No. 9 - Fall 1999, Harm Reduction Communication by National Harm Reduction Coalition

H A R M R E D U C T I O N COMMUNICATION BY ANO NYMO US

The last time I overdosed I was revived with Narcan. While it was a terrifying experience, I am extremely grateful to both the person who found me and the paramedic who saved my life. I overdosed because I used too much dope in too short a time period, and because I had taken a large quantity of viks, percs and benzos1 within the last 24 hours. Even as I did repeated shots, I knew I was using too much. But at the time that fact was irrelevant; the most important thing to me was to get out of my head! Looking back, I can say that I was stupid, acted irresponsibly and put a lot of people at risk for getting busted, or having to deal with a dead body upon arriving home. But that’s in retrospect. C O N T I N U E D O N PA G E 9

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HARM REDUCTION COMMUNICATION F A L L

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This issue of Harm Reduction Communication is dedicated to the memory of Angela Daigle, 1973-1999 Overdose! by Anonymous . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Letter from the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 After the Fall by Gale Miklo . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 New Jersey: A Grassroots Groundswell by Chris Lanier . . . . . . . .6 Understanding Heroin Overdose by Kristen Ochoa, et al . . . . .10 Rescue Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Heimlich Maneuver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Naloxone Availability: Yet Another Positive Change by Dan Bigg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Naloxone Availability: Not a Silver Bullet by Robert Swarner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Drug Users Tools of the Trade by Ro Giuliano . . . . . . . . . . . . . .18 Turning Blue by Dante Brimmer . . . . . . . . . . . . . . . . . . . . . . . .24 Witches’ Brew by Donna Odierna . . . . . . . . . . . . . . . . . . . . . . .26 On the Ground by Delaney Ellison . . . . . . . . . . . . . . . . . . . . . .28 Gimme Shelter: Drug Users Need Housing by Sandra Fuentes and Daliah Heller . . . . . . . . . . . . . . . . . . . .30

Cover illustration by Eleanor Herasimchuk, reprinted from JUNKPHOOD PRESENTS: THE UFO STUDY

H A R M

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 well-being 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. Any part of this publication may be freely reproduced as long as HRC is credited. Editor: Paul Cherashore Graphic Design: Dolly Meieran Printing: Alpina Printing, NYC © HRC 1999

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, 5th Floor, New York, New York 10001, hrc@harmreduction.org

R E D U C T I O N

Allan Clear, Executive Director Danine Hodge, Director of Finance & Administration Donald Grove, Director of Development Suzie Ko, Assistant to the Executive Director Alvaro Arias, New York Office Manager Nankhat Felock, California Programs Assistant Chris Lanier, Director of Community Organizing Andre Robertson, California Programs Coordinator Paula Santiago, National Community Organizer

C O A L I T I O N

Teresa Vega, Community Organizing Systems Manager Don McVinney, Director of Education & Training Vanessa Brown, National Training Coordinator Amu Ptah, Assistant Training Coordinator Maria Quevedo, Administrative Director of Training-California Alessandra Ross, Staff Trainer Edith Springer, Senior Trainer Paul Cherashore, Resources & Publications Coordinator Orlando Roman, Treatment Advocate

Main Office 22 West 27th Street, 5th floor, New York, NY 10001, tel.212.213.6376 fax.212.213.6582, e-mail: hrc@harmreduction.org West Coast Office 3223 Lakeshore Avenue, Oakland, CA 94610, tel.510.444.6969 fax.510.444.6977, http://www.harmreduction.org

letter

“W

hen I make the choice to use by myself, it is usually because I want to get as high as I can and not have to be accountable to anyone, or it means I have a habit—which would make it physically impossible to use with someone every time I do a shot. It is not because I want to kill myself, and not because I don’t understand how to avoid overdosing, but because I am depressed and because I am bored. For a lot of people, I know it is either deeper than that, or it isn’t. Some people are on a suicide mission every time they use. Others just wanna get off.” It is this description of the drive to use, from the cover article, an anonymous account of the author’s overdose, that resonates for me—not the psychobabble and judgments of physicians and psychotherapists, researchers, and social workers, public health officials and policy makers. And I assume for most users, it is as simple as the above sentence, “Others just wanna get off.” I remember the subject of overdose coming up at HRC’s Second National Harm Reduction Conference. I said then

DISCLAIMER HRC has included five instructional pieces on overdose response: two are planning tools—Calling 911 and Make a Plan— and three are instructions for reviving an overdosed individual—Drug Users’ Tools of the Trade (including Measurement Math), Rescue Breathing and Heimlich Manuever. Although some of the material here describes possible responses to specific medical situations, HRC is providing this material for informational purposes only. HRC distributes it with the understanding that we are not in the business of rendering medical, legal or other professional services, and we believe that it is always best to seek professional medical help in the event of an overdose. That said, we also understand that until users are able to call 911 without fear of arrest or other repercussions, they will continue to avoid doing so. Although the resuscitative material here cannot be a substitute for training received from professionals, until such training is universally available it may be the best we can offer. In the mean time, ask your local needle exchange program to set up an overdose prevention/response course if they don’t have one, or contact your local red cross or health department for CPR training. Thanks to Dan Bigg for use of material that appears in Make a Plan, and Van Asher and The Lower East Side Harm Reduction Center for materials appearing in Rescue Breathing and Heimlich Manuever.

from the

editor

that it was a kind of litmus test; if people in the movement really cared about the lives of users they would be addressing the issue. Communicable diseases impact all of us, but overdose kills only drug users. There does seem to be a critical mass of interest coalescing around overdose prevention and response: a few grass roots agencies around the country have begun devising strategies for addressing what had been up to very recently a silent problem, and a major conference on overdose convenes in Seattle on January13th. This issue of the Harm Reduction Communication focuses on the subject of overdose, particularly opiate-induced ODs. In addition to the cover article (anonymous) there is Dante Brimmer’s not-soanonymous OD story, Kristen Ochoa and colleagues’ overview of the heroin overdose problem, Dan Bigg and Robert Swarner’s arguments on the pros and cons (respectively) of distributing naloxone (aka Narcan) to users and Ro Giuliano’s instructions on how to use it, along with a great deal of practical information to assist users in responding to heroin overdoses. Why the emphasis on opiate-induced ODs? Because opiate ODs are eminently treatable, are usually more apparent as overdoses when they do happen and because they appear to be more approachable as a topic than other types of drug ODs, especially among heroin users themselves. As Kristen Ochoa and her colleagues point out, the topic of drug overdose has until recently received little attention. In the US, when the issue does surface, it is usually centered on heroin overdose, possibly due to the fact that heroin ODs often come in clusters, which can make for dramatic news coverage. Our approach is pragmatic here; given the opportunity to address the problem of heroin ODs, we must respond. Tackling one type of overdose will make it easier down the road to take on another. In fact, we want our readers to take this information and modify it to suit their own situations, whatever drug is being used. What counts is saving lives. If you want to create effective over-

dose prevention and response programs, you must do as Delaney Ellison suggests in the first installment of his new On the Ground column, “ask the experts”—the users we see day in and day out. Otherwise, such programs will wind up just being further examples of “the narcotics of self-serving political agendas”….those of the other “experts,” the well paid ones. This is the responsibility we harm reduction providers agree to take on— working with users to take the strategies they use to survive, and converting them into effective services that can be duplicated by other providers or made readily available, as is, to other users. So when the “official” experts get together to formulate a planned response to this longneglected killer, overdose, we must be vigilant to ensure that they don’t complicate things in their zeal to appear politic or scientific. If they do so they run the risk of devising programs that are ineffective at best and life-threatening at worst, and if we sit back, proud of ourselves for just getting overdose on the agenda, then we become complicit in the creation of misguided and dangerous policy. On a different note, HRC has undergone a few staff changes. Sara Kershnar, well known to many and one of HRC’s original two staff members, has moved on to collect her Masters in Public Health from Harvard. We wish her much luck and love. She’ll be sorely missed. We welcome Don McVinney as the new Director of Training and Education. Don is a top rank professor, educator, clinician and hard core harm reductionist. We also welcome Amu Ptah, Alvaro Arias, Nankhat Felock and Maria Quevedo (see the masthead for their respective positions). Allan Greig has also left his part time post as editor of Harm Reduction Communication. This is my first issue replacing him, and it’s been a trip. I hope you enjoy it.

—Paul Cherashore

AFTER

THE FALL BY GALE MIKLO

ew Brunswick, N.J. here, trying to give you a perspective after the fall of the Chai Project’s needle exchange program on September 29, 1998. I’m writing not only from the point of view of an injection drug user (IDU) but also from that of a program participant, supporter and member of the Chai Project’s staff as a peer educator/street outreach worker. It’s funny, looking back now on the police raid, on that particular Tuesday evening, realizing how naive and complacent we had become. Diana, our Executive Director, and I were sitting on the back of the Chai Project’s van shootin’ the breeze, paying no particular attention to the streets. Suddenly, out of no where, a dark nondescript van pulled diagonally across our path, and men jumped out, shouting, “this is a raid, don’t move, put your hands where we can see them.” It wasn’t the local New Brunswick police but rather Middlesex County Prosecutor’s

Office Narcotics Task Force detectives. Oh, and one New Brunswick police officer just to cover the bases. Talk about a rude awakening. We had become all too comfortable in our situation. After all, here we were operating an illegal syringe exchange program out in the open. We even advertised the locations of our exchange sites, specifying the days and/or nights and hours. The local police had been aware of our services for quite some time (years, in fact), plus we’d been receiving a lot of local and statewide press including some national media coverage as well. Michael Beltranena, New Brunswick’s Director of Police Services, had gone so far as to make a statement to the press expressing his admiration at our efforts and determination to save the lives of a segment of New Jersey’s population that is usually discounted, discarded and totally dismissed. This irritated the hell out of our illustrious governor, Christie Todd Whitman, to the point where she “targeted” us for extinction (sounds archaic, doesn’t it?) and she succeeded—to a degree—by

shutting down our needle exchange program. However, much to her chagrin, we received a plethora of press, 95% of it in our favor. Even her own appointed AIDS Advisory Council came out in favor of syringe exchange. The negative effects of New Brunswick’s loss of the exchange program are truly sad and disheartening. Within one week, IDUs were suffering the results of Whitman’s revenge: they were out of clean syringes and sharing with other IDUs. Within one month they were picking used and dirty syringes up off the ground and using them. By this time their syringes were so old, dull and bent that they were not only causing abscesses, they were breaking off in users’ arms, too. Within a couple of months, Diana received a request for collaboration from the Police Director’s Office. It seems that the streets, alleys, vacant lots and even backyards of New Brunswick were littered with discarded syringes. This was never a significant problem before—in the year prior to our being shut down, we took in approximately 47,000 used syringes for proper disposal. Since Whitman had us shut down, we’re no longer able to operate in this capacity; therefore most of the used syringes end up reappearing in New Brunswick, whether it be in the streets, the parks, vacant lots or even in the river. There is currently no way to properly dispose of them without risking arrest and prosecution. The Chai Project agreed to help—after all, our business is harm reduction—go out into town, with a police escort, to clean up in and around the city’s local “hotspots.” Once wasn’t enough, so this is something we still do with police cooperation. The risk to the everyday, average citizens’ children caused the establishment to look for a possible solution to the syringe disposal problem. But neither the politicians nor the public gives a damn about the user, or how the exchange program’s closure affects us. Nor do they care that our lives are more at risk now than ever before, or that the lives of our families and children are also affected. Our lives and those of our children mean nothing since we are just “druggies.” This monthly clean up is not a solu-

Within one week, IDUs were suffering the results of Whitman’s revenge: they were out of clean syringes and sharing with others. tion; it’s part of the problem. If syringe exchange programs were allowed to operate as before, IDUs would have access to clean, sterile syringes. This has been proven to cut the transmission rate of AIDS and hepatitis. Used syringes would once again be properly disposed of in labeled hazardous waste containers, thus reducing the risks to the community and its residents. It would also eliminate the illegal sales and distribution of syringes on the streets, making our streets, parks and yes, even our own backyards, safer and cleaner. Implementing the return of the (Chai Project’s) needle exchange program is really the only feasible answer. Unfortunately, sad to say, that’s not going to happen anytime soon, at least not as long as Christie (a/k/a Witless Whitman) remains in office. She’s condemned us all, not only the drug users but the families

