Chapter 7: Stigma, Harm Reduction, and the Future of Medication-Assisted Treatment

Killing Us with Stigma

At a time when heroin use and overdoses are exploding across the country, Tennessee just passed a law tightening restrictions on Suboxone (buprenorphine), one of the most effective treatment options available to opiate-dependent people.

Advocates for laws like this rely on the excuse that Suboxone is sometimes misused, which is true. But what’s missing from this equation is that its misuse can be an unintended consequence of restricting access to it. What’s also ignored is that, even when it’s misused, Suboxone is safer than unregulated street drugs like heroin or prescription pain medications.

Buprenorphine, the active ingredient in Suboxone, causes less respiratory depression (the usual cause of overdose) than other opioids because it only partially activates the brain’s opioid receptors. There are very few cases of overdose death by buprenorphine, and almost all those cases involved mixing with other drugs.

Stigma contributes to the lack of accurate information available to the public on medication-assisted treatment (MAT) and its effectiveness. It also contributes to policies that severely restrict access to those who need it most, directly contributing to the likelihood of increased diversion of these medications.

Maine’s Governor Paul LePage is pushing to cut funding for methadone clinics in favor of suboxone, despite the fact that 98% of patients in MAT programs rely on methadone and methadone is still considered the “gold standard” for treatment by the CDC.

Methadone treatment has been controversial for decades, despite studies that indicate long-term success rates as high as 60-90%. We see and hear plenty of methadone horror stories, but the media rarely covers the lives of those who have been saved by MAT (props the Gainesville Times for being one of the few to take that bold step).

Lack of Availability

Because of laws restricting the number of methadone clinics in certain areas (like the one in Indiana, which was just eased after a wave of overdose deaths and an HIV/HCV outbreak) or the number of patients allowed by clinics and suboxone doctors, patients seeking treatment are often left on waiting lists or unable to find treatment where they live.

I live in rural North Georgia, about 70 miles north of Atlanta. There are no methadone clinics and one Suboxone doctor in my county. The nearest clinic is over 30 minutes away. In eastern Tennessee there are only two cities with methadone clinics. In Mississippi there is one clinic. North Dakota and Wyoming have none. (A methadone clinic directory is available here, and a list of Suboxone doctors here)

Even in large cities with multiple clinics the wait time can be weeks or months. Having been in that situation, I know I’m not the only heroin user who never made it to my intake appointment.

The art of quitting opiates and other drugs is delicate. It has to be done on the patient’s schedule. When someone is ready for treatment, that opportunity needs to be available immediately, because next week their mind might be somewhere else. (Once, I changed my mind after checking myself into a hospital, which led to an awkward showdown with an elderly security guard and enough ativan to put an elephant out for a week)

To become eligible to prescribe Suboxone, doctors must pass a special course, after which they’re eligible to prescribe to 30 patients at a time. This limit can eventually expand to 100. No other drug is administered or regulated in this way and it creates a barrier to treatment that not only makes getting an appointment difficult, but makes office visits nearly impossible to afford, on top of the cost for the medicine.

Many patients coming off years of misusing drugs don’t have insurance, or even a job, so that money comes out of pocket. Considering the low risk of overdose and abuse (some people do misuse Suboxone–I’ve tried and got absolutely nothing, so take that for what it’s worth), and the high cost of people dying from overdoses, spending time in jail or prison, and drug-related property crimes, increasing the patient limit is critical toward making suboxone a viable route for treatment.

Teaching Harm Reduction to Counselors

In my 3+ years in a methadone program, I had five different counselors. Not only did that complicate building a relationship with someone I could trust, it put me at a greater risk for relapse. The counselor had no idea why I was sitting in front of them, aside from the notes my previous counselor had typed into a computer.

During my time in that methadone program, I was never taught about or provided naloxone, instructed what to do if I witnessed an overdose, or any other harm reduction practices. The only thing we heard was not to take benzos (xanax, klonopin, etc) which is certainly good advice, but that didn’t stop it from happening.

Even when I failed a drug test, there was no discussion about why I failed, how dangerous it might have been, or how I could have at least made the situation less dangerous.

Fortunately, I discovered SMART Recovery not long after entering that program, and learned the skills there. But from what I’ve seen, and what evidence from other clinics indicates, there’s a desperate need for methadone counselors to be trained in harm reduction practices.

One of the groups I work with, Georgia Overdose Prevention, is visiting methadone clinics across the state to train counselors about naloxone and how to administer it. When we raise the idea of providing naloxone kits to patients, a group that often has direct access to the most at-risk drug using communities, the issue is tabled until later; which boggles my mind. It seems that, even if they have to absorb the cost, their legal obligation of patient overdosing would be greatly reduced.

The fact that such an important issue is treated with so little concern demonstrates not only the need for teaching harm reduction skills to counselors and clinic directors, but proving the value of harm reduction in those settings.

Alternative and Progressive Treatments
As we continue our struggle to de-stigmatize methadone and suboxone programs and patients, there are progressive treatments that reveal promising research–and are likely to make steam blow out of the ears of some US journalists and politicians.

Heroin-assisted treatment (HAT) has been used in parts of Switzerland, the UK, Germany, Spain, Denmark, Belgium, Luxembourg, and recently Vancouver, as a second-line treatment when methadone and suboxone treatments fail.

HAT patients are administered controlled amounts of pharmacological-grade heroin in a safe, clean setting with sterile equipment. Contrast this to sitting in a car, ducked down, seat-belt wrapped around your arm, trying to find a vein (with a needle you’ve been using since who-knows-when), praying the cops don’t roll up on you. Never mind there’s no telling how potent or what’s contained in the shot of dope you just put in your arm.

HAT can be effective for patients where other forms of MAT have failed. It has the benefits of reducing use of unregulated and unsafe street heroin, reducing crime, has better retention rates than other forms of MAT, and reduces demand for heroin on street markets–which leads to a reductions in violent and nonviolent crime. (More information on HAT from the Drug Policy Alliance, The Lancet, and the British Journal of Psychiatry)

Alternative treatments, such as ibogaine and other psychedelics, will require more research before they’re viable, but show promising results. Some long-time heroin users have reported being “instantly cured” after ibogaine treatment, but such treatment is illegal in the US, making research difficult and treatment (which might be administered by someone with no medical credentials) dangerous.

