No. 5 - Fall 1997, Harm Reduction Communication by National Harm Reduction Coalition

COMMUNICATION

NO. 5

onejunky’s Odyssey

H A R M

R E D U C T I O N

C O A L I T I O N

F A L L

1 9 9 7

I haven’t had much experi-

ence in my life using health

BY I. THAC A

care services. The working

class ethos under which I grew up dictated that folks take care of their own problems to the extent that they could: one needed to be really sick before a visit to a doctor or the emergency room was in order, and the idea of seeking professional help for mental

A YEAR IN THE LIFE OF THE BAN

health issues (“getting one’s head shrunk”) was even more outrageous, self-indulgent, and bourgeois. So, I never had a “family physician” or any kind of doctor I saw on a regular basis. Suffering stoically—but remaining in control of one’s own body—was my family’s modus operandi, one that prepared me

BY CHR IS L ANIER

Back in February, HHS Secretary Donna Shalala admitted that clean needles do in fact reduce the spread of AIDS. But she still refuses to lift the ban on federal funding for needle exchange. S T O R Y O N PA G E 18

well for my later life as a junky. CO N T I N U E D O N PAG E 4

he Harm Reduction Coalition (HRC) is committed to reducing drug-related harm among individuals and communities by initiating and promoting local, regional, and national harm reduction education and training, resources and publications, and community organizing. HRC fosters alternative models to conventional health and human services and drug treatment; challenges traditional client/provider relationships; and provides resources, educational materials, and support to health professionals and drug users in their communities to address drug-related harm. The Harm Reduction Coalition believes in every individual’s right to health and wellbeing as well as in their competency to protect and help themselves, their loved ones, and their communities. Editorial Policy Harm Reduction Communication provides a forum for the exchange of practical, “hands on” harm reduction techniques and information; promotes open discussion of theoretical and political issues of importance to harm reduction and the movement; and informs the community through resource listings and announcements of relevant events. Harm Reduction Communication is committed to presenting the views and opinions of drug users, drug substitution therapy consumers, former users and people in recovery, outreach and front-line workers, and others whose voices have traditionally been ignored, and to exploring harm reduction issues in the unique and complicated context of American life. Since a large part of harm reduction is about casting a critical eye toward the thoughts, feelings, and language we have learned to have and use about drugs and drug users, Harm Reduction Communication assumes that contributors choose their words as carefully as we would. Therefore, we do not change ‘addict’ to ‘user’ and so forth unless we feel that the author truly meant to use a different word, and contributors always have last say. The views of contributors to Harm Reduction Communication do not necessarily reflect those of the editorial staff or of the Harm Reduction Coalition. Editor: Alan Greig Graphic Design: Dolly Meieran Printing: Alonzo Environmental Printing © HRC 1997

in this issue… Letter from the Editor . . . . . . . . . . . .3 One Junkie’s Odyssey: Drug Users and the Health Care System by I. Thaca . . . . . . . . . . . . . . . . . . . . .1 A Year in the Life of the Ban by Chris Lanier . . . . . . . . . . . . . . . . .1

Minimum Standards for Syringe Exchange by HRC Public Policy Committee and the NCSLN . . . . . . . . . . . . . . . .11 The Experts Speak: Injecting Crack— Report From a Focus Group by Mark Kinzly . . . . . . . . . . . . . . . .12

You Can Leave That Baggage at the Door, Miss Thing: Examining Our Personal Judgments in HIV Prevention Work by Heather Edney . . . . . . . . . . . . . . . .6

How To Run a Drug Use Management Group by Jon Paul Hammond . . . . . . . . . . .13

The Withdrawal of SSI Disability Benefits for Drug and Alcohol Addiction by Jennifer Lorvick, Ricky Bluthenthal, and Alex H. Kral . . . . . . .7

Ask Mother Dog, Your Fairy Dog Mother . . . . . . . . . . . . . . . . . . . . . .15

On the LAAM: Users Are Finally Gaining Access to a “New” Drug Treatment Option by Rod Sorge . . . . . . . . . . . . . . . . . . . .8 LAAM: One User’s View by Victor Perez . . . . . . . . . . . . . . . . . .8

Witches’ Brew by Sara Kershnar . . . .14

Meeting Participants’ Needs: The Experience of the Lower East Side Harm Reduction Center by Donald Grove . . . . . . . . . . . . . . .16 Harm Reduction: The Case Management Connection by Rachel Odo . . . . . . . . . . . . . . . . .24 Your Letters . . . . . . . . . . . . . . . . . . .26

Who Defines “Safe Syringes”? by Drew Kramer . . . . . . . . . . . . . . . .10

Harm Reduction Coalition Allan Clear, Executive Director Paula Santiago, National Community Organizer Rod Sorge, Director of Development Sara Kershnar, Director of Education & Training Doug Gary, Administrative Director Paul Cherashore, Office Manager East Coast Office 22 West 27th Street, 9th floor, New York, NY 10001 phone: (212) 213-6376; fax: (212) 213-6582 West Coast Office 3223 Lakeshore Avenue, Oakland, CA 94610 phone: (510) 444-6969; fax: (510) 444-6977 http://www.harmreduction.org e-mail: hrc@harmreduction.org a big thank you and best of luck to alyshia—we love you

●

Letter from the

EDITOR

“Now I am troubled by the term “authority of experience,” acutely aware of the way it is used to silence and exclude. Yet I want to have a phrase that affirms the specialness of those ways of knowing rooted in experience…[that]…does not emerge from the “authority of experience” but rather from the passion of experience, the passion of rememberance.”*

any contributions in this edition of Harm Reduction Communication are written from and with the passion of experience. The experience of being HIV positive and being sick in a hostile health care system; the experience of being judged for one’s sexuality and drug use; the experience of deciding for ourselves what “safe” means in terms of safer drug use. This sharing of experiences is one of the most powerful forms of communication about harm reduction, because such sharing allows us to experience the other person as a real, living being. In this way, the harm reduction movement fights the de-humanization of current policies and debates on drugs and drug users and shows a basic, human respect which seems to be in such short supply these days. Sharing experiences is a way of taking care of each other. In this issue, some folks in Bridgeport share their experience of injecting crack while Victor Perez reports on his use of

LAAM (levo-alpha-acetylmethadol). Getting the word out in this way is straightforward harm reduction. Harm Reduction Communication is committed to providing a platform from which users’ voices and views can be heard because it is the passion of this experience that makes the U.S. harm reduction movement the creative and committed force for change that it is. We recognize that we take care of ourselves when we share the stories which this society tries so hard to silence and to shame. But when we share our stories we also take a risk, make ourselves vulnerable. Heather Edney, in her article, reminds us “how difficult it is to disclose information that is very private, very intimate, and potentially damaging if heard by the wrong person.” She raises the question of how to share and use our experiences in an honest way, faced not only with society’s laws and judgments but also the judgments of those whom we might consider our peers? Thinking about how we share and use our experience within the harm reduction movement, as bell hook’s quote at the start of this piece suggests, is an important part of appreciating how we relate to each other and how we relate to others outside of the movement. In the same way that acknowledging our own experience enables us to reflect and take action on it, so acknowledging other people’s experiences, and appreciating the commonalities, can lead to collective action.

Collective action is more important than ever, given the increasing attacks on the harm reduction movement. In August, Diana McCague and Thomas Scozzare of the new Brunswick, NJ, needle exchange program were convicted of violating New Jersey State law banning needle and syringe distribution (their $500 fine and suspension of driver’s licenses were put on hold pending appeal). Later that month, the Family Research Council (FRC), an extreme right-wing policy group, held a press conference urging Congress to take action to prevent the Administration from allowing Federal funds to be used for needle exchange. Chris Lanier, of the National Coalition to Save Lives Now, reports on this and the National Coalition’s response. Seeing these attacks as part of the broader conservative, right-wing backlash emphasizes the common agenda that the harm reduction movement shares with other progressive organizations and individuals. The report on the early impact of SSI cuts by Jennifer Lorvick and her colleagues highlights, for example, how central the issue of welfare reform is to such an agenda. As the Harm Reduction Coalition brochure states, HRC: “locates itself as part of a broader movement for progressive change that challenges social, cultural, and economic structures—including current drug policy— that foster and sustain disadvantage, discrimination, and denial of civil liberties and human rights.” Harm reduction’s values of respect and self-determination, born of the passion of experience, are values around which such a movement can coalesce and fight for our vision of social change, together. —Alan Greig

*bell hooks “Teaching to Transgress: Education as the Practice of Freedom”

onejunky’s

C O N T I N U E D F R O M PA G E 1

his past year, I made up for all those years I never saw a doctor. In August 1996, two days after returning from a six-week consulting trip to Eastern Europe, I found myself in the emergency room of a New York hospital, extremely weak and breathing only with tremendous difficulty. I was admitted, and, after a broncoscopy, diagnosed as having a life-threatening case of pneumocystis carinii pneumonia (PCP). Although I’d suspected for some time that I was HIV+, I’d never taken an antibody test. I was told that I had advanced AIDS (it turned out I had a whopping 15 T-cells) before I’d ever had the chance to grapple with what being HIV+ meant. As someone who was closely involved in the original (illegal) efforts to establish needle exchange in New York City and having worked in one position or another as an advocate for the health needs of illicit drugs users for the past ten years, I was intimately aware of the incredible stigma, discrimination, and outright hostility and disgust injection drug users routinely face when attempting to seek health care services of any kind. Suddenly, I was my own client, and all of those years I’d spent advocating for other drug users, while giving me insight into some of the systems I would now have to negotiate for myself, did not prepare me for the treatment I would also receive as a heroin injector with AIDS. While I had no unfounded expectations that things would be different or better for me than they’d been for so many of my former clients—why should they be?—nothing could’ve prepared me for the humiliation and emotional trauma I would experience over the next year as I tried simultaneously to deal with the fact that I had advanced AIDS, cope with a body that was quickly deteriorating (I’ve been hospitalized six times since the beginning of 1997), and, after years of hiding my own heroin use from colleagues, acquaintances, and even my closest friends, end my life of duplicity and begin the process of com-

ing out as a junky both in the public context of my job and the harm reduction movement and in my private world composed of those to whom I looked to and relied on for support in my personal life. The journey I’ve taken this past year as I tried to find appropriate health care—now literally a life-and-death necessity for me—has been a textbook case of how not to effectively engage illicit drug users in health care services. I share my story in the hopes that it will illuminate why harm reduction is so critical to reaching the population of which I now find myself a member.

was concerned I would engage in “drugseeking behavior” if he let me out of the hospital (he actually used those words!); his treatment strategy was to keep me chained to a hospital bed until the PCP was completely cured. After he wrote me prescriptions for Bactrim, prednisone, aclyclovir, and the other pharmaceuticals I needed, I began to ask, “Would you give me a prescription for…” but before I could finish my sentence he shot back, his voice brimming with hostility, “I can’t give you methadone. You’ll have to go Beth Israel for that.” He was convinced that the only reason I’d come to his office at all was not to get the PCP treatments I needed but to scam him for a methadone script. The clinical decisions he made about my care were clearly influenced by his personal beliefs about what junkies supposedly do, even though I had been a model patient interested only in recovering from the PCP and frankly too sick to be running around looking for drugs. His condescending, infantilizing treatment of me was unbearable, but I was the one who looked like a non-compliant, “drug-seeking” dope fiend when I checked out of the hospital because I wouldn’t stand for it.

drug the health ca When I landed in the hospital with PCP.…

…I had no physician of my own and, since I was working as a consultant, no health insurance of any kind. A doctor at the hospital where I was admitted luckily (I thought) agreed to take me on as a patient during my stay. I was maintained on methadone tablets (Dolophine) and pumped continuously with intravenous antibiotics for the treatment of the pneumonia. Although all the toxic drugs made me incredibly sick, I was relieved that I had connected with a doctor willing to care for me. My relief soon dissipated, however, when he stopped coming to see me and began to refuse my telephone calls (I would call his office and hear him in the background tell his secretary to say he wasn’t in). After several days of unsuccessful attempts to simply get him on the phone, I was infuriated at being ignored, removed my I.V., and checked out AMA (against medical advice) under the hostile glare of several residents and nurses. My doctor was furious when I showed up at his office in order to get prescriptions to continue to treat my pneumonia (I learned later that my case was apparently serious enough that I should have been in the hospital for several more weeks of intravenous therapy). The explanation I received was that he

“You smoke?”.…

…the emergency room intake nurse wants to know. After answering a barrage of questions about one’s health status and history in the ER, the same questions are again put to patients by another intake nurse once one gets to the floor, and then again by the admitting physician or resident.

“No, never have,” I say. “Wouldn’t dream of poisoning my body that way.”

Odyssey “Drink?” “I used to drink heavily but don’t anymore. Haven’t really touched alcohol for the past year.” I’m starting to look like a goody-two-shoes, completely pure in body. I can tell the nurse asks the next question only because she’s required to and not because, given my answers to the previous ones, she expects there to much in the way of illicit drug use going on with me. “Well, uh, I, uh, shoot um, inject, you know, dope, uh, heroin.” Despite the fact that I long ago mastered proper injection technique, I’ve always bruised profusely, and it seems, permanently. Track marks squirrel up and down the veins on both of my arms, upper and lower, like pictures from an anatomy textbook or tattoos. If I decided to lie about shooting dope, I’d be caught the instant someone went to take my blood pressure or plant an I.V.; besides, I have to let the hospital staff know that I’ll need methadone if I’m going to be admitted. In the complicated calculus a junky employs when deciding how to answer each of these questions—a calculus used to try and determine what answer will bring the least amount of reprisal, discomfort, and shame—I figure it’s better to be branded a plain old junky than a junky who lies.

go to sleep at night; have an appetite and digest my food properly (not an insignificant thing for a PWA); get through a day without feeling crushing depression; enable me to get to work and be productive in a very challenging job; control the horrible diarrhea I get as a result of taking toxic medications; manage the diffuse pains I experience that I’m told are caused by HIV attacking my muscles and joints; and, contrary to the stereotypical images of junkies nodding out in doorways, junk gives me huge amounts of physical energy and the motivation to get things done. This is not to say that my heroin career has always been easy or problem-free. Believe me, I know the dread of waiting for withdrawal to set in after you’ve shot your last bag and are out of money. I know what it’s like chasing down dope in the dead of winter (that blizzard we had in ‘95 was a bitch!); buying drugs from asshole dealers; and spending one’s last $20 on two beat bags. Using is not a complete bed of roses for anyone, and I am no exception, but the positives still outweigh the negatives for me, and always have.