EXECUTIVE DIRECTOR SOUGHT Harm Reduction Services of Sacramento, CA, is seeking a qualified person to direct agency activities. Must advocate for harm reduction. © Master’s degree in health, mental health, psychology, or social services preferred. Progressively responsible experience may substitute. © Demonstrated experience in related health or social services program administration. © Experience in administrative and business management including planning, budgeting, accounting, and personnel. © Experience working with a governing board. © Excellent written and verbal communication skills. Demonstrated success in grant writing. © Knowledge of drug treatment programs and the criminal justice system. Send Letter of Interest and Resume to: Executive Director Ad 1400 S Street, Suite 100 Sacramento, CA 95814 (Please include salary requirements in your letter.)

and the community of New Brunswick also, to risk exposure to a long, lingering illness almost always ending in death. I’m sorry to say this, but she’ll never understand until AIDS hits her family. Just because they’re not IDUs doesn’t give them any special immunity. I hope and pray her family stays healthy and safe. Why can’t she do the same for ours? n The impact of this story would be more dramatic if it ended with the Chai Project discontinuing services. Thanks to the dedication of our staff and participants, nothing could be further from the truth. The New Jersey AIDS Partnership has funded a peer-based outreach project targeting women at high risk for sexually transmitted infections and HIV. Support from the Tides Foundation helped us to establish a community organizing group that has as one of its goals the utilization of participants’ networks to disseminate information

and supplies. (Indeed, it was the efforts of the members of this group that made the April 29, 1999 Trenton rally in favor of syringe exchange a success. They recruited more than 50 rallyers, and several spoke publicly about their own drug use, their HIV status and the impact the injection-related AIDS epidemic was having on their families and communities.) The Chai Project is still a struggling, grassroots organization. It has continued to survive and in some ways we are doing better work than ever before. However, the results are still devastating; despite everyone’s best efforts, drug users in New Brunswick are, again, at very high risk for needless and preventable disease and injury. —Diana McCague Executive Director, Chai Project Gale Micklo is full-time Junkie, part-time Hooker, Peer Educator, Outreach Worker and Prevention Case Manager. She has been with the Chai Project for two years

ANT WE W OU FOR Y HRC MEMBERSHIP 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. _____ $35 Individual _____ $100 Organizational _____ $150 Senior Member _____ $500 Core Member _____ $1000 Harm Reduction Partner Name: _________________________________________________________________ Organization: ____________________________________________________________ Address: _______________________________________________________________ City: _______________________________ State: _________ Zip Code: ______________ Phone: ( ) _______________ Fax: ( ) _______________ E-mail: _____________________________________________________________

Send all membership subscriptions to: Membership, Harm Reduction Coalition, 22 West 27th Street, 5th floor, NY, NY 10001 phone: (212) 213-6376; fax: (212) 213-6582; e-mail: hrc@harmreduction.org

NEW JERSEY: A GRASSROOTS GROUNDSWELL BY CHR IS L ANIER

ew Jersey is a more dangerous place than you may think. If you live in New Jersey, you have a better chance of contracting the HIV virus than in 44 other states. If you are a woman living in New Jersey, you are more likely to contract HIV than anywhere else in the nation. Newark (#5) and Jersey City (#2) are among the top five US cities for percentage of the population living with AIDS. Nearly two decades into the AIDS epidemic, New Jersey remains the only state in the Northeast U.S. without a provision for legal syringe exchange. The result is a public health meltdown: over 50,000 people infected with HIV—37,000 of whom have AIDS—and 23,000 of whom have already died as a result of the virus. Over 70% of the AIDS cases are among people of color. While IDUs account for only 28% of all AIDS cases nationwide, 47% of New Jersey’s AIDS caseload is directly related to needle sharing, with another 25% of the cases caused by unprotected sex with IVDUs or those with a history of intravenous drug use. That adds up to a total of over 70% of infections directly or indirectly related to intravenous drug use. According to a recent report by the New Jersey Alcohol and Drug Abuse Data System, New Jersey meets less than one third of the need for heroin drug treatment, with 25,665 admissions last year out of a need for over 70,000 slots. This means that the average user’s request for treatment takes weeks to meet. In New Jersey, if you can’t quit dope by

yourself, and you’re not wealthy enough to afford the Betty Ford Clinic, you sure as hell won’t get access to the tools you need to prevent catching and spreading a disease. Where is the Needle Exchange? NJ Governor Christine Whitman opposes needle exchange, stating that it sends the wrong message to children: “Government cannot on the one hand say that drug use is bad and illegal and on the other provide the tools for this destructive behavior in the name of health.” The intransigence of the current administration led to the hostile shutdown of the state’s only openly operating NEP, the Chai Project in New Brunswick. Fortunately, some State legislators have more public health–oriented views, but since 1995 conservative resistance has continually blocked the passage of pending legislation to create needle exchange programs. The inflexibility of the current administration has led to cynicism among many of the legislators, who avoid discussion of needle exchange, fearing Whitman’s vehement opposition. HRC’s New Jersey Campaign to Save Lives Now! (NJCSLN!) does not share their cynicism, and has shown that there is substantial constituency support for needle exchange that has never been mobilized. NJCSLN! is a statewide public education campaign designed to build awareness about needle exchange programs, and develop consensus among the leadership of the most hard-hit communities in support of needle exchange. Since

January of this year, HRC organizers have worked with members of city councils in Jersey City, Paterson and Newark to build a dialogue on needle exchange and drug treatment, with the goal of generating supportive action among elected officials. NJCSLN! is a growing coalition of service providers, health professionals, community leaders and faith leaders, advocating for pending NJ state legislation which would allow a three-year pilot needle exchange as part of a comprehensive HIV prevention program. The Strategy Most needle exchange programs started “underground” and built public support by demonstrating their efficacy. Bold activists in New Jersey took this traditional route of starting exchange underground, but the results did not follow standard history for other parts of the country: a series a vicious arrests led to their total shutdown. Until a more supportive governor presides in Trenton, the pending legislation is the only thing that will allow drug injectors to keep themselves and their families free of HIV infection. In other eastern states, such as New York and Massachussetts, health departments have focused exclusively on outreach to injectors, never acknowledging that general community support for needle exchange is crucial to the success of programs. Instead, the programs are forced to fend for themselves in response to hostile groups and self-promoters. In New Jersey, with no place to look but UP, NJCSLN! is targeting entire

communities. NJCSLN! uses grass roots outreach to New Jersey’s urban communities of color, offering the facts on HIV and its prevention, and the importance of legislation to create legal needle exchange. The strategy combines basic public health education and awareness with political advocacy. In the same way that injectors reduce their HIV risk by implementing safer injection practices, communities reduce their HIV risk by implementing civic action. NJCSLN! hosts community forums, offers street-based HIV risk awareness education, organizes constituent visits to city councilmembers and state legislators and conducts petition and voter registration drives. The work is done by a team of peer educators and volunteers

from over 80 different New Jersey churches, AIDS service organizations and drug treatment programs. NJCSLN! hopes that these efforts can be replicated in other parts of the country. The legislation includes a requirement for municipal resolutions of support before a program could be opened in any area. NJCSLN! has focused on gaining passage of these resolutions in the urban areas of New Jersey hardest hit by HIV. NJCSLN! takes the lead from Frank Fulbrook (a South Jersey-based AIDS activist), who successfully lobbied the Camden City Council to unanimously pass such a resolution last year. The NJCSLN! team researched the positions of city councilmembers in several cities and developed a “vote count”

of those for, against and undecided. Armed with this information, the team conducts intensive outreach to constituencies in key selected areas to turn out support for needle exchange. In every case, the support has been there. NJCSLN! created the impetus for a hearing on needle exchange with the Jersey City Municipal Council, and with the Health and HIV Committees of the Newark City Council. A victory for HIV prevention was scored in April of this year, when the Jersey City Municipal Council passed a resolution supporting needle exchange and the legislation. Introduced by Councilmember Rev. Fernando Colon, Jr., the resolution passed the council 8-0, with one abstention. Numerous people with

NEARLY TWO DECADES INTO THE AIDS EPIDEMIC, NEW JERSEY REMAINS THE ONLY STATE IN THE NORTHEAST U.S. WITHOUT A PROVISION FOR LEGAL SYRINGE EXCHANGE.

AIDS and family members, as well as the Hudson County HIV/AIDS Planning Council, testified at hearings held by the council. Rev. Colon, a Pentecostal minister, explained his advocacy for needle exchange by saying, “maybe if we had had these programs ten years ago, I would still have two of my sons with me. I would have given them the needles myself had I known this would keep them alive.” This resolution has already changed the mood of some legislators, as they are aware that their constituency may have more sophisticated views on AIDS than the governor. State legislators, particularly those legislators from the Jersey City area, cannot claim that the public supports the status quo. To date, 13 state legislators have met with concerned community representatives and NJCSLN! to discuss passage of the legislation. The work in Newark and Paterson continues. NJCSLN! is building support in the faith community, community based organizations and city government. Newark City Councilmember Luis Quintana is determined to pass a pro-needle exchange resolution before the end of the year, and is planning a large public forum on November 20, 1999. This forum, at City Hall, will honor Wynona Lipman—sponsor of the original State Senate needle exchange bill in 1995—who died earlier this year. In Paterson, activists continue to collect signatures, register voters and organize meetings with city council members. Over 3000 signatures have been collected on petitions supporting needle exchange in Newark and Paterson. A major event planned for World AIDS Day 1999 (December 1) is a giant

HOW CAN YOU HELP If you are a resident or work in New Jersey, and would like to know how you can support the New Jersey Campaign to Save Lives Now!, please contact us at 973-596-6066. For municipal resolutions of support for needle exchange in NJ: • Get a list with contact information for members of your city or town council; get a calendar of council meetings. If possible, get the rules for introducing legislation. • Put together a package of needle exchange information for distribution to members of your city or town council. Include a cover letter requesting a meeting. Make lots of copies, because you will have to distribute them more than once. NJCSLN! has sample materials, and can help you get started. • Make appointments with each councilmember. Be persistent, but don’t get mad. Get to know everyone’s secretary! Councilmembers may try to avoid you—that’s OK, decide not to give up. • Get a group of people together who can join you for meetings with councilmembers: people infected/affected by HIV, doctors, someone who runs an AIDS service agency and/or local clergy. • We also urge you to contact your state legislators. You can find out who these people are and how to reach them online at: http://www.njleg.state.nj.us/html98/njmap.htm. Or call us and we’ll find them for you. Ask your legislators (every district has two assemblypersons and one senator) how they would vote on the needle exchange bills. • If you would like to collect signatures in support of the legislation, we can send or fax you a copy of the petition. Over 3,000 signatures have been collected as of August 1st, 1999. • Also check out the NJ Medical School chapter of STAR (Student Activist Response) which has an online sign-on for the petition, and other information: http://students-njms.umdnj.edu/Organizations/Star/. NJCSLN! tactics can be duplicated by anyone. Many legislators ignore the issue of needle exchange because they don’t think people are talking about it. Change their minds! “syringe pickup” in Newark. Volunteers, trained in hazardous sharps pick-up, and armed with bio-waste containers, will go to the streets and alleys to collect used sy-

THE BILLS The bills, A. 1807 (sponsored by Assemblypersons Reed Gusciora, D-Trenton, and Rev. Alfred Steele, D-Paterson) and S. 453 (sponsored by Senators Vitale and the late Wynona Lipman), call for a three-year pilot needle exchange program, implemented by the Department of Health and Senior Services, within a context of comphrehensive HIV prevention, and with available referrals to drug treatment. You can read these bills online at the following addresses: Assembly bill 1807: http://www.njleg.state.nj.us/9899/Bills/a2000/1807_i1.htm Senate bill 453: http://www.njleg.state.nj.us/9899/Bills/s0500/453_i1.htm Senate bill 267: http://www.njleg.state.nj.us/9899/Bills/s0500/267_i1.htm (Deregulates the sale and possession of hypodermic needles and syringes.) You can also request these pieces of legislation by fax or mail by calling NJCSLN! at 973596-6066 NJCSLN! office: Newark: 604 Martin Luther King Blvd., Newark, NJ 07102

ringes. This action will be supported by a press conference, a speak-out at the city council and demonstrations. The message will be clear, “Would you rather have these on your street, or safely disposed of at an NEP?” (If you want to try this in your area, be careful. Not only are used syringes hazardous, but their possession is illegal in most states. Be well-prepared for the risks. The more overtly careful you are about handling the waste, the better you make the point that syringe exchange reduces risks for everyone). n Chris Lanier is the Harm Reduction Coalition’s Director of Community Organizing. For additional information about the NJ Campaign to Save Lives Now! contact Chris at 212 213 6376 x17 or Paula Santiago at our Newark office: 973 596 6066.