The Future of MAT and Saving Lives the Hard Way

We have decades of evidence demonstrating the success of MAT, yet stigma and legal restrictions around these treatments create barriers that are literally letting people die, suffer, and waste away in prison cells. Our nation’s ‘War on Drugs’ has literally become a ‘War on Drug Users.’

To end on a bright note, the medical and drug treatment communities are finally casting aside the old, failed methods of drug treatment in favor of evidence-based treatments–individual and family psychotherapy based on a biopsychosocial model that treats the whole person, MAT, and new alternative treatments that were unimaginable just a few years ago.

The future of drug treatment and life for those living with SUDs shows promise for improvement, but it’s going to take hard work, from many angles. Whether we’re out in the streets or in the halls of our legislative buildings we can, and with the right determination will, make it happen.

FSDP is dedicated to bringing together these resources and people to neutralize stigma, advocate for more common sense drug policies, and employ our collective power to stand up and “Just Say No” to the War on Drugs– and the stigma, pain, and death it leaves in its wake.

Chapter 6: Substance Use and Mental Illness

I first noticed signs of a mood disorder shortly after I turned 16. One month everything was awesome, life was grand. Then the next month I couldn’t even crawl out of bed for work or school. I remember hearing “Manic Depression” by Jimi Hendrix and thinking: That’s what I have!

I grew up with a stepdad who was physically and verbally abusive, used drugs (sometimes) and alcohol (almost always). When he was sober, my stepdad was a great guy. Sometimes I even wanted think of him as my dad–especially given that my biological father abandoned us. But in that environment, talking about my feelings wasn’t safe, and so, I bottled them up.

You can only pack so many feelings into your brain’s inner-bottle before something gives. In my mid-20s, when I found myself tossing and turning every night, butterflies kicking around in my stomach, and bad thoughts racing through my mind, I finally went looking for help.

I told my doctor what was going on: My anxiety was so bad I had physical symptoms. I hated being around people. It was impossible to form an emotional bond with anyone, even my kids. Sometime I couldn’t sleep, others I could work all night, non-stop.

She sent me home with a box of antidepressants, a sample dropped off, no doubt, by the latest pharmaceutical rep.

I tried the pills for a few weeks with no luck. I went back complaining that my symptoms were getting worse. So she wrote me a prescription for another antidepressant. This yielded the same result. After a few times of that, I gave up on doctors.

Within a few months of my last visit, I was injecting heroin every day.

When Self-Medication is the Only Medication You Can Find

Despite the “Drug War” myths I’d heard growing up, I wasn’t “hooked” on heroin instantly (and, in fact, most people who try drugs–even heroin–never become addicted). I did, however, notice an immediate effect on my mental condition. It was like someone twisted the top off that bottle and a decade’s worth of worries floated away. Heroin felt like medicine.

I was able to function for two years as a software engineer using heroin every day. The stereotypes you hear about drug users aren’t always true.

Heroin almost completely eliminated the stress of a 70-hour, 24/7 on-call work week. Later, when I began bartending and waiting tables, I relied on the excuse that being on drugs made me “more fun to be around” and better at my job (which was true to an extent, until my habit spun back out of control).

Eventually life caught up with me. Heroin is expensive. Even with a well-paying job, I was unable to support a daily habit and pay the rent. I found myself in a self-perpetuating cycle that only reinforced my need for more drugs.

When I started seeking treatment, the only options I could find were twelve step programs. I attended meeting after meeting, and nothing clicked. If anything, being told that I used drugs because of character defects and that I was powerless seemed counterproductive. It crystallized what I already thought about myself by that point: I was a bad person doomed to be an “addict” for life.

Through countless AA and NA meetings, several trips to inpatient and outpatient treatment, a detox facility, a dozen different courtrooms, and two years in prison (where I was offered no substance abuse treatment), at no point-of-contact with any of these institutions was I offered, or was it suggested I might benefit from, mental health treatment.

USA! USA!
It was only after I entered a methadone program and started attending SMART Recovery, a free,  evidence-based alternative to twelve step programs, that a facilitator suggested I might be self-medicating mental health issues.

The tools I learned in SMART made me feel like I could take back control of my life. Through SMART’s cognitive-behavioral therapy (CBT) and rational-emotive behavioral therapy (REBT), I learned several important skills:

  • Instead of giving in to urges or cravings to use, I could distract myself with positive activities
  • I could be on methadone or suboxone and still be in “recovery.” This was critical, because opiates did, and still do, feel like a critical part of my medical care
  • REBT taught me to dispute irrational thoughts–it wasn’t certain events that made me sad or depressed, but my thoughts about those events
  • That using once wasn’t a traumatic failure. I could slip and still keep moving forward. They differentiate between a slip, a lapse, and a relapse
  • That by changing the words I used to express thoughts about myself, my using, and my problems, I could move beyond being an “addict” to simply a person dealing with problems that I was now empowered to overcome

One of the most important things SMART taught me was unconditional self-acceptance (USA). This turned my self-esteem around and helped me survive until I was able to find effective mental health treatment. I still use these skills today, and they can be applied to more than just substance use disorders (SUD) or mental health issues.

I first noticed symptoms of mental illness in 1994. I started using heroin in 2004. It wasn’t until 2015 that I was properly diagnosed with bipolar disorder, general anxiety disorder, and post-traumatic stress disorder (PTSD).

It took me 20 years to even find my entry point to treatment for mental health issues which, had they been treated sooner, might have spared me that decade-long relationship with heroin.

The 2012 SAMHSA National Survey on Drug Use and Health indicates that 43.7 million (almost 19%) of adults live with some form of mental illness and that 20.7 million adults (almost 9%) have an SUD. About 8.4 million have both mental health disorders and SUDs. That means over 40% of Americans with SUDs also have mental health problems (and those are only the people who have been diagnosed).

According to the National Institute on Drug Abuse (NIDA), 40% of those with an SUD also have a mood disorder and about 30% have an anxiety disorder. They also estimate that genetics constitute 40-60% of a person’s risk for developing a SUD. So what about the rest?

