First come the scattered plunks and plops of bloody syringes hitting a trash can by the dozens.
Then arrive brown paper bags stuffed with scores of unused needles and a trove of tools to help an addict cook the next fix of heroin.
The entire exchange takes three minutes, maybe four.
It's necessary, advocates say, to stem the rising tide of blood-borne infectious diseases, which are rising at alarming rates across El Paso County amid an epidemic of heroin and illicit prescription drug use.
On Monday, the El Paso County Board of Health will begin formal discussions on whether to green-light the Pikes Peak region's first syringe exchange program. No vote is expected. If approved in coming months, though, Colorado Springs would join every other major Front Range city in turning to a program hailed by the Centers for Disease Control and Prevention as a key means to combat the life-altering and expensive diseases that have accompanied the nation's epidemic of heroin and illicit prescription drug use.
Already, the proposal faces long odds of passage. Opposition emerged last week when the El Paso County commissioners unanimously voiced their disapproval in a resolution opposing the concept. It quoted Sheriff Bill Elder as being "adamantly opposed."
"We need to do a better job of getting people off drugs, not giving people tools to use them," said the sheriff's spokeswoman, Jacqueline Kirby.
The sheriff also opposes it because it amounts to a "needle donation" program, where "you don't have to exchange your needles to get your needles in return," she said.
The Board of Health - which has the final say - voted down a similar proposal in 2013 by a 6-to-3 margin, amid concerns that it enabled drug use, and that its proponents did not get enough public input before seeking approval.
Since then, hepatitis C rates have skyrocketed in El Paso County amid a nationwide epidemic of heroin and opioid-related overdoses.
New cases of the disease more than doubled from 247 in 2013 to 576 last year. Another 635 cases have been reported through Nov. 30 this year - an upward trend that has alarmed El Paso County Public Health's medical director, Dr. Christine Nevin-Woods.
"It's a very frightening and significant public health issue," Nevin-Woods said.
New infections of HIV haven't followed a similar trajectory in El Paso County. Instead, infection rates have oscillated every year since at least 2012 somewhere between 28 and 42 new infections every year.
HIV isn't as easily transmitted as hepatitis C. And, as is typical of hepatitis C, which can cost tens of thousands of dollars to cure, all but a handful of new cases every year became chronic, setting the stage for liver cirrhosis.
Public health leaders say there's no way to say for certain whether not having an exchange influenced those figures. In-depth surveillance of the disease does not exist in Colorado.
However, Nevin-Woods said there's no denying that rising rates of illicit drug use likely played a role. And she points to the Centers for Disease Control and Prevention's guidance, which touts syringe exchanges as proven means to help stem that tide, while reducing overdose deaths and needle stick injuries among firefighters, police officers and sheriff's deputies.
State health officials agree.
"The idea that adding syringe exchange programs could drive an injection drug crisis, I would argue we're already in the midst of that crisis," said Dr. Daniel Shodell, medical director for the state health department's disease control and environmental epidemiology division. "This is a proven public health measure to reduce the spread of disease."
The latest proposal is modeled off an exchange in Pueblo run by the Southern Colorado Health Network, formerly known as the Southern Colorado AIDS Project.
There, a small crowd gathers every Tuesday - a dozen people hooked on heroin, methamphetamine, or some other type of drug, even prescription painkillers crushed up and sucked into a syringe.
They usually hail from Pueblo, but occasionally they're from Colorado Springs, Salida and the San Luis Valley - even New Mexico, Kansas and Oklahoma, said Bob Benvenuto, interim prevention manager of the Southern Colorado Health Network.
Most of them shake the needles out of maroon, plastic bottles supplied by the exchange, called "sharps containers," into bins just inside the front door. In the process, they pass a basket of free condoms and scores of brochures lining the walls on how to shoot up safely, get tested for infectious diseases and seek help for drug addiction.
Then each visitor fills out a half-page questionnaire seeking their order - how many new needles? What size? How about some cookers, tourniquets, cotton balls or alcohol swabs?
No names are requested here - only their first, middle and last initials, their year of birth, gender, race and age. A final question asks whether they're a man who has sex with other men.
Each user winds their way through the tiny building, filing orders, then waiting patiently as dozens of syringes are stuffed into a brown paper bag. Supplies for preparing their drug - quarter-sized metal pans, pea-sized cotton balls, rubber tourniquets and stacks of individually-packaged alcohol swabs - are thrown in as well.
The reason: A clean needle is no good if blood from other users gets mixed into their illicit cocktail. Botulism and sepsis are just as great of a concern among drug addicts as hepatitis C or auto-immune disorders, said Benvenuto.
Visitors who bring back used syringes can get 70 unused needles in return. Those who bring nothing can get 40.
On Tuesday, 115 people visited this exchange, which is open once a week.
They returned an estimated 4,573 needles, and left with 6,880.
More needles always go out than come in. But, advocates say, nearly as many needles would still circulate throughout the community without an exchange - having come instead from drug store shelves. And with the supply being tighter, they'd be more apt to reuse or share syringes.
At least here, they can be safety disposed, said Jessica Kobylinski, the Colorado Health Network's program quality officer.