CONTINUED FROM COVER

ne of the things outreach workers always tell us is not to use drugs alone. This is an excellent idea but not always a viable one. Being strung out is more about day to day survival and less about partying and being social. Furthermore, we often use drugs in isolation because of the social stigma. All of this makes it difficult for each of us to interact with other users. From experience, I understand why it is safer to use with someone else. For instance, I know I am using too much if the other person is doing one shot for every five I do, or vice versa. Dangerous things can still happen, but at least you have a sounding board. Also, if you are using with someone else or a group of people, this would imply that you want to be around others (or have to because you have no choice) and therefore have to interact on a social level to some degree. If you are using by yourself, the implications are completely different. At least they are for me. When I use alone it is because I want to get as high as I can and not have to be accountable to anyone, or it means I have a habit—which would make it physically impossible to use with someone every time I do a shot. When I make the choice to use by myself, it is usually for the reasons I stated above. It is not because I want to kill myself, and not because I don’t understand how to avoid overdosing, but because I am depressed and because I am bored. For a lot of people I know it is either deeper than that, or it isn’t. Some people are on a suicide mission every time they use. Others just wanna get off. I am pretty clear about my intentions before and after I use, and yet that still does not prevent me from repeatedly overdosing. Going back to the last time I ODed, I was alone all night, while my husband was at work. The agreement was to wait for him to get home so we could get high together, but I was bored and decided I wanted to get a few shots in before he re-

turned. In the five hours he was gone I did a ton of dope, and the fact that I was going to be gowed2 when he got back didn’t seem to matter all that much. In fact, when he finally came home, I was more than gowed—I was unconscious. Despite having fears about calling 911, he realized he could not revive me on his own. We were fortunate in that the cops did not respond to the call along with the paramedics. Like all users, I have heard horrible things about Narcan. But, as I said in the beginning, I am grateful to the paramedic who administered it because if she hadn’t, I wouldn’t be alive. The

nauseous. (I’ve been with people who have been brought back from an OD with Narcan and just hearing the word “Narcan” makes them stand up and bolt for the door.) But no matter how fucked up it felt, if it had not been given to me by someone who knew what they were doing, I wouldn’t be writing this today.

realize that within the harm reduction movement there is a debate among service providers surrounding the pros and cons of the distribution of Narcan. Until we understand the effects of consistent, widespread Narcan distribution, the debate should continue, without hindering users’ access to this potentially lifesaving tool. However, as an opiate user, I also feel it is imperative to let other opiate users know that a shot of Narcan will not revive someone from an overdose every time. Every overdose I have been involved in where Narcan was nec-

One of the things outreach workers always tell us is not to use drugs alone. This is an excellent idea but not always a viable one. paramedic who gave me the shot did not hate junkies. After I had been revived, she was decent enough to explain to me the steps she’d taken to bring me back. First, she took care of my breathing so I didn’t die while she was waiting to see how much Narcan was needed to revive me. Second, my breathing was monitored for over three hours to see whether I needed additonal shots. Getting hit with Narcan is fucked up. One minute you are unconscious, and the next minute you are completely straight. The main thing I remember about it is that I really wanted to get high again, and I couldn’t stop shaking or get my teeth to stop chattering. I was also super agitated, a feeling I spend a lot of time, energy and drugs trying to avoid. Narcan is scary; even the name makes me

essary has required more than one dose, administered over several hours. In fact, it has required repeated injections, and more importantly, someone who knew how to perform resuscitative breathing. Users have learned how to do this through their own self-education and through needle exchange programs that offer CPR training and overdose prevention groups. When you throw Narcan into the mix, you are merely providing an additional tool to prevent a lethal overdose. But it should not be used exclusively in the absence of a more extensive program of overdose prevention and lifesaving tools. n 1 Ed: Vicodan, Percodan and benzodiazepam, like Valium or Xanax 2 Ed: loaded

Understanding Heroin Overdose BY KR ISTEN O CHOA, H E AT H E R E D N E YMESCHERY AND ANDREW MOSS

verdosing is probably the most immediate life-threatening health issue facing injection drug users today. It is a major cause of excess mortality among heroin users in the United States,1 and in many countries, deaths attributed to overdose are equal to or greater than deaths attributed to HIV.2 Despite the number of persons who overdose, the issue has received little attention. In the U.S., very few studies of overdosing exist and few programs are focused on overdose prevention. The issue is only just beginning to emerge. Perhaps the advent of better treatments for HIV has allowed us the space to consider the risks of overdose more carefully, or perhaps the deaths among our peers and co-workers have become far too common. For heroin injectors, overdosing is an occupational hazard. It’s hard to avoid— the fact is that heroin overdose will continue to happen as long as heroin users continue to use. What can be done? While we may not be able to completely prevent overdoses, we can prevent overdose fatalities. No one should ever have to die from a heroin overdose—we have rescue breathing (CPR) and we have the antidote (naloxone). However, there are many barriers that stand between users and these lifesaving measures. Understanding the barriers may be the first step towards breaking them down. Dispelling Myths About Who Overdoses and Why Contrary to widespread views, we found

in our recent study of San Francisco injectors that overdosing is just as common for the seasoned injector as it is for the new initiate.3 Just because someone has a long-time habit does not mean they are safe from overdosing. It’s also just as common for women to overdose as it is for men. Another misconception is that heroin overdoses are often suicide attempts. This is actually very rare. Few injectors intend to kill themselves when they overdose; more often they attribute the cause to just wanting to take too much. Intention falls into a gray area, where there are no plans to OD, but there is a kind of ambivalence about the possibility. The most concise explanation comes from a participant in our study: “Tolerances go up and down, some drugs are more cut than others, someone accidentally can do more.... From what I’ve seen, people who overdose, they don’t have intentions of doing it; their intentions are just getting really high.” Obstacles to Seeking Help in the Event of an Overdose The primary barrier to seeking help during an overdose is fear of police involvement.4 For this reason injectors are usually apprehensive about calling 911. Most, in fact, will try several things to bring the person back before calling 911. Real or perceived, the threat of arrest greatly impacts decision-making at the overdose. According to our participants, using with others, which is common among young injectors in particular, is not necessarily protective, given this fear: “A lot of people freak out and just run away. I’ve made so many friends in the park by finding them blue and bringing them back because everybody just flips out, ‘man, I can’t call the cops because I’m holding and I don’t

want to get caught.’ It’s really stupid because you can call from somewhere way across the scene, but if you did survive it’s because somebody called 911.” According to our study, 71% of injectors have witnessed at least one overdose, so there is great opportunity for intervention because others are often present and can take action to keep the person alive. People need skills to effectively intervene, including CPR training. It is also important for people to know locationspecific details about how to make a 911 call. What you say to the dispatcher, depending on the city and county, will sometimes elicit a police response in addition to an emergency medical response; other times it will not. (See sidebar, Calling 911, p.12.) Policy and the Police Though education about calling 911 is needed, it is not enough. Since we began our study, we have learned of injectors being arrested in different cities as a consequence of their overdose or someone else’s overdose. In Santa Cruz, officers issue citations to program participants at the hospital where they are recovering from an overdose. The problem of police involvement in overdoses is probably the largest barrier to preventing fatal overdose. Many needle exchanges have come to agreements with law enforcement, keeping the police from arresting people in and around their exchange sites. Similarly, we must work collaboratively with the police to insure that they will not arrest, search or charge drug users who have made a 911 call. If this can be accomplished, programs should spread the message to injectors that punitive actions will not be taken if they do call for help.

The cost-benefit analysis of minimizing police involvement at drug overdoses saves both officer time and court costs. If we don’t work with the police, we continue to limit injectors’ access to paramedics and the emergency room, and we continue to lose lives. Though there is still much work to be done in San Francisco, the police generally do not seek prosecution of those present at an overdose. Unfortunately, because users have had bad experiences in other cities, many still do not have faith that it is safe to call 911 here. A participant in our study explains what goes on in San Francisco: “We’ve all experienced when a friend goes out and they don’t want you to call 911, but the police aren’t there to arrest you. The only time they will arrest you for a drug overdose is if you refuse to go with them to the hospital, and they only do that so you will seek medical care. If you have a problem with the cops coming, let the paramedics know and they will listen to you.” Recognizing and Defining the Problem in the U.S. One of the major barriers to solving the overdose problem is recognition. Even when programs and researchers ac-

knowledge and work on overdose, it is usually due to their own interest and initiative. Government and private funding set aside specifically for overdose scarcely exists, if at all. As a result, overdose and ways to prevent overdose are not as well understood in the United States as they are in Europe and Australia. Heroin, the heroin epidemic, the relationship between drug users and the police and between drug users and health care providers, are all very different in the U.S. For this reason it is hasty to conclude that findings in other countries accurately reflect the overdose epidemic here. We must work to better understand our own epidemic in order to create effective prevention strategies at home. Preventing Overdose A comprehensive overdose intervention would include direct service organizations, hospitals, emergency services, police and research. Educational campaigns, CPR and basic life-saving courses as well as grief and loss support should be major components. The distribution of naloxone (the opiate antagonist-aka Narcan) to drug users as part of a larger prevention program should also be explored. Since opiates usually stay on

The primary barrier to seeking help during an overdose is fear of police involvement. Real or perceived, the threat of arrest greatly impacts decision-making at the overdose. board after naloxone has been administered, more than one dose may be required. Following up with a call to 911 or a visit to the emergency room may therefore still be necessary in order to completely bring the person out of danger. Naloxone may buy time for some, but it will not solve the problem for people who inject alone—only an educational program can do that. Outreach and

ARE HIV+ USERS MORE LIKELY TO OD? In Baltimore, the ALIVE cohort study has found that overdose deaths in injection drug users were more common in HIV seropositive individuals than in uninfected injection drug users. (For a description of the study, see note at end). In HIV-positive drug users, AIDS accounted for one half of the deaths. When looking at deaths before AIDS, HIV-positive users were more likely than uninfected drug users to die from sepsis, endocarditis and drug overdose. (Drug overdose was recorded on death certificates, but also confirmed by autopsy from the chief medical officer.) The researchers examined why HIV-positive drug users were more likely than uninfected users to die from overdose. Although this study did not track co-factors that might have been immediately responsible for death, such as the use of alcohol or tranquilizers with heroin, some important trends were noticed, notably that the risk of overdose death increases with duration of drug use. Two plausible reasons are: 1) as HIV-positive drug users become more ill with HIV, they tend to reduce or even stop drug use for a while, and when they start up again, it is possible that they might have reduced tolerance for the doses they may have taken previously, and 2) drug users with late stage HIV infection who have recently had pneumonia might have reduced lung capacity to tolerate heroin (which has the side effect of reducing breathing rates). One possible factor that has been ruled out is the money study participants received for both participating in the study and getting tested for HIV. Time since last study visit was tracked, but individuals who had just participated did not differ in rates of overdose deaths from those who hadn’t been seen in some time–suggesting that the extra money earned from participating in the co-hort (or learning HIV test results) did not lead to doing more heroin, and, in turn, overdosing. More attention needs to be devoted to understanding the causes of overdose, and the interrelationship between injection drug use and HIV. Specifically, additional investigation needs to be initiated to explore these particular findings. Confirmation that HIV+ IDUs are truly at higher risk for death from overdose will hopefully lead to attempts to gain a better understanding of the other factors that may be involved. Note: This is a new finding, but the Alive study uses different protocols than previous studies: it looks at comparisons of drug users by HIV serostatus within the same city, during the same calendar time, rather than solely looking at trends over time. The ALIVE study has been following 3,000 out-of-treatment injection drug users every six months since 1988. The population was 90% African-American, 80% male; 90% were active injectors at baseline with 45% injecting more than once a day. The overall mortality rate was 2.8% per year in a population where the average age was 34 years old. Deaths increased with age, over time, and were more common in men than women. Information supplied by David Vlahov, Ph.D., Director of the Center for Urban Epidemiologic Studies, New York Academy of Medicine.