Good News, It’s Not Your Brain — It’s Your Everything
For many years addiction was treated as a “brain disease.” This model presumed some people were “wired” to become addicted to drugs or alcohol, powerless victims with no ability to control their behavior. This was the standard belief in most of the drug and alcohol treatment community for over half a century.

But recent research (and in fact, some that dates back to the 1970s) paints a much more complicated picture. The brain does play a role in SUDs, but there’s more to a person than just their brain, and the same holds true for people who use drugs.

Data from NIDA and the CDC indicate there are a number of contributing factors to substance misuse, including emotional trauma, physical or sexual abuse, poverty, social pressure, and more. The “psychobiolsocial,” model provides a better explanation for why some people are at greater risk of developing an SUD than others.

Dr. Andrew Tatarsky, in his article “We Don’t Treat Brains, We Treat People,” describes a more comprehensive approach to managing SUDs. He writes that:

Accumulating data and clinical experience support a “psychobiosocial” model in which biology and behavior intersect with meaning and social context in complex ways that are unique to each person and give rise to the problematic and addictive behavior.”

Psychotherapy, which focuses on the patient’s mental, emotional, and physical well-being, is a critical component of treatment for people with SUDs and mental health disorders. Instead of focusing strictly on the brain, psychotherapy also addresses physical, social, and environmental causes. Tatarsky describes his approach as “a personalized treatment for substance misuse and addiction that goes beyond the one size fits all model of abstinence.

Connecting the Dots
As my experience demonstrates, finding effective treatment for mental health disorders or SUDs is not easy. While more effective treatments are becoming available, connecting patients to those treatments remains a problem.

From a policy level we must, at a minimum, provide better opportunities for mental health screening and treatment at every point of contact with the medical, drug treatment, and criminal justice systems. It shouldn’t take over 20 years for someone to find help, especially given my multiple encounters with all three.

We need funding for mental health programs and evidence-based treatment programs, but we also need an integrated approach to treatment for SUDs and mental health issues. We need more effective educational resources so that when people recognize symptoms, like those I first noticed as a teenager, they know where to turn and aren’t afraid to ask for help.

Life for those of us with co-occurring mental health issues and SUDs is especially dangerous, especially when it comes to suicide and encounters with police, not to mention overdose. There are effective treatment options out there, but without resources that make them accessible, most of us with co-occurring disorders might never find our way to a “normal” life.


More resources:

More from NAMI on Substance Use Disorders and Mental Health Conditions: http://www2.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/By_Illness/Dual_Diagnosis_Substance_Abuse_and_Mental_Illness.htm

NAMI Dual Diagnosis Fact Sheet: http://www2.nami.org/factsheets/dualdiagnosis_factsheet.pdf

Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems, by Dr. Tatarsky

Practicing Harm Reduction Psychotherapy, Second Edition: An Alternative Approach to Addictions, by Pat Denning

Chapter​ ​5:​ ​Disease​ ​Transmission:​ ​HIV​ ​and​ ​Hepatitis​ ​C​ ​are​ ​Still​ ​Killing​ ​Us 

HIV and Hepatitis C (HCV) are nothing new in the United States. Most of us have heard about them; but not many of us know much about them. Both still represent a major health problem in our country.

I used IV drugs for over a decade. During that time I shared needles with other people. I was naive, though, and thought that if I only shared with people I “trusted” I’d be in the clear. You know what they say about hindsight. Even if those people were careful, and only shared with people they “trusted,” it only takes one bad link in the chain to infect the whole bunch–and that’s just what happened.

When I entered a methadone program that I was forced to confront HCV. Most methadone clinics run diagnostic blood and urine tests to check for HIV, HCV, STDs, etc. My liver enzymes were slightly elevated, but I did some research on the Internet and convinced myself I was probably OK.

Fortunately, my spouse wasn’t so blindly optimistic. She ordered me a home test kit. I’ve never been afraid of needles, but the finger-prick device that came with that kit, and the subsequent effort to squeeze enough drops of blood from my finger to fill the little circle is an scene I’ll probably never forget.

We sent the test off in the mail, I said a silent prayer, and went about my business.

A week later I received a phone call. You know the one. “Call this number for more information.” The call that means you’re not in the clear. That you’ve got problems, and it’s time to face reality.

Fortunately, I was privileged enough to be covered by my spouse’s insurance. I was able to get an appointment with one of the best liver doctors in the state, who performed a liver biopsy to confirm I did have HCV.

The treatment medications at the time were nothing short of terrifying. Interferon injection and ribavirin, which are only successful about 50% of the time for the most common HCV genotypes, were described to me as “six months of having a really bad case of the flu.”

By a stroke of luck, which I also attribute to the privilege of being in a certain social class and of a certain race, just as I was filling my interferon prescription I got called back to the doctor. They were running a clinical trial for a new drug and I fit the profile.

I hesitated. I had a close friend die during a clinical trial for asthma a few years earlier. But it turns out I made the right choice. The medication had no side effects–to the point my nurse was positive I was on the placebo (and as such I skipped the last two weeks of my regimen–oops!).

That medication is now marketed as Sovaldi (Sofobsuvir). It’s a miracle drug–if you can afford it. A 12-week regimen of the drug runs anywhere from $84,000-94,000. Many insurance providers won’t cover the cost, which leaves interferon, with all its miserable side-effects and partial success rate, the only option for the less privileged.

This comes at a time when HCV statistics are on the rise in many places. The CDC estimates that 3-million people in the US have HCV and only 1 in 10 infected people are aware they have the disease. It can sometimes take years for symptoms to appear, at which points it might be too late. It’s estimated that about 15,000 Americans die every year from HCV.

There have been recent outbreaks of HCV in rural areas like southern Indiana and Central Appalachia, where infection rates have more than tripled.

Most people contract HCV by sharing needles. Bleaching, boiling, or rinsing them out will NOT remove the virus. This is why needle exchange programs and syringe access are so important.