There have been times when admittedly my habit’s gotten out-of-hand with miserable results (including just recently), but largely I’ve been able to slow down or stop using when I’ve needed to. While detox and withdrawal are never easy or enjoyable, a gradually-decreased, three-to-five day course of Dolophine (which my new doctor used to prescribe for me) would usually get me through if I needed to take a break or travel for work. At other times, I’d shoot coke for three or four days to get through a jones (something I refrain from doing these days because of my health) or just go cold-turkey and suffer through it.

users and My heroin use has always played a very functional role in my life.…

Earlier this year I learned that detoxing is much harder to do with 15 T-cells…. …and virtually impossible when you’re on rifampin for tuberculosis treatment and the anti-seizure medication Dilantin, both of which cause the liver to metabolize methadone at outrageous rates.1 The longer I was on rifampin, the more efficient it became at clearing methadone from my body until at one point, 90 milligrams was lasting me only about 12 hours. My TB meningitis infection caused me to have seizures whenever I went into withdrawal, and the diarrhea and sweating that are part of detox were now much more dangerous to me as a person with advanced HIV-disease than they had been previously. For the first time in my life, I felt I had very little control over my ability to stop using heroin if I wanted to. Here’s really where my ordeal begins. After months of getting health care however and wherever I could, in the fall of 1996 I finally had health insurance and a doctor who agreed to work with me. This physician seemed truly intent on providing me with health care for my HIV-disease without unnecessarily problematizing my drug use. He made it clear that he felt it would be better if I wasn’t using, but I didn’t feel judged or belittled. After several weeks of seeing him, he offered me—without

are system I’ve been fortunate.…

…I suppose, in that I’ve always felt pretty much in control of my drug habit. After a lifetime of depression, and long bouts of self-medicating with alcohol, cocaine, and whatever else was available, heroin was a godsend. In fact, I can truly say that junk is one of the best things that’s ever happened to me. People are always telling me—including my doctor—that anti-depressants would work just as effectively and I wouldn’t have to shoot up or involve myself in an illegal economy. All I know is that dope has worked and continues to work for me: it helps me wake up in the morning and

…primarily as a means for coping with depression, and perhaps it is this conscious awareness of why I use that’s enabled me to never really be scared of junk or afraid that my habit would become so out of control that I’d end up, literally, in the gutter. My passionate belief in the efficacy of harm reduction— borne out again and again by my personal experience—has allowed me to use successfully and confidently, for the most part, and in ways that are beneficial to me instead of harmful. I do not buy into the idea that eventually I will hit some “bottom” and finally come to my senses. Using does not have to entail despair, misery, and heartache.

C O N T I N U E D O N PA G E 2 8

examining our personal judgments in HIV prevention work

YOU CAN

LEAVE THAT

BAGGAGE

AT THE DOOR,

MISS THING B Y H E AT H E R E D N E Y

This article is based on a presentation Heather gave to the Fifth Annual Women & HIV Conference that took place in San Francisco in January 1997. hen I have been asked to speak about my experience as an injection drug user who identifies as a femme who predominantly gets fucked by butches, sometimes fucks men, and engages in other activities that could be construed as “high risk,” I’m never really sure what angle to come at it from. While I feel that my personal experience is valuable, it is only one woman’s experience and is not inclusive of the injection drug-using community or femme dykes within the lesbian community. In fact, my experience is specific in that I

W 6

have access to resources that many injection drug users do not—a new syringe every time I shoot up, for instance. This is one of the benefits of having worked with and directed a needle exchange program for the past six years. I also have access to economic resources and I’m white, all of which set the context for my particular experience, but are not what’s necessarily essential about it. Because I was asked to speak specifically about my personal experience and feel compelled to meet the needs of the conference organizers, I will do that but with a few stipulations. First, I do not perceive myself as a vector for HIV transmission to the lesbian community because I shoot drugs and fuck men. And I ask that for the duration of this presentation that you put that idea aside and hear what I have to say on this topic. Second, I ask that you understand how difficult it is to disclose information that is very private, very intimate, and potentially damaging if heard by the wrong person due to the illegality of drug use and the ways in which segments of the lesbian community stigmatize femmes who fuck men. Finally, I ask that you consider the political ramifications of what it really means to have someone speak on a panel because of the behavior(s) they engage in. Some of you may be wondering why I’m spending so much time asking you to consider these issues, but I am doing this for a reason. It’s because I’ve presented on this same topic in the past, on several different occasions, and each time I’ve been verbally beaten down or made to feel fucked up for being a whore because I talked about multiple sex partners, some of whom were HIV+, and because I have been told on more than one occasion after the presentation is over that I will never be anything as long as I continue to stick a needle in my arm. I don’t want that to happen today. I don’t want to leave this room terrified that you have more on me than I have on you. Instead, I want to share my experience with you because that is what I was asked to do and unless we can speak openly about our experiences, we will continue to operate under assumptions that are not necessarily accurate and which are alienating and dangerous to me and women like me, assumptions

that do not support us, as part of a larger community, in addressing the complexity of our risk for HIV. I am not asking you to agree with me. I am not asking you to change your mind about what you think about anything I present. But if you think what I am about to say is fucked up, please don’t put that on me: it is not my responsibility to take on your feelings of discomfort surrounding these issues. I started using drugs when I was about fifteen years old. At approximately the same time, I started having sex with women, but it was always violent sex. Also at this time, I started having sex with men, and with them, it was also in the context of violence.

But if you think what I am about to say is fucked up, please don’t put that on me: it is not my responsibility to take on your feelings of discomfort surrounding these issues. Since then, there has not been a point in my life when I have not used drugs. The way I have sex is similar to my drug use in that it is oftentimes dangerous and oftentimes unsafe. The way in which I have sex is similar to my drug use in another way in that I am always moving along the continuum of what is safe and what is unsafe in regards to the violence associated with fucking. I have been strung out on amphetamine, crack, heroin, morphine, Valium, C O N T I N U E D O N PA G E 31

The Withdrawal of SSI Disability Benefits for Drug and Alcohol Addiction BY JENNIFER LO R VICK, RICKY BLUTHENTHAL, AND ALEX H. KRAL

he withdrawal of SSI payments from individuals whose eligibility for benefits is related to drug or alcohol dependence is currently an issue of great concern. Supplemental Security Income (SSI) is a federal income support program for the aged, blind, and disabled. Effective January 1, 1997 under the “Senior Citizen Freedom to Work Act,”1 SSI benefit payments were to cease for individuals whose drug or alcohol addiction is considered “to be a contributing factor material to the … determination that the individual is disabled.” William Thomas (R-Bakersfield), co-author of the bill, cited concern that SSI funds were being spent on drugs as the major impetus for the legislation.2 The number of SSI beneficiaries classified as drug addicts and/or alcoholics (“DA&A”) increased from 16,100 in 1989 to 130,924 in 1995.3 The number of beneficiaries who have DA&A as a partial reason for their eligibility has also grown, from 5,210 to 61,569. Thus, over 190,000 people will potentially suffer from these cuts. When the policy change was announced in mid-1996, the Urban Health Study (UHS) began to examine what these cuts in SSI might mean for injection drug users (IDUs). UHS conducts data collection and HIV-antibody testing and counseling with street-recruited IDUs in six San Francisco Bay Area communities. We present here the results from our pilot study exploring the potential impact of SSI cuts, conducted before benefits were withdrawn. We are currently conducting a second study designed to measure the effects of the cuts as they happen. Those results are not yet available. We examined 1995 data from six Bay Area communities (n=1,224). Thirtyeight percent (466) of study participants

were SSI recipients. This includes people eligible for any reason, not just drug or alcohol addiction. SSI recipients differed significantly from non-recipients in a number of demographic and social characteristics, some of which are listed in Table 1, below. As Table 1 shows, SSI recipients were less likely to be homeless, less likely to report receiving income from illegal sources, and more likely to be in drug treatment. In June 1996, UHS conducted a separate pilot study to determine what percentage of SSI recipients receive benefits specifically for reasons related to drug or alcohol dependence. This pilot study was conducted in a single community with 202 participants. Thirty-eight recipients (18%) reported receiving SSI benefits specifically for drug or alcohol addiction. Respondents were sometimes unclear as to how their eligibility for SSI benefits had been determined. Therefore, the percentage of IDUs affected by the DA&A policy change may actually be higher than 18 percent. These preliminary data suggest that IDUs who received SSI benefits were more stably housed, less reliant on illegal income, used drugs less frequently, and shared needles less often than IDUs without SSI benefits. In other words, it appears that SSI benefits contribute to general life stability and a reduction in

drug-related harm. This finding is consistent with many other studies that have shown that drug users who receive income supports and/or subsidized drug treatment are less likely to be homeless, engage in illegal activities, or use drugs. Conversely, penalizing drug users by withholding benefits may in fact increase the severity of the social ills of homelessness, incarceration, illegal activity, and unsafe drug use. The authors are researchers with the Urban Health Study of the University of California-San Francisco. Public Law No. 104-121, enacted March 29, 1996. M. Garcia, “Cold Turkey: New Law Axes Disability Benefits for Alcoholics, Addicts; Advocates Fear Homeless Upsurge,” SF Weekly, July 14, 1996. 3 S. Barber, Supplemental Security Income Recipients for Whom the Alcoholism and Drug Addiction Provisions Apply (DA&A Recipients), December 1995. Washington DC: Office of Program Benefits Policy, Social Security Administration (1996). 4 National Opinion Research Center, University of Chicago and Research Triangle Institute, National Treatment Improvement Evaluation Study. Prepared for SAMHSA/Center for Substance Abuse Treatment (1996); R.H. Needle and A.R. Mills, Drug Procurement Practices of the Out-of-Treatment Chronic Drug Abuser. Rockville, MD: National Institute on Drug Abuse, NIH Publication No. 94-3820 (1994); S.B. Sells, R. Demaree, and C. Hornick, Effectiveness of Drug Abuse Treatment Modalities. Rockville, MD: National Institute on Drug Abuse (1980); and R.L. Hubbard, M.S. Rachal, S.G. Craddock, and B.A. Cavanaugh, “Treatment Outcome Prospective Study (TOPS): Client characteristics before, during and after treatment,” in F.M. Tims and J.P. Ludford (eds.), Drug Abuse Treatment Evaluation Strategies, Process, and Prospects. Rockville, MD: National Institute on Drug Abuse, Research Monograph No. 42 (1984). 1 2

TABLE 1. SSI RECIPIENTS V. NON-RECIPIENTS IN THE SAN FRANCISCO BAY AREA, 1995 (N=1,224) Variable SSI Non-SSI (n=466) (n=758) n (%) n (%) African-American 314 (67) 450 (59) Considers self homeless 73 (16) 244 (32) # weeks living on street during past year mean (s.d.) 3.0 (9.8) 7.1 (15.5) Received income from illegal sources 85 (18) 291 (39) Jailed during past year 163 ( 5) 333 (44) Currently in drug treatment 144 (31) 81 (11) # injections during past 30 days mean (s.d.) 53.9 (53.0) 70.9 (60.3) # times shared syringes in past 30 days mean (s.d.) 2.9 (11.9) 4.9 (16.8)

Bivariate p value 0.001 0.001

0.001 0.00001 0.002 0.00001 0.001 0.013

One User’s View

Users Are Finally Gaining Access to a “New” Drug Treatment Option

ON THE LAAM: 8

BY RO D SO RGE

LAAM (levo-alpha-acetylmethadol) was approved for the treatment of opiate dependency by the Food and Drug Administration (FDA) in July 1993, and is manufactured by Roxane Laboratories, Inc. under the brand name Orlaam®. For a variety of reasons, LAAM maintenance is just now being made available in many states even though it received FDA approval almost four years ago. First, each state had to apply to the federal government to have LAAM reclassified as a Schedule II drug, that is, a drug with some recognized medical benefits despite a high abuse potential. There are only three states—Maine, Tennessee, and Pennsylvania—that did not seek rescheduling and in which LAAM is therefore legally unavailable, although Pennsylvania’s application is currently pending. Secondly, various factors at the state level have held up LAAM availability in many locations. For example, MediCal (California’s version of Medicaid) will not begin reim-

BY VIC TO R PER EZ

I’ve been on buprenorphine, methadone, and LAAM maintenance, and of all three of these pharmacotherapies, I prefer and find that I function best on LAAM. I first came to LAAM treatment about one-and-a-half years ago through a research study that was being conducted in Los Angeles where I live. The only reason I agreed to begin LAAM maintenance treatment was because it was free; otherwise I don’t think I ever would have agreed to it. What little I had heard about LAAM did not sound too appealing: I kept hearing that you got a “less loaded” feeling, and that it took much longer to detoxify from than methadone. Less loaded? You only dose three times a week? You go a whole weekend without anything?! Switching from heroin to methadone is psychologically hard enough as it is (fixing every few hours to dosing only once a day leaves you with 23 hours to kill!), but only three doses a week? I

bursing clinics for LAAM doses until July 1, 1997, which has severely limited the number of providers in California that currently offer LAAM. New York State just approved LAAM maintenance this past September.1 Finally, any methadone clinic that wishes to offer LAAM maintenance must individually apply for approval to do so. While the paperwork to gain such approval is apparently fairly straightforward, and any clinic that is in good standing with federal and state methadone regulatory agencies should have no problems being approved for LAAM maintenance, some clinics have been slow to make this treatment available. If your clinic doesn’t yet offer LAAM, advocate with the administration to apply for approval. Users should have as many choices for treatment as are legally available! Heroin users wishing to begin LAAM maintenance need not be maintained on methadone first but can start maintenance with LAAM directly. Patients are typically given an initial dose of 40 milligrams and raised by increments of 10 milligrams a day until an appropriate

didn’t think it was possible. For this reason, my personal opinion is that anyone considering LAAM treatment should start out on methadone and then switch over to LAAM after you feel you’ve adjusted to the one-dose-a-day methadone schedule. I’m so successful in my recovery now that I don’t know what I’d do if I had to go to the clinic on a daily basis. It would be such an inconvenience. The narcotic blockade effect LAAM produces has given me the strength and the time to face situations in which I normally would have run and gotten loaded. It’s like being on a long-lasting methadone and naltrexone at the same time. I’ve heard some people complain about side-effects from LAAM, the most common being nausea and/or dizziness upon standing up. I’ve never experienced this problem, but I did have other side effects when I was on LAAM and drinking alcohol regularly. I would get bad abdominal pains and sharp throbbing at the ends of my fingers. After some Saturday nights of excessive boozing, I would even wake up with a

maintenance dose has been reached. A LAAM maintenance dose is on average 20 to 30 percent higher than an equivalent methadone maintenance dose. The major difference between methadone and LAAM is its duration of action. While therapeutically-appropriate methadone doses last anywhere from 24 to 36 hours, a single dose of LAAM lasts between 48 and 72 hours, requiring that a patient be dosed only every three days. “Take homes” are therefore not legally allowed for anyone maintained on LAAM. The effects of LAAM begin about two to four hours after ingestion, and supposedly reduce an individual’s “cravings” for opiates without producing the “highs” and “lows” many methadone patients report. Because LAAM and methadone are so structurally similar, all of the drug interactions and contraindications that apply to methadone also apply to LAAM. Patients taking rifampin for the treatment of tuberculosis, for instance, will find that the body metabolizes LAAM (just as it does methadone) at much faster rates than normal and will therefore require dosing or dosing schedule adjustments.