education can also offer tools for dealing with less severe overdoses that do not require naloxone, as many people are revived simply with rescue breathing or by their friends keeping them awake. One of harm reduction’s strengths is its pragmatism and realism. Harm reductionists are generally aware of the need for integrative approaches and are wary of single solutions. If naloxone alone were provided to injectors, would it prevent people from accessing emergency services? More work must be done before we understand the complexities of naloxone distribution. Only one Australian study has evaluated the acceptability of naloxone among drug users, but there is no published study of naloxone use itself. It is a more difficult task to raise consciousness and create change among drug users and emergency authorities than it is to simply give out vials of naloxone. Programs that can do both are likely to provide a longer lasting, more fail-safe method of curbing the overdose problem. n Kristen Ochoa (kochoa@itsa.ucsf.edu) is Project Director and Andrew Moss is Principal Investigator for the University of California, San Francisco’s UFO Study. Heather EdneyMeschery (scnep@got.net) is Executive Director of the Santa Cruz Needle Exchange Program. The UFO Study is a collaboration between UCSF, the Haight Ashbury Youth Outreach Team and the Santa Cruz Needle Exchange. The Santa Cruz Needle Exchange routinely provides overdose prevention trainings to participants and high school students in Santa Cruz County. The UCSF Department of Epidemiology and Biostatistics has been studying overdose in young injection drug users for three years.

1 Heroin Abuse in the United States. Rockville, MD: U.S. Department of Health and Human Services; 1997. 2 McGregor C, Darke S, Ali R, Christie P. Experience of non-fatal overdose among heroin users in Adelaide, Australia: circumstances and risk perceptions. Addiction 1998 93 (5): 701-711. 3 Ochoa K, Hahn J, Lum P, Page-Shafer K, McLean R, Moss A. Overdose common among young injection drug users. American Public Health Association 127th Annual Meeting, Chicago, IL, 1999 (abstract). 4 McGregor.

CALLING 911: PARAMEDICS & THE COPS Many of us are afraid to call 911 when someone we know ODs. You may have had a bad experience with cops or paramedics, or heard horror stories from others. But if you don’t know how to do rescue breathing and/or CPR (or don’t want to), and you don’t have naloxone or Narcan, calling 911 may be the only way to save the person’s life. Here are a few tips, some suggested by paramedics, some by other users, that can help you get through this stressful situation with a minimum of grief. Some of the suggestions appearing below may seem obvious upon first glance. But after conducting focus groups on heroin and overdose it’s become apparent to me that a public discussion on these topics can both reduce the risk of get busted for those who choose to intervene at an OD and help save lives—which is, of course, the object here. Remember, though, every locale has its own protocols. Just because San Francisco rarely dispatches the police doesn’t mean that it works that way in your suburban community. In fact, in both Chicago and New York, police are usually dispatched to overdose calls.1

THE CALL… l Lots of noise in the background, or yelling and screaming, can cause the dispatcher to send the cops along for crowd control. Be as calm as possible (which I realize is often difficult given what’s happening—but try anyway), and before you speak to the dispatcher tell anyone else in the room to be quiet. l Be clear and concise. Tell the dispatcher someone has stopped breathing. That’s enough to get the paramedics zipping through the streets. l If you’re calling from a location that’s been the scene of prior calls for ODs, the dispatcher will often know this. Most 911 systems—especially ones in big cities—are computerized and keep records of these kinds of things. (They may keep records of calls where paramedics run into trouble, too.) If they ask you if it’s an overdose, don’t lie; it might make them more suspicious. You can say you think the person took something, but you’re not sure exactly what it was. l If they’re asking too many questions, you can always say you’re alone with the person and you have to get back to doing rescue breathing. Just make sure you’ve given them the address, phone number—if there is one—and instructions on how to get into the building. (If you’re squatting, send someone out to the street to wait, if you can.)

YOU HAVE WARRANTS, ABSOLUTELY CANNOT STAY AND NO ONE ELSE IS AROUND… You can still call 911, using any of the above tips that are relevant. If you’re on the street or in a park, calling from a pay phone is pretty anonymous. l If you can do so without hurting your friend, drag him into the street, or the building doorway, if inside; l

the easier it is for the paramedics to get to him, the better. l Keep up the rescue breathing for as long as possible. It will give your friend extra time. Stick around until you hear the sirens close-by. l If it’s happened on the street, or you brought your friend outside, before you leave try to get a passerby to help. l If you can’t move your friend, you can stay until you hear the sirens get really close, then split. Just make sure help can get to your friend: leave the door open, put a note up, etc. A final suggestion: if it’s not your place and there’s a fire escape or back door, you can always wait until the last minute and duck out the back way.

WHILE YOU’RE WAITING… Continue rescue breathing. If for some reason you can’t do rescue breathing, try to wake up your friend—shaking by the shoulders, yelling his name, etc. l If your friend wakes up, and you’re really afraid of the police coming, you can cancel the 911 call. Because a person can go out again after waking up, it’s a important to take your friend to the emergency room. This way, if he ODs again he can get proper medical care. Another suggestion, which may already be standard practice for many of you: hide your shit, especially anything that might have residue—like cookers, cottons, empty bags, etc.—before anyone comes. And coming up with a uniform story in advance may save you from getting caught in any lies to police or paramedics; I once went to jail because my friend told the cops stuff that contradicted what I said. l l

WHEN HELP ARRIVES… l If it’s just paramedics: The paramedics don’t care what someone has taken; they’re there to help. With paramedics, saving lives is a point of pride. Give them as much info as possible: what the person took, whether they were already on anything else, any medical conditions you know about, etc. (You can always say you just got there, but the guy who just left told you what happened.) l If the cops come too: Generally paramedics are pretty smart and can figure out what’s happening medically on their own. Sometimes, though, when a person is really overdosed, or has taken drug combinations, it’s not as obvious. Even if you have to pull the paramedic to the side to inform them of the substances taken, this can make a difference in the outcome-especially if more than one drug is involved! The key here is to remain calm, not have any attitude, be polite and be as honest as you can without getting yourself into trouble.

In the end, if you save a life, it will be worth it. 1 Oral communications by Dan Bigg and a NYPD public affairs officer, respectively.

5th National Harm Reduction Conference Sponsored by the Harm

Reduction Coalition

November 11-14, 2004 New Orleans Astor Crowne Plaza Hotel

New Orleans, LA PREVENTING HEROIN OVERDOSE: PRAGMATIC APPROACHES JANUARY 13-14, 2000 SHERATON HOTEL, SEATTLE, WA Sponsored and presented by: Alcohol and Drug Abuse Institute, University of Washington, Seattle; The Lindesmith Center, New York and National Institute on Drug Abuse, Washington D.C. Heroin overdoses and overdose fatalities are increasing in North America and around the world. Many of these are preventable, often with simple and inexpensive interventions based upon scientific research, epidemiological and ethnographic insights and common sense. This two-day conference brings together leading experts from around the world—scholars, service providers, users, outreach workers and others who deal with and are affected by heroin overdose—to present and discuss: Risk factors and epidemiology of heroin overdose; Treatment modalities; Outreach and education; Naloxone distribution; The roles of researchers, emergency medical services, law enforcement and families and friends of overdose victims. For complete information and registration: http://depts.washington.edu/adai/conf/heroin.htm or email Nancy Sutherland, adai@u.washington.edu THE FIRST INTERNATIONAL CONGRESS ON WOMEN & DRUGS SUNDAY APRIL 9, 2000 HOTEL DE FRANCE, JERSEY, CHANNEL ISLANDS, BRITISH ISLES Presented by the International Network On Women & Drugs For additional information: Email: women@hit.org.uk Web: http://www.jersey2000.co.je/seminars.html#womsat

IITH INTERNATIONAL CONFERENCE ON THE REDUCTION OF DRUG-RELATED HARM APRIL 9-13, 2000 HOTEL DE FRANCE, JERSEY, CHANNEL ISLANDS, BRITISH ISLES Presented by International Harm Reduction Association For complete information and registration contact: International Harm Reduction Association c/o HIT Conferences First Floor, Cavern Court 8 Mathew Street, Liverpool UK L2 6RE Tel: +44 (0)151 227 4423 Fax: +44 (0)151 236 4829 Email: ihra@hit.org.uk Web: www.jersey2000.co.je NORTH AMERICAN SYRINGE EXCHANGE CONFERENCE X APRIL 26-29, 2000 PORTLAND, OR Presented by North American Syringe Exchange Network For additional information contact NASEN at: Tel: (253) 272-4857 Email: nasen@seanet.com Web: www.nasen.org 12TH INTERNATIONAL CONFERENCE ON DRUG POLICY REFORM MAY 17-20, 2000 WASHINGTON PLAZA HOTEL, WASHINGTON, DC Presented by Drug Policy Foundation For additional information contact: Tel: Whitney Taylor, (202) 537-5005 Email: conferences@dpf.org Web: www.dpf.org/html/conferences.html

UPCOMING CONFERENCES

For more information contact Paula Santiago, HRC Conference Organizer: Tel: 212-213-6376, extension 15; email: santiago@harmreduction.org

RESCUE BREATHING: THEY CALL IT THE KISS OF LIFE… If you are going to call 911, first check the person carefully for any drugs on their person. It would suck to be resuscitated, only to be arrested. Note: These instructions are not a substitute for real-life training; check with your local NEP or Red Cross for classes in CPR. STEP 1: CHECK RESPONSIVENES 1. First, tap then shake the person’s shoulder. If that doesn’t work try pinching an earlobe or fingertip. 2. Ask “Are you O.K?” Shout the person’s name; shout, “Wake up!” If no response, continue.

∂

STEP 2: CALL 911 (get EMS in motion) 1. Ask someone to call 911. 2. If alone, yell for help. If no one comes, call 911 and quickly return. SECONDS COUNT!

∑

STEP 7: NEXT, CHECK FOR PULSE (See illustration) 1. DO NOT USE THUMB—It has its own pulse. 2. Maintain head tilt. 3. Feel on neck for pulse using 2 or 3 fingers using hand nearest person’s feet. 4. Take 5-10 seconds to feel for pulse.

Perform rescue procedures based upon findings. IF THERE IS A PULSE BUT NO BREATHING 1. Give 1 rescue breath every 5-6 seconds, 10-12 a minute. Use same methods as STEP 6 above, but only give 1 breath at a time. 2. Check to make sure there is a pulse, every minute. 3. Continue until person revives, OR Trained help, such as emergency medical technicians (EMTs), arrives and relieves you, OR You are completely exhausted. IF THERE IS NO PULSE, GIVE CPR.

STEP 3: ROLL PERSON ONTO BACK 1. Do this as gently as possible to avoid injury.

∏

STEP 4: OPEN AIRWAY (Use head-tilt/chin lift method-see illustration) 1. Tilt head back with your nearest hand by applying backward pressure to person’s forehead. 2. Place fingers of other hand under chin bone and lift. Do not use your thumb to lift the chin. 3. Tilt head back WITHOUT closing mouth.

STEP 5: CHECK FOR BREATHING (Take 3-5 seconds-see illustration) 1. Place ear over person’s mouth and nose while keeping airway open. 2. Look at chest to check rise and fall: listen and feel for breathing.

∫

STEP 6: GIVE 2 SLOW BREATHS (See illustration) 1. With head still tilted back, PINCH nose shut. 2. Take a deep breath; seal lips around person’s mouth. 3. Give 2 slow breaths, each lasting 11⁄2 to 2 seconds (take a breath after you give one). 4. Watch chest to see if breaths go in. 5. Allow chest to deflate after each breath. 6. If neither breath went in, TRY AGAIN! 7. If the 2nd attempt fails check for windpipe blockage, usually caused by vomit obstructing the airway (see box on Heimlich manuever on next page for instructions for clearing airway).

