Insite, in downtown Vancouver, British Columbia. Opened in 2003, advocates in the United States speak about Insite with awe, as a sort of holy grail of harm reduction. Clients there, who sign in with an alias, are legally allowed to bring pre-obtained illegal drugs to the office. They shoot up in a booth, and in the event of an overdose, a trained nurse administers naloxone. “There's been no overdose deaths at Insite, ever, and they get about two ODs a day,” says Anna Marie D'Angelo, spokesperson for Vancouver Coastal Health, the agency that oversees the facility.
Initially, she says, some businesses and cops in the area weren't happy about the site. They feared an increase in crime, an increase in overdoses, and an increase in heroin use — none of which came to pass, according to more than 30 peer-reviewed studies specifically on the facility. Neighborhood overdoses dropped 35%, crime rates either stayed level or decreased, and only one of 1,065 people was a first-time injector. “If you go to Insite at 10 a.m., there's a line of people waiting to get in,” D'Angelo says. “It's people who have been drug addicts for a long time. There's not any novice in there.”
She says that if a new user did “show up and is adamant they're going to shoot up, even after all the education, all the counseling, they have the means and they're going to go in the alley if we don't let them in, that's allowed. But it's a real minority of cases, that's not what it's for.” Insite has a detox program one floor up, which ends up removing much of the red tape that users in the United States face.
Though some advocates in the U.S. express hope that their country will one day have supervised injection facilities, even less controversial methods are by no means universally accepted. Needle exchanges, for example, are still effectively illegal in about half of the states, and federal money can't be used to fund them. President Obama lifted that ban in 2009, but Republicans in 2011 fought successfully to reinstate it.
Congressman Hal Rogers (R-Ky.), chair of the House Appropriations Committee, was a key part of that fight. The Atlantic previously reported a spokesperson as saying, "Chairman Rogers ... is concerned that needle exchange programs only encourage drug addicts to remain addicted to drugs and perpetuate the cycle of drug crime." His office did not respond to requests for comment, nor did House Speaker John Boehner's.
Other observers criticize exchange programs for not being aggressive in promoting detox and rehab for heroin users, and suggest a harsher approach. “Using the criminal justice system to force them to go into treatment has proven to be very productive,” David Evans, special adviser to the Drug Free America Foundation, tells me. “The drug courts that do that have an outstanding record of success of freeing people from their addictions.” (Critics of drug courts argue coerced rehabilitation actually expands, rather than lessens, a punitive approach to drug treatment.)
Some opponents of harm reduction also express skepticism about expanding naloxone access to family and friends of drug users. “Naloxone can save lives in an overdose situation, but many opioid users do not use with their family,” John Walters, who was drug czar under President George W. Bush, writes in an email. “[T]hey may use alone or in the company of other users, who may not be a reliable source of emergency medical care.” Using alone is dangerous, without question, but available data largely contradicts fears that other users can’t administer naloxone effectively. A 2013 scholarly study found that overdoses are overwhelmingly witnessed by other users, and, in the study, administration of naloxone was 98% effective in reversing the overdose.
At the state level, a recent Kentucky bill that would’ve expanded money to treat heroin addiction failed in part because it included the option for health authorities to create a needle exchange program.
But, as with all prohibitions, banning exchanges doesn't eliminate them. They just went underground.
Linda (a pseudonym), 38, has run an illegal needle exchange for the last seven years in a city in North Carolina she asked me not to name. In addition to needles, the exchange also provide naloxone kits and training. “We provide them sometimes a space to use drugs, you know, all the things so that they can do it safely,” Linda tells me over the phone.
The program doesn't have a fixed site because it would almost certainly be raided by the police. Linda adds that the cops have harassed her in the past, but don't know where she is right now. When I ask if she moves around a lot, she simply answers, “Yes.”
Linda previously worked in harm reduction in a more official capacity but began the underground exchange to “do the work that [other organizations in the state] were not able to do.” That work, however, comes with risks. “I've actually been arrested and charged because of [used] syringes in biohazard containers,” she says. Whether those charges will land her in jail remains to be seen, as she says her cases have “been tied up in court for years.”
For Linda, who has a master's degree in public health, the work is also personal. “I've struggled with addiction my whole life, ranging from chaotic use, to manageable use, to no use,” she tells me. “So I know the community pretty well.” When I ask her if she's using right now, she says not heroin, but she is on methadone. “I don't really buy into the whole 12-step abstinence from everything and all of that. So I'm not abstinent from all things right now.”