mild feeling of withdrawal, like I was slightly dope-sick. That all ended as soon as I stopped drinking. All I get now are mild pre-sleep twitches and a little constipation. Otherwise, I’m healthy, happy, sane, enjoying a good sex life, but most importantly, I’m able to do things I couldn’t do while on heroin—like have a life. Because clients are medicated only three times a week, LAAM can be especially useful to those individuals who cannot or will not give clean urine samples for their monthly, random tests, which I find to be the majority of patients. Many people can also benefit from not having to go for the medication every 24 hours. Those patients who do not qualify for methadone takehomes because of continued “dirty urines” but who wish to reduce the frequency of their clinic visits can switch to LAAM and perhaps function better than they otherwise would as a result of not having to visit their clinic every day. For some of us, the only contact with the drug world that we have occurs when we visit our clinics. For others, it

Like methadone, Orlaam is manufactured as an oral solution that must be ingested in front of clinic personnel. Because it is reported to have virtually no psychoactive effects and is so long lasting, LAAM is being lauded by everyone from neighborhood coalitions to the DEA as a substance that will be much less prone to “diversion” onto the black market, therefore reducing “loitering” and other illegal activity near methadone clinics. Readers and consumers: please keep Harm Reduction Communication informed about LAAM-related developments in your area, and let us know what your experiences using this form of treatment are like. Roxane Laboratories, Inc. representatives can provide you with prescribing information and pharmacology data on Orlaam: P.O. Box 16532, Columbus, OH 43216; phone: (800) 848-0120. Lisa W. Foderaro, “An Alternative To Methadone Is Approved: New York Clinics See New Hope for Addicts,” The New York Times, September 6, 1997, p. B1.

might mean a 21-day detox every so often to reduce our tolerance. For those of us who have decided that we’ve had enough of it all, the fewer times we have to enter the drug world and the fewer times that we have to be reminded of “the life,” the better. Unfortunately, right now LAAM is still not available to the majority of the population. In all of Los Angeles County, there is only one clinic that offers it so patients have to come from surrounding counties just to get treatment. Hopefully, more clinics will offer LAAM to their patients in the near future. Maybe LAAM will even be approved by the Food and Drug Administration (FDA) for take-homes and we’ll only have to visit our clinics a few times a month. That would really be something, wouldn’t it?! Victor Perez is a writer/poet who works under the pseudonym Vladik Cervantes. His work has appeared in several L.A. literary publications and he is currently at work on his first novel.

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First National Harm Reduction Conference

Audiotapes Available Audiotapes of all plenary and break-out sessions of HRC’s First National Harm Reduction Conference are available individually or as a complete set from the Conference Recording Service. Call them at (510) 527-3600 for a price and title listing.

Who Defines “Safe Syringes”?

? BY DR EW KR AMER

New York State came close to deregulating the sale and possession of syringes this year. Although Governor Pataki withdrew at the last minute, the process of advocacy and negotiation around deregulation was instructive, in particular for the role that users played in determining decisions taken. A case in point is the decision on so-called “safer technology syringes”. It is illegal to possess or distribute syringes without a prescription in New York. For years, a bill to change these laws stalled in the New York State legislature. Although there was support for the bill in the State Assembly, the Senate—controlled by conservative, upstate Republicans—could not be moved on the issue. Last year saw a breakthrough. The word spread that the State Senate might be interested in passing a deregulation bill if it was limited to “safer technology syringes.” From its first mention, the Coalition for AIDS Prevention (CAP), a grassroots, state-wide coalition of activists and service providers advocating for de-regulation, was concerned at the implications of the safer technology approach. The implication was that a safety syringe is a single-use syringe. But any sterile syringe which is conducive to safe injection practices is definitionally “safe”, including the common syringe now in use. A single-use syringe that would inhibit safer injection practices would not be safe. A single-use syringe that would be unusable for injectors would also not be safe, as such a syringe would have no impact on the scarcity which drives syringe sharing. But the single-use, lockable syringe, which has a metal collar located inside the top of the syringe barrel, was exactly

the product being pushed as the safer technology. The manufacturer claimed that the syringe was bootable. The plunger could be moved up and down freely during injection. To disable the syringe, the user could pull the plunger all the way back, thus engaging the metal collar. At this point, the plunger could only be moved downwards. When it reached the bottom of the barrel, it would lock in place. Samples of the syringes were obtained and injectors put them to the test. Lockable syringes were hated by all those who tested them. Beyond the fact that the syringe was awkward to use, there were other problems: it wasn’t clear how far back you could move the plunger, so it was easy to accidentally lock the syringe. Also, the plunger couldn’t be removed. Several users who tried the syringe lost their shot. Following these tests, CAP put forth a position opposing the restriction of deregulation to single-use syringes, stating that anything less than across-theboard deregulation would not serve the cause of HIV prevention. This position was adopted by the State Senate in the bill which Governor Pataki eventually refused to sign. In the process of rejecting the lockable, single-use syringe members of CAP who were active users also established guidelines for the development of safer injection technologies. These guidelines ensure that safer technologies can be developed which do not interfere with the needs of injectors.

Drew Kramer is Director of the Harm Reduction Care Network of New York.

Characteristics of a safety syringe + Allows free and full aspiration (up and down motion of the plunger); + Syringe barrel is clearly visible at the point to determine the presence of air bubbles and blood during injection; + Plunger must move freely to permit one-handed injection; + Syringe barrel must be slim enough to allow for the greatest possible positioning of syringe at an angle necessary for injection; and + Removable plunger to allow for retrieval of contents in the event of a syringe failure. Beyond these essential elements, it is further possible that a safety syringe may: + Allow for reversible, manual, voluntary activation of a disabling mechanism to reduce possibility of third-party syringe reuse or accidental needle stick. Note that this disabling mechanism must be active to the point where any accidental disabling is impossible. This disabling mechanism can involve covering of the needle tip or locking plunger or otherwise disabling the syringe. Characteristics of an unsafe syringe – A syringe which locks or is passively disabled after a single use or can be accidentally disabled; and – A “non-reusable” syringe which is rendered non-reusable in any way that: • does not permit full aspiration • obscures visibility of contents of the syringe barrel • makes the plunger move with difficulty • means that the syringe barrel is thick to the point at which angle of injection is inhibited • would result in the loss of syringe contents in the event of a syringe failure.

Minimum Standards — for —

Syringe Exchange

f syringe exchange is finally recognized by the federal government as a legitimate HIV intervention measure, it’s reasonable to believe that the U.S. government will attempt to develop standards for regulatory oversight. After years of apathy and neglect on this aspect of the AIDS epidemic, there is no evidence

that federal agencies have the knowledge or expertise to competently develop such standards. The following are minimum standards for effective syringe exchange provision developed by the Harm Reduction Coalition’s Public Policy Committee and the National Coalition to Save Lives Now!

• Syringe exchange participants must have access to anonymous services; • Syringe exchange must be available in and accessible to communities in which drug users live and/or frequent; • Any and all organizations capable of providing syringe exchange services should be allowed to do so; • Over-the-counter sale of syringes and syringe exchange programs are both important aspects of HIV prevention and complement each other. The existence of one approach should not preclude the implementation of the other; • No limits should be placed on the number of syringes a participant may exchange at a given visit; • No limits should be placed on the frequency of visits an individual may make to an exchange site; • Access to services must be low-threshold, i.e. non-intrusive registration, walk-in hours and reasonable waiting time, etc; • Protocols and policies must be developed with input from syringe exchange participants and providers; • Drug injectors must be recognized as essential partners in the development of program services and policies; • Syringe exchange programs can be used to facilitate access to drug treatment and other services, but should not be used to coerce participants into those services; and • Syringe exchange must be recognized as a valid stand-alone HIV prevention measure. Continued access to syringe exchange services must not rest on fulfilling other conditions.

•CALL FOR•

METHADONE GRIEVANCES Have you, as a methadone client, ever experienced what you felt was severe abuse or vindictiveness on the part of a methadone clinic staff? Have you felt that a certain experience was so terrible, that you considered changing programs or even re-locating to avoid client maltreatment by a methadone staff member? If so, we would like to hear from you. The Journal of Maintenance in the Addictions is sponsoring a professional METHADONE GRAND ROUNDS in every issue. This is a platform for those who have felt that one or more staff members have not acted professionally in one or more situations, and for those who feel they have been unfairly punished by the clinic’s staff. Submissions should be approximately 2 or 3 pages, typewritten or word processed. The author should know in advance that his or her name cannot be used, nor the name of the clinic or the names of the staff members involved. A copyright release must be signed, and regretfully payment must be in the form of 5 free issues of the journal to share with your significant others. Your grievance will be analyzed by at least two clinical medical directors, and a third formal overview by the journal’s column Editor would be published as well. Please send the description of your situation with 3 clean photocopies to: J. Thomas Payte, MD, Editor, Journal of Maintenance in the Addictions, 3701 West Commerce Street, San Antonio, TX 78207

Sara Kershnar, Director of Training and Education and the Training Program has moved to Harm Reduction Coalition’s New York office You can reach Sara or get training information from: phone (212) 213-6372 ext.14 fax (212) 213-6582 email: kershnar@harmreduction.org

the experts speak: For several months now, HRC has been receiving reports from providers around the country that, for various reasons associated with the economics of the cocaine market, the practice of injecting crack is apparently becoming widespread. That is, users are purchasing crack, transforming into an injectable form, and using it as they normally would powdered cocaine. To help understand what’s going on out there, Mark Kinzly of the Bridgeport (CT) Health Department conducted a focus group on May 30, 1997, of 11 men and one woman ranging in age from 24 to 70 years, with an average age of 40. Three of the men were African-American, two were white, and six Latino; the sole female participant was white. —R.S.

sistency of the high from injecting crack was also one of the draws. Some said that when they do speedballs with powder, they often experience nausea but with the crack they haven’t found that problem. Each time you inject crack the initial high is the same. The high from the crack apparently lasts about four or five minutes before the heroin kicks in.—M.K.] The difference between smoking and injecting crack and the high involved is not even close according to all involved in the group. Nobody talked about the craving that people get when smoking. As stated earlier, most are using the crack only with heroin but even the few that said they have injected crack without the heroin didn’t mention the craving. The one thing that they did mention was that they would rather not do it without the dope and that if it came down to being able to get a slab or a bag of dope, all said the dope wins out.

injecting

Q: Why are you injecting crack cocaine? Is there a lack of powder out there or does it have to do with the cost of powdered cocaine? There are many reasons why people are injecting crack. It is cheaper and more accessible for most. There are no nickel bags of cocaine on the streets. Powder is harder to find, and in Bridgeport, most of the dealers who are selling heroin are also selling crack. Most of the powder here is sold in $20 bags and you can get a slab “rock” for $5. Most are saying that one slab is just as good as a $20 bag of coke when used in a speedball. Most started injecting it because of the word-ofmouth and the talk of the awesome high and the longer lasting effects that it has.

Q: What is the high like when injecting crack? How long does it last? How is it different from smoking crack? The high seems to come on a little slower and last a little longer. Most users who are injecting crack are doing so in a speedball combination and are saying that the high is what they call a “creeper” where the crack comes on mellow and lasts longer than a regular powdered cocaine speedball before the heroin kicks in. Most say they are much more satisfied with the high. [A few of the users said that the con-

Q: How much crack are you injecting? When do you want or feel you need more? It was agreed that one slab ($5 rock) was enough, especially when speedballing. For those speedballing, there wasn’t a need for another shot for a couple of hours. For those who have injected just crack, they said the craving was less than with smoking, if at all.

Q: Have you had any reactions to injection crack? What harms, if any, have you experienced? Some said that there has been some problem with veins collapsing. Most expressed that the biggest reaction was the redness around the injection site. One user in particular had a tremendous abscess in his groin area. They seem to come on a little quicker than other abscesses but no one could really give a specific time. Certainly the biggest complaint was that they were now having a more difficult time finding a vein.

Q: What can we as providers do to help you reduce the harms associated with injecting crack? Conduct more focus groups so that users can find out what each other are doing to keep each other safe. Distribute updated information on the latest things that can help them be safer. Conduct groups on safer injection. Keep handing out citric acid and if we find out anything else let them know. At the end of asking some of these basic questions, one of the users went and purchased a $5 slab and broke it down into its injectable form. The end result was that the ratio of rock to powdered citric acid was about 10 parts crack to one part pure citric acid. The other important part of this was that it was agreed that the more water used the better, and users decided that 30 to 40 units of water really helped to take away some of the burning effects. We also discussed the importance of injecting the crack into the vein as slowly as possible so that it would give the veins more time to adjust to the acid, hopefully cutting down on trauma to the veins. There was some concern about individuals who are now smoking crack finding out that it is also injectable and starting to use that method of administration, similar to pattern we often see with heroin use going from snorting to injecting.

crack

Q: How are you breaking down the crack in order to inject it? Most were using vinegar to break it down. The people using the citric acid liked it better than the vinegar or lemon juice as long as they didn’t use too much of the powder. There were two people in the group who had just recently heard about the citric acid and had yet to try it. All of the users said that they were smashing the rock up as much as they could and then also using as much water as they personally felt comfortable with (usually about 30 to 40 units of water).

For more information about the Bridgeport focus group, contact Mark Kinzly of the Bridgeport Health Department at (203) 576-7679 or by e-mail at bhd95@aol.com.

How to Run a Substance Use Management Group B Y J O N PA U L H A M M O N D

Since the beginning of 1997, substance use management1 (SUM) groups have been established here in the San Francisco Bay Area. It is hoped that the following outline of the SUM group process will be of use to whomever would like to use it. The SUM group which has formally started here in San Francisco has been fairly successful. With the enthusiastic support of the Cannabis Helping Alleviate Medical Problems (CHAMP) buyer’s club, the SUM group which meets weekly at its facilities continues to grow. While the group itself remains small in size, its effectiveness for those who consistently participate is clearly notable. The group itself has covered many topics on which it repeatedly touches, such as pain management, AIDS treatment drugs and alcohol, heroin, and methadone, to name a few. We also examine in depth other life issues which affect our drug use. The group is informal in its structure, being co-facilitated by two people who fully participate as individuals who are also working to substance use manage in a healthier fashion. There are no “experts” in the group and it is very non-hierarchical. From our experiences here in San Francisco, it can be said that establishing SUM groups wherever drug users would be willing to meet regularly could be of great harm reduction benefit to drug users and to those who sponsor SUM groups. For more information on SUM, contact the author c/o Oakland’s Harm Reduction Coalition office. Jon Paul Hammond is an activist and member of the Board of Directors of the Harm Reduction Coalition.