If this doesn’t work give 2 more rescue breaths!

STEP 8: CPR: FIND HAND POSITION (See illustration) 1. Slide fingers up ribcage nearest you to the notch at the end of sternum. 2. Place your middle finger on the notch and index finger next to it. 3. Put the heel of other hand next to index finger. 4. Remove hand from notch and put it on top of hand on chest. 5. Interlace, hold or extend fingers up.

DO 15 COMPRESSIONS (See illustration 9, below) 1. Place your shoulders directly over your hands on the chest. 2. Keep arms straight and elbows locked. 3. Push sternum straight down 11⁄2 to 2 inches. 4. Do 15 compressions at a rate of 80 per minute. Count as you push down: “one and two and three and four and five and six and seven and…fifteen and.” 5. Push smoothly; do not jerk or jab; do not stop at the top or at the bottom. 6. When pushing, bend from your hips, not knees. 7. Keep fingers pointing across person’s chest, away from you. GIVE 2 SLOW BREATHS Complete four cycles of 15 compressions and 2 breaths (takes about 1 minute) and check the pulse. It there is no pulse, restart CPR with chest compressions. Recheck the pulse every few minutes. If there is a æ pulse, give rescue breathing. GIVE CPR OR RESCUE BREATHING UNTIL… Person revives, OR Trained help, such as emergency medical technicians (EMTs), arrives and relieves you, OR You are completely exhausted.

MAKE A PLAN TALK WITH YOUR PARTNERS TO WORK OUT A PLAN IN CASE ONE OF YOU OVERDOSES. Obviously, the time to talk is when all of you can talk. Among the questions to consider are: ÁWhen should someone take action? (How slow should the person’s breathing be? If which part of them is turning blue?) ÁWhat’s prefered regarding calling 911(Immediately, or should resuscitation be tried first?), the use of CPR (If it’s not working, at what point is 911 called or Narcan used?) and trying Narcan (Where/how administered? How much - 1mg or less, multiple doses?)? ÁWhat should be done after the person resumes breathing (What kind of support is desired? Will the person go to the ER?)? ÁWhat’s the plan when the naloxone wears off (Do you go to the ER? Who will stay with the person? What’s to be done if the person’s really dopesick afterwards?)? ÁIs it OK to remove your partner’s ID, in case he or she has outstanding warrants? If you’re going to use naloxone or Narcan, make sure you have a kit made up, and put it in a place where everyone can find it. It’s a good idea to have a short instruction sheet, especially something written that gives the proper dosage info. (Narcan/naloxone comes in different strengths and container sizes, and syringes also differ in capacity. It can sometimes get pretty confusing.) If you have a CPR cheat sheet, that’s even better, too.

REMEMBER, THE MORE YOU PLAN OUT IN ADVANCE, THE LESS ROOM THERE IS FOR ERROR AND PANIC IN THE EVENT OF AN ACTUAL OD!

HEIMLICH MANUEVER: FOR THE PERSON WHO’S CHOKING ∂

STEP 1: GIVE UP TO 5 ABDOMINAL THRUSTS (Heimlich manuever—see illustration) 1. Straddle person’s thighs. 2. Put heel of one hand just a few inches above belly button and well below sternum’s notch (fingers of hand should point toward person’s head). 3. Put the other hand directly on top of first hand. 4. Press in and up—5 quick independent thrusts. Note: For a pregnant woman or obese person consider chest thrusts—see below.

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STEP 2: FINGER SWEEP (On unconscious person only—see illustration) 1. Use only on an unconscious person. On a conscious person, it may cause gagging or vomiting. 2. Use your thumb and fingers to open mouth and pull tongue away from back of throat and away from object. You can do this by grasping person’s jaw and tongue and lifting upward. 3. With index finger of other hand slide finger along inside of one cheek deep into mouth, using a hooking action to dislodge object. 4. If foreign body comes within reach, grab and remove it. DO NOT FORCE THE OBJECT DEEPER. If the above steps are unsuccessful… CYCLE THROUGH THE FOLLOWING STEPS IN RAPID SEQUENCE UNTIL THE OBJECT IS EXPELLED OR EMS ARRIVES 1. Give 2 rescue breaths. If unsuccessful, re-tilt head and try 2 more breaths. If there is no pulse, perform CPR too— see Step 8, Rescue Breathing, on preceeding page. 2. Do up to 5 abdominal thrusts. 3. Do a finger sweep. CHEST THRUSTS FOR PREGNANT WOMAN OR OBESE PERSON

UNCONSCIOUS 1. Kneel beside the person, placing one hand on the center of the person’s breastbone and then placing your other hand on top of it. 2. Give 5 quick thrusts, compressing the chest 11⁄2 to 2 inches. 3. Do a finger sweep (see above), open the airway with a head tilt and a chin lift and give 2 slow breaths. If air still will not go in, continue giving chest thrusts, finger sweeps and 2 slow breaths until the object is expelled and air goes in. If there is no pulse, perform CPR too—see Step 8, Rescue Breathing, on preceeding page. CONSCIOUS 1. Stand behind the person, placing your arms under the person’s armpits and around his or her chest. 2. Make a fist with one hand and put the thumb side of the fist against the center of the person’s breastbone. 3. Make sure your thumb is on the breastbone—not the ribs—and that you are not near the tip of the breastbone. 4. Put your other hand over the fist and give quick inward thrusts. 5. Continue giving thrusts until the object is dislodged. If the person becomes unconscious while you’re doing this, use the method for unconscious people. ONCE THE OBJECT IS DISLODGED If the person is not breathing and has a pulse, perform rescue breathing. If the person is not breathing and does not have a pulse, give CPR. (See Steps 7 and 8, Rescue Breathing, on preceeding page.

NALOXONE AVAILABILITY

Yet Another Positive Change BY DAN BIGG

aloxone is a miracle of a drug: it can bring a person not breathing due to opiate intoxication back to life very quickly. Naloxone availability—ideally over the counter—and its legal possession is a positive change critical to our ability to effectively reduce the epidemic of opiate overdoses in the US. In order to make this a reality, we must confront biases and tendencies towards oppression of people using opiates as well as our own limitations in harm reduction thought. When administered properly, naloxone quickly reverses the respiratory depression associated with an opiate overdose and lasts for a period of about an hour. If given to someone with a tolerance to opiates it can also stimulate with-

drawal symptoms, as well as helping them start to breath in the event they’ve used too much. Naloxone has no impact of its own other than the reversal of opiate effect. It will not reverse an OD caused by non-opiate drugs, nor automatically mean that you will not die of an opiate OD, but it can seriously help to increase the odds of survival and rapid recovery. The major benefit of widespread naloxone availability should be fewer premature deaths from opiate overdose. Additional benefits are also likely from increases in overdose awareness and preparedness, which in turn can lead to the greater practice of overdose prevention measures (modulated injections, more consistent use of care partner injecting dyads, etc.) as well as increased capability and competence in preparing for and treating ODs. The rationale behind this

Not a Silver Bullet B Y R O B E R T S WA R N E R

roper response to opiate overdose can be complex. Professional medical care is always the best option, but there are several obstacles that stand between opiate users and such medical care: fear of police, hostile attitudes from emergency workers and hospital staff and minimal awareness among users of the important medical options available.1,2 There are also many avenues for improvement on existing interventions to heroin overdose. With proper training other injectors, family and friends have the ability to intervene when someone overdoses, and the attention from the harm reduction community to supporting user-based interventions is well deserved. However, because perfect solutions do not exist, excessive attention is given to the role of naloxone (or “Narcan”) in reversing an overdose. The idea

of providing Narcan to the injection drug using community as a cure for overdose is misleading and ill-conceived. Distribution leading to broader access to Narcan wouldn’t pose any benefit in a preventative sense, and it is a dangerous mistake to offer access to this drug as an alternative to professional emergency care. Meanwhile, this discussion is obscuring the most crucial life-saving procedures in overdose response: getting oxygen into the overdose victim’s body is the action which saves lives. Although almost universally purchased in its generic form, Naloxone is most commonly known by its trade name, Narcan. (The difference between generic naloxone and Narcan is price, just like the difference between facial tissue and Kleenex.) Narcan was solely designed to compete with opiates for certain receptor sites in the brain for use in treating opiate overdoses, and as a di-

is clear upon close examination of three points: 1) possession of naloxone inevitably leads to thinking about overdose, and, of course, drug-taking practices that lead to dangerous situations, 2) the use of naloxone is an unpleasant experience for most people—even if it is saving your life—and there is no desire to use it again, and 3) having naloxone on hand means that users potentially have a lifesaving tool at their disposal for immediate lifesaving intervention. The fear that by offering people greater control over their lives—what I would call the essence of harm reduction—leads to greater risk taking is fallacious, as we have learned through years of experience with syringe exchange. Just as providing sufficient access to sterile syringes doesn't necessarily increase people’s drug use, having the antidote to opiate overdose hasn’t led to users doing too much and overdosing. Quite the opposite, in fact. Giving users access to a tool which can prevent unnecessary deaths helps to develop and encourage

self-reliance; self-reliance which is expressed in the form of more deliberate drug-taking and strategies for preventing and dealing with overdoses. This only goes to show that the many distant and removed fears of failure are more evidence of bias, and less powerful than a single observed success in the practical world of the harm reductionist. There are potential risks arising from naloxone distribution, including ineffective use that might delay or prevent sufficient OD treatment. However, negative effects of naloxone use on a person who’s no longer breathing are almost always less harmful than the alternative: death that results from lack of oxygen. In addition, thorough knowledge about opiates, naloxone use and CPR/rescue breathing techniques are excellent tools that can reduce potential harm from opiate ODs and prevent the aforementioned incorrect use from happening in the first place. Obviously, the more training and assistance we can offer people as they become more “overdose compe-

tent,” the better. However, this does not mean that we should deny access to naloxone until someone achieves a certain level of comprehensive overdose treatment competence. Today it is hard to find anyone other than paramedics and ER doctors who has access to naloxone. These health care professionals sometimes use it in ways that punish opiate-dependent users—by administering too much in bringing the patient out of an OD, thereby putting him or her into full withdrawal, or simply

agnostic tool in treating people who are unconscious or not breathing, when the cause isn’t known. Once there, Narcan occupies these sites, keeping the opiate from binding to the brain. The opiate then continues to circulate in the blood supply until it can be metabolized, and ultimately excreted. Narcan will only interrupt the effects of opiates like heroin, morphine and the like. If the drug in question is not made from opium, nor made to act like an opiate, then Narcan will have no effect on an overdose. Narcan is generally thought of as one of the safer emergency medicines. Sometimes, though, Narcan has been found to cause sharp increases in blood pressure, allergic reactions, cardiac arrhythmias and other peculiar side effects, including death. Though these unwanted effects are rare, and Narcan is used broadly, and with a great safety record in overdose resuscitation, like any drug it cannot be thought of as absolutely safe for everyone. One other problem with Narcan is that most opiates last longer than Narcan does. Therefore Narcan usually needs to be administered repeatedly in order to get people through an overdose.