HIV gained public attention in the 1980s. The AIDS panic is one of my earliest memories. At the time very little was understood about the disease. I remember my mom flipping out because someone at the group home where she worked shared food from her plate from me. Everyone was scared of contracting it and, of course, the gay community that suffered most from the outbreak was marginalized and stigmatized even more than they already were thanks to myths and propaganda. The federal government paid very little attention until the disease reached epidemic proportions in the late 80s.

Despite perceptions that HIV and AIDS are no longer a problem in the US, they still have a devastating effect, especially in communities of color. Here are some of the more troubling HIV statistics from the CDC and the aids.gov website:

  • More than 1.2 million people are living with HIV in the US and 1 in 8 unaware of their status
  • More than 658,000 people in the US have died from HIV
  • About 50,000 new HIV cases are diagnosed each year
  • Black Americans account for 44% of new diagnoses each year
  • In 2012, almost 14,000 Americans died from HIV
  • Injection drug users represent 15% of those living with HIV

In response to the government’s failure to address the AIDS crisis, on-the-ground, grassroots organizations like ACT UP, AIDS Brigade, and Urban Health Study took matters into their own hands. Groups like these formed the nation’s first needle exchange programs, advocated (sometimes militantly) for AIDS research funding, and offered HIV and HCV testing for at-risk communities (ACT UP is still pushing for a 0.05% tax on certain Wall Street transactions to fund AIDS research and provide universal healthcare). This was effectively the birth of the US harm reduction movement.

Harm reduction groups in many US cities operate needle exchange programs, which has helped reduce transmission of HIV and HCV. In most areas these programs operate in a legal “gray area,” where the distribution and possession of syringes without a prescription might be illegal, but law enforcement often turns a blind eye (in fact, some law enforcement organizations have been surprisingly supportive of these programs).

In Georgia, where I live, it’s illegal to possess a syringe without a prescription, but drug stores–at the pharmacist’s discretion–can sell them to anyone. When I was using, thanks to the myths that circulate in drug using circles, I thought there was only one pharmacy in Atlanta where we could by syringes. Sometimes were weren’t even able to scrape together the spare $3 to buy a pack. I used the same syringe for 3-4 weeks sometimes, and my arms have the battle scars to prove it.

It’s ridiculous, given what we know, that access to clean syringes is so limited. This is an area where groups like FSDP can have a real impact by educating vulnerable populations and advocating to decriminalize possession of syringes, legitimize needle exchange programs, and even grant immunity for syringes with small amounts of drug residue.

It’s difficult to understand how anyone can be opposed to such measures (though some still are [trigger warning: picture of syringes]). Given their record of success–and their amazing accomplishments against all odds–harm reduction and needle exchange programs should not only be decriminalized, they should be publicly funded at a Federal level.

I’m well over my word count, but if you readers get anything from this, I hope that you’ll realize: 1) HIV and HCV are still major health problems in the US and; 2) Harm reduction groups provide a model for filling in gaps when the government fails to provide. At FSDP, we have the collective power to push for policy changes at the state and federal level and coordinate with harm reduction groups out on the front line, risking their freedom, to help victims of the “War on Drugs” survive another day.


More about Sovladi (Sofobsuvir), for treatment of Hepatitis C:
http://www.nytimes.com/2015/05/20/business/high-cost-of-hepatitis-c-drug-prompts-a-call-to-void-its-patents.html

CDC Incarceration Fact Sheet on Hepatitis C:
http://www.cdc.gov/hepatitis/HCV/PDFs/HepCIncarcerationFactSheet.pdf

CDC Basic HIV Statistics:
http://www.cdc.gov/hiv/statistics/basics/ataglance.html

More on the Hepatitis C Outbreak in Appalachia:
http://www.nytimes.com/2015/07/24/us/kentucky-struggles-to-contain-hepatitis-c-among-young-drug-users.html
http://www.cnn.com/2015/06/05/health/appalachia-hepatitis-c-rates/ [trigger warning: needles]
More on the Recent HIV Outbreak in rural Indiana
http://www.chicagotribune.com/news/chi-indiana-hiv-outbreak-drug-use-20150330-story.html

More on ACT UP and the Beginnings of Harm Reduction in the US:
http://actupny.com/actions/index.php/act-up-news/70-latest-news/106-act-up-chronology-in-brief
http://nynmedia.com/news/harm-reduction-lessons-learned-from-the-aids-crisis
http://www.huffingtonpost.com/allan-clear/harm-reduction-in-the-uni_b_525390.html

Database of syringe access laws in different states:
http://lawatlas.org/query?dataset=syringe-policies-laws-regulating-non-retail-distribution-of-drug-paraphernalia

Other Good Resources:
http://harmreduction.org/about-us/principles-of-harm-reduction/
http://www.druguserpeaceinitiative.org/
http://ndri.org

Day 4: Naloxone Access and 911 Medical Amnesty (2/2)

Picking up where we left off yesterday, there’s room for optimism when it comes to naloxone access and 911 medical amnesty laws, but we still have lots of work ahead of us.

I’d like to see a recovery scene where not only is naloxone provided to opiate users in any type of treatment program, but where methadone patients are provided naloxone, with training in its use, when they enter a program. The same goes for rehab facilities. Every rehab should have naloxone on site in case of an emergency. And, of course, methadone programs, rehabs, and drug courts should be required to provide (or at least offer) naloxone and educate patients/clients about it when they are discharged from theirprograms.

All this comes at a time when opiate overdose deaths show no sign of slowing down. We have a social obligation to provide naloxone to at-risk communities and to empower those most in need, whether they’re ready for recovery or not. Groups like FSDP can make this a reality.

The naloxone access laws that have been passed in many states are a great start, but from a policy and grassroots level, we need more:

  • We need affordable access to naloxone and networks capable of getting it in the hands of those who need it most.
  • Methadone clinics must provide naloxone, even if patients have to cover the cost (which isn’t ideal and creates a barrier to treatment). It boggles my mind that methadone clinics aren’t already doing this. I’m not familiar with the internal workings of methadone clinics, but it seems that distributing naloxone to patients would reduce their legal liability if a patient does overdose and help educate the drug using community about naloxone and harm reduction.
  • Rehab programs and drug courts, especially those that impose an abstinence-only protocol, should be legally required to provide enrollees with naloxone. I believe their failure to do so is a contributing factor to many opiate overdoses. With what we now know about naloxone and the risk of overdose after a long period of abstinence, these programs should be held accountable to some degree.
  • As family members and advocates, we need to hold these institutions accountable. Not only methadone clinics, rehabs, and drug courts, but our entire legal system. The treatment provided in most state correctional systems is archaic and abysmal. It sets those who come into contact with the legal system for failure, which has given birth to an endless cycle of recidivism that can only be escaped with a strong support system and effective treatment.