As for funding, Linda says, “We've received a couple of small grants,” but the nature of the program by definition limits their options. She says the number of clients they serve varies, but it's in the hundreds. “We do a lot of secondary syringes, so that means we have people come [to pick up needles] and serve the people they know. Lots of people that sell drugs too come and use our supplies and give it to their, um...the people they serve.”
North Carolina recently passed a Good Samaritan law, but Linda says, “We don't really trust it.” Another new law, one that says users won't be charged if they inform cops they have a needle in their possession prior to a search, also hasn't worked out well. "The cops aren't really respecting the law. And until we see real changes on the ground we're not gonna trust those laws. These policies are great in theory, but on the ground, they're not making much of a difference.”
And on the ground in North Carolina, prescription painkillers are in high demand and are going for as much as a dollar a milligram. When people can't keep paying $60 or $80 for a pill, as Linda says, “because they don't want to be a heroin addict,” they might start buying $10 bags of heroin. CDC spokesperson Courtney Lenard says there isn't enough data to conclude whether the clampdown on prescription pills is what caused heroin rates to go up, but “there is evidence that heroin use follows opioid use, whether or not reductions in opioid access are driving up heroin use.” (The DEA suggests increased use may be due to expanding distribution networks from Mexico-based cartels.)
Josh Lucas, 31, of Marinette, a small town in northeast Wisconsin that's been devastated by heroin, couldn’t keep paying for pills. Growing up, Lucas got into weed and coke, but says, “you never even heard the 'heroin' word” in his town. The idea of using heroin was ridiculous to him. “Just like everybody says: 'I'll never do that.' But then, I was getting a little bit older. The Vicodin, the pills, and all that started, because we had a really dirty doctor. I think that was pretty much how everybody in this town got hooked.” The doctor, Louis Cannella, was indicted on charges of improperly prescribing Oxycodone, methadone, and other drugs to his patients. He eventually pleaded guilty to one count of inappropriately prescribing methadone and was sentenced to four years in jail.
“One of my friends, we always did pills together. He came over one day with some heroin, and it was way cheaper. Tried it, and I was like, 'OK, this is much better.'” Like virtually everyone, he sniffed it the first few times. Then, “the lines get bigger, bigger, bigger, and you're watching your friends shoot up. Then you're finally like, they're using way less I guess I'll try it out.” He used off and on, until serving four months in jail for an outstanding warrant. He's clean now, and is writing songs about his struggles with addiction.
Unlike in major cities, rural drug users often don't have access to harm reduction services. For Josh, the closest syringe exchange was in Green Bay, a 50-minute drive, and although recent state bills have expanded naloxone programs to include EMTs, when Lucas was using heroin, only hospitals had the lifesaving drug. That means when it came to overdoses, which Lucas saw a few of, they had to go old-school. “Had to throw them in the snow, in the shower with cold water. We actually left someone for a while and had to run to Walgreens and get a shot of adrenaline,” he says.
Incredibly, none of those people died.
On the second floor of a converted billiard hall in upper Manhattan, a janitor cleans a large bathroom. It's one of the few times during the day someone isn't using it. The oversize digital clock and the wall-mounted speaker next to the open, single toilet make the sterile room seem somehow futuristic. One wall has a floor-to-ceiling chalkboard with a weekly schedule for meetings and group sessions written out on it, reminiscent of a Friends-era coffee shop. Behind the toilet hangs a colorful, handwritten “rules of the bathroom” sign. But the metal medical table, two hazardous material disposal boxes, and good vein maintenance posters are the real centerpieces.
The bathroom in the office of the Washington Heights Corner Project is perhaps the most politically significant bathroom in the country. When the workers at Corner Project realized their clients were shooting up in the bathroom, they didn't respond, as some other organizations have, by closing it, or changing to blue-tinted lights to make it harder to find a vein. They instead adopted a more radical approach, resulting in a boundary-pushing policy that's on the leading edge of how harm reduction programs are trying to keep users alive. The staff at Corner Project estimate that the bathroom is occupied around 85% of the time, and sometimes the waiting list to use it can be up to two hours long.
