Is the opioid epidemic bringing harm reduction into the mainstream?
“Are those Danskos?” she asked pointing to my red sandals. I nodded and we briefly discussed the benefits of comfy-yet-cute shoes for women like us, who suffer from bunions. I had plopped myself on the driver’s seat of the Austin Harm Reduction Coalition van, still unsure of what to do with myself, so I appreciated the chance at conversation. The woman — blonde, in her fifties, wearing shorts and stylish sunglasses — stood next to the van’s door waiting for her turn to get in. It was a Friday evening, and we were in a parking lot on East César Chavez, in Austin.
She smiled at me as she passed by to get to the van’s service area. Two volunteers sat behind a custom-made wooden front desk divided up into square compartments: a big one for used needles, and smaller ones for supplies that ranged from cookers (metal bottle caps with twister handles) to single-use plastic vials of water and saline solution to alcohol wipes and tourniquets. She chatted casually with the volunteers while she dropped used needles, picked and chose supplies that she put into a brown paper bag, and asked for clean needles size 28. As she was leaving, a man — also blonde, also in his fifties, also wearing sunglasses that he lifted for me to see his “baby-blue eyes” — came in. He got supplies and asked if someone could check his wrist, which looked somewhat swollen. He was sent to the back of the van — an area with two sets of worn gray car seats facing each other — where an affable volunteer paramedic checked the wrist, and recommended that he stay out of it. “If you need to use, try here or here,” she said pointing to areas in the man’s upper arm. Later on, one of the volunteers talked with a young man in a leather jacket about how to use naloxone to prevent an opioid overdose. The man left with a green plastic sachet containing three vials of injectable naloxone, clean needles, and printed instructions.
The Austin Harm Reduction Coalition (AHRC) has been providing services like these to the drug-using community since 1995. Harm reduction is a public health model that seeks to reduce or eliminate drug-related harm, such as the spread of HIV and Hepatitis C or death from overdose, without requiring abstinence from drug use or necessarily promoting it as the only solution. In addition to clean supplies, harm reduction programs offer support and access to health education and services.
“It definitely challenges your views of traditional service providing,” James Walker told me. He is a UT Austin social work master’s student and the AHRC staff member who drove the van the day I joined the mobile outreach.
“The client is the expert on their own needs, and if a clean needle is what they need to stay healthy, it’s not your job tell them otherwise, your job is to give the clean needle to them,” he elaborated. “We all know this deep down in our heart as social workers, but in many agencies there are lots of restrictions that come between ourselves and the clients. That was not the case at AHRC, and I really liked that when I started. I fell in love with the harm-reduction framework.”
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Harm reduction has been the basis of addiction services in Western European countries since the 1920s. But in the United States, where drug policy has been mostly based on prohibition in a criminal justice framework, most services have operated on abstinence-only models and through 12-step programs based on Alcoholic Anonymous’ Big Book, first published in 1939. Harm reduction groups only emerged in the 1980s in response to the HIV/AIDS epidemic and its association with injection drug use. In this context, practices such as needle exchanges helped contain the spread of the HIV/AIDS virus by reaching individuals who were not necessarily seeking abstinence, and therefore were not accessing services through traditional 12-step programs.
Although many see harm reduction and abstinence models as polar opposites, UT Austin social work professor Lori Holleran Steiker believes that we are better off thinking about them as part of a continuum of services. This is not, however, what she thought back in 2000, when she came to the Forty Acres as an expert in addiction and prevention services.
“I grew up with a mother in recovery and the mantra ‘a drug is a drug is a drug,’” Holleran Steiker told me one morning, during a break between meetings with students. “My mother was an addiction counselor and she believed, and there was not much evidence to the contrary back then, that whether it’s alcohol or oxydocone the solution was the same for everyone: stop and stay stopped if you didn’t want to die.”
Research by Sam MacMaster, a friend and colleague at the University of Tennessee who was studying women who injected drugs, made Holleran Steiker question her assumptions.