Dan Bigg, “Substance Use Management: A Harm Reduction -Principled Drug Treatment Approach,” presented at the 6th International Conference on the Reduction of Drug-Related Harm, Florence, Italy, March 30, 1995.

Goals of Substance Use Management 1. Improved health, relationships, job performance and/or satisfaction, legal standing, community involvement, or pleasure. • Job performance. Does your drug use affect your job performance? For better or for worse? If for the worse, how can you change that? Are there ways you can better deal with your employment situation? What changes in your drug use might help you improve your employment situation? • Legal standing. Are there legal issues which you may need to deal with? What are the ways they can be dealt with? What assistance might you need to deal with them? • Community involvement. What community involvement do you have? What kind would you like to have? What kind of involvement would be helpful to you and your community? • Pleasure. Is your drug use pleasurable? How is it and how is it not pleasurable? What are ways you could make the majority of your drug using experiences pleasurable? In what ways could you make your drug use both more pleasurable and more healthy? 2. Developing and enacting a safer use plan: intake method, dose, drug combinations, preparing yourself to use. • Intake method: injection, sterile injection, smoking, inhaling vapors, orally. • Dose: drug purity and effects; being able to afford what you use; having emergency drugs available. • Drug combinations: effects of mixing drugs; synergistic, agonistic, and antagonistic effects.2 • Preparing yourself for use: consider your purpose in using (e.g., pleasure, escape, repose, enhanced thought, relief from pain/emptiness, to facilitate sociability). Are you ready for the effects of the drug? 3. Abstinence. As people freely define it for themselves. May include one or more drugs and be permanent or of a limited period. 4. Closure. As any combination of the above items may be discussed at any given meeting, it is important to make sure that some time before the end of the meeting be left to focus participants in a focused and useful way. Three things need to occur: • Some summation of the discussion, just as a recap of the main themes of the discussion. If there aren’t any discernible themes, then the group should do the best it can to summarize what was discussed. Get a participant from the group (as opposed to a co-facilitator) to do this. • Everyone in the group should spend a moment recalling what they originally wanted to get out of the meeting and then reflect on what they actually got out of it. • Everyone should decide how they would like to set a goals or goals for themselves that will healthfully affect their substance use. These goal(s) can be long-term or short-term, big or small, in the spirit of “any positive change.” Participants also need to seriously consider how they can achieve their goal(s). Synergistic: working together to produce a stronger effect; agonistic: combative or straining for effect; antagonistic: when on drug counteracts the effects of another drug.

Witches’ Brew will be a regular item in Harm Reduction Communication. It will feature recipes for herbal remedies, holistic health care tips for general wellness as well as drug use-specific medical issues.

WB IR TE CW H E S’

Our first brew is a recipe for Junkie Cream. The cream will help heal and reduce bruising and track marks. This recipe was used in creating two batches of Junkie Cream at the Santa Cruz Needle Exchange Project. During the nine months that it’s been available, it’s been in high demand and has gotten rave reviews. The recipe is based on 128 ounces of lotion (816oz bottles of lotion), which made approximately 250x1oz bleach bottles full of junkie cream. You can decrease or increase it accordingly. Remember: *Junkie Cream is for external use only. *It is not for use on open wounds. *If possible, wait a minimum of 1 hour after injection to apply.

junkie cream recipe INGREDIENTS: ★ Thick Lotion: 128 ounces This is the base of the cream. We used Kiss My Face Honey Calendula Lotion, because it’s thick, rich, healing, very high quality, and smells great. However, it’s expensive and we will probably switch to a cheaper lotion. The lotion needs to be thick, non-perfumed, and natural—thick Vitamin E or A lotion or cocoa butter is a good base.

★ Vitamin E Oil: 8 ounces of 15,000 IUD’s each Strong and thick vitamin E oil— cheap is fine. ★ Herbal Essential Oils: We made the following herbal extracts ourselves using the directions below (see sidebar). However, you can buy essential oil extracts at health and herbal stores. You’ll need essential oil of: Calendula: 16 ounces Arnica: 16 ounces Comfrey:16 ounces Chapparell: 4 ounces St. John’s Wort: 4 ounces ★ Dry Calendula Flowers: Approximately 2 cups, but the flowers are for thickness and for look, so the amount is flexible. These need to be crushed or broken down, and can be bought at any herbal shop. MATERIALS NEEDED: Large mixing bowl Large spoon Pastry Bags Junkie Cream Labels with title, ingredients, and directions Lots of towels Sterile cream containers: Bleach bottles are cheap and work, but they are a nightmare to fill. Cream jars are more expensive, but a huge time saver and last longer. You can get cream jars from glass/bottle companies or plastic ones from some plastic container companies. We use California Glass, they are reasonable and ship all over the country. Their phone number is (510) 635-7700. DIRECTIONS: ❶ Thoroughly clean all materials being used ❷ Empty the bottles of lotion into a large bowl ❸ Empty Vitamin E and Herbal Essential Oils into the bowl and mix well ❹ Crush Calendula flowers, empty them into the bowl, and mix well ❺ Place lotion into the pastry bag and then distribute into the cream jars or bleach bottles ➏ Wipe off bottle or jar and place labels on

DIRECTIONS FOR MAKING ESSENTIAL HERBAL OIL EXTRACTS Extracts take two weeks to make, are relatively simple to make and end up saving you A LOT of money. A great book of reference is The Way of Herbs by Michael Tierra. Ingredients and Materials: ✩ Organic olive oil (if no organic is available, then virgin): 56 ounces ✩ The following dry herbs: Calendula: 2 ounces Arnica: 2 ounces Comfrey: 2 ounces Chapparell: 0.5 ounce St. John’s Wort: 0.5 ounces ✩ 3x24 ounce glass jars (preferably amber): For Calendula, Arnica, and Comfrey ✩ 2x8 ounce glass jars (preferably amber): For Comfrey and Chapparell Directions: ➀ Label all jars with the herbal names ➁ Place dry herbs in appropriate jars ➂ Place 16 ounces of olive oil in Calendula, Arnica and Comfrey jars ➃ Place 4 ounces of olive oil in Comfrey and Chapparell jars ➄ Shake well and place in a dark storage area: it will be here for two weeks or longer and needs to be shaken well every day ➅ At the end of two weeks, strain the oils in cheese cloth and place back into their jars They are ready for use in the Junkie Cream.

Please send us any recipes you might have, feedback on any recipes you try, health tips, health book lists, and any suggestions on information and recipes you would like to see featured. Send to: Witches’ Brew, Harm Reduction Coalition, 22 West 27th St., 9th Fl. New York, NY 10001 Fax: (212) 213-6582 Email: kershnar@harmreduction.org

A s k Yo u r

Fairy

elcome to the second edition of Ask Mother Dog, an advice column by, for, and about parents who use drugs and their interests and concerns. Your first introduction to this harm reduction column will most likely take place in the office of some service provider. My sincerest best wishes to you. Hopefully, you will not be humiliated, hurt, frightened, or discouraged to any measurable degree in your search for assistance and knowledge. I have not yet received any specific questions or comments from the first Mother Dog column to answer. So, instead, I will begin to undo some of the damage wrought by society’s negative messages about drug-using parents. Please, my sisters and brothers, do not judge your worth according to a society that would vastly outspend its wealth on prisons rather than providing education for its young! I beg you to see that such a measure of “family values” is warped and perverse and therefore incompetent to identify or judge human worth. First off, I am a firm believer in “Knowledge is power.” In this case, I mean understanding yourself: how you work in and respond to the world. It is so important to sort out what is social conditioning from what is your “true will”, deciding what to eliminate from and cultivate in the garden of your psyche. These are the tools of self-knowledge which get us through life, which support us in our parenting. Don’t fret, it is not as difficult as it might sound. Certainly a lot easier than supporting a family of three on $600 a month. Let’s start with family values. What is it about the right wing that makes them think they can define “family values” for the rest of us? While they attempt to convince you that you are less than “hard working” and that you are not worthy of help, they are destroying families through welfare reform. As part of reform, anyone with a new (as of October 1996)

M o t h e r D o g

drug conviction is permanently ineligible for welfare. We’re tired of our money being misused. The vast majority of welfare and drug-using moms are providing astonishingly good family homes despite inadequate funding. These are not value systems to be judged by! No way! Valuing ourselves as parents begins with being absolutely clear that as a mother/parent you are fully employed. For those of you non-custodial parents, think in terms of part-time but steadily employed. As a fully-engaged parent, you have every right to expect resources and support to carry out your sacred task. If the resources are insufficient, it falls to the rest of the members of ‘society’ to subsidize the development of its people. This is what society is about. Welfare is the way that society supports all its members. But instead, the message given out is

D o g ,

M o t h e r that society cannot bear the burden of your family. You should be at work, contributing your share of the bill to build more prisons and create new weapons. These are the ‘family values’ of the obviously diseased and insane. So, beware of such clearly depraved establishment opinions, judgments, and messages about anything! What do you think? Please write me with your questions, ideas, responses, experiences c/o The Editor, Harm Reduction Communication, Harm Reduction Coalition, 22 West 27th St. 9th floor, NY, NY 10001 Note: To service providers/subscribers: Especially those in drug-related fields, please reproduce this column and make it available to those you serve. Thanks! —Mother Dog

WE WANT Y HRC M Becoming a member of the Harm Reduction Coalition is one of the most significant ways you can support our organization’s work and mission. As a coalition of harm reduction practitioners, providers, and consumers, HRC draws its strength, diversity, and expertise from the nationwide network – people and organizations like you – that is HRC. As a member, you will receive regular reports about HRC activities and events; a one-year subscription to Harm Reduction Communication; and discounts on HRC conferences, trainings, publications, and merchandise. So demonstrate your support of harm reduction and the Harm Reduction Coalition by becoming a member today. _____ _____ _____ _____ _____

$25 individual $35 not-for-profit organizations $75 international rate $100 corporate and for-profit organizations Other

☛

Name: ____________________________________________________________________

Organization: _______________________________________________________________ Address: __________________________________________________________________ City: ________________________________ State: _________ Zip Code: ________________ Phone: (

) _____________________ Fax: (

) ________________________

E-mail: ___________________________________________________________________ Send all membership subscriptions to: Membership, Harm Reduction Coalition, 22 West 27th Street, 9th floor, NY, NY 10001 phone: (212) 213-6376; fax: (212) 213-6582; e-mail: hrc@harmreduction.org

MEETING PARTICIPANTS’ NEEDS: BY DO NALD GROVE

recording basic information about who uses services and how they use them has enabled the Lower East Side Harm Reduction Center (LESHRC) not only to demonstrate effectiveness to funders but also to understand how services could be improved to better meet the needs of participants. To be acceptable for participants and providers of services, such a system of recording needs to be straightforward, not time-consuming as well as guarantee confidentiality. This article discusses the system developed by LESHRC and how it has been used to track and improve service delivery. When a participant comes to the needle exchange, they are enrolled anonymously and provided with a unique identifier code. Letters from the participant’s name and mother’s name and numbers from the participant’s birthdate are used to construct the code. The code is made in this way so that it can be easily reconstructed if the participant loses her card or forgets his code. Participant’s full names are not requested and no one’s name is recorded anywhere—only the letters needed for the code. Information about sex, race, zipcode of residence, and birthdate are also recorded. The participant is issued an identification card. Each time a participant comes to the exchange for sterile syringes, they give their code number and this is recorded along with the number of syringes returned and distributed, the date, and the venue of the exchange (e.g., storefront, walkabout, women’s hours, closed group, etc.) With this information, it is possible to generate statistics on utilization which include the following variables: sex, race, age, zipcode of residence, location of exchange, frequency of participation, and the number of syringes returned and distributed.

Meeting daily injection needs LESHRC used its tracking system to question the value of its one-for-one model of exchange, especially in a city where prescription and paraphernalia laws severely restrict access to clean injection equipment. In keeping with the New York State Department of Health regulations, LESHRC’s one-for-one policy means that although participants receive start-up syringes and incentive syringes for no returns, it is necessary to return used syringes in order to receive significant numbers of new ones. How well does such a policy meet the daily injection needs of participants at LESHRC? The Beth Israel Medical Center Chemical Dependency Institute’s evaluation of syringe exchange programs in New York City estimated an average daily injection frequency of 3.5 injections/day among program participants. It can be assumed that participants who receive syringes that do not meet this goal may actually be at continued risk for syringe reuse. Using an even more modest figure of 3 sterile syringes per day, the following analysis examines participant ability to use LESHRC as a remedy to severely restricted syringe access. In order to establish a consistent venue for analyzing utilization, this analysis looks at people who use the storefront exclusively. In addition, the sample consists only of people with five or more visits to the exchange during 1996. This gives a sample population of

1,170 participants. The number of days between first and last visit was noted for each participant. This number was multiplied by three to identify the target number of sterile syringes the participant would need to receive during that time to meet estimated daily frequency of injection. The total number of syringes distributed to each participant in 1996 was measured against this amount, and a percentage of the target number of syringes reached by each participant was defined. The analysis revealed that less than one third of LESHRC’s participant population (28.29 percent, n = 331) are getting 90 percent or more of the syringes that they need to meet their daily injection needs. This means that 71.71 (n=839) percent of participants received a number of syringes below their individual target. In looking at a breakdown of the sample population broken into five categories representing varying closeness to the daily syringe goal, it is striking that the smallest number of participants (15 percent, n = 176) fell between 50 percent and 90 percent of the goal. In other words, if you are not meeting your goal, it is likely that you are meeting less than half of it. This is a worrying finding. It means that the onefor-one needle exchange policy in New York is inadequate to meet the daily injection needs of a majority of program participants. Seen by some as a safe compromise, in fact the one-for-one exchange policy is a part of the problem of HIV transmission in New York City, rather than contributing to a solution. It is not possible to accuse injectors of wantonly infecting

This is a worrying finding. It means that the one-for-one needle exchange policy in New York is inadequate to meet the daily injection needs of a majority of program participants.