On a brighter note, as of April 2015, 25 states have naloxone access laws, 19 have 911 medical amnesty laws, and 17 have both. That’s quite a disparity, and there are still quite a few states missing from the picture, but the tide is turning.

The primary argument against these laws is that they will increase use or make drug users “careless,” relying on emergency services to “save” them. This has proven not to be the case. There has been no measurable increase in misuse of opiates in states that have passed these laws, despite unsubstantiated rhetoric from some journalists and politicians.

Georgia’s laws were enacted in April 2014. Since then, the Atlanta Harm Reduction Coalition (AHRC) and Georgia Overdose Prevention (GOP) have worked to train and equip law enforcement officers (who are often first-responders and have been surprisingly supportive of the laws) with naloxone. We also distribute naloxone to at-risk communities.

As of July 2015, over 260 overdoses were reversed with naloxone distributed by AHRC and GOP. Twenty local, county, and college police forces are now equipped with naloxone, and 35 overdoses have already been reversed by law enforcement officers. Maybe not all those victims would have died, but that’s almost 300 people in Georgia alone who now have a second chance.

People use drugs for a host of reasons. Sometimes they’re self-medicating mental health issues or emotional/sexual trauma. Sometimes they have pain can’t be managed with prescription medications. Sometimes they’re using prescription pain medications as prescribed and their doctor decides to cut them off because of stricter government regulations–and so they turn to alternative sources that aren’t regulated and are, therefore, even more dangerous.

Despite the different paths they take to misusing substances, they all share one thing in common: their lives have value.

In my work with overdose prevention, I sometimes see stickers or banners that say “Every overdose victim is someone’s child.” That may be true, but that’s not the whole picture. Their life doesn’t have value because of who cares about them, but because of who they are. Drug users’ lives have value they are human.

Naloxone access and 911 medical amnesty laws have come a long way in the last few years, and the future looks promising; but as those skyrocketing overdose statistics demonstrate, it doesn’t stop here. We have a long road ahead of us.

What can we do to more effectively get naloxone into the hands of those who need it most? How do we make sure that when someone witnesses an overdose they don’t fear calling 911 because they’re not sure what the law is and they don’t want to risk going to jail?

And how do we take these laws further, to remove confusion, create consistency, and make conditions safer not only for drug users, but for sexual partners who might be at risk from disease, police who might be at risk from being stuck by infected needles, and the parents and loved ones who worry whether tonight will be the night they get that phone call and hear that they’ve lost someone they care about to an overdose that could have been prevented?

Chapter 3: Naloxone Access and 911 Medical Amnesty (1/2)

Having used heroin for over six years before becoming involved with overdose prevention, when I started doing research to get overdose prevention laws passed in my state, some facts didn’t surprise me. Others blew my mind.

I knew how frightened heroin and prescription pain pill users were to call for help when a friend overdosed. I’d heard stories of trying bystanders trying to revive overdose victims by splashing cold water on their face, dragging them into a cold shower, injecting them with saltwater, smacking them in the face, sticking Suboxone under their tongue, and so on. All of these are unlikely to work, and sometimes might make a situation more dangerous. (And, of course, there’s that infamous scene from Pulp Fiction that’s been the bane of overdose prevention efforts since the mid-90s: No, you cannot revive someone from a heroin overdose with a shot of adrenaline to the heart!)

Interestingly, I rarely heard stories of friends calling 911 or taking victims to the hospital (although one friend came very close to doing this for me when I had a close call). In their minds, at least, there was good reason for this: Everyone heard tales of that friend-of-a-friend who dropped someone off at the ER only to be arrested on the spot.

In my research I found that police didn’t arrest bystanders at overdose scenes nearly as much as people suspected; but just the thought of a police encounter, the fear of going to jail, of having to kick cold turkey, and–if you were on parole or probation–a lengthy prison term, was a strong deterrent to calling for help.

Overdose statistics in the US are mind-blowing, and they’ve increased exponentially over the last 15 years. Drug overdose is now the number one cause of accidental death (around 44,000/year, with automobile accidents coming in second, at 33,000). According to the Centers for Disease Control (CDC), between 2001-2013, heroin overdose deaths increased 500%. Overdose deaths from prescription painkillers increased 300%. And overdose deaths from benzodiazepines (Xanax, Ativan, and Klonopin, etc.) increased 400%.

These numbers are unacceptable. At first I didn’t know what to make of the numbers. In my home state of Georgia, overdose numbers were particularly difficult to track because of the way they were reported (metro Atlanta counties had their method, counties in the rest of the state had another).

The only thing that mattered to me was that my closest friend had just died from a heroin overdose because someone was scared to call for help. At Georgia’s first Overdose Awareness Vigil I heard story after story just like his. It was clear something had to change.

911 medical amnesty laws and naloxone access laws aim to address these problems. Here’s a brief summary of each:

911 Medical Amnesty: These laws provide legal immunity from arrest, prosecution, or conviction when someone calls to report an overdose and police show up, where they might find small amounts of drugs. The person who calls and the victim are generally protected. In some states, everyone at the scene is protected. Laws vary from state-to-state, with some states even providing protection for those with active arrest warrants preventing probationers and parolees from having their term violated. Some states also include underage alcohol provisions.

Naloxone Access: Naloxone is a medication that can almost always reverse an overdose from heroin and other opiates when administered in time. For many years, only EMTs and emergency rooms had access. These laws make it legal for anyone to carry naloxone and provide legal civil and criminal amnesty for unintended results when administering naloxone in good faith (although naloxone is almost 100% harmless when used on healthy adults) It has no recreational value and, when administered to opiate-dependent people, causes immediate withdrawal (which, in the case of an overdose is a good thing).