This is the first time they've spoken outside of the harm reduction community openly and specifically about the bathroom, though they've told their funders — which include both city and state agencies — about it. “It's time,” Executive Director Taeko Frost tells me in a small meeting room in their office. When I ask her why she's talking to me, she says, “I'm applying the same principle that harm reduction applies. I don't think that by not talking about it we're doing anybody any favors.” The issue is so sensitive that no other organizations or people I spoke with were willing to talk about their current or past bathroom policies on the record, beyond saying they'd added a sharps container to keep the toilet from clogging.
First and foremost, Frost says, the Corner Project bathroom is not a supervised injection facility, which is illegal. “If you come in here and ask to use the bathroom because you need to get high, we're gonna say no,” she says. The rules are: No drug use in the bathroom, but if you do use drugs and overdose, they're not going to let you die. And it hasn't been a top-down formulation — participants have been instrumental in developing the policies. “By opening the conversation, acknowledging that this happens, not ignoring it, offers an opportunity for our participants to equally be accountable and engage with us about making sure that it's as safe as possible,” says Frost.
The Corner Project began in 2005 as a street-based syringe exchange, and although it grew quickly and secured several different office locations in the following years, it wasn't until moving into a new space in 2009 that it was able to function as a syringe-exchange site out of its office. Initially, the bathroom in that office was just supposed to be a place for Corner Project participants, most of whom are homeless, to shower and be alone for a few minutes. But it soon became clear that people were going to get high there too.
“In 2009, we had our first experience — a couple months into being at the new office — of somebody overdosing,” Frost tells me. After hearing “a thud on the door,” employees raced to the bathroom, and after a frantic search for the correct key they got the door open. “And somebody had overdosed in the bathroom. The needle, the cooker, the tie, there was some blood. We had Narcan, fortunately, and we were able to reverse the overdose successfully and call 911.”
But then there was another overdose. And another. And another. And the staff at Corner Project, along with their clients, had a decision to make. “If we close the bathroom, what does that mean? The bathroom is clearly serving this need, we're the best equipped people in the neighborhood to handle it,” says Frost, who estimates she's personally reversed around 30 overdoses. “If we close the bathroom, people will die.”
But she offers other justifications for keeping the bathroom open as well, from improved community relations to the high cost of incarceration for nonviolent drug crimes. And closing the bathroom won't keep people from getting high; they'll just go to other public bathrooms nearby, in part because most of their participants either street-homeless or have a precarious living situation. “We've had people from Burger King run over and say there's an overdose, because they know we do Narcan,” Frost says.
By 2012, when the Corner Project moved to its new office, it had ironed out some of the initial kinks. Now the bathroom door has an electric strike on it, so staffers don't have to fish for a key in a moment of crisis. Instead of knocking on the door after five minutes (halfway through the allotted time) to check on a user — which could startle them and result in vein damage — an employee at the front desk can communicate with them through the speaker next to the toilet. If there's no response from the bathroom, the staff will physically check on the person and administer naloxone if the person is OD'ing.
The staff run overdose drills regularly so people know their designated tasks, one of which involves calling 911. When EMTs and cops show up, Frost says there's usually a mix of curiosity and relief when they see the bathroom. “The police ask a lot of questions about Narcan, and that's a really great opportunity to provide them with education." They've never had a fatal overdose in the office, and Frost estimates they've reversed more than 50.
Clara, 47, a peer turned staff member at Corner Project, just reversed her first OD — though it wasn't in the office. On April 2, she and her mom went grocery shopping with a family friend. When they got back to Clara's home, the friend lay down on Clara's small, twin-size bed next to the wall. “He was kind of slouched, and this guy is obnoxious, so I was like, 'Let him sleep.' But I said, you know what, maybe you should lay him down because he looks uncomfortable.” When Clara's mom went to move him, they noticed his stomach wasn't moving. He still had a pulse, but he wasn't breathing.
“Honestly, my first impulse was to run,” Clara tells me. “I had never seen an overdose, you know — only on that fake doll we practice on. I'm not really good with death.” Instantaneously, she remembered he used to do heroin. She ran to him and began rubbing his sternum with her knuckles to wake him up. Clara told her mom to call 911. “I pinched his nose and started breathing. Breathing. Breathing.”
“At that moment, everything I had learned just all came to me at once,” she says. She ran to her drawer and got her naloxone kit, the nasal spray kind. “I gave him half in one nostril, half in the other nostril. And I kept breathing.” That wasn't enough naloxone to revive him, which is common — depending on the amount and strength of the drugs used — but because of her nerves she couldn't find her extra naloxone. “Later on I found it inside a [latex] glove.”