Narcan does not cure heroin overdoses. Narcan is an important tool, one useful part of an organized approach to resuscitating overdoses, which helps in the overall management of the overdosed patient. The cure for a heroin overdose is oxygen, breathing support and airway control, and anyone at the scene of an overdose has all of the equipment they need to provide these things to a person through mouth-tomouth artificial respiration. These resuscitations happen in a prioritized order so that no aspect of life support is overlooked in favor of any other one. Any emergency medical treatment evolves from the basic to the advanced. At the beginning of any emergency treatment are the “ABC’s.” Anyone who has taken a CPR class or first aid training knows that A is for airway, B is for breathing and C is for circulation. Resuscitation doesn’t progress until each is secured in its order, so any emergency medical worker would make sure that A, B and C are being provided for before using any tool like Narcan. Used properly, Narcan restores a person’s drive to breathe on his or her own, and allows

them to become conscious again. Given without proper attention to the ABC’s of resuscitation, Narcan may give the would-be rescuer the illusion of a cure when in reality the patient is still dying. Narcan is not necessary for reviving an overdosed person in the strict sense. It isn’t uncommon that we begin breathing for an overdosed person and they wake up. Many overdoses are currently treated by the friends of the overdosed who keep them awake and breathing by doing painful things to them.3 For people who are deeply overdosed it is important to give Narcan at some point in the course of their resuscitation. However, the administration of Narcan doesn’t change the outcome of the resuscitation at all. The moment when a person’s life is saved or not comes before Narcan is administered. There are clinical studies that show that any patient whose breathing was supported before the paramedics arrived lived through their overdose, while those who died were the ones who had no breathing support, and weren’t breathing when the paramedics arrived.4,5 In order to work, Narcan has to

DRUG USER’S TOOLS OF THE TRADE:

NALOXONE AND NARCAN BY RO GIULIANO

THE SCENARIO You and a friend score some dope (heroin) and go get high. You’re fine, but your friend is beyond nodded and now blue. She has a pulse but is not breathing. Fabulous, you have an overdose on your hands. But you are prepared—you have naloxone (Narcan is the brand name; naloxone is the generic formula)—and know how to do rescue breathing. You would like to avoid calling 911, due to possible police involvement. THE EQUIPMENT Have an overdose kit ready. The kit should include the following: •Muscle syringes…usually 1cc, 23 or 25 gauge—but sometimes 2 to 5 ccs—with a 11⁄2 inch long point. (If nothing else is available an insulin syringe will do, but be careful that the point doesn’t bend or break.) •Naloxone/Narcan…most commonly comes in two different strengths: .4mg/ml or 1mg/ml, in either a singledose glass ampoule containing 1ml, or a multiple-dose vial containing 10ml. Narcan is more often found in the 1ml ampoules, naloxone in the 10ml multi-dose vials, but if you look carefully at the picture on page 17 you’ll see they’re both in the same size (10ml) vial. Because naloxone/Narcan comes in different strengths and sized containers, including some not mentioned here, always check the label first. (Note: This drug needs to be stored at room temperature and kept out of the light.) •Alcohol wipes are a nice touch, as is a small sharps container. Written directions, like cheat sheets on rescue breathing and Naloxone/Narcan administration, are a good idea just in case you panic. Hopefully the number 911 is ingrained in your psyche!

THE PROCEDURE: You’ve tried shouting her name, shaking her, the head chin lift and the whole rescue breathing trip. No luck. It’s Narcan time, baby. You are going to administer 1mg of (1mg/ml strength) naloxone/Narcan intramuscularly. (There is no time to poke around and try to hit a vein.) 1. Have one brand new muscle syringe ready for action: the point must be 11⁄2 inches long in order to reach the muscle. 2. If using a 1cc ampoule, break off the top, and draw up 1mg (1cc) of naloxone/Narcan. If using a vial, insert the needle in the rubber top and draw up the naloxone/Narcan to the 1cc mark (see Measurement Math at right). 3. Choose a site—upper arm, front of thigh, hip/upper butt—and insert the syringe and push down the plunger. 4. IMPORTANT: Begin rescue breathing again. It will take 2-3 minutes for the naloxone/Narcan to take effect. If you don’t continue to breathe for the person she could suffer brain damage, or even die, before the Narcan takes effect. 5. If the person has not begun breathing after 2-3 minutes, administer another 1mg. You can safely administer up to 5mgs to get her breathing; if that amount doesn’t wake her up she’s probably been put out by something other than an opiate. 6. Naloxone/Narcan’s effects may only last 20-45 minutes, so when it wears off your friend may slip right back into an overdose. Be ready to re-administer the drug. You must stay with her during this time and monitor her breathing. 7. Once the person is breathing decide whether you’re going to take her to the hospital, call for an ambulance or see a doctor. Follow up care is needed.

not have a habit they will not experience any withdrawal or ill effects. If, however, they have a habit they can experience extreme withdrawal. This is why S.F.N.E. recommends the 1mg dosing. If you are really afraid and freaked out and want to bring them around immediately—or they haven’t been breathing for a few minutes—then use 2mgs. Be prepared, though, to sit out the awful withdrawal with this person, a withdrawal that may even include violent behavior. Most hospitals and paramedics use 3mgs, which we feel causes the OD victim undue suffering. The whole point of users administering naloxone/Narcan to each other is to have another tool that provides us with the power to reduce drug-related harm—while remaining healthy and retaining our dignity and compassion. Also remember they cannot get high during this time. If they try it will just be blocked and come on when the naloxone/Narcan wears off; this could send them right back into another overdose. One of the most dangerous situations that can arise is when you administer naloxone/Narcan in a situation you can’t control, the person insists on using more after he or she has been revived and a bit later, after the naloxone/Narcan wears off, dies. If you’re unsure whether or not you can prevent this kind of scenario, it may be better to call 911 and let the paramedics take over. One last important point: NEVER, ever use the same ampoule of naloxone for more than one person, and always use a new syringe for each dose. You don’t want to revive someone only to discover you’ve transmitted HIV or hepatitis to the person.

IMPORTANT POINTS TO REMEMBER Naloxone/Narcan starts the breathing process by blocking all the opiates in the person’s system. If the individual does

THE LAW Naloxone/Narcan is not a controlled substance, but federal law prohibits dispensing without a prescription. So, if you get jacked by the cops you’ll get cited for

possessing a prescription drug without a prescription. In S.F. the cops will just confiscate it, maybe cite you and then it most likely gets thrown out of court.

Reprinted from JUNKPHOOD PRESENTS: THE UFO STUDY.

San Francisco Needle Exchange and Harm Reduction Services is a peerbased, community level intervention by and for young injection drug users in the Haight Ashbury district of San Francisco. S.F.N.E. provides the tools and education that our participants need to reduce injection-related illnesses, fatal overdoses and the spread of HIV and hepatitis B/C. We reduce drug-related harm by providing easily accessible, non-judgmental syringe exchange, medical care, abscess and wound clinics and saferusing education at our indoor site three times per week. Our goal is to empower

MEASUREMENT MATH 1ml=1cc Syringes’ capacities are measured in ccs, but some syringes, like insulin and tuberculin, have a second set of markings for measuring the dosage of the medications they are made for administering. To avoid confusion, ignore those markings (called units) and concentrate on the cc markings; otherwise you may administer the wrong dose. (This is particularly true with insulin syringes. Insulin comes in different strengths—U-40, U-100 and U-500, with 40, 100 and 500 units per cc—and syringes are marked accordingly. With 1cc syringes, 40 units on the U-40 syringe=1cc, but 40 units on the U-100 syringe=.4cc.) Tip: 1mg/ml Narcan/naloxone is 21⁄2x as strong as .4mg/ml Narcan/naloxone, so you need 21⁄2x as much of the latter to equal the same amount of the former. (Narcan—but not naloxone—also comes in a .2mg/ml strength; you’d need 5x as much of it to equal the same amount of 1mg/ml Narcan.). The following chart should help: DOSE STRENGTH OF NARCAN/NALOXONE AMOUNT NEEDED (CCs) 1mg 1mg/ml 1cc 1mg .4mg/m 2.5cc 1mg .2mg/ml 5cc 2mg 1mg/ml 2cc 2mg .4mg/ml 5cc 2mg .2mg/ml 10cc

young injectors to protect themselves, educate each other and reduce drugrelated harm within the community.

S.F.N.E. has been doing an overdose management and prevention program for 11⁄2 years with young (under 30yrs old) IDUs in the Haight. Young IDUs have reported saving 16 individual’s lives thanks to the knowledge gained from the S.F.N.E. trainings (rescue breathing/CPR). During 1998 and 1999, 30 young IDUs received the OD management and prevention training prior to our introducing the naloxone component. That training consisted of the what, how and why of opiate, meth and coke ODs (primary emphasis on heroin), 911 protocol, developing an OD plan with injection partners (or alone), plus rescue breathing and CPR training and certification and OD prevention tools. Six months ago we incorporated the naloxone administration training into our instruction plan. We have taught 17 young IDUs the new, naloxone-improved OD management and prevention training course. Currently the two part training consists of the causes of an OD; how it happens/stages of overdose; OD prevention tools such as letting the tourniquet off after you register (to taste the shot), rescue breathing and CPR training and certification; 911 protocol; naloxone administration and most importantly—next to breathing for the person—developing an overdose plan. SHARE DRUGS NOT NEEDLES Ro Giuliano is Co-executive director of San Francisco Needle Exchange & Harm Reduction Services. Thanks to Dr. Dan Ciccaroni, Dan Bigg, Quijaun Maloof and Dr. Pam Ling for all their help.

NALOXONE AVAILABILITY

Yet Another Positive Change C O N T I N U E D F R O M PA G E 16

administering naloxone in cases of nonOD opiate intoxication. It has been suggested that no competence exists to use naloxone outside of the realm of medical professionals. This statement is shortsighted and paternalistic: if the medical profession, in all its wisdom and compassion, were able to handle opiate ODs by themselves, then thousands of people who currently die each year would instead be alive. I believe harm reduction theory suggests that the improvements described here are possible—and essential! The serious alienation/isolation illicit drug users face from society in general—and EMTs, health care providers and police in particular—as well as a medical system which restricts users’ access to naloxone, currently obstructs the potential lifesaving impact of this drug. In certain parts of Chicago (poor areas) and with certain calls (illicit drug user-related) you might as well be on an island when trying to get emergency medical help. Similar situations apply to users living in squats and on the street. In Italy, to counter such problems, thousands of vials of naloxone have been distributed to opiate users by street outreach workers. In the US, a very small number of opiate users have been collaborating with outreach workers to learn about preventing and managing ODs. They have also been given naloxone as part of this training. They appear to be using it to increase their feeling of empowerment, to care for others around them and to save lives! There are people alive today who wouldn’t be if some nonmedical opiate users hadn’t been allowed access to naloxone. Naloxone should be an OTC medication available freely or at minimal cost to everyone who wants it. As it is, limiting naloxone’s availability to medical providers deprives opiate users of hands-on access to an important life-saving tool. Its distribution would potentially prevent thousands of deaths from opiate ODs each year, and it would afford widespread opportunities to bring users the information and practical skills they need to successfully deal with, what are for them, relatively common life and death situations. The future role for

naloxone in harm reduction practice includes over-the-counter availability and wide dissemination of instructions for its proper use. Hopefully this empowerment to manage opiate overdose will be integrated into all places where opiate users are reached and harm reduction is practiced. Ideally, it would be part of a training on naloxone’s benefits and limitations, as well as certification in CPR, rescue breathing, etc. As for calling 911 and solely using CPR, the recommended intervention for lay people: does a typical heroin user have breathing equipment, training, stamina or bottled oxygen and the necessary airway tools to intervene successfully in a respiratory arrest? Is there a medical person in the same circumstances who would be able to perform rescue breathing (without using special equipment) for the length of time needed? I believe the emergency care system is very good, but it does not adequately address the problems illicit drug users all too often encounter when using the system to get help for an OD: excessive response times due to prejudice against drug-related calls, a punitive approach to overdose treatment and the frequent coupling of police presence with EMT response. I am proposing these changes to make the system better than it currently is. Anyone who has lost a loved one to opiate overdose should take notice that these premature deaths can be easily and cheaply avoided if we are willing to face the realities of opiate use and work to give people another tool to preserve life. Understanding and possessing naloxone is definitely part of “any positive change” for opiate users. The more options the user has to manage opiate ODs, the more capacity he or she has for reducing drug-related harm. Naloxone information, training and availability increase the options harm reductionists can offer those looking to reduce drug-related harm in their lives. Sterile syringes, naloxone education and access, better veincare/safer injection information, CPR and first aid training, and as many other options as conceivable should be promoted and expanded as possibilities within the harm reduction movement. Our greatest strength is our willingness to entertain improvements in spite of societal requirements for perfection. I hope