Before naloxone access laws were enacted (and many states still don’t have them), harm reduction groups distributed naloxone to at-risk communities despite the legal status. Sometimes those of us at the front line of the “War on Drugs” resort to “extralegal” means to save lives.

Naloxone has been used for decades by EMTs and emergency rooms to save lives. Thanks to these new laws, it’s now saved thousands of lives out in the streets.

There’s room for optimism with 911 medical amnesty laws. With more states passing them, it seems inevitable that, within the next few years, all states will provide some level of medical amnesty. But some problems still remain:

  1. Many active drug users don’t know about these laws. We need to find ways to erase myths and get accurate information into their hands. Families can help by talking about these laws with loved ones, but sometimes that’s not enough. These laws should be discussed at every point of contact with active and recovering drug users. I think methadone clinics are an ideal place to start. Patients in these programs often maintain ties to active users and, based on my experience, word travels fast in these circles.
  2. We need consistency between laws at a national level. Some states provide very little protection–for only the victim and caller, and for very small amounts of drugs. Others provide protection for victims, callers, and bystanders with active warrants or who are on probation and parole. Consistency and clarity in how these laws are written and implemented is crucial to educating at-risk communities and eradicating misconceptions that might still prevent someone from calling 911 or administering naloxone.

We’ll continue this discussion tomorrow, considering steps we can take to improve existing laws, find more effective ways of educating at-risk communities, getting naloxone to the people who need it most, and looking at innovative approaches save lives and reduce harm both, from a policy perspective and at the grassroots level.

Chapter 2: Different Pathways to Recovery

Everybody’s path to recovery is different. It seems like common sense to me now, but for a long time I was led to believe otherwise.

As I’ve mentioned before, I first started trying to quit heroin within four months of starting. I went to a doctor, which was a total failure. This was the same doctor who less than a year earlier had offered me a “free sample” box of Wellbutrin for what was obviously more than just a case of mild depression.

Most of my attempts at quitting heroin for the next two  years involved buying various different types of prescription painkillers to ‘taper down.’ When the withdrawal symptoms disappeared, I imagined I was cured. Then, I convinced myself, if I just cut back to using once every 2 or 3 days I’d be good. You can guess how well that turned out.

Eventually my habit became so expensive I gave up on my well-paying software job and developed a fairly lucrative career as a petty thief. At one point I was bringing in over $500, almost all of which went toward drugs, and the occasional ‘Debbie Cake’ for nutritional sustenance.

When you’re stealing all day, every day, even when you’re really great at it, statistics are bound to catch up with you. And so began my many run-ins with the law.

My first offenses were met with probation and suggestions I go to twelve step meetings. As I racked up more offenses, the 12-step meetings became mandatory.

The mere fact that I was being forced to attend made me less-than-receptive to their message. I just went to get my sheet signed to keep from going to jail.

But eventually I started listening. And I wanted to try. But their message just didn’t click. “Try a different meeting,” folks would tell me. And so I did. Didn’t work. None of them spoke to me. And, given that I had a crippling fear of talking with strangers when I wasn’t taking drugs, there’s no way I was going to get a sponsor.

Twelve-step programs work for some people, but the number is substantially smaller than advocates have led us to believe. Their response is that, well, they just weren’t working their program. They haven’t hit their bottom. And so on. The logical fallacies in this approach–and that so many people blindly accept them–are mind boggling. To me, those meetings just seemed like a place to gossip and share stories about our awful pasts, not the hope we had for a brighter future.

Before I was ever introduced to twelve step programs, I’d heard about methadone. And almost everything was negative. “Liquid handcuffs.” “Worse than heroin.” “The withdrawals last for months.” “Trading one drug for another.”

More than six years after I first started using I entered a methadone program. Within a few I discovered much of what I’d been told were myths. For me, methadone was a miracle. By that point I’d given up hope of ever quitting. I was simply counting the days away until it was all over; me dead in some gutter, lost and forgotten, and missed by no one. Methadone turned my life around.

Methadone won’t work for everyone–and that’s OK. For me, a long-time heroin user ready for a change, it did. After about three years I switched to Suboxone. The great thing about Suboxone, and I won’t get too scientific here, is that it binds to your brain’s opioid receptors more strongly than just about any other opioid. For me, that was great. It meant when I was on Suboxone and I did a shot of dope I felt nothing–NOTHING! If I wanted even a little buzz I had to skip my dose for a day or two. Eventually I decided it wasn’t worth the hassle. My love affair with heroin quietly faded away. I don’t count my non-using days because I don’t even remember the last time I used. It was unremarkable in every way, although it was a major milestone in my life.

Once I was on Suboxone I was finally able to get treatment for everything I’d been self-medicating with heroin: anxiety disorders, bipolar disorder, PTSD, emotional trauma, the list goes on. The unbelievable thing is that through all my tries at recovery, getting proper mental health care (not just handfuls of useless antidepressants) rarely came up. It never came up at twelve step meetings, although my SMART facilitator did gently suggest I consider it more than once.

My story is packed with twists and turns, as are most stories of those struggling with substance use disorders (SUDs). Most of us try to stop using when we’re ready, but unless we have the proper support and guidance, it’s just like Sisyphus, pushing an unbearable load up a mountain we’ll never scale.