She also did chest compressions, even though her supervisor had previously told her she didn't have to. “By the time the ambulance got there I was drenched,” she says. He was still purple, but breathing lightly on his own. “At that moment I felt really, like, confused, scared, creepy,” she says. “I was in my house, alone, and his face looked like my dead grandma's face. Everything was, like, pulled down. Lips: white. And that's all I could see after he left for the hospital.”
She immediately called her supervisor to talk about it, but it wasn't until the next day, when she came to the Corner Project office, that she began to process what she did. "I was all nonchalant and everybody was like, 'How you gonna come in like that, you just saved a life!' And then it started feeling very good.”
At 9:45 a.m. on a Wednesday in mid-April, Scott, two other outreach workers named Sarah and Shannon, and I drive the FROST'D van from their office over to the Bronx. They'll spend the morning doing outreach at a Single Room Occupancy (SRO) building — generally a grim place that's pretty much the last stop before homelessness — then leading a naloxone training around the block.
On the drive there, I ask about several of the Coney Island clients I met on my first day with the van about one month ago. Apparently the woman who got the female condom demo became a convert, as she's been back for more of them, as well as for clean needles. The “I'm fucking sick of this shit” guy has been back for needles, and has a referral for a detox program and Scott's phone number if he needs to get in touch. Willy has been back for pantry; apparently he still has enough clean sticks. Others haven't been back at all.
After knocking on doors and leaving fliers for people in the SRO, Sarah walks outside and points at a duplex across the street. “That's a shooting gallery,” she says. “We have a lot of clients who come in and out of there.”
The training takes place near an elevated subway stop on an unseasonably cold day. Only two people show up for the first session, which Sarah conducts in the van: Sanchez, 37, and Cindy, who looks to be in her late forties. Cindy is prescribed a heavy dosage of OxyContin, and she struggles to focus as Sarah explains how to load an OD-reversing nasal dose of naloxone.
About a minute later, Cindy needs to get fresh air. “That's why I'm here,” Sanchez says once she's outside. “If something bad happens to her I want to be able to help.” They've only known each other for a few months — both live in the SRO — but Sanchez's concern for her clearly runs deep. Naloxone reverses Oxy overdoses, just like heroin, and Cindy's stories of falling asleep only to wake up to pills scattered around her room and no memory of nodding off have him worried.
Outside, Scott stands at a card table surrounded by five women laughing loudly about various orifices they're going to use their newly acquired finger condoms in. All are new to FROST'D, though they live nearby. When I introduce myself as a journalist, one of the women bursts out laughing and yells: “Oh shit, and here we are smoking a blunt!” She tells me to call her Ruby. “Ruby from the Bronx. They'll know who you're talking about.”
As Scott goes through the steps of what to do in the event of an overdose, Ruby answers all of his questions immediately. When he asks how she knows so much, one of the other women says plainly, “She's an ex-heroin addict.” (Ruby will later deadpan to me: “This isn't my first rodeo.”)
Ruby, 49, hasn't used heroin for eight years. During the training she alternates between easy bravado — “I'm gonna have to stick a bitch, for real,” she says about the naloxone shot — and solemnity, like when she tells me she reversed two overdoses with ice baths and salt-water shots when she was much younger. When I ask her how she quit using heroin, she immediately responds: “Harm reduction.” Over the years she's gone to several NYC organizations: CitiWide (now BOOM!Health), St. Ann's Corner of Harm Reduction, Lower East Side Harm Reduction Center. At her heaviest period of use she was going through two bundles — 20 bags, $200 a day, with coke on top of it. She points to her arms and says she has “crazy tracks.” But she tells me that by using methadone and lowering her weekly heroin use, she was able to get off all of it, blunts notwithstanding.
A man walks by the condom bin next to the card table and grabs one of the bags of Lifestyles, then does a double-take at Ruby and calls her by her real name. “Damn, you looking good,” he says, clearly startled.
“I'm not getting high no more,” she responds, then turns to me. “He knew me when I was on everything.”
“You name it, she did it. She was lost,” he says. Then, again: “You look good.” The two smile at each other, then he keeps walking down the street. A few minutes later, Ruby and her four friends walk the other way, holding their blue anti-overdose kits, and shout good-bye as a passing elevated 4 train roars by overhead.