Naloxone’s…distribution would potentially prevent thousands of deaths from opiate ODs each year. we do not lose this perspective as we move to include naloxone or other medical interventions among the possibilities for reducing drug-related harm. I have heard some harm reductionists say naloxone is not a good idea because it incorrectly promises to “solve the OD problem.” I have always felt the beauty of harm reduction is in its ability to learn from the past. Harm reduction has learned that no single approach works for everyone, that any improvement is better than none and that the greater the level of user empowerment and number of options for improvement the better. Anyone who claims to solve every facet of a problem as complex as drug addiction or misuse, overdose, etc. has failed to learn from the past and seems unable to appreciate the power of “any positive change.” Generating as many options to handle overdose as possible is harm reduction’s work. Similarly, access to sterile syringes does not “solve the disease problem” among injectors, as many opponents claim it should, but many of us have fought for the availability of sufficient sterile syringes to help reduce disease risk from injection. Criticism of this variety is contrary to the recognition and practice of improvements in a person’s life as they prescribe them for themselves. Ultimately, the best criticism of the current approach to overdose treatment is the thousands of people who die of opiate ODs each year in spite of the miraculous options available. It doesn’t seem like we can wait for the medical system to respond. All of these issues—overdose, opiates, naloxone—have been around for decades and there is still no medical solution offered beyond the emergency care system. Clearly, there’s little difference from other take-home injectables like epinephrine for allergic reactions, insulin for diabetes, etc. once you strip away the bias against drug users. What is novel is helping drug injectors to

reduce OD risk through medical means as is done with allergics, diabetics, etc.— and such assistance is long overdue. The physician’s Hippocratic Oath would seem to dictate naloxone’s use, but apparently biases against people using opiates have kept it from progressing as a take-home medical approach for years. Opponents of naloxone distribution don’t answer the hard question of cost efficacy, as most medical providers often don’t. Hepatitis B vaccination has been medically recommended for injection drug users since 1982 but is still largely ignored. Why? I would contend that biases against drug injectors and high medication prices have limited this intervention far more than sensible public health practice would suggest. Only good research will answer the question of cost effectiveness with the OD treatment issue. In the meantime we should do all that we can with all of the options available to us. Certainly, our meager resources would more effectively train and provide naloxone use than CPR training. A 10ml multiuse vial of 0.4mg/ml naloxone (generic Narcan) costs less than $3.00, and the information needed to use it well is easily shared. CPR is very resource intensive and generally not very effective for lay people to do in cases of opiate overdose, primarily due to the difficulty in doing it correctly and for a sufficient length of time without equipment. Ideal vs. reality. What is happening

with OD management today? It appears that if not for naloxone and injection rooms (which have shown major reductions in lethal ODs) as the lightning rods, little discussion would be happening now. Many opiate users were talking about OD treatment after the Pulp Fiction thing. Imagine the talk on the street if the movie had portrayed a real treatment for opiate OD: the priority of breathing and naloxone’s correct use. Hollywood screwed up this opportunity, and I can’t help but think that it did it so to avoid the charge that was leveled against the movie anyway: that it glamorized drug use. In the end, Quentin Tarantino dissed the lives of drug users. (In Trainspotting naloxone was used in a sadistic way only after the person was dragged to the ER; this is reality but not all that is possible.) The people most excited about naloxone empowerment and provision are people using opiates. The enthusiasm among many opiate users, resulting from their awareness of naloxone’s possibilities, should be the most significant guide for harm reductionists about its use. Finally and ultimately, your struggle about naloxone availability should include the ultimate test of validity: if you were using an unknown quantity of heroin (as is almost always the case), would you want your injection partner to have naloxone among his/her other options for intervening in case of your overdose? Why not help show all your fellow brothers and sisters the same respect? n Dan Bigg is the Director of the Chicago Recovery Alliance and holds a CRADC addictions certification. Dan has been involved in both the addictions treatment system and the practice of harm reduction since 1984.

If the medical profession, in all its wisdom and compassion, were able to handle opiate ODs by themselves, then thousands of people who currently die each year would instead be alive. 21

NALOXONE AVAILABILITY

Not a Silver Bullet C O N T I N U E D F R O M PA G E 16

get to the patient’s brain. For a paramedic, getting it there is fairly simple. We either use IV dosing, or we use IM (intramuscular) or other types of injections. We can even administer it via their lungs if the situation dictates. The process commonly takes time, and if the patient’s breathing isn’t supported for the duration, the Narcan is too little too late. Even we see delays in the effects of Narcan that last minutes. For the layperson, getting Narcan to a person’s brain could be difficult or impossible. If the patient has been down for any period of time, their blood supply will be shunted away from their muscles. If they’re given Narcan by IM injection, as might be the choice by a layperson under stress, the medicine could sit in that muscle until the patient is dead. Also, you have to consider that there may be some time spent searching for the vial of Narcan, etc., time that should be spent on oxygenating the patient. It has been said that many paramedics and other health care providers give Narcan maliciously. While there may be some people in any profession who are motivated to abuse people, I think that most of the harmful administrations of Narcan can be attributed to inexperience. Most experienced paramedics and nurses I know will see to the airway and breathing needs of a patient, and then carefully give enough Narcan to allow the patient to be conscious, and to breathe for himself. Typically, less experienced workers give medicines exactly as specified in a doctor’s order or in a treatment protocol. Such orders do not typically prescribe a tailored approach to a particular patient’s problem. They are generally simple instructions including the name of the medicine, and the dose or dose range, along with the patient’s name and date and so on. Newer practitioners may not have the sophistication, or may not have seen enough patient responses, to give a medicine like Narcan in the most humane way. Someone who finds themselves at the scene of a heroin overdose with only a vial of Narcan, and lacking proper first aid training and the ability to provide

rescue breathing, would likely give Narcan in a large dose, by the quickest route possible. And, in a sense, people who have little experience with overdose resuscitation could not be faulted for giving it by the quickest route available. Unfortunately, if used too aggressively, Narcan can drive a patient straight from heroin overdose to heroin withdrawal in a matter of several seconds, causing violent withdrawal reactions that on their own can be life-threatening. This would be seriously harmful to anyone with a habit, and would create a dangerous situation where an individual who’s been thrown into a state of agony is suddenly able to walk and become physical. This is a terrifying situation for the patient (not to mention the person giving assistance), and can be dangerous for anyone nearby. I frequently see friends of altered patients who are convinced that the patient is alert simply because they are able to talk, look them in the eye or get up. Without a definite plan, situations like these could get out of control quite easily. A patient who seems alert could walk into traffic, fall down stairs, pick up a knife and hurt their friends (I have seen tremendous violence precipitated by the rapid use of Narcan) or disappear into the night and very quickly become re-overdosed. This is an important consideration, and should be part of discussions about Narcan distribution to laypeople and others. There are additional risks posed by the elements of an overdose that can’t be addressed by Narcan use in the field, and for which the only available treatment is in the hospital. The aspiration of stomach contents into the lungs can often lead to pneumonia. Acidotic blood and tissues, caused by cessation of breathing for a period of time, can lead to a few potentially lethal, delayed problems such as cerebral edema, or swelling of the brain, and non-cardiogenic pulmonary edema, where the membranes in the lungs become leaky and blood serum moves into the air spaces of the lungs. Repeated use of Narcan can be fatal with the former condition, and people suffering from the latter often need to be managed in an intensive care unit. Lastly, many medical problems cause unconsciousness, and could readily be mistaken for hero-

in overdose by a well-meaning rescuer. In such a situation, this confusion would likely delay access to effective help while the rescuer is focusing on giving Narcan. Supporters of easy access to Narcan have made comparisons with take-home injectible medicines prescribed for various medical problems. There are several differences between most of these cases and the problem Narcan has been suggested to address. Take diabetes and bee sting allergies for comparison. Both of these types of patients require medicines that need to be injected. In the case of the diabetic, the patient requires injectible insulin like non-diabetics require water or food. The patient makes insulin injections part of his/her daily routine. This patient is generally supported in the use of this medicine and all the necessary testing equipment that goes with it by an ongoing relationship with a doctor. These patients require frequent followup for changes in their treatment strategy as they respond to changes in their lives. While I would like to see a medical establishment that is willing to engage in this type of relationship with heroin users, I don’t think anyone has suggested that Narcan distribution could become the cornerstone of such change. Rather, I believe Narcan distribution is being suggested as an alternative to currently available medical care. In the patient who has a serious allergy to bee stings, or other environmental toxins, epinephrine is prescribed in an easy-to-use, spring-loaded pen that accomplishes an injection when pressed to

You will set people up to fail if you give them a vial of Narcan without giving them the skills to provide breathing support.

the patient’s thigh. These patients have precious few minutes to receive this treatment, and they generally have one of these epi-pens on their person most of the time. One major difference between this type of take-home treatment and that proposed for Narcan distribution is that patients allergic to bee stings don’t stop breathing. They remain conscious, and identify the problem themselves as their doctor has explained it, and as they have experienced it before. They use the epinephrine, and then go immediately to the emergency room for follow-up care. (As with heroin overdose and Narcan, the problem of anaphylaxis doesn’t stop once the patient has used his or her epi-pen.) Patients with heroin overdoses immediately become unable to help themselves. This is a critical difference. In patients with diabetes or life-threatening allergies, the take-home treatment is prescribed to them, to be used by them, to treat their own illness by recognizing symptoms they’ve experienced before. In the case of heroin overdose, Narcan distribution is more like take-home medical practice to be used by people who have no experience differentiating between heroin overdose and other causes of unconsciousness. These people would be put in a position to make decisions for their friends, in essence practicing medicine. I agree that access to the tools of overdose resuscitation does need to be increased. But the first step toward increased access should be the elimination of the fear of calling 911. This barrier is not insurmountable. By exposing health care workers to the philosophy of harm reduction in their primary training, and by educating police agencies about the effects of their enforcement policies, I think the fear of calling 911 can be reduced. There may be situations where people are using in squats or in places that are otherwise far away from help. For these cases it may be beneficial for the people at this scene to have a vial of Narcan. However, if they choose to use the Narcan in lieu of breathing support, or if they use the Narcan in a way that precipitates withdrawal, they may find themselves in a situation just as difficult as the overdose itself.

The legal barriers to distribution of Narcan to untrained people are sound, and are not the first hurdle that the harm reduction movement needs to jump. Education about risk factors in overdose, post-overdose counseling and a healthier relationship between the injection drug using community, the health care establishment and the police are far more likely to have an impact on the numbers of people dying of heroin overdose. Even as part of our consideration of Narcan distribution, resuscitation training must come first. You will set people up to fail if you give them a vial of Narcan without giving them the skills to provide breathing support. Users and service providers need to know that Narcan is not a magic pill that fixes the situation ala the dramatized resuscitation scene in the movie Pulp Fiction. The distribution of Narcan will be harmful if its use is guided by such notions. It is unfortunate that the focus of overdose intervention has shifted to Narcan. While it is a useful part of the resuscitation, it is one which gets used late in the game, and which should be used carefully, by someone with experience administering it. An informed understanding of the medical care one receives or has access to is important, and this discussion will help to increase the harm reduction movement’s understanding of the use of Narcan. There is much to be done in the primary and ongoing training of paramedics, nurses and doctors to expose them to the philosophy of harm reduction, and to highlight the risks of the improper use of Narcan by newer practitioners. The addition of harm reduction philosophy to training of practitioners will lead to more attention being given to Narcan’s proper use, and eventually to an improvement in Narcan’s role in health care. At best this discussion may help to inform our decisions as we try to deal with the overdose issue. We could be desperate because people are dying, and it seems like every possible solution should be tried until one works. We could be zealous because we think we’ve found the ultimate solution, and any effort spent on any other idea seems like a waste of precious time. And we could be regretful because we saw a situation, did

The cure for a heroin overdose is oxygen, breathing support and airway control. what we thought was best at the time and later found out that our efforts hurt or killed someone. Or we could invite all available expertise to a discussion that ultimately will allow us to reconcile the desperation, zeal and regret into a meaningful effort to deal with overdose. In my years as a paramedic I’ve felt the desperation, I’ve been the zealot and, for the rest of my life, I’ll deal with the regret. One situation at a time, over several years and through thousands of patient contacts, I’ve learned that there is nothing I do as a paramedic that is 100% benign every time. The choice is ours: either to be driven to action by desperation or zeal beyond all considerations of unintended consequences, or to consult expertise and learn from the investigations and mistakes made by others before us, thereby avoiding the consequences of impetuous action. n Robert Swarner is a paramedic field training officer in Santa Cruz, and has spoken frequently on the topic of overdose at harm reduction conferences. He has worked with the Santa Cruz Needle Exchange Program since 1991, primarily doing overdose trainings and fundraising. 1 Hall, Wayne D. How can we reduce heroin ‘overdose’ deaths? Medical journal of Australia 1996; 164:197-198. 2 Darke, Shane et al. Overdose among heroin users in Sydney, Australia:II. Responses to overdose. Addiction; 91(3):413-417. 3 Ibid. 4 Sporer, Karl A, MD, et al. Out-of-hospital treatment of opioid overdoses in an urban setting. Academic Emergency Medicine; 3(7)660-667. 5 Bertini, Giovanni, MD, et al. Role of prehospital medical system in reducing heroin-related deaths. Critical Care

Reprinted from JUNKPHOOD PRESENTS: THE UFO STUDY. JUNKPHOOD â&#x20AC;&#x2122;zine was started by and for young users of the Santa Cruz Needle Exchange Program (SCNEP). For more information about the UFO Study, or to order copies of JUNKPHOOD, call 831.425 3033 or check out their website, www.ufostudy.org.

