On a sunny afternoon the first week of March, in an alley behind the University District post office, volunteers for the People's Harm Reduction Alliance needle exchange open the doors, set up their outreach table, and begin another afternoon's work.

They greet and chat with clients while handing out clean syringes and other injection tools: little metal containers for cooking up a dose, tiny balls of cotton, strips of latex for tying off an arm or leg (as well as a non-latex option). They also offer kits of naloxone, a drug that can be administered via needle or nasal spray to reverse the effects of an overdose. Two young volunteers from the Hepatitis Education Project encourage people to go inside for free hepatitis C testing. A nearby shelf holds dozens of pamphlets on subjects like proper vein care, which parts of the body are safer for injection than others, what to do if you're with someone who overdoses, HIV and hepatitis C information, a "bad date list" by sex workers about johns who are known to be difficult or dangerous, and so on.

The clients who approach the table seem to come from all over the place: innocuous-looking people in midrange cars, scruffy older gentlemen with baggy clothes and gentle voices, a few cackling, wise-cracking ladies, the occasional jagged and angry young man, and one very young woman who looks painfully timid as she approaches the table. "We love you and respect you," a volunteer reassures her.

It was the kind of afternoon you might expect at any needle exchange, but the People's Harm Reduction Alliance (PHRA) is a little different than most needle exchanges. As an independent operation, not run by any government agency, it offers services you won't find elsewhere. They're willing to hand out many syringes at once, for example, instead of the traditional "one-for-one" policy. And they're willing to hand out more than just needles and naloxone. That afternoon in the alley, volunteers give clients small glass stems for smoking crack and bubble-ended pipes used to smoke methamphetamine. Syringes, crack pipes, and meth pipes are all technically drug paraphernalia, and handing out drug paraphernalia is technically illegal, though Washington State courts have given public-health officers broad powers to do what it takes to prevent the spread of disease.

Even within the context of lenient local harm-reduction policy, PHRA—which took over the University District needle exchange in 2007—has earned a national reputation for being rogues and experimenters. They pioneer new ideas, like trying to bring crack and methamphetamine users into the fold, and letting them know there are services and health-care options for them, not just the more traditionally accepted services for heroin users. Because of the HIV crisis in the 1980s, says PHRA director Shilo Murphy, heroin injectors have gotten decades' worth of attention from the public-health community that has passed other drug users by.

Five years ago, PHRA began handing out glass stems to crack users to help prevent the spread of hepatitis C. The thin glass tubes used to smoke crack get very hot, sometimes blistering users' lips, and blisters on lips make shared stems a potential vector for infection. Murphy says this was a controversial move, but PHRA did it anyway. They let local law enforcement know what they were up to, but the police never interfered.

After PHRA took the initiative, other needle exchanges around the country began to follow suit—although the effectiveness of the crack-pipe program is still unknown. A 2008 study by the National Institutes of Health concluded that transmission of hepatitis via crack stems "seems possible," but a 2012 study published in the Journal of Public Health found no significant connection between sharing crack pipes and hepatitis. (Both studies also said there needs to be more research.) PHRA provides crack stems anyway—not because of some robust data anyone in the organization could point to, but because the local community of crack users asked for them. Public-health-run needle exchanges are still too timid to do this work. You can imagine what Fox News would do if it got wind of a government-funded agency handing out crack pipes.

PHRA cofounder Tom Fitzpatrick, a medical student, says the crack-stem program has had one undeniable effect: It's diversified PHRA's client base. The community they served used to be "very, very white," he says. "Whether it's correlation or causation I don't know, but since we began handing out crack pipes, the percentage of people who come here and identify as white has decreased every year." (PHRA conducts annual surveys and elections, where users can vote on what they'd like the organization to do differently—like hand out crack pipes.)

A few weeks ago, PHRA quietly launched its latest project: providing pipes to methamphetamine users. Meth can be consumed several different ways, but injecting it is said to pack the most punch. (Preparing a meth injection is similar to preparing a heroin injection—the drug is mixed with water, but isn't heated.) Smoking is generally considered a safer way to take any drug than injecting it, especially if there's a risk that you're injecting with a needle that has been used by somebody else. But handing out meth pipes has another more long-term benefit: starting a conversation with meth users.

As Allan Clear, executive director of the Harm Reduction Coalition in New York City, puts it, "If you want to engage with drug users and build their trust, you have to provide something meaningful to them. A stem or a pipe helps build that relationship... it makes it more likely that they'll return for advice or medical care if you have provided them with something useful in your first interaction—something you didn't have to give them."

In the alley behind the post office, Murphy, the PHRA director, makes the point a little more strongly: "Drug users need more respect and love," he says. "Why is it always us that has to step up? Because we're drug-user run instead of run by bureaucrats?"

PHRA, like some other independent needle exchanges, is "peer run"—meaning that the board, staff, and volunteer base include active narcotics users.

Just then, Murphy calls out to a client as she steps away with a new meth pipe: "We love you! We love you just the way you are!"