The Experience of the Lower Ea 16

themselves with used syringes when access to adequate numbers of sterile syringes is non-existent. It is despicable that the spread of HIV should be considered acceptable for injectors who are unable to comply with one-for-one exchange restrictions. This finding reaffirms what we already knew, namely that the sharing of syringes in New York City takes place in an environment where the number of sterile syringes is inadequate to meet the number of injections. “Exchanging” those few syringes which are already being reused will not increase the numbers needed to prevent reuse. Given that the existing rates of HIV infection already amply demonstrate the failure of restricted syringe access (through drug paraphernalia laws) to “control” drug injection, it is difficult to understand how HIV prevention efforts which apply the same restrictions will accomplish anything different. Of course, the greatest single remedy to this problem would be the decriminalization of syringe possession and over-the-counter sale. It would also be optimal for drug injectors to have access to disposal in the places where they are injecting, which would eliminate the need for them to save and carry potentially infectious waste. But in the absence of these solutions, what can needle exchange service providers do? LESHRC has tried other remedies, which include providing alternative disposal resources and raising the number of incentive syringes. LESHRC makes waste containers available to participants who request them, which has increased some participant’s return rates, particularly for women, by as much as 1,500 percent. Resources are extremely limited, however. A further response was suggested by the tracking system. This made clear that the majority of participants who were not getting sufficient needles and syringes to meet their daily injection needs were also those participants who tended to have a low return rate and who visited the program less often. LESHRC’s utilization statistics also re-

vealed that people accessing supportive services (such as support groups, earacupuncture detox, counselling and case management) have a higher visit frequency, implying that increasing the availability of these services would probably increase the visit frequency and return rate for more participants. For instance, while the average number of visits to LESHRC’s needle exchange program by participants during 1996 was 6.3 visits, those who used supportive services made an average number of 16.39 visits to the exchange.1 Thus, LESHRC has developed a low threshold model for the provision of supportive, non-needle exchange services. The LESHRC definition of lowthreshold is based on users being supported in identifying their own needs and setting their own pace. Such services target active users living with HIV or AIDS, but in order to reach this population, supportive services are aimed broadly at all injectors and/or people seeking substance use treatment through our facility. Given that current information indicates that 47 percent of needle exchange participants in New York City are HIV+, by targeting the broader population we can assume that we make contact with HIV+ people who do not necessarily choose to disclose immediately but still require services. LESHRC does not believe that HIV status is the sole justification for providing urgently-needed supportive services to active drug users. Typically marginalized from health and welfare support, participants are able to access services at LESHRC which are commonly denied to drug users. Our utilization statistics suggest that we are meeting a real need. The figures also tell us that supportive services are a valuable complement to needle exchange, increasing visit frequency and thus the likelihood of increased return rates. While funding for supportive services to drug injectors must be a national priority anyway, the experience of LESHRC is that such services can increase the effectiveness of a needle exchange operating within the constraints of a one-for-one exchange policy.

LESHRC’s utilization statistics also revealed that people accessing supportive services (such as support groups, earacupuncture detox, counselling and case management) have a higher visit frequency, implying that increasing the availability of these services would probably increase the visit frequency and return rate for more participants. Donald Grove was the Data Specialist at the Lower East Side Harm Reduction Center in New York City until August, 1997. This article is based on a presentation made to the 1997 North American Syringe Exchange Convention in San Diego, CA. Data collection and analysis at LESHRC is supported by an operational capacity building grant from the New York City Department of Health. The average number of visits to the exchange among those in the Ryan White target population who used acupuncture services was 16.03 visits; 20.95 visits among those exchangers who also attended a support group; 17.30 visits among individuals seeing a substance use counselor; and 22.77 visits among those who visited a case manager.

st Side Harm Reduction Center 17

A YEAR IN april THE LIFE june OF THE 23rd BAN

Secretary Shalala writes a report to Senators Spector and Harkin in which she states that “. . . studies indicate that needle exchange programs can be an effective component of a comprehensive strategy to prevent HIV and other blood borne infectious diseases in communities that choose to include them.”

The National Coalition to Save Lives Now is founded at the North American Syringe Exchange Network conference in San Diego.

BY CHR IS L ANIER

Currently, Federal funds cannot be used to conduct needle exchange. This ban was imposed by the Congress, which also gave the Secretary of Health and Human Services (currently Donna Shalala) the power to end these restrictions, if she finds that: needle exchange reduces the spread of HIV; and that needle exchange does not encourage drug use. In February of this year, Shalala made the determination, in a report to Senators Spector and Harkin, that needle exchange does, in fact, reduce the spread of AIDS. The same Federally-funded studies, which were used to make this determination, also showed that needle exchange did not encourage the use of drugs. However, the Secretary declined to make a public determination on that subject. Secretary Shalala has also declined to lift the ban, despite her own report and the overwhelming body of scientific evidence in favor of needle exchange.

In his speech to the United States Conference of Mayors, meeting in San Francisco, President Clinton expresses his desire to “continue to identify sound public health strategies that enable local communities to address the twin epidemics of AIDS and substance abuse,” in what many consider an expression of support for the Mayor’s resolution on syringe exchange.

The US Conference of Mayors passes a resolution which states, in part, that the Clinton Administration should, “in recognition of the overwhelming scientific evidence that needle exchange is effective in preventing the spread of HIV and does not increase the use of illegal drugs, exercise the waiver authority provided under the FY 1997 Labor, Health and Human Services, Education and Related Agencies appropriations legislation,” and “that state and local public health officials, consistent with the scientific and public health evidence supporting needle exchange as an effective HIV prevention tool, may utilize appropriate federal resources for needle exchange as part of a community’s comprehensive HIV prevention plan.”

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The American Medical Association reiterates and strengthens its stance in support of syringe exchange, citing “an urgent public health need.” The Association’s House of Delegates votes to work with members of Congress to initiate legislation revoking the 1988 ban on Federal financing for needle exchange programs and to encourage state medical societies strongly to initiate legislation relaxing drug paraphernalia laws so users can legally buy and possess needles.

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july In his State of the City address, Mayor Wellington Webb of Denver announces that he “will propose an ordinance to the City Council to allow for the establishment of a needle exchange program in the City and County of Denver.” Mayor Webb had previously been an opponent of needle exchange programs, and his reversal sparked a prolonged debate in the Denver press, capped by an August 2nd editorial in the Post by Dr. David Hutchison, President of the Denver Medical Society, which read, in part, “Needle exchange works in 87 American cities. It can work here if legislators, law enforcement officers and others will set aside their preconceptions.”

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New York City mayoral candidate, the Reverend Al Sharpton, leads a march from St. Ann’s Corner of Harm Reduction in the Bronx, protesting bad government policies which prohibit or discourage syringe exchange, leading to the HIVinfection and death of thousands of New Yorkers. In his accompanying press release, he announces that in the face of the AIDS epidemic “[t]he only humane, socially and fiscally responsible position for New York City Government to take is an aggressive ‘harm reduction’ effort.” Coalition member and Executive Director of the Community Health Awareness Group in Detroit, Harry Simpson, testifies before the Congres-

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MICHAEL ROTHBART

february

sional Black Caucus’ Health Braintrust, chaired by Rep. Louis Stokes, and urges the CBC to advocate for an end to Federal funding restrictions on needle exchange. Mr. Simpson, founder of Michigan’s largest and oldest needle exchange program, speaks from personal experience, saying “Treatment is not always successful the first time, and treatment is not always available for those who require it. The dual epidemics of substance abuse and AIDS require greater collaboration between AIDS prevention and substance abuse treatment efforts, not a policy choice between one or the other.” Congresspersons Elijah Cummings (D-MD) and Nancy Pelosi (D-CA) submit a bill (H.R. 2212) which would require Secretary Shalala to carry out a program regarding sterile hypodermic needles in order to reduce the incidence of the transmission of HIV. Titled the ‘HIV Prevention Outreach Act of 1997,’ the bill has yet to come to the House floor for a vote. Observers doubt this bill will ever emerge from the Committee on Commerce, to which it was submitted; however, it is a first step in what may become a long battle in Congress to gain legislative acceptance for needle exchange.

22nd

they gave clean needles and other drug paraphernalia to an undercover police officer posing as the relative of a user. The conservative movement takes action. Citing increased pressure on Shalala to lift the ban, and financier George Soros’ decision to provide funding for “needle give-away programs,” the Family Research Council (FRC), an extreme right-wing policy group, holds a press conference in which they release a ‘poll’ which they claim shows that Americans do not, in fact, support needle exchange. They urge Congress to take action to prevent the Administration from allowing Federal funds to be used for such programs, and urge Clinton to heed the advice of his Drug Czar, Barry McCaffrey, who apparently opposes needle exchange. In its report, “Will Exchanging Needles Save America’s Future?,” Robert L. Maginnis, Policy Analyst with the FRC, writes: “If America seeks to reduce drug use, it must stop coddling addicts. Drug abusers need treatment, not encouragement to keep injecting deadly drugs. Although AIDS will kill some, most will die from drug overdoses or other high-risk behaviors.” One hour later in the same venue,

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NCSLN holds its own press conference, debunking the FRC propaganda with testimony from researchers and public health officials. Press coverage of the ‘dueling press conferences,’ almost universally provides answers to FRC claims. At the NCSLN press conference, Winnie Fairchild, a program participant at the Whitman-Walker clinic in Washington, D.C., states, ‘If there had been needle-exchange during the time I was using drugs, I would not be HIV+’ and then dramatically held up a bill for one month of medications, which came to over $1,000. ‘If you’re a taxpayer, you’re paying for this,’ she said, ‘you figure it out.’ That day, McCaffrey’s office (the Office of National Drug Control Policy,“ONDCP”) releases a statement saying that ‘drug treatment moneys should not be used for harm-reduction efforts such as needle exchange,’ and the White House Drug Czar himself is quoted in the press saying, ‘…needle exchange sends the wrong message.’ No answer or mitigating statement would come from HHS or the White House, so the ONDCP statement became the most current Administration position. One month later, on September 20th in Denver, McCaffrey would say that he never officially opposed needle exchange programs.

august At its annual meeting in San Francisco, the American Bar Association adopts a resolution stating the ABA’s support for “…the removal of legal barriers to the establishment and operation of approved needle exchange programs that include a component of drug counseling and drug treatment referals.”

5th

Diana McCague and Thomas Scozzare of the New Brunswick, NJ, needle exchange program are convicted of violating New Jersey State law banning needle and syringe distribution. Their $500 fine and suspension of driver’s licenses are put on hold pending appeal. McCague and Scozzare had been arrested in April 1996 after

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The Day of Reckoning, Wednesday, September 17, 1997, Washington, D.C.

Congress responds to immense pressure from the well-funded FRC. In considering 1997-98 appropriations legislation, the House of Representatives passes an amendment which would effectively end Secretary Shalala’s authority to lift the ban. During the debate on the House floor, Representative Hastert (R-IL) declares “…we might as well give ‘em a clean gun…,” while Representative Coburn (R-OK) says “…keep in mind, these are felons we’re talking about. We’re giving needles to felons.” Other supporters of the amendment argue that needle exchange is too important an issue to allow the HHS Secretary to decide by herself, without Congressional approval, and express the concern that needle ‘giveaways’ will open the door for drug legalization. Speaking strongly on behalf

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of needle exchange, against the amendment, were Representatives Pelosi (DCA), Ganske (R-IA), Stokes (D-OH), Waxman (D-CA), Delauro (D-CT), Becera (D-CA), Nadler (D-NY), Morella (R-MD), among others. In support of the amendment, Representatives consistently cite the FRC poll, a ten-year-old Swiss experiment which provided a ‘safe haven’ for drug users and dealers, as well as the Swiss’ liberal drug policies, claiming that ‘it all started with needle exchange’. 59 Democrats support the Hastert/Wicker (R-MS) Amendment (see list below). Also, Representative Porter (R-IL), chairman of the appropriations subcommittee on Labor, HHS and Education, who had previously assured AIDS advocates that he would vote against any restrictive action on the issue, caves in and supports the amendment, influencing an estimated 40-50 Republican votes. The language of the Amendment is as follows:

“Sec. 516. Notwithstanding any other provision of this Act, none of the funds made available in this Act may be used to carry out or promote any program of distributing sterile needles for the hypodermic injection of any illegal drug.” In other words, EVEN IF the Secretary determines, based on evidence, that needle exchange reduces the spread of AIDS and does not encourage drug use, the amendment ensures that she cannot allow Federal prevention funds to be used for needle exchange, period. The Senate version of the appropriations legislation continues to allow Shalala to make a determination on needle exchange and lift the ban. House and Senate subcommittees will conference in October, to determine the final language. The NCSLN organizes a demonstration in Washington. Some 1200 activists and supporters from needle exchanges, ACT UP, Housing

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MICHAEL ROTHBART

september

Works and other groups march and rally at the headquarters of the U.S. Department of Health and Human Services to protest Government inaction on and impediments to the Federal funding of needle-exchange programs in the U.S. The demonstration is addressed by Sheila Catherine Fuoco of Mothers’ Voices, Denise Paone of Beth Israel’s Chemical Dependency Institute, Howard Josepher of Exponents/Arrive, Inc, Keith Cylar of Housing Works and Joanne, a program participant from Philadelphia. Demonstrators create a mock graveyard, with “headstones” bearing each State’s current total of HIV deaths due to the lack of access to needle exchanges and Government inaction. Protesters also attempt to raise a banner which says “Needle exchange saves lives” up the HHS flagpole—the flag flies for about 30 seconds before it is removed and confiscated by police. A small group also attempts to enter the building to present

HHS Secretary Shalala with a 20-foot papier-mache spine symbolizing the ‘moral backbone’ that Shalala and President Clinton require to resist politics and rely on sound public health to make a decision on needle exchange. Twelve people are arrested. The police wear rubber gloves during the arrest. While appearing at Case Western Reserve University, Cleveland, Ohio, HHS Secretary Donna Shalala is visibly nervous when challenged by Cleveland ACT UP members Brooke Willis and Ken Vail to explain her failure to lift the ban. Willis and Vail each read off a list of facts about needle exchange, hold signs depicting the strong spine which the Administration needs to lift the ban and leave the building chanting: “How many more have to die before you lift the ban?” Fox Channel 8 provide television coverage of the protest and report Secretary Shalala as saying that there is no issue that the administration cares more deeply about than AIDS and that needle exchange is an issue that needs to be settled.

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october The Mother’s March coalition, a statewide, non-denominational, non-partisan coalition, holds its demonstration in Trenton, NJ in support of needle exchange and programs of drug treatment on demand as measures of public health and HIV prevention. This demonstration gives a voice to all those affected directly or indirectly by the HIV epidemic, who mean to do everything in their power to prevent its further spread. Though not endorsing or indicting any elected official, the coalition aims to draw attention to needle exchange and the availability of drug treatment as crucial public health issues in the November elections in New Jersey. Currently, New Jersey has the most restrictive environment on needle exchange of any state in the Northeast, and, alone among its neighbors, has no legal needle exchange program. Not surprisingly, Jersey City has the highest AIDS rate in the nation.

