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?

FSDP is the Voice of the Family at UNGASS 2016

ungass2016_0Families for Sensible Drug Policy (FSDP) is representing the voice of families impacted by substance use at the United Nations General Assembly Special Session (UNGASS) on the World Drug Problem in New York City on April 19-21, 2016.

UNGASS 2016 is a meeting of the United Nations member states to assess and debate global issues such as health, gender, or in this case, the world’s drug control priorities.

The last time a special session on drugs was held, in 1998, its focus was the total elimination of drugs from the world. UNGASS 2016 Today, political leaders and citizens are pushing to rethink that ineffective and dangerous approach.

Why this summit matters

International debates on drugs are rarely more than reaffirmations of the established system. But 2016 is different because never before have so many governments voice displeasure with international drug control approaches. Never before, to this degree, have citizens around the world have put drug law reform on the agenda and passed regulatory proposals by referenda or popular campaigns. Never before have the health benefits of harm reduction approaches—which prevent overdose and transmission of diseases like HIV—been clearer. For the first time, there is significant dissent at the local, national, and international levels.

Why the family voice in drug policy matters

The role of the family is what is missing from much of the drug policy debate. Substance use doesn’t takes place in a vacuum but in the normal context of family life and relationships as well as the wider culture that the family resides in. Families are in a unique position to directly influence the development or resolution of substance use problems.

UNGASS 2016 held an Informal Interactive Stakeholder Consultation in February 2016 to give nonprofit and civil society organizations from around the world an opportunity to submit their statements and recommendations for drug policy reform. With the input and support of our diverse community of stakeholders and advocates, Barry Lessin made this statement at this meeting on behalf of the families of FSDP.
UNGASS Flyer

We will co-sponsor this Day of Protest and Action with the Drug Policy Alliance, Students for Sensible Drug Policy, The Center for Optimal Living and Help Not Handcuffs culminating in a workshop that bridges the gap between public policy and our homes, between parents and children, and connects the voices of diverse impacted communities.