Shilo Murphy came out as an active opiate and cocaine user in 2011 at a national harm-reduction conference in Austin. While sitting on a panel, he told the stunned audience that "heroin saved my life" and that he had no intention of quitting. The reaction was swift and strong, especially among harm-reduction experts who see needle exchanges as a short-term solution to a long-term problem, and treatment and abstinence as the eventual goal. One renowned needle-exchange leader told Murphy he'd set the harm-reduction world back 25 years.

But Murphy maintains an unapologetically activist stance. Shortly before his watershed moment in Austin, he'd founded the first chapter of the Urban Survivors' Union (also called the "users' union"), an advocacy group for people who use more stigmatized drugs such as heroin and methamphetamine. To become a member of the USU, you have to be a user—marijuana doesn't count. The idea for the users' union occurred to Murphy after a PHRA member described him as a hero. He didn't think that label could possibly apply to him. "I thought, 'Heroes don't use heroin,'" Murphy says. "The union came out of my own inner struggle."

"Our program is run by drug users for drug users," Murphy says about PHRA. "Our program is a reaction to our community's needs... we don't provide a service that's pretty, we provide a service that's necessary." Then he repeats his frequent refrain: "I'm a drug user and I'm proud."

The meth-pipe project could be PHRA's most controversial move yet. Unlike crack pipes, meth pipes are not suspected to have any more infectious potential than marijuana pipes. Murphy thinks PHRA is the first group to distribute meth pipes in North America—and he's proud to be doing it. Usually, Canada beats the United States to the punch on harm reduction for hard-drug users. Clear, of the Harm Reduction Coalition in New York City, says he isn't 100 percent certain that PHRA is the first to pass out meth pipes. Regardless, he says the organization has certainly "taken the leadership role on this."

Just like the crack stems, PHRA is offering meth pipes primarily because its clients have said they want them. "People who inject meth would come to the table and say, 'I'm only grabbing these needles because I don't have access to a pipe,'" Murphy says. "Eventually, I was handing them needles and I'm like, 'This is dumb.'" He points out that men who have sex with men and inject methamphetamine have the highest rates of HIV infection in King County. Why not give them the option to smoke instead?

Kris Nyrop—who ran the University District's needle exchange before PHRA, back when it was under the aegis of a group called Street Outreach Services—says smoking drugs is generally preferable to shooting them, and not just because of the potential for infection. "Every time you put a needle in your arm, you run the risk of hitting an artery and losing a finger or thumb or a whole appendage," Nyrop says. "As part of the general public-health, harm-reduction thing, I would encourage people to smoke their drugs instead of inject them."

But not everyone agrees that handing out meth pipes will have a significant impact on public health. Susan Kingston, who worked with King County's HIV/AIDS prevention program from 2002 to 2008 (a high-water mark of meth use among gay men), says she's a little perplexed by PHRA's meth-pipe initiative. Kingston knows better than anyone that men who have sex with men and inject meth have high rates of HIV. But she says that's because of the sex, not the meth: "The primary mode of transmission was not the injection, but unprotected sex while high on methamphetamine—and lots of it."

Methamphetamine injectors, she says, use relatively few needles, injecting once a day or even once a weekend. Regular opiate users, on the other hand, tend to inject several times a day. In her mind, giving out pipes isn't really addressing a major, population-wide health concern and burns up resources that could be used to address more urgent problems. During our interview, she even questions the newsworthiness of this article, saying the pressing harm-reduction story right now is about pharmaceutical companies "jacking up" prices for naloxone just as opiate-overdose-prevention programs are finally getting more traction with the public and demand for the drug is increasing. "I guess that's just capitalism and entrepreneurialism at its best," she says. (For the record, King County public health officials say the naloxone price hikes have not affected their access to naloxone because the county qualifies for a federal program to provide medications to the public at significantly reduced rates—but, they admit, things are unstable and could change at any time.)

"Smoking would, in theory, reduce your risks," Kingston says. "I'm all for providing drug users, if they're not going to quit, any measure to make their drug use safer." But she questions the logic behind devoting resources to any program, such as the distribution of meth pipes, that isn't going to show a statistically significant return on the investment. "I don't dismiss this as a potential harm-reduction strategy that would have a benefit for individuals," she says. "But on a larger scale, I don't think it's going to have a big impact."

That difference between the PHRA approach and Kingston's approach—give the people what they want versus give the people what the data says they need—reveals a difference between user-union needle exchanges and government-run needle exchanges. "Harm-reduction programs, the activist ones, begin work in an environment where what they're doing isn't strictly authorized," says Clear. The very first needle exchanges in the country were committing crimes by distributing drug paraphernalia, but the HIV crisis led 27 states—including Washington—to carve out explicit exemptions for them.

Crack stems and meth pipes do not enjoy similar legal protection.

Clear argues that independent operations like PHRA are vital for staking out new territory that is not officially sanctioned (yet) and widening the bandwidth for what government-run programs might be able to get away with in the future. It's not unlike the old conventional wisdom of politics—radicals make extreme demands to broaden the political field, giving mainstream parties more room to maneuver while still appearing moderate. We need people at the fringes to change what mainstream culture will eventually consider acceptable.