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WHERE ARE WE NOW? As we write, the Senate and House meet in committee to determine whether appropriations legislation will prevent Secretary Shalala from lifting the ban. By the time you read this, some determination will have been made. We can think of several outcomes: a) the Senate version will stand (we will have the same language we have always had, it will be up to Shalala and Clinton to lift the ban), b) the House version will be enacted (to lift the ban will require Congressional approval—highly unlikely to happen for years to come, if ever), c) some form of compromise will occur (the Secretary’s authority will remain, on the condition that needle exchange pro-

grams, should they be Federally funded, will have to follow some form of guidelines which the Committee will invent.) To find out what happened, call your Congressperson. ALL CONGRESSPERSONS CAN BE REACHED THROUGH THE CONGRESSIONAL SWITCHBOARD: 202-224-3121. Or get on the National Coalition to Save Lives Now Action Alert fax list, by leaving your fax number at 212-2136376, ext. 17. The National Coalition urges you to hold your Congresspersons accountable! To that end we have provided you with a list of Democrats who voted FOR the Hastert/Wicker amendment (against needle exchange), and Republicans who voted AGAINST the amendment (for needle exchange).

(by State)

“ . . . the president apparently once shared a needle with a political coward, and so he has said nothing on the subject.” —Richard Cohen, Op-Ed, The Washington Post, September 18, 1997, “A Debate We Never Had” More than half of new AIDS infections overall, almost all of the infections among women and children, are directly or indirectly related to the sharing of an infected syringe. Donna Shalala, and President Clinton, have had the opportunity since they have been in office to lift the Federal funding ban on needle ex-

16 R EPUBLICANS VOTED AGAINST THE AMENDMENT. C ALL AND

59 D EMOCRATS VOTED FOR THE AMENDMENT Cramer . . . . . . . . . . . .Alabama Condit . . . . . . . . . . . .California Boyd . . . . . . . . . . . . . . .Florida Davis . . . . . . . . . . . . . . .Florida Costello . . . . . . . . . . . . .Illinois Lipinski . . . . . . . . . . . . .Illinois Poshard . . . . . . . . . . . . .Illinois Hamilton . . . . . . . . . . . .Indiana Roemer . . . . . . . . . . . . .Indiana Visclosky . . . . . . . . . . .Indiana Boswell . . . . . . . . . . . . . . .Iowa Baesler . . . . . . . . . . . .Kentucky John . . . . . . . . . . . . .Louisiana Barcia . . . . . . . . . . . .Michigan Kildee . . . . . . . . . . . . .Michigan Stupak . . . . . . . . . . . .Michigan Luther . . . . . . . . . . . .Minnesota Minge . . . . . . . . . . . .Minnesota Oberstar . . . . . . . . . .Minnesota Peterson . . . . . . . . . .Minnesota Taylor . . . . . . . . . . .Mississippi Danner . . . . . . . . . . . .Missouri McCarthy . . . . . . . . . . .Missouri Skelton . . . . . . . . . . . .Missouri Pascrell . . . . . . . . . .New Jersey LaFalce . . . . . . . . . . . .New York McNulty . . . . . . . . . . . .New York Etheridge . . . . . .North Carolina Hefner . . . . . . . .North Carolina McIntyre . . . . . . .North Carolina

WHERE IS THE WHITE HOUSE?

Hall . . . . . . . . . . . . . . . . . .Ohio Strickland . . . . . . . . . . . . .Ohio Traficant . . . . . . . . . . . . . .Ohio Doyle . . . . . . . . . .Pennsylvania Holden . . . . . . . . .Pennsylvania Klink . . . . . . . . . .Pennsylvania Mascara . . . . . . . .Pennsylvania Murtha . . . . . . . . .Pennsylvania Spratt . . . . . . . . .South Carolina Clement . . . . . . . . . . .Tennessee Gordon . . . . . . . . . . .Tennessee Tanner . . . . . . . . . . .Tennessee Bentsen . . . . . . . . . . . . . .Texas Edwards . . . . . . . . . . . . .Texas Green . . . . . . . . . . . . . . . .Texas Hall . . . . . . . . . . . . . . . . .Texas Hinojosa . . . . . . . . . . . . .Texas Ortiz . . . . . . . . . . . . . . . .Texas Reyes . . . . . . . . . . . . . . . .Texas Rodriguez . . . . . . . . . . . .Texas Sandlin . . . . . . . . . . . . . .Texas Stenholm . . . . . . . . . . . . .Texas Turner . . . . . . . . . . . . . . .Texas Goode . . . . . . . . . . . . . .Virginia Sisisky . . . . . . . . . . . . .Virginia Mollohan . . . . . . .West Virginia Wise . . . . . . . . . . .West Virginia Johnson . . . . . . . . . . .Wisconsin Kleczka . . . . . . . . . . .Wisconsin

THANK THEM FOR THEIR COURAGE AND SUPPORT.

Kolbe . . . . . . . . . . . . . .Arizona Campbell . . . . . . . . . .California Horn . . . . . . . . . . . . .California Thomas . . . . . . . . . . .California Johnson . . . . . . . . .Connecticut Shays . . . . . . . . . . .Connecticut Foley . . . . . . . . . . . . . . .Florida Young . . . . . . . . . . . . . . .Florida Ganske . . . . . . . . . . . . . . .Iowa Leach . . . . . . . . . . . . . . . .Iowa Cooksey . . . . . . . . . . .Louisiana McCrery . . . . . . . . . . .Louisiana Morella . . . . . . . . . . . .Maryland Frelinghuysen . . . . .New Jersey Houghton . . . . . . . . . . .New York Greenwood . . . . . .Pennsylvania 9 R EPRESENTATIVES DID NOT VOTE . Dellums(D) . . . . . . . .California Hastings(D) . . . . . . . . . .Florida Meek(D) . . . . . . . . . . . . .Florida Payne(D) . . . . . . . . .New Jersey Schiff (R) . . . . . . . .New Mexico Taylor (R) . . . . . .North Carolina Borski(D) . . . . . . .Pennsylvania Bonilla (R) . . . . . . . . . . . .Texas Gonzalez(D) . . . . . . . . . . .Texas

“ . . . the president apparently once shared a needle with a political coward, and so he has said nothing on the subject.”

ABOUT THE NATIONAL COALITION TO SAVE LIVES NOW! The National Coalition to Save Lives Now! consists of over 200 organizations nationwide, and thousands of individuals in 43 states. Representing the groups who are currently struggling to conduct syringe exchange, this ad hoc coalition is dedicated to lifting the Federal ban, by demonstrating support for lifting the ban on syringe exchange funding, educating elected and appointed officials on the importance of increased syringe access and ensuring that efforts to lift the ban are sustained. Since its inception, the National Coalition has vigorously fought the right-wing agenda, and has forced the debate on needle exchange out into the open. The Coalition has mobilized groups and individuals around its National Call to Action which concludes with: “Finally, we call upon all Americans to lift their voices against this genocidal neglect that is devastating our families and communities and reaffirm the humanity of all persons at risk of contracting HIV.” Call the National Coalition at (212) 213-6376 ext.17 for more information on its work and how you can get involved.

change, and prevent tens of thousands of new AIDS infections between now and the year 2000. An estimated 33 new infections occur every day, that would not

have if Federal resources supported comprehensive syringe exchange. Certainly, Shalala’s February determination provided an ideal opportunity to end the

SIMPLE MATH Total cumulative AIDS cases in the United States related to injection drug use:

146,3591 Total cumulative AIDS cases in the United Kingdom related to injection drug use:

6142 If the total population of the United Kingdom was the same size as the total population of the United States, the U.K. would have 3,070 AIDS cases related to injection drug use. The differential is 143,000 American lives. The missing variable in balancing this equation is a willingness by the United States government to realistically address the AIDS crisis within our communities. While the British government prevented an HIV epidemic through extensive needle and syringe exchange, over-the-counter needle and syringe access, and expanded services, the U.S. government created one. It ís time to end the federal ban on needle exchange funding.

NATIONAL COALITION TO SAVE LIVES NOW! For more information call: (212) 213-6376 ext. 17 1. Through December 1996. Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, 8(2). 2. Through March 1995. Centre for Research on Drugs and Health Behaviour, London.

restriction. AIDS advocates were therefore justifiably shocked in July in a meeting with senior White House policy staff, when it became clear that there was no White House plan, timeline or serious consideration given to lifting the ban. Further, had the Administration used their clout, the chances are that the restrictive House amendment would never have passed in the first place (59 Democrats voted FOR the amendment). The President, to this point, has completely abdicated his responsibility to act in the face of an escalating health crisis. Secretary Shalala, with all the science at her disposal, has yet to make an official policy recommendation on lifting the ban to the President, to say nothing of actually taking such action. Assuming the Administration still has the authority to do something on this issue when you read this, tell them to stop wasting time and LIFT THE BAN NOW. White House: email: president@whitehouse.gov (e-mail should have “LIFT THE BAN” in the subject line) Fax: (202) 456-2883 Phone: (202) 456-1111 *PRESS “0” TO GET A REAL PERSON. HHS Secretary Donna Shalala: hhsmail@os.dhhs.gov

H a r m Re d u c t i o n :

The

Case Management

Connection BY R ACHEL O DO

undamental to successful clinical case management are the notions that the worker must join the client in a non-antagonistic alliance, start where that client “is at,” and work at the client’s own pace of change and progress in order to provide a sound therapeutic experience and to facilitate comprehensive service linkages and coordination. Illicit drug users are a unique challenge in this work. Since most agencies work from an abstinence-only model, concrete services—such as supportive housing— have become “rewards” for those who are or become drug-free. Those individuals who cannot or will not follow an arbitrary set of rules about drug abstinence are punished by the system: whereas alcohol users are often eligible for housing, heroin users most frequently are not. Within such a framework, how can we address the needs of those who may be unwilling or unable to maintain abstinence? The wholesale rejection of an entire segment of the population and of a significant aspect of these individuals’ daily lives is unconscionable. Do we deny drug users access to services in order to support a theoretical framework, or do we consider modifications that would allow us to work in a manner that is both faithful to the principles of our profession and helpful to our clients? Case managers who work with illicit drug users do so in a society that prefers to criminalize drug use rather than struggle to understand and constructively deal with it. As such, they may find themselves at odds with social policy that seeks to condemn drug users rather than

to work with them towards productive membership in their communities. Nondrug users may find it very difficult to understand why some people use drugs; that different individuals may have very different reasons for using drugs; and that in fact, those reasons are valid and worth exploring from a case management point-of-view. Frank discussions of drug use—including its benefits—does not encourage such use, but rather the development of critical thinking about one’s use. We cannot know why our client began using drugs, prefers a particular drug to another, or acts as she does until we engage in an honest and open discussion with her about her use, and we cannot formulate appropriate interventions until we have contracted with the client towards goals that are established by the client, not on the client’s behalf. As case managers who are often charged with the overwhelming task of “linking” people to services that may not be readily available, flexible, or friendly to the drug-using individual, the temptation to label such clients “resistant” and to determine that nothing can be done for them until they stop using drugs is immense, particularly when working from an abstinence-only model. If drug use a priori signifies failure, then the case manager is going to burn out and the client is not going to have the opportunity for personal growth and development or even successful linkage to concrete services. If however, success is linked to the reduction of drug-related harm by modifications in personal behavior that are determined by the client in conjunction with the worker—not imposed by the worker, agency, or society—then both the client and the worker are more likely to feel successful and to attain their contracted goals.

The issue of motivation often emerges in discussions of case management with drug users. We talk about the import of client motivation in work towards positive change. However, the concept of motivation often becomes divorced from the individual, and we forget that there are ways in which we, as case managers, can help to uncover and to develop it. What is clear is that the imposition of the worker’s personal constructs and beliefs does not lead to high levels of client motivation, but that the mutual exploration of issues relevant to clients’ lives does indeed do just that. Engaging clients in an assessment of their lifestyle, desires, fantasies, and satisfaction can then be tied into discussions about short-term, long-term, and life-long goals. This enables them to think critically and to begin a guided process of self-evaluation that can lead to personal growth and development in addition to greater investment in the case management process. Clients will begin to view themselves as agents of change rather than passive recipients of it or reactors to it. In this way, the case manager’s job becomes easier and more satisfying as she is better able to help her clients meet their needs. Many case managers have already incorporated some of these harm reduction principles into their practice, finding that the harm reduction approach corresponds quite neatly with that of social work and case management. Most case managers do attempt to maintain a client-centered approach to the work. They advocate for clients and help them negotiate what are often confusing and frustrating social service systems. They strive to avoid the imposition of their own values and beliefs while helping clients to develop ways of relating that

allow them to be constructive members of the community. In many ways, the work that is already occurring parallels harm reduction techniques on a broad scale; however, the issue of drug use is so socially negatively-charged that some case managers begin to feel pressured to “deal” with the drug user in a less-thanideal manner. Stereotypical images of out-of-control addicts who cannot think or act constructively for themselves continue to prevail and, unfortunately, affect our work in this arena. As case managers, we are obligated to challenge these stereotypes and to experience the entirety of the person with whom we are interacting so that we can truly work “in their best interest.” I spent the past year as a social work intern/case manager at a New York City-based agency that serves people who are dually-diagnosed with AIDS and a serious and persistent mental illness. The majority of our clients are also illicit drug users. Although they may not be defined as such, the use of harm reduction principles made it possible for the case managers to function meaningfully with a population that is extraordinarily marginalized and often simply ignored. With regard to the issue of illicit drug use, the agency itself does not discriminate based on past or current use. Case managers are encouraged to engage their clients in frank discussions about their drug use; the reasons for it; and the role that it plays in their lives. A “safe space” is established where clients can talk about drug-related concerns that they might not otherwise be able to address. The case managers help clients explore both the positive and negative aspects of their use and to work toward specific, self-determined goals ranging from safer use to abstinence. The direct engagement of the client in contracting and discussing goals related to their drug use not only ensures that they will be meaningful for the client since he or she establishes them, but also fosters a sense of self-control and power over life events. E is a 43-year-old, heterosexual, African-American woman living with AIDS who has been a poly-drug user since she was 23. Currently, crack and alcohol are her drugs of choice. Working from a harm reduction perspective, rather than coming in with an abstinence agenda, allowed me to be open to an

honest exploration of the issues that were of concern to her. Ultimately, she would like to stop using illicit drugs and I supported this goal. However, the reality of 20 years of drug use and the significant role that it played in her life made this a particularly challenging one. Drawing from harm reduction principles, we have been able to make the process, including relapse, feel successful. Now when E goes on a three-day crack binge after having been “clean” for four weeks, we talk about the entire experience, exploring the reasons for it and the results of it—and we look at the four weeks’ “clean” time, too, and don’t just concentrate on the fact that she started using again but also discuss the great strides she’d made in being abstinent for some time. Rather than focusing on her “failure” to maintain a drug-free state, we discuss her attempts to take care of herself during the binge—perhaps borrowing money to buy crack instead of trading (often) unprotected sex, or insisting on using a condom when trading sex for drugs. In this way, I not only have the opportunity to reinforce self-protective actions, but to understand more about the role that drugs are playing in her life. M is a 32-year-old, gay white man who, during our first interview, described himself as an “addict in recovery” who believed in the 12-step approach. He initially stated that he was not using any illicit drugs. During our work together, however, we explored M’s drug use history in a non-judgmental way and it eventually emerged that in spite of his selfstated commitment to abstinence, he was using both street drugs and prescription medications in a dangerous manner. He was taking various pain killers in addition to heroin, defining this usage as “self-medication” for pain stemming from AIDS-related neuropathy and migraines. While he had been unable to obtain certain medications because of problems in securing Medicaid, he had been able to obtain others through friends on the street. Again, rather than working from an abstinence-based model, where I might not have encouraged a comprehensive discussion of his use, I utilized an approach that was based on harm reduction principles. So while simultaneously advocating for him with the Medicaid system and with clinics where medication vouchering