If you have a loved one struggling with substance misuse, here are a few pointers, based on my experience and the stories I’ve gleaned from others. These aren’t hard and fast rules, but I think they do deserve consideration:

  • We need a loving, non-judgmental support system. Too often parents and loved ones impose their own thoughts or preferences, with the best of intentions, which only pushes us further away. We need someone to support us, someone we can lean on, someone who loves us unconditionally. It’s maybe the most important factor to successful recovery. (Community Reinforcement and Family Training [CRAFT] is great at teaching family members these skills)
  • Sometimes we’re not ready to stop using, but that doesn’t mean we haven’t thought about it. Until we’re ready to stop, harm reduction approaches can keep us alive. Harm reduction approaches look to engage more people in treatment by taking judgment out of the equation, acknowledging that people move through stages of change, they meet us ‘where we’re at’, and encourage small positive steps. I wasn’t exposed to harm reduction until after I stopped using–and I ended up with hepatitis C because I was sharing needles. I still have scars on my hands, arms, and feet from reusing the same needle–sometimes for as long as a month. Harm reduction keeps us alive and more healthy, but it also makes us think about our using in a different (safer) way. Harm reduction practices can break down barriers we often don’t even notice.
  • The Internet is packed with myths and misinformation about drugs and drug treatment. You might be amazed what getting the right information into the hands of a loved one with an SUD can accomplish. If I’d known the truth about methadone when I was first exposed, I might have been spared that two year prison sentence. If I’d known where to get clean syringes, I might not have contracted HCV or have to wear long sleeves in the summer to hide the reminders of my dark dance with heroin.

There’s no shortage of alternatives to abstinence-based approaches out there. Here are just a few treatment and support options, but it’s by no means comprehensive. Feel free to chime in with comments with on what’s worked for you:

  • Methadone-maintenance treatment (MMT)t: sometimes patients can come off opiates entirely this way, but sometimes they’ll need methadone the rest of their lives. And that’s OK. The decision should be up to them and their doctor. The CDC has declared the most effective treatment for heroin use, but the stigma around treatment remains a critical barrier to treatment.
  • Suboxone treatment: similar to MMT. It’s recommended long-time opiate users stay on suboxone at least a year before trying to taper off. Some of us might need suboxone the rest of our lives. I’m one of those people and, while I’m cool with that now, it took a long time to accept it because of the stigma.
  • SMART Recovery: Self Management and Recovery Treatment (SMART) is an evidence-based recovery recovery program that uses cognitive-behavioral therapy and other proven methods. Most importantly for me, they accept medication-assisted treatment (MAT), like methadone, suboxone, and anxiety medications. That’s something many twelve step groups look down on, marginalizing some attendees to the point they take their medicine (even antidepressants and antipsychotics) in secret.The SMART terminology helped reduce much of the stigma I’d internalized and helped me realize I wasn’t using because I had character defects, but because I had mental health issues that weren’t being addressed.
  • Moderation Management (MM): For decades the dominant position in the recovery community was that total abstinence from drugs and alcohol was the only way to recover. “One is too many and a thousand is never enough,” the old saying goes. We’re powerless over our addictions and even one drink or hit of weed constitutes a relapse. Recent research suggests that, for some people, this isn’t necessarily the case. Some people can reduce their drinking to healthy levels. With drugs, the case is a little cloudier. Can one use moderate amounts of heroin, cocaine, or methamphetamine successfully? I’ve know a handful who can, but I can’t say for sure.

One thing is certain: The old mantras the rehab industry and much of the recovery community have propagated for decades are being called into question. There are no hard and fast rules when it comes to recovery.

Now, what can we do from a policy perspective to insert these alternatives into a justice system and rehab industry that are slow to adapt? Many drug courts won’t even consider allowing clients to participate in MAT or twelve-step alternatives. That’s slowly changing, but not nearly fast enough. The abstinence-only position of many rehabs and drug courts are not only likely to fail, they can be fatal. When opiate users leave a 30-day program, get kicked out of rehab, or leave drug court, they’ve lost their tolerance for opiates. When they go back out and use, they’re at a significantly higher risk of overdose. This has to change.

The evidence is out there that we’re all different and, as such, all our needs are different. With that in mind, what will it take to find people with SUDs the treatment that’s most effective for them? What steps are we willing to take to make sure rehabs and courts don’t treat our loved ones as just another statistic, or a cardboard cutout capable of being “cured” by a one-size-fits-all approach?

These are important questions, and how we respond to them will determine the course of substance misuse treatment–and the lives of our loved ones–for years to come.

Chapter 1: Opening Pathways and Breaking Down Barriers at Home and In the Legal System

I began using heroin when I was 26. First drug I’d ever tried. Not your typical story, but then, everyone’s story is different. So, too, is everyone’s path to successful recovery.

Within 4 months, and realizing I needed it every 8 hours just to keep away the heebie jeebies, I looked for help. I went to my family, thinking they could help me get back on track. That was a mistake.

They meant well, but they didn’t know where to begin. So they turned to the Internet, which offered nothing useful and plenty that reinforced dangerous myths that derail people like me from seeking treatment in the first place. Mom wanted to send me to inpatient rehab for 6 months, which I refused to even consider.

After that I went to my doctor (because I had a good job and insurance, something many of us don’t have). I asked about methadone and Suboxone, but instead the doc wrote me a prescription for trazodone and wished me luck. I was back to using within two days.

Two years later I called a methadone clinic, despite the stigma tied to methadone maintenance treatment and the promise from my mom that she wouldn’t support a “legal heroin” habit. The intake fee was $175, which equaled about three days of using at the time. Needless to say, I never made my intake appointment.

I tried outpatient programs, inpatient programs, and went to countless twelve-step meetings, both willingly and by court order. Twelve-step works for some people. It never resonated with me. In fact, I feel like some of what I learned there (especially about relapse) helped me sabotage several later attempts at recovery.

It wasn’t until I met my spouse that I found someone willing to support me in my recovery on my own terms, with help and guidance when I needed it. She urged me to stop using, but didn’t set strict rules. Within a couple weeks I was in a methadone program.

Methadone-assisted treatment was a game-changer for me. I don’t hesitate to say it saved my life. It wasn’t the “liquid handcuffs” I’d been promised by so many people who failed to comply with their treatment and later went back to using. It didn’t eat away my bones or make me gain 300 lbs. It was medicine and I took it in a clinical setting, which changed the way I thought about using and took away the rush I got from finding ways to get drugs every day — which was a good thing.

I slipped a few times. When I thought I could get around a drug test, I would use occasionally. But a few months into it, I stumbled into SMART Recovery. SMART is an evidence-based alternative to twelve-step programs. It clicked with me from the start. The greatest benefit was that it taught me when I did slip up and used once or twice, I didn’t have to start over at the beginning (“here’s your white chip” as he surrendered once again and hung his head in shame). As long as I kept moving forward and worked to address what caused my slip, it wasn’t a big deal; which took a world of pressure off my shoulders.