"Right now in El Paso County, there is not a safe place to take your syringes and dispose of them," Kobylinski said. "So they end up on the streets and in parks."
She said one tree trunk behind a Walmart off Eighth Street contained hundreds of needles stuck into it and broken off by addicts. "That's what folks are doing in El Paso County right now," she said.
She said needle exchange programs are a key means for the nonprofit to help inform addicts of options for substance abuse treatment.
Its staff offers hepatitis C and HIV tests, referrals for substance abuse treatment and help enrolling in Medicaid. More recently, they've begun offering Narcan, or naloxone - the powerful opioid antidote that can punch a person out of an overdose, helping them to breathe long enough to get to an emergency room.
So far, the nonprofit has handed out 845 naloxone kits at its locations across the state, including 118 in Pueblo, according to Kobylinski. It's been informed of 87 instances where the kits were used, and refills were needed, she said. Twenty-one of those instances were in Pueblo.
Clutching a bag of 70 syringes, Geoffrey Partee-Gallegos, 22, called the program a "blessing."
He ticked off 13 scarred track marks running the lengths of his forearms and hands, one pinprick still bloody from his last heroin-loaded hit. Having injected drugs for more than two years, he's learned not to reuse needles.
But, he added, there are no guarantees when the cravings hit, and even dull, dirty, fishhook-looking needles shared among friends or lovers hold terrifying appeal.
His girlfriend, Alysia Moreno, 20, agreed.
The effects of heroin withdrawal can be devastating - causing addicts' bodies to turn against them, leading to uncontrollable vomiting, diarrhea, shaking and anxiety and worse.
"I'm not hesitant about it," said Moreno, 20. "There's no second guessing. I'll just grab it and squirt whatever's in there and use it, no questions asked."
Tazio Salazar, 55, knows that dilemma well.
He usually shoots heroin or methamphetamine once or twice a day - an addiction that began with prescribed opioids and incrementally grew more serious over the last several years, he said.
Before learning of the exchange from a friend, he said he stole syringes from local pharmacies. Not anymore.
"It keeps us clean," Salazar said, of the exchange. "From the hygienic side of the story, it's good because you don't have to be sharing needles.
"There are some weeks you go through a lot more needles than you should," he added. "Without places like this, we end up going to the emergency room."
Of more than a dozen utilizers interviewed by The Gazette last week, several said they routinely drop off syringes they find in the city's parks and gutters.
Asked if the exchange kept them from quitting their habit, they were nearly unanimous: Not at all.
They routinely said they'd still use their drug of choice without the exchange open. They'd just be more apt to use dirty needles.
"People who are shooting it, they're going to do it no matter what," Partee-Gallegos said.
Colorado exchanges grow
In a nod to that trend, the number of syringe exchanges across Colorado has risen sharply in the last few years.
Legislation in 2010 legalized the programs in Colorado, and state and federal money has since helped pad their expansion across the state.
Exchanges now exist in 13 locations across Denver, Aurora, Boulder, Longmont, Lakewood, Fort Collins, Pueblo and Grand Junction.
All told, state and federal money for exchanges in Colorado is expected to hit $1.2 million for the current fiscal year, ending June 30, 2018, said Dr. Shodell, who also oversees needle exchanges for the state.
That's up from $392,000 the previous fiscal year, and $274,000 the fiscal year before that.
That helped pay for the purchase and distribution of just more than 2 million syringes during the current fiscal year - more than triple the amount from just two years ago.
Even so, more needles are needed, Shodell said.
"We're really not certain we're even meeting demand out there," he said.
That boost in state funding would pay for the exchange proposed in Colorado Springs, Kobylinski said, along with a newly-approved program in Alamosa and a program under consideration in Greeley.
If those programs in Colorado Springs and Greeley aren't approved, the money will be redistributed elsewhere in the state, such as to the Denver Metro area, Fort Collins and Pueblo, Kobylinski said.
No El Paso County Public Health funding would be used to run the program, she said.
Dan Martindale, the agency's director, reiterated that point late last week. However, he's stoutly refused to take a side on the issue - arguing instead that the "decision needs to be made by the Board of Health."
The same largely went for Nevin-Woods, the county's medical director, when asked whether the county's public health would be better served with one in Colorado Springs, given the county's growing rates of hepatitis C infections.
"It helps to prevent them, which is what we want to see," Nevin-Woods said.
In contrast to the opposition by county commissioners, Colorado Springs Mayor John Suthers, Police Chief Pete Carey and Fire Chief Ted Collas appear inclined to sit this one out.
In a letter to the Board of Health supplied to The Gazette, Suthers said he and Carey said the decision "should be made on the basis of whether it is beneficial or detrimental to public health," and they vowed to support whatever decision the board makes.
The Fire Department opposed the measure four years ago, citing the prospect of increased 911 calls. But a statement from Collas disputed that notion - claiming that previous calls to other departments serving areas with an exchange did not see an increase in calls associated with the exchange.
"I would like to allow the El Paso County Board of Health to render an opinion based on facts and not influenced either way by a CSFD position," Collas' statement said.