H E PAT I T I S C The Spring 1998 issue of Harm Reduction Communication will look at Hepatitis C. To learn more about this massive, but unacknowledged, public health problem, we want to hear from you about: • people’s experience of Hep C • self-care and support for Hep C Positive people: experiences, issues, thoughts • treatment approaches, therapies and clinical management • issues relating to HIV and Hep C If you have a contribution for the newsletter on any of the above or any other aspect of Hep C, please write, fax or email your contribution by December 12 to: The Editor, c/o HRC, 22 West 27th St., 9th Fl., NY, NY 10001 fax 212.213.6582 email hrc@harmreduction.org We look forward to hearing from you.

was available while the Medicaid was pending, I also worked with him to explore safer ways to manage his pain while waiting for the vouchers to be issued. Rather than worrying that a frank discussion of how better to manage his self-medication in order to avoid an overdose would “encourage” his drug use, I accepted the fact that he was going to self-medicate and worked with him to reduce the level of harm that he might potentially experience. The harm reduction model offers an effective option for working with drug users. For case managers, it can be a valuable theoretical base from which to approach the work. Its emphasis on client input in the therapeutic process helps ensure that clients will be motivated to work towards agreed-upon goals that are truly beneficial and desirable for them. Harm reduction is an inclusive model that can be used in conjunction with abstinence-based frameworks to meet the needs of those who are not benefiting from such models. Given the similarities in the value base between harm reduction and social work/case management, the integration of harm reduction principles is not hard to envision. The benefits of such an integration, particularly an expanded repertoire of interventions for working with drugusing populations, are significant. Rachel Odo is a student at New York University’s Ehren Kranz School of Social Work.

Your Letters Dear Newsletter Editors: I am sending two responses to articles in the Spring 1997 newsletter issue. Firstly, I wanted to respond to the article written by “Anonymous” regarding the untimely death of Nelly Velasco. I appreciated Anonymous’ visceral and honest response to the news of our loss of her. The message of caution and selfcare cannot be overemphasized—and should be reiterated so much that we, in the harm reduction movements and nonusers, hopefully, internalize it. Some years ago when I was using, it took me two near-fatal overdoses to get the points Anonymous is making. You finally cop, you’re fixing your hit, you get greedy/overeager/anxious/whatever (you know that feeling in your stomach) or you get different dope, and it’s so easy to go on out. I knew and cared very much about Nelly. As Outreach Director of Street Survival Project, I was also her supervisor. She talked a lot to me about her struggles with heroin. I use the word “struggles” because much of the time, heroin did not make Nelly happy, although sometimes it did. Several weeks before Nelly’s death, I told her in a staff meeting that I was afraid for her and wished she did not use. I told her I worried about her because as long as she used in the context of an illegal drug market, that the availability of the product, its potency, her suppliers, the danger involved, and the potential for arrest, were factors that were out of her control and constantly changing, thereby increasing her risk of harm. This is one of the reasons I think that we in the harm reduction movement need to remember that heroin creates a physical dependency and that this dependency occurs in a criminalized context. We must be very careful about making the claim that people are able to

be in control of their use or that it’s possible to work and use as long as it is normalized. In the contorted societal context of US drug policies and laws, encompassing such mind-boggling contradictions between what we say and what we really do, nothing is that simple or easy. The fact that obituaries are such a part of our newsletters bears this out. Moreover, as Pat Denning pointed out in the last issue, there are emotional, spiritual and psychological elements involved in drug use (especially in this cultural context) not to mention the pharmacology of the drug at work in use/addiction. Significant also is the cultural/socioeconomic factor of the meaning of use within an illegal proscribed context (use as a means of “finding” oneself/use as resistance to society/use as a means of transcendence/use as a coping mechanism). Use in a globalizing capitalist culture that alienates people, yet forces them to internalize their own alienation must be factored in. One of the reasons Nelly used and kept going back to using was to cover up pain. As an outreach worker and in many other things, Nelly was gifted, and her work was brilliant. Her drug history allowed her to reach people others could not. When Nelly was “there,” she was the best, and I loved to watch her at work. However, having to maintain her use in an illegal, criminalized market made her inconsistent, and she frequently did not function well at work using. Her use did create problems for her and her co-workers, plus wellfounded anxiety for her safety. No doubt, even in an illegal environment, there are some users who are able to retain considerable control, although it seems that the most elementary prerequisite for that is sufficient financial resources at one’s disposal not to have to “shop” at the street level of the underground economy. Unfortunately this does not describe most of the users I know. When I used, I was not in control of my use, and I don’t think I could have worked and used. Other people I know say the same thing, and we should all

think carefully before making claims that more often than not may be invalid. Bendiga nos, Nelita. Te estrano muchismo y pienso mucho en ti. * * * As always I enjoy the insights provided by Pat Denning and this is in no way meant as a criticism of her article, “Beyond the Disease Model: Clinical Psychology and Substance Use Management,” which was excellent. However, I would like to point out that we have all been bombarded so long with War on Drugs propaganda, that even the most sophisticated of us have internalized its pervasive lies. One of the first, most basic lies of this paradigm is the way drugs/alcohol have been carefully and historically linked in the public perception to people of color. For this reason, I am writing to clarify one of Dr. Denning’s statements. She wrote, “The majority of people who get into serious, chronic problems with substance abuse are not the white, middleand upper class folks in this country.” I would like to insert the word public before “serious, chronic problems”, because without the addition of this one word, the sentence is factually incorrect. It is, precisely, this population, (along with, of course, working-class and poor white people), who have always made up the bulk of this country’s population of addicts and alcholics (look at the founders of AA). The difference is that the using populations with greater financial resources have always been and still are able to cushion and hide their use, and thus we do not see it. Budget cuts, beginning in 1980, that have continued to destroy low-income housing and other programs for poor people, have poured them out into our streets. Whatever problems they originally had, having been abandoned by the society into which they were born will only further exacerbate them. Their use of consciousness-altering chemicals is not only a coping mechanism but a rational reaction to an irrational situation; I would use too—as much as I could get my hands on. Moreover, the vast majority of the addicted poor living on the streets have life histories of severe, cumulative trauma, made worse by the inhuman conditions homeless people face. Getting high is also one

way to have a little privacy—at least in your own mind. We are confronted with poor people’s problems daily as we walk our streets, and our guilt and fear about this, along with sheer mass and volume of stigmatizing propaganda, makes it easier to accept the stereotypes and pathologize them too. African Americans, who make up a disproportionate share of our poor and, thus, our homeless poor, may seem to be more numerous among the addicted living on the streets, their problems more severe. And, most importantly to service providers not of color, they present differently. Their problems may seem more glaring to many white service providers because their clients are still the Other and thus something unfamiliar. Because African Americans have been so stigmatized and pathologized, especially around drugs, alcohol, and crime, it takes a conscious and constant effort not to blame the clients and their addiction, but rather to confront the Lie, reject it and (vocally and publicly, by definition, part of the process) blame the society that created them. A study of the history of our country’s drug use and laws bears out the fact the first populations of cocaine and opiate addicts were middle and upper-class white women and men, then working class white folks, and this is no different today. Indeed, the use of halucinogenics, pharmaceuticals and amphetamines has historically been concentrated largely among white people, while the new “resurgence” of heroin has occurred among the middle-class, etc. young white people. Moreover, until Prohibition created an illegal alcohol market and the subsequent growth of African American organized crime groups distributing it to their own people, even alcohol use in that community was not proportionately high and still is not. Not until the sixties when Mafia distributors (maintained in business by our CIA) made a marketing decision to flood the politically awakening and restive barrios and ghettos with heroin, in combination with returning soldiers traumatized and addicted while in Viet Nam, did heroin addiction become more widespread in the African American and Latino communes. Until they figured out how to make cocaine cheap enough for poor people and began marketing it

to people of color, use of powdered cocaine and freebase was widespread primarily among white people with enough money to indulge. Crack is a drug of poor folks, because even the lowest quality of cocaine can be greatly increased through the chemical process. Neither the War on Drugs propaganda nor our sentencing policy acknowledges the large numbers of poor white people who have been smoking it for the duration. Higher income white people rock up good cocaine to smoke as they once freebased; they don’t want to smoke crack. It is the widespread internalization of these pervasive stereotypes that has fueled the obscene growth of our prison/industrial complex, the new plantation, filled with black and brown people, once again doing slave labor. (Although increasing numbers of white people find themselves stuck in the web of mandatory minimums and zero-tolerance sentencing laws.) It is the same context in which people with drug convictions are now permanently barred from receiving public aid. In a society built from the beginning upon such a seamless, wraparound racism, we have all (white folks and folks of color) internalized racism. How can we not, when it takes a conscious, constantly vigilant effort to unlearn that which we take have taken in with our first breaths. Moreover, being known as someone who will be regularly pointing these things out can get you fired, ostracized, condemned, or worse. It makes one a very unpopular, “negative” person. It is in this spirit that I have taken off at such length over the addition of one word, not to criticize anyone or to accuse them of being the ‘R’ word (another of the ridiculously ironic exercises regularly perpetrated upon the public), but as part of my own unlearning process, hopefully to help others along with me. Carol A. Draizen, MSW Oakland, CA Please write in with your comments, feelings, responses— we want to hear from you. Send them to: The Editor, Harm Reduction Coalition, 22 West 27th Street, 9th Floor, New York, NY 10001

9Overdose 11 1 Prevention & Survival

Brought to you by the Harm Reduction Coalition

The second brochure in HRC’s STRAIGHT DOPE education series on drugs and drug-related issues, Overdose: Prevention and Survival discusses what overdose is; how it happens; how you can prevent it happening; how you can prepare for it happening; how to recognize if someone else has overdosed and what to do and what not to do in an overdose situation. Written by users themselves, Overdose: Prevention and Survival provides accurate, non-judgmental, and practical information in straightforward language. Overdose: Prevention and Survival brochures can be purchased in bulk at 10 cents each, total cost pre-paid. Please send me _______ brochures x 10¢ each = $ _________ (enclosed):

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Send all orders to HRC’s New York office: Brochures Harm Reduction Coalition 22 West 27th Street, 9th floor New York, NY 10001

drug the health my asking—a one junkyDolophine sey ’s Odysprescription C O N T I N U E D F R O M PA G E 5

that I found to be incredibly helpful as a drug management tool. He said it would always be available and all I needed to do was ask. (Since doctors can’t prescribe methadone for maintenance, he prescribed it for “pain management.”) I thought I had died and gone to heaven. For the next several months, having access to legal methadone without being on a clinic was extraordinarily helpful in letting me lead a stable life and still get high when I wanted or needed to. I could travel for work without having to make ridiculously complicated and risky arrangements, and my finances were more often in the black than the red. Unfortunately, my doctor came to believe that he was probably over-prescribing for me as far as the DEA was concerned, and since neither of us wanted him to get in trouble, I agreed to taper off the methadone when my doctor asked me to. What he hadn’t told me, however, was that he’d already decided that the last prescription he’d written for me was the final one he would write. Because the rifampin ate away at the methadone I took, I found it impossible to successfully detox off this prescription, and wrongly assumed that he’d write me another until, within reason, of course, I could successfully detox. I felt extremely betrayed when, with absolutely no forewarning, I was told I couldn’t get even one more script. I was out, and would have to find some dope that afternoon in order not to be sick. Although I understood and could sympathize with my doctor’s very justified fears about the DEA, I couldn’t get over the fact that he gave me no time to make some alternative plans. In what other circumstance would it be perfectly acceptable for a doctor to simply cut a patient off of medicine that was working perfectly? My doctor was surprised and somewhat dismayed when I told him I’d rather shoot dope than go onto a methadone program. My health problems were becoming increasingly severe. I was hospitalized twice in January 1997 for TB meningitis, and then twice more I would find myself admitted to—and checking out AMA from—the hospital. The 40

milligrams of methadone a day I was given was no match for the rifampin; after the humiliation of begging for more methadone, I’d sometimes be given 40 more milligrams which, because by this time I’d been in complete withdrawal for several hours, had absolutely no effect on alleviating my withdrawal. Because I’d been given 80 milligrams of methadone—no matter that it was dispensed to me in a way that was completely ineffective—hospital staff and even my own doctor became annoyed when I complained that I was still in withdrawal. Drenched in sweat, wracked by stomach cramps and diarrhea, unable to eat or barely swallow my medications, and seizing like crazy, I was apparently supposed to be satisfied with the treatment I was receiving. In both of these instances, I was in much worse shape after being in the hospital for two days than before I went in. Continual seizing made me confused for days, and caused me to have great difficulty speaking and thinking clearly. No amount of explaining to the doctors would convince them that the seizures I was having were being caused by the fact that they were forcing my body to go into withdrawal every several hours. In fact, on these two occasions my health was actually jeopardized because no one would or could properly medicate me. At one point there was talk about putting me in intensive care when a higher dose of methadone would have done the job. What was so wrong about providing me with proper opiate maintenance? I was again forced to be the non-compliant junky patient and, much to my doctor’s chagrin, and with great difficulty on my part due to my weakened and traumatized body, checked out of the hospital AMA, vowing never to return unless I had within my own control the means to selfmedicate my own body.