Eventually I switched to Suboxone, which carries less stigma, but is still considered “trading one drug for another” by detractors and, especially, by many journalists and politicians who unfortunately still have a lot to learn.

It was then that a therapist suggested I seek treatment for mental health issues. In all my twelve-step meetings, stays at rehab, and encounters with “addiction specialists” not once had anyone suggested something so obvious.

Now I’m getting the care that I need. I’m still on Suboxone and I have no problem accepting I might be on it the rest of my life. It’s medicine for me and, to be frank, I don’t give a damn about the stigma people attach to it. That’s their problem, not mine — but it is a barrier we need to eliminate for other people seeking help.

My story is my own, but there are thousands just like it. Statistics show that when those who misuse substances find their way to recovery, they do it on their own terms, not when they’re coerced by courts or forced into it by families with interventions or a misguided “tough love” approach.

With that in mind, what can we do to tear down those roadblocks that make getting treatment so difficult? I spent ten years trying to quit heroin, and for most of that time I sincerely wanted to stop. The problem was I didn’t know how — and the folks who wanted to help me didn’t know how either.

To break down those barriers we need at least these three things:
1. We must eliminate the stigma around medication-assisted treatment (MAT). MAT is the most effective method for getting opiate users to reduce the harms associated with their use and to take positive steps toward healing. That’s proven.

2. We need effective educational materials that are accessible, appealing, and easy to follow. When someone finds out their child, spouse, or friend is using, how do they approach the situation? How can they be supportive? How can they keep their loved one alive until they’re ready for help? There is an evidence-based family therapy approach–Community Reinforcement and Family Training (CRAFT)–proven to be an effective intervention, based on compassion and the strengths and resources of families, and empowers family members to take care of themselves and the safety of their family

3. We need to break down barriers to treatment. Most heroin or pain-pill users won’t spend 200 bucks to enter a methadone program, then spend $12 to $20 a day just to not be sick — especially with the stigma and myths that exist. Some methadone clinics are great (I went to one) and some are awful. How to we establish standards that don’t create more barriers? If medication-assisted treatment is readily-accessible, I believe (and statistics likely bear this out) those with substance use disorders who do want to quit will find their way into them.

From a policy level, let’s get this out of the way first: “Nothing about us without us!” If you’re going to make laws that affect drug users, you need to include us in the process. We’ve been excluded for decades and that’s part of the reason our system is so awful now. We’re people. Our lives matter. And we’re a helluva lot smarter than you give us credit for.

Furthermore, how do we make lawmakers see that this is a problem that affects us all? Drug use can lead to property crime, which leads to jail, and probation, and prison, and more drug use, and more crime, and so on. Even if we don’t know someone who’s using, we’re paying a price for the failed “War on Drugs.” Members of groups like FSDP are empowered to use our collective energies to push drug policy toward a treatment-based model, not the punitive, prison-based model that’s given our country the world’s highest incarceration rate.

That’s a lot to take in, but we have a lot of work to do. I don’t have all the answers. None of us do. But I do believe that when we put our minds together, and put our thoughts into action, we can make changes that save lives and keep our friends and loved ones off drugs. I’ve seen it happen and I know we can do it.

What do you think it will take and how far are you willing to go to make it happen?

A Treatment and Support Guide for the Rest of Us

Good Treatment is Hard to Find

I spent a decade using heroin and about nine years trying to stop. It’s not that I didn’t want to quit–I didn’t know where to turn. In my Internet research and through word-of-mouth, I either came up empty or ran into a lot of myths and misinformation. Stigma created an additional barrier to me getting the help I wanted.

In recent years we’ve learned much more about addiction and effective treatments, but significant barriers remain. While the county I live in has one of the highest overdose rates in the state, there are no opioid treatment providers. This is a common problem in rural, and even some urban and suburban, areas.

With that in mind, here’s a comprehensive (though not overwhelming) list of treatment and support options which are either evidence-based or use evidence-based tools, followed by links to harm reduction resources. Harm reduction organizations provide education, treatment referrals, naloxone overdose rescue kits, syringe exchange programs, access to contraception, HIV and hepatitis C testing, and other vital services which might otherwise remain unmet.

Everyone is different and there are many pathways to recovery. Guides like this will grant broader access to recovery resources for people who want to stop harmful substance use, without having to navigate through a series of ads and promotional materials, and provide access to life-saving tools for active substance users and people with mental health disorders.

Jeremy G


Find Treatment:

Self Empowering Addiction Treatment Association Provider Directory
SAMHSA Methadone Treatment Locator
SAMHSA Buprenorphine (Suboxone) Physician Locator
SAMHSA Comprehensive Treatment Locator
Comprehensive Directory of Methadone Treatment Providers (US & Canada)
Moderation Management for Alcohol

Support Groups:

Self-Management and Recovery Training: SMART Recovery, offers structured in-person and 24×7 online meetings)
LifeRing Secular Recovery
SOS Sobriety (Secular Sobriety)
Women for Sobriety
Harm Reduction for Alcohol (HAMS) Support Group
Mental Health Peer-Support Resources
National Alliance on Mental Illness (NAMI) Support Directory

Resources for Parents:

Drug Policy Alliance’s Safety First Program
Community Reinforcement Approach and Family Training: CRAFT (for Parents and Families)
SMART for Family and Friends Online Resources
Families for Sensible Drug Policy: FSDP

Harm Reduction Resources:

What is Harm Reduction? from Harm Reduction International and Drug Policy Alliance
Harm Reduction Publications from Harm Reduction Coalition
Connect Locally to Harm Reduction Organizations in Your Area
International Network for People Who Use Drugs: INPUD

Originally posted at: Making Noise in the South


Useful Videos:

Stanton Peele: What is Harm Reduction

Tom Horvath, founder of Practical Recovery and SMART Recovery, on Self Empowering Addiction Treatment

“Everything You Think You Know About Addiction is Wrong” from Kurzgesagt (based on the work of Johann Hari)

Intro to CRAFT (Community Reinforcement Approach and Family Training): CRAFT vs Alternatives