The first publicly funded needle exchange program in the United States began in Tacoma, Washington, in August 1988. The exchange's history is characterized by a series of firsts: the first American publicly funded exchange; the first pharmacy exchange; the first American needle delivery program; and the first state Supreme Court ruling not only supporting the existence of a needle exchange program but superseding existing drug paraphernalia laws. It is also unique because it began outside of the public health system and was not compromised by political feasibility. This article documents the events and personalities which led to the exchange's establishment and its expansion over time; the program's local, state and legal challenges and advocates; its portrayal in the local and national media; the research that documented its successes; and its important contribution to the fight for drug users' unencumbered access to sterile needles.