“He was the first one who said to me, ‘Lori, you are wrong. These women’s experience of craving is different, their brain chemistry is different, their ability to stay stopped is different. If they don’t have access to treatment and only come to 12-step meetings many of them are going to end up dying because the risk of an opioid overdose is very high during relapse.’”
New scientific evidence on the neurobiology of alcohol and other drugs corroborated MacMaster’s assertion. Holleran Steiker now teaches a popular signature course, Young People and Drugs, where she covers the science that made her put her childhood mantra “a drug is a drug is a drug” to rest.
“Different substances pose a different risk of developing a compulsive chemical dependence in which you can’t stop using without help. For example, the risk for alcohol is 15 percent, but for heroin is 23 percent,” she explained, citing the work of pharmacy professor Carlton Erickson, who is a regular invited speaker in her signature course. “In addition, because compulsive substance use is a brain disease that does not develop overnight, sometimes lifetime treatment and monitoring are necessary for recovery.”
Holleran Steiker thinks that given this evidence, it makes sense to embrace a range of treatment options, including abstinence but going beyond it, to help individuals seeking recovery find what works best for them: “Particularly with opioids, over the years we’ve recognized that sometimes it’s necessary to have medication-assisted therapies, which we know are effective.”
But this view, she says, is not widely shared in the recovery community.
“Here in Central Texas the recovery community is incredibly strong, and almost all built around abstinence. There is resistance against medication-assisted therapies and other harm-reduction initiatives. The thinking is, how are you considering yourself a person in recovery, if you are still using a substance to fix yourself? So the social stigma attached to drug use is also present in the recovery community.”
Although personally she more easily embraces abstinence models, Holleran Steiker says that she has learned that her experience is not everybody’s.
“Having witnessed kids going through this, I understand the need for medication-assisted therapies, and I’m so grateful that harm reduction exists. My goal, being involved with both 12-step programs and harm reduction groups, is to bring those two groups closer together and break down those silos.”
In 2015, in fact, she invited MacMaster to Austin for a recovery conference she helped organize. To her memory, it was the first time that abstinence and harm-reduction groups were in the same room to purposefully talk about this schism: “It was a hard conversation, but one we need to have. And the time is now.”
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Since it emerged in the 1990s, harm reduction has not only remained on the margins of addiction services but also on the margins of the law. Despite some reforms under the Obama administration, U.S. national drug policy is still dominated by the war on drugs, which criminalizes substance use, endorses abstinence-only programs, and portrays harm reduction as contrary to the goal of a drug-free America.
The AHRC, for instance, operates in a legal gray zone. The volunteer manual I was given to read states that distribution of syringes is considered a misdemeanor in Texas — possession of drug paraphernalia with the intention to distribute — that providing clean syringes to anyone under 18 is a felony, and that when volunteers spot new participants they must inform them that needle exchange is illegal and therefore discretion is important.
Before we left for the outreach, Walker assured me that in his three years with the AHRC he had never had an incident with the police. But during a quiet moment in one of the stops, as we were chatting in the back of the van, he stiffened in slight alarm to the sound of a siren. He only relaxed when the paramedic came to tell us that she had seen an ambulance go by one of the cross streets.
One element of the AHCR outreach, however, has been recently made legal in the state of Texas: the distribution of naloxone, a highly effective antidote to an opioid overdose.
Often known by the brand name Narcan, naloxone is classified as a prescription drug and as such must be prescribed by a licensed health care provider after an individualized evaluation of the patient. But in September 2015 Texas joined the majority of other states by passing a law (Senate Bill 1492) that allows qualified Texas pharmacists to dispense naloxone to patients and/or third parties, and makes it easier for community organizations like the AHRC to acquire, store, and distribute naloxone.
I asked Lucas Hill, a professor at the UT Austin College of Pharmacy, why making naloxone accessible was acceptable now when harm-reduction groups have been trying to expand access since the 1990s.
“The most cynical reason is that white people started to die,” he answered.
Hill was referring to death by opioid overdose. Once the bane of poor and African-American communities, in the last decade addiction to opioids — in the form of both controlled substances like heroin and prescription pills like OxyContin — and death from overdose have moved into predominantly white suburban and rural areas. As the face of opioid addiction has changed, many argue, using naloxone to save lives from overdose has become more acceptable.