After these two traumatic hospital visits.… …my heroin use admittedly was out of control and my depression was incredibly severe. Although I swore I’d never do it, at my doctor’s urging but against all

of my better instincts, I finally enrolled in a methadone program. The notion of surrendering my daily ability to function to a program where the staff made no bones about their opinion that I was a dysfunctional fuck-up was repugnant and utterly disempowering to me. It was unbelievably depressing to sit in waiting room after waiting room with a bunch of other junkies who thought they were being “saved”; I could only feel like a complete failure. I went armed with documentation from my doctor about the fact that I was taking rifampin and Dilantin and had next to no T-cells, but despite a showdown with the clinic doctor on my first day, I was told I’d be given only 40 milligrams of methadone and raised 10 milligrams a day until an “appropriate” dose was reached. (Apparently, I was lucky: most patients are started off at 30 milligrams and raised by increments of 5 milligrams a day.) Never mind that I had TB infection of the brain that caused me to seize when I experienced withdrawal and that I’d been shooting 10 bags of dope a day: I’d have to be content with 40 milligrams of methadone. Now in “drug treatment,” I was nonetheless forced to continue to shoot dope on top of the methadone I was getting from the clinic or buying street methadone to supplement my dose. I soon had a double habit—dope and methadone—and found that several weeks later when I was finally receiving 90 milligrams of methadone at the clinic that even this dose, above which the clinic said it absolutely would not prescribe, was inadequate because of the effects of the rifampin. I’d be at the clinic at 7:30 am sharp each morning, sick as a dog, to get my methadone. Because I was in withdrawal, it would take nearly an hour for the methadone to make me feel even slightly human. After spending the entire day feeling like I was constantly on the verge of withdrawal, I’d wake up each morning around 1:00 or 2:00 am, drenched in sweat and unable to sleep, again in complete withdrawal. I’d get up and, in intense pain, have to wait until 6:30 am to get dressed and travel half the length of Manhattan to the clinic, again drenched in sweat and freezing by the time I got there, to receive a non-therapeutic dose of methadone. I maintained this maddening schedule for nearly two weeks,

going into methadone withdrawal every single day—something that was physically very traumatic for my body and emotionally devastating—while trying not to supplement my dose so as to give the methadone a chance to work. The clinic continued to refuse to increase my dose, and every time I tried to explain to them that I was taking rifampin, the staff would look at me like I was simply trying to scam them for more methadone. What I actually needed—and what I am convinced anyone on rifampin and methadone needs—was not necessarily a higher dose of methadone but rather two doses of methadone a day. Even a regimen where I took half of the 90 milligrams in the morning and half later in the day would have worked better than what I was offered, but I was told that such an arrangement was impossible. I was so physically and emotionally beaten down after several weeks of this routine, so tired of being sick every day, absolutely exhausted from a lack of sleep and the trauma of continuous withdrawal, and so infuriated that I’d humbled myself and asked for help only to be kicked in the teeth, that I was willing to do just about anything to get out of the cycle of daily withdrawal I was in that was so dangerous to my already debilitated body and quite literally driving me to suicide. Although I’d watched one of my former needle exchange clients die a gruesome death from tuberculosis, and although I’d been a health educator for years and knew very well the consequences of interrupting tuberculosis treatment, I stopped taking my daily rifampin dose in the hopes that my body would reach some point of homeostasis and the methadone would begin to work. (I was on three other TB medications, and hoped that if I became resistant to the rifampin the others would take up the slack.) If my experience was at all typical, I am convinced that methadone programs—because of their unwillingness to properly medicate people taking rifampin for tuberculosis treatment—are responsible at least in part for the resurgence of drug-resistant and multi-drugresistant TB New York City experienced in the 1980s and early 1990s. The program I was on at Beth Israel Medical Center in New York, in any case, was completely unwilling to accommodate

even the serious, life-threatening health needs of the kind I was experiencing. Nothing, I was told, could be done about my dose or dosing schedule. Eventually I became too debilitated to travel to the clinic every day in order to receive my non-therapeutic dose of methadone. I ended up kicking the 90 milligrams I was on cold-turkey at home, a process that no doubt severely endangered my health and which caused me unbearable and completely unnecessary suffering, and a process which again landed me in the hospital for another two weeks because my body was so shot. In trying to make sense of my ordeal trying to access appropriate and humane health care, several themes come up again and again. Everywhere I went—from my private physician to the hospital to the methadone clinic—certain assumptions guided the care I received and what the providers would or would not do for me.

Like many other opiate-dependent individuals, I was fine when I was using. It was when I ran out of drugs that the difficulties began. Withdrawal was my real enemy during this whole ordeal and because of the effects of the rifampin, being under-medicated at the hospital and the methadone clinic, and being forced to switch back and forth between dope, street methadone, and the methadone I received through the clinic, I experienced more withdrawal while I was in “drug treatment” than I ever did while I was using. The constant withdrawal I was forced to undergo was so dangerous for my body and so hurtful to me psychologically, yet everywhere I went my use, and not the withdrawal, was perceived to be my problem.

users and e care system drugs are your real problem.

Every provider I saw assumed that one of the most serious, if not the most serious, issue I was facing was my opiate dependency, despite the fact that this was not something I defined as problematic inand-of-itself. (Of course, for harboring this attitude I was constantly accused of being “in denial.”) Among the things that I was experiencing that I considered to be my most serious problems were: the TB meningitis infection I had and the seizures that it constantly caused; the fact that I had only 15 T-cells and a threeand-a-half million viral load, a condition that kept my body on the constant verge of collapse; the persistent, recurrent herpes zoster infection on my face and head, treatment for which entailed going to my doctor’s office every day, including weekends, to receive an intravenous infusion of an extremely toxic drug; the fact that I was undoubtedly experiencing crazy drug interactions as a result of being on no fewer than 14 different pharmaceuticals; the deep depression I was feeling as a result of trying to deal with such huge life changes by myself; and the challenge of trying to earn a living, pay the rent, and continue to perform my job successfully in the midst of this other shit. All of these issues would apparently resolve themselves if only I stopped shooting dope.

Opiates are ruining your health.

There is a widespread belief among health care professionals that the “nonmedical” use of opiates (at least heroin), apparently because it is illegal, is infinitely bad for the body. That was a risk I willing to take. In my estimation, however, the daily intravenous infusions of ganciclovir (Cytovene®) I was receiving for the treatment of herpes zoster were much more damaging to my body than the heroin I was shooting. One of the side effects of ganciclovir treatment is a severe depletion of the body’s white blood cells (which to me doesn’t seem like the greatest thing for a severely immunocompromised individual to undergo), and several times my white blood count reached such low levels that I had to be given Neupogen injections to stimulate their production. This artificial lowering and raising of my white blood cells can’t have been very good for my body, but it was part of a medical treatment regimen and so apparently constituted an acceptable risk. I was also taking isoniazid (INH) for the treatment of tuberculosis, a drug which can cause iatrogenic hepatitis; Dilantin, which made my brain feel crazy all the time; and, as I mentioned, a host of other toxic pharmaceuticals that must have been causing drug interactions of all kinds. For a while I was taking the protease inhibitor nelfinavir (Viracept®), an extremely powerful substance that was tested in clinical trials of a mere several hundred

individuals (none of whom were likely self-identified heroin or methadone users) for a period of less than a year. On the other hand, people have been shooting dope in the United States for more than a century now. I would not be surprised at all to learn that the Viracept and the two nucleoside analogues I was taking each day were much more dangerous to my health than the dope I was shooting. Certainly they were more toxic.

Methadone programs are there to help you. My brief stint on methadone was one of the most humiliating experiences of my life. Everyone with whom I came into contact—from the intake counselors to the woman who drew my blood to the physicians’ assistant who examined me to the dispensing nurse—treated me like shit simply because they knew they could. If I wanted to be medicated in a timely fashion or at all, I had to do exactly as they required, without protest or qualification. I could not get over the outright hostility with which even the most routine interaction with staff took place. Because they had control over you and knew it, no one hid the fact that they believed you to be completely dysfunctional, pathetic, and no doubt morally bankrupt. Knowing absolutely nothing about my life or circumstances, every staff member I dealt with harbored fucked-up assumptions about who I was and why I was at the clinic. At a time in my life when I needed some support, I was met with rejection, disgust, and hostility. The clinic’s refusal to help me feel comfortable despite the fact that I was on rifampin was nothing short of criminal, and the role of methadone clinics in the drug-resistant TB epidemic—if my case was at all typical—must be exposed.

I am completely on my own.… …when it comes to my opiate use. I’ve always managed my habit on my own, problems and all, and enrolled in a methadone program (and gave up that control) only because my health problems were becoming so serious. I had to

re-learn what I already knew very well: that I must remain in control of my ability to function, and never surrender this to any individual or agency ever again. My physician remains steadfastly unwilling to acknowledge that the extent to which I’m able to successfully and sanely manage my drug use has a direct impact upon my ability to manage my HIV-disease. He insists on treating only half of me—the part he feels comfortable dealing with—despite the fact that it is impossible to separate the issue of my opiate use from my overall health care needs. When I ask him why he refuses to write me a prescription for a few days’ worth of Darvon or Dolophine to help me get through a detox, I receive a vague answer that he’s “not comfortable” doing it. It does bother me that I can’t rely on my doctor to offer even moral support, and I have no idea if I had to go to the hospital tomorrow whether or not he would prescribe methadone for me during my stay. That I should be forced to purchase a supply of drugs or methadone to take with me to the hospital is insane, but I have no other choice. That I may have to put off checking into the hospital at some point in the future because I’m unable to get the money or the drugs together is criminal. I’m sure there are people who’ll read this and whose only response will be that I’m pretty fucking good at finding ways to rationalize my continued drug use. I have tried—and succeeded several

times, for short periods—to stop using drugs during the past six months while I was experiencing the events I describe. Every time I encounter a health care professional, a social worker, or sometimes even a friend who counsels me to stop using, I listen and I struggle with what they have to say, yet I always ask, “Why? Why is it so crucial for me, someone with a life-threatening illness who finds in heroin terrific comfort and few adverse health effects (even health benefits) to stop using and subject myself to a disruptive, major life change?” I’m able to perform a challenging job successfully, have so far been able to continue paying the rent (albeit sometimes late), but most importantly, am willing to suffer the inconveniences and take the risks that are involved in using illicit drugs. That is a choice I’m willing to live with, and I’m so alone in believing that it is a choice that can be consistent with a happy and successful life. That is the hardest part about being a user: not internalizing the belief that I am a piece of shit and trying to live a life of satisfaction and dignity that everyone tells me is impossible. The author lives and works in New York City. See American Thoracic Society, “Treatment of Tuberculosis and Tuberculosis Infection in Adults and Children” (a joint statement of the American Thoracic Society and the Centers for Disease Control, adopted March 1986). Reprints are

“Varieties of Success: A Collection of Stories of People Who have Successfully Resolved Problems With Substances” a book in progress by Andrew Tatarsky, Ph.D. I am looking for contributions to a book that I am currently editing. The book is a collection of stories by and about people who have successfully dealt with problems related to substance use. My hope is that the collection of stories will illustrate the variety of ways that people define problems related to substance use and define success (i.e. harm reduction, moderation or abstinence) and the variety of ways that people work toward achieving their personal goals with substances (self-help programs, professional treatments or self-management strategies). I am currently looking for stories by current or former substance users who would like to share their stories as representations of one possible route to success. These can be submitted anonymously or under a pen name if that is preferable. I am interested in brief and more lengthy (20-30 pages) contributions written in a style that will be accessible to a non-professional audience. These stories will be integrated with stories written by professionals working from a variety of different points of view. As a whole, the collection of stories will yield a picture of the many options for change that are available and should be helpful both to users and providers of services. I can be contacted in confidence for more information at tel. 212-633-8157, fax. 212-604-0830, email Atatarsky@aol.com and snail-mail: 31 W. 11th St., NY, NY 10011.

YOU CAN

LEAVE THAT

MISS THING C O N T I N U E D F R O M PA G E 10

Percocet, Percodan, Vicidan, and Dexedrine. It wasn’t until I started volunteering with the Santa Cruz Needle Exchange and working with the Harm Reduction Coalition that I learned how to use drugs and maintain a life where I could be productive and still be strung out. I’m not saying that this can happen for everyone who uses drugs. But because of the exposure I have had to other drug users who are also trying to negotiate the fine line between being strung out and controlling their use, I feel I have figured out a way to negotiate this line in my own life. This does not mean that I have a handle on my drug use. Sometimes I don’t. Sometimes I have a very difficult time with my drug use, just like sometimes I don’t have safe sex and sometimes I engage in “violent” sex.* I’m not always safe even though I know how to be safe. I have access to all of that information as a health educator and am surrounded by other women who claim to follow all the rules. Because we have access to this information, we are not supposed to overdose, get the virus, miscalculate the amount of coke we shoot up and have a heart attack or a stroke, nod out in a meeting, or let our girlfriend choke us until our eyes roll back in our head and we get real dizzy and black out but it feels so good so we don’t stop her. But generally we don’t talk about this, especially in the lesbian community. Someone might mention an overdose, but ‘she deserved it anyway because she shouldn’t have been putting that poison in her body, and it was just a matter of time because everyone knows that drugs will kill you and aren’t you glad you didn’t fuck her?’ And we don’t talk about how in the queer community we fuck with no latex, whether it’s a girl with a strap-on or a man you know is HIV+. Because a real lesbian would never fuck one of us whores like that, even though you stare at us down on the street and fuck us in staircases, alleyways, and at parties in the bathrooms in houses full of “real” lesbians. You fuck us all right, just as long as we promise not to tell. And when one of us does test positive or overdoses, we are largely forced to be silent because if we’re not, we will be accused

of being a junkie or a whore, and whether or not it’s true, no one wants to be told that about themselves—especially since they’ve probably been told that their whole lives and believe that about themselves anyway. For every experience I have like this, there is another woman participating in this behavior(s) with me. We are not a subculture in the lesbian community. We are as much a part of it as you believe you are. But we are invisible because we have no other option than to keep quiet about what we do. Or we do it alone, in isolation. Or with people who couldn’t give a fuck if we live or die. Or we hide our track marks from our girlfriends as long as we can and lie and pretend to be outraged when we hear about another woman in the community who trades sex with a man for drugs or money or food or a place to stay, or because there is nothing better around to fuck. Most people don’t lie unless they are put in a position where they are forced to lie. A lot fewer of us will get the virus if we don’t have to lie about what we do. And I promise you that you’ll be much more effective if you do not judge your friends and lovers because of the drugs they use, the people they have sex with, or the type of sex they engage in that may not considered “safe” in the queer community. Instead, my suggestion would be to offer support, or find a place where they can get that support, as it is identified and defined by them.

BAGGAGE

AT THE DOOR,

MISS THING

I’m not always safe even though I know how to be safe. Heather Edney is the Director of the Santa Cruz Needle Exchange Project. “True Stories by Girl Junkies” is a magazine put together by a group of women at the Santa Cruz Needle Exchange that contains interviews, stories, poetry, artwork, and safer injecting tips by women who shoot drugs ranging in age, sexual identification, and ethnicity. It is available from the Santa Cruz Needle Exchange Project by calling (408) 429-9489. *I use the term ‘violent sex’ instead of ‘sadomasochism’ or ‘S/M’ because to me the latter implies a community-defined and -supported set of rituals and structured experiences, and the type of sex I’m talking about does not include these characteristics.

HARM REDUCTION COALITION

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HARM REDUCTION COALITION

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