Activist needle exchanges in New York are starting to experiment with supervised-injection sites, which aren't legal but could reduce the number of deaths and infections associated with opiate injections. (The only legal supervised-injection site in North America, called Insite, is located in Vancouver, Canada.) "If you run a syringe exchange and do it indoors, you spend an awful amount of time figuring out how to patrol the bathrooms," Clear says. "People swear they're not going to inject drugs in there, but then they do. So switch it around: If people are already injecting, how do we make it safer?" One New York program, he says, has installed a countertop (a more sanitary place to prepare an injection than a toilet seat) and an intercom to check on people if they've disappeared for a worryingly long period of time.

Independent activist groups can get away with that—and take the political heat, when it comes—without jeopardizing their jobs, their funding, or the services they provide to their clients. While organizations like PHRA are occasionally accused of being reckless, they have the luxury of operating without the same degree of fear. King County doesn't provide funding to PHRA, although it does provide some in-kind support, including roughly 40 percent of PHRA's syringe stock. PHRA is funded primarily by foundations and private individuals who support its work, even if it pushes at the boundaries of what's legal or considered acceptable.

"That's the history of harm-reduction movements in the US," Clear says. "Those activist programs, underground programs, are in the vanguard. They make the connections, do the outreach, do the HIV and hepatitis C prevention. Then they see if they can get health departments to do something about it afterward."

In many parts of the country, underground and user-union exchanges are all people have. In Greensboro, North Carolina, government-run syringe exchanges don't exist, because they're against the law. "Things that are accepted as totally okay in Seattle are illegal in North Carolina," says Louise Vincent of the Urban Survivors' Union. The organization was founded in Seattle but went national in 2013. Vincent is now the president of the USU Greensboro chapter. She admits she's been arrested many times for her own drug offences, but also says she's been arrested several times for simply doing harm-reduction work. On one occasion, she was charged with heroin possession for having used syringes in a biohazard container, she says. (Robert BB Childs of the North Carolina Harm Reduction Coalition confirmed the risks of running a syringe exchange there, saying, "There have been arrests in North Carolina related to syringe exchanges.")

"North Carolina is conservative," Vincent says. "We are backward." And being "backward" comes with real costs. According to a 2011 report by the Centers for Disease Control and Prevention, the Greensboro area has one of the highest rates of HIV infection in the United States—and is number one for HIV infection among women. King County, on the other hand, has one of the lowest rates for HIV infection among injection-drug users in the country.

Vincent says that when she learned about the harm-reduction movement 10 years ago, "I really felt like I'd found something wonderful—something that made sense, was based in science, and was compassionate." Users are among the most likely people to be cut out of social-services programs, she says. "If you can't abstain or won't abstain, you are told to leave treatment until you're ready," she says. "Basically, 'Come back when you're well.' It's outrageous, when you think about it."

Regg Thomas, current president of the USU Seattle chapter and former volunteer with PHRA, says the stigma against drug users is more dangerous than the drugs themselves—the shame, the furtiveness, and the cycle of incarceration make users' lives unnecessarily perilous. Thomas speaks from firsthand experience: He's 48, has been using methamphetamine off and on since his early 20s, and has been to prison several times. "The users' union is all about undoing the stigma against drug users laid out by the war on drugs," he says. "Of course, we don't have any problem with people abstaining, but if you're going to use, I want you to be the safest user you can be." He says activist and user-union-type programs like PHRA are on the front lines of changing attitudes that could eventually change legislation.

Michael Hanrahan, who manages King County's HIV/STD prevention program, cautions against thinking there's any significant schism between independent and government-run needle exchanges. "I don't think there's any more tension there than there is among alternative newspapers," he says. "Weekly newspapers have different approaches, but they have more in common than differences."

He points to the origin of King County's syringe-exchange program in 1989 as an example—that was a collaboration between public health officials and activists from ACT UP, who pushed for an exchange while the county worked to align support from the mayor, the police, the county executive, and the city and county councils. Within three months of ACT UP's start date for the syringe exchange, the county public-health department was able to assume responsibility for the program. Hanrahan also points out that King County has supported PHRA for a long time—like the syringes it donates—and that independent needle exchanges aren't the only ones that respond to clients' needs. "We talk to our clients with quite a bit of regularity," Hanrahan says. "Suggestions and requests that people make pretty often find a way into the program."

But Clear says the partnerships between activists and government-run needle exchanges aren't always so amicable. "I've been in that position, I've been really frustrated with health departments, and I've done my share of screaming and yelling," he says. "And there are a fair number of idiots working in public health—just like there are a fair amount of idiots in activism and harm reduction. We can be shrill and annoying."

Out behind the post office in the University District, Murphy talks about trying to reverse the lack of solidarity in the drug community. "When we first had crack pipes, injectors would ask why," Murphy says. Five years later, he thinks the heroin injectors and crack smokers are getting closer to seeing themselves as part of the same constituency. Moving the organization to become more inclusive of methamphetamine users is the logical next step. PHRA's work is not just about preventing infections and overdoses, and not just about getting new faces to the table to see what other programs might be available to them.

"It's about creating a community," Murphy says. "Our thing is that whoever you are, you should be the best damn drug user you can be." recommended