"It's absolutely a problem," he says.
Users typically snort or smoke the drug at first, according to local treatment specialists, but the spiral of addiction usually nudges them toward the needle. "If you're using meth, you're eventually going to be shooting it," says Duke.
Using meth is like putting "rocket fuel in a VW bug," says John Garcia, a naturopathic physician at InAct, a Portland drug-treatment center.
Injection produces an intense high and triggers a new cycle of obsessive behavior, says Garcia: "They start feeling like they have critters or ants under their skin. They just pick at themselves. They just pick, pick, pick."
Once hooked on quick delivery, users will search every inch of skin for a place to inject. "People will inject in all locations of the body," Garcia continues. "Neck, penis, hands and feet."
Gary Cobb, 43, a recovering addict, contracted Hepatitis C sometime during the 1990s, when he was shooting both meth and heroin.
Now co-chair of the Recovery Association Project, Cobb says the appeal of injection is an amplified rush that can't be achieved any other way.
"It's right, straight, no chaser," he says. "You get an accelerated heart rate, a real increased sense of awareness. There's nothing like it."
The city Bureau of Housing and Community Development recently recommended chopping its $23,000 annual contribution to Outside In's needle exchange to meet 2005 budget requirements. Duke says the proposed cut will hurt his clinic's mission to direct users into treatment programs.
Beth Kaye, the bureau's policy manager, says it came down to choosing between homeless shelters and the needle exchange. She doesn't deny the importance of the exchange, which will continue to receive about three-quarters of its budget from the county.
When meth users switch to needles, their health risks multiply. Hepatitis C is the biggest concern. Between 50 and 80 percent of injection drug users contract Hepatitis C (by comparison, approximately 4 percent of the clients at Outside In's needle exchange have HIV, says Duke).
Public-health officials have no concrete data on how much Hepatitis C has spread. Unlike AIDS, the virus is not classified as a reportable disease, which means most cases never end up in a database. Ann Thomas, a state epidemiologist, says extremely rough estimates put the number of infected Oregonians at 60,000.
The disease, she says, is "an increasing burden on the health-care system." But even if exact numbers are known, she quips, "no one is going to double our budget."
"Any budget cuts in the realm of outreach to injection drug users…have a potentially devastating effect on the epidemic," Thomas says.