But Hill also pointed out that in terms of sheer numbers, the current opioid epidemic involves more users and more deaths than ever before. According to the Centers for Disease Control, in 2015 opioid overdoses killed 33,091 Americans — nearly as many as those killed by guns and car crashes, and almost three times the number who died of an opioid overdose in 2002.
“From 2000 to 2010 opioid overdose was the fastest growing cause of death in the United States. Nothing is changing in a bad direction as quickly as drug overdoses,” Hill said. “It takes an average of seven to ten years for facts about epidemiology to find their way into practice and policy. That’s where we are now, and that’s another reason why states are passing naloxone laws.”
The current opioid epidemic may have shifted attitudes about drug laws and allowed for less punitive approaches. But the stigma attached to drug use is still strong and creates hurdles for people to get the help they need.
In Texas for instance, Senate Bill 1492 created the legislative environment for the prescription of naloxone via a “standing order,” a sort of open order that a physician signs and a pharmacist can use to dispense naloxone to someone the physician has not personally examined.
But, Hill says, “It was left to individual physicians and pharmacists to find each other, create an agreement, a template for the order … there was not much incentive for anybody to do that.”
It took months of tireless work of advocates making the necessary connections until finally, in June 2016, the Texas Pharmacy Association issued a standing order.
“It is interesting, because the law is so much about pharmacy but the process has not been driven by pharmacists. It has been driven by advocates and social workers and harm-reduction groups,” Hill reflected.
After the standing order was issued, in theory any pharmacist could get it from the TPA website, complete a one-hour online training, and start dispensing naloxone to anyone requesting it. In practice, Hill said, this is not yet the case.
“Many pharmacists don’t know about the standing order or have misconceptions about naloxone and may decide they don’t want to dispense it. They may fear that naloxone will enable patients to use higher doses of opioids, or will discourage them from seeking treatment. All the available scientific evidence says the opposite, but they may not be aware of that.”
Hill is trying to address this knowledge gap through Operation Naloxone, a collaboration among the UT Austin’s College of Pharmacy and Steve Hicks School of Social Work and a community organization (the Texas Overdose Naloxone Initiative) that provides free opioid overdose prevention and naloxone trainings on the Forty Acres and throughout the community. Holleran Steiker is part of the executive team, and Walker is a student member.
“We have trained the UT Austin Police Department and given them naloxone; we have trained resident advisors and now dorms are stocking naloxone. We are one of the few pioneering universities around the country that are being really proactive in this matter,” Hill said. “My dream now is to train pharmacy and social work students so they pair up, visit pharmacies and give naloxone information — like drug reps but for a good cause and not for money!”
In the meantime, even with naloxone laws on the books, many people with an addiction to opioids still depend on harm reduction organizations like the AHRC to stay alive.
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The second outreach stop, in South East Austin, was busier than the first. I sat on the back of the AHRC van, rolling donated tourniquets tightly and holding them with tiny, brightly colored rubber bands. People came in and out, and many left with naloxone kits: a young professional-looking couple driving a silver SUV, a middle-aged Hispanic man who said he had kicked heroin but his children were addicted and he feared for their lives, an older woman with platinum hair lovingly carrying a yappy little dog, a young man with many questions — where should he inject the naloxone? How long should he wait to give a second dose? Did it have to be kept in the fridge?
Walker and the AHRC volunteers listened with attention to everyone who came to the van for services, answered questions, joked back, and made small talk. It was Good Friday, and a few people wished us a happy Easter before leaving.
Later on, as we were driving back to the AHRC office in the Austin dusk, I thought about something that both Hill and Holleran Steiker had suggested: If there is a silver lining to the current opioid epidemic, it may be that it brings more compassion for all drug users and a greater acceptance of solutions other than laws that criminalize addiction and approaches that require abstinence to obtain services.
“From a social work perspective,” Holleran Steiker had also said, “if we get this right and everybody can access the whole spectrum of approaches, then we can help people find what best helps them.”
By Andrea Campetella. Photos by Shelby Knowles.