W IB TR CE H E S’

Starting with this edition, Sara Kershnar will no longer be writing Witches’ Brew. She will be missed here, but I am delighted to be following in her footsteps as “Witch-inResidence.” Like Sara, I am an herbalist in the Western tradition, a harm reductionist and a health educator. I am also a holistic nutritionist, so I’ll be writing lots about herbs and foods that users and other folks might find useful. I love getting letters and email about what works for you. I am especially interested in old family recipes—you know, the home remedies your grandma made you drink or slathered all over you, or the plant your dad knew from the old country, be it Senegal or Sicily or Southern California. — Donna Odierna

This “Witches’ Brew” will focus on the change of the seasons, and how to stay healthy during the cold and flu season. As fall arrives, the light fades and the days and nights cool down. Flu season approaches, and your doctor or the health van folks may suggest that you get a flu shot. Whether or not you choose to get the shot, there is a lot more that you can do to boost your immune system and stay healthy throughout the winter months. First, let’s take a look at foods that bolster the immune system by enhancing the body’s virus-fighting abilities, or strengthen tissues so that microbes of all sorts have more trouble mounting a successful invasion. If you have a place to make your own food, of course, it’s easier to control what you eat, but if you sometimes get prepared food, or even if you mostly eat at free food programs, you may have a choice about your foods. You can also show this column to the people who prepare your food, and ask if they can incorporate some of the suggestions.

FEEDING THE IMMUNE SYSTEM In general, it’s best to eat heavier, warming foods during the colder weather. We tend to want more protein, and we like foods that are rich in fats and oils. Fats are necessary—they keep cell walls strong and better able to fight off invading germs. A little olive oil or butter is good, as are raw nuts and seeds, which also provide protein. Autumn is nut harvest time,when nuts are cheaper and fresher. Go for walnuts, almonds, brazil nuts, filberts (hazel nuts) and seeds—sunflower, pumpkin and flax. Sesame seeds and cashew nuts should be roasted before they are eaten, though. Try to eat at least two tablespoons of nuts and seeds every day, and 3-5 servings of cooked vegetables (a serving is about half a cup), and don’t forget to have

an apple (or other fruit) every day. Get plenty of variety if you can—the more colors on your plate, the better! GARLIC improves circulation, while keeping your tissues healthy and making you feel warmer. It also kills off nasty microbes and boosts your immunity, if you eat it raw or lightly cooked. A clove or more of raw garlic every day should do the trick. Some herbalists place peeled garlic cloves in a jar, cover them with honey and cover the jar, letting the garlic flavor the honey. When a cold is felt to be coming on, the sufferer swallows a whole garlic clove, or takes a spoonful of the honey. GINGER is another warming, stimulating herb. When you’re coming down with one of those tight-chested coughs, hot ginger tea can loosen things right up. Make ginger tea by grating or thinly slicing about 1” of fresh ginger root into a cup, covering with boiling water and letting it steep for 10 minutes before drinking. Hot ginger tea can make you sweat, which is good if you are in a warm, dry place (it can stimulate and break a fever). However, it is not good if you are sleeping outdoors or in an unheated building: if you are not warm enough after the sweating passes you can become chilled. CAYENNE PEPPER gets the circulation going, warms up cold hands and feet and helps the body get rid of toxins. If you put some red pepper powder between your socks and shoes it gets circulation going and makes your feet feel nice and toasty. In fact, GINGER, GARLIC and RED PEPPERS all improve circulation and help to keep your veins healthy and strong. Look for them in Asian, Mexican, Italian and Ethiopian food. SHIITAKE MUSHROOMS, also called BLACK MUSHROOMS, are found in lots of Chinese food. You can also find them dried, in Asian grocery stores. If you eat a few of these several times a week, your body’s anti-viral defenses will be in good shape to fight off the cold and flu virus. WINTER WELLNESS HERBAL SOUP 2 quarts water or broth (Chicken, beef or vegetable. Canned is fine.) 4 or 5 cloves of garlic 1-2 inches of fresh ginger, sliced thin, skin on 4-6 dried shiitake mushrooms 3-4 slices of dried astragalus root (from the herb store or Chinese market. Astragalus looks like the tongue depressors you find in the doctor’s office). A handful of parsley Celery, chopped Carrots, chopped

Hot pepper and salt to taste 2 T sesame oil or olive oil Put all of the ingredients into a pot. Heat to a low boil, reduce heat and simmer at least 45 minutes. Take out the astragalus and the ginger slices. Drink this nice and hot, 4-5 times a week, or every day if you like. Be sure to eat the mushrooms and garlic! FALL TONICS Fall tonic herbs strengthen your system and keep everything working in top form. Burdock root is my very favorite fall tonic tea. It nourishes the liver, the skin, the kidneys and the digestive tract. It has a rich, sweet-bitter taste. Drink burdock daily for up to three months. One great thing about burdock is that it grows like crazy in almost every urban area in the East. Get someone who knows the plant to show it to you so you can have your own supply. You have to be ready to dig, and watch that the place you are harvesting from hasn’t been sprayed with pesticides or rat poison, and is free from dog shit. Cut the roots up into strips and dry them, or buy burdock root at the local herb store. Another great thing about this herb is that you don’t need to boil water to make burdock root tea. It’s good as a cold infusion, and all you need is some dry burdock root, a quart jar with a good cover and some clean water. BURDOCK ROOT COLD INFUSION (no heat needed) 1 ounce dried burdock root 1 quart of cool water Place the burdock in the jar, fill to the brim with water. Cover the jar tightly. Steep 8-12 hours, or overnight, shaking every now and then. Strain (or not) and drink the infusion (fancy word for tea) throughout the day. Make a fresh batch every night, especially if you don’t have refrigeration. Other good winter teas are mint, lemon balm, red clover, oat straw and linden (also known as tilo or tilia, available in Latino groceries). These teas are all made the usual way, with boiling water. Lots of folks report that they always get sick after they kick dope, especially during cold and flu season. Whether or nor you have a detox planned, herbal tea can help you stay healthy during the colder months. COLD SEASON/AFTER KICK TEA Mix together equal parts of any or all of the following dry herbs: echinacea, Siberian ginseng, burdock, pau d’arco, nettles, chamomile, hawthorn berries. Add licorice root to taste (licorice is very sweet). Put an ounce of herbs in a jar, cover with boiling water and cover the jar. Let it steep for at least 20 minutes (2-4 hours is best), strain and drink throughout the day. If you do get sick after all of this, your symptoms

are less likely to be severe, and they won’t last as long. Your recovery time will be shorter, too. TO FIGHT OFF A COLD OR FLU At the first sign of a cold—fatigue, achiness, tight chest or sniffles—try one or more of these things to boost immunity and stay healthy: —Vitamin C, 500mg every 4 hours, to bowel tolerance (if you get diarrhea, stop taking it or reduce the dose). —Echinacea, 30-60 drops of tincture, or 1 capsule, every 2 hours until symptoms subside. If you do take echinacea in tea, be sure to get “aerial parts,” because the roots don’t make good tea. (Note: Echinacea stimulates white blood cell activity, and some unconfirmed research indicates that this may worsen some auto-immune conditions like HIV. People with HIV infections, especially new infections, should take this into consideration when deciding whether or not to use echinacea.) —Ginger or linden or mint tea, 3-4 cups per day. —Drink lots of water—8 or more glasses a day, to keep mucus thin and flowing. Thick mucus is a favorite breeding ground for germs and microbes. —Stay warm and dry and get lots of sleep. —A Chinese remedy called “Yin Chiao” is great for fighting off a cold. It’s inexpensive, and you can get it at Chinese herb stores and many health food stores. Fall is a good time to start turning our energy inward, in preparation for winter. It’s a good time for contemplation, and for self-assessment. By mid-December the temperature has dropped, the nights are long and the leaves have fallen. Growing things go dormant and conserve energy in their roots. We can learn from their example, and use this time to pay attention to our inner needs. What do we need from our relationships, what can we do to keep ourselves healthy and happy as we define those things, what can we do to start filling empty places and unmet desires? If we turn our thoughts inward now, we will be prepared to take action in the spring, when the light begins to return and everything begins to move again—our energy flows much as the sap rises in the trees to meet the warming sun. Please send your comments and suggestions to: Donna Odierna c/o HRC/Witches’ Brew 22 W. 27th St., 5th Floor, New York, NY 10001 FAX: 212 213-6582 EMAIL: hrc@harmreduction.org

Donna Odierna is a herbalist, nutritionist and health educator. She is in private practice and also works with IDUs at Casa Segura in Oakland, CA.

BY DEL ANEY ELLISO N

arry Dean was a Syringe Distribution Outreach Worker and he overdosed in Benton Harbor last summer. He was up on what it was like to be treated like shit. Larry Dean knew something about the drug policy and civil war on drug users that may be news to some. He knew, in the north amerikan nightmare, that most of the problems faced by drug users stem from the way they are treated by drug treatment providers, the criminal justice system and society at large. He did not die alone. He died in the arms of another outreach worker. I have

nority neighborhoods into armed camps. Ironically enough, the current paradigm pervades the way we deal with people who don’t meet our provider-centered standards. Larry Dean understood this. Usually, Larry would deal with those individuals no one wanted to fuck with. Remember, he knew something about being treated like a sub-human! He knew that sometimes even we, the harm reductionists, the outlaws, could ask the people we served to trust us without giving them any reason to trust. We could place conditions, like pointless one for one exchange on the number of syringes supplied to them, without concern for their very real injection needs, or require

homes. He didn’t talk about it in debriefings. He wouldn’t do that. He just made secondary distribution work. He told us one day, “Nobody can sell sets in the dope house, I got that covered!” We didn’t believe him, or we didn’t want to because we were supposed to be in touch with the street. But people began to return 40-50 used syringes, capped, in the plastic bags he distributed. When the subject of re-sale came up, he ended the discussion with, “That ain’t none of our business.” Larry Dean did not care that drinking alcohol reduced vitamin k (clotting factors) in the blood and accelerated the absorption of the drug, although he

On the

g r Oun d to hope if he were to choose, he’d have chosen this way. Larry knew, though he never said it, that even the people he worked with could have been bombarded so long with the war on drugs propaganda that even the most intelligent and sophisticated of us have internalized the lies. The most pervasive and basic of the lies has to do with the way drugs/alcohol have been carefully and historically linked to African American, inner-city males to the exclusion of other groups. This paradigm allows criminal justice to violate the constitutional guarantees of all of this country’s citizens. Forgotten is America’s early history of opiate use. At the turn of the century, white, middle-class men and women represented the major consumers of morphine derivatives. This middle class got their dope from the pharmacist with a prescription from a doctor, not from neighborhood kids! Ignored is the history of ever repressive drug policies where the illegal black market has turned mi-

them to choose goals we thought were appropriate. He realized that we often only offer people the same compassion they get in the dopehouse, from dealers: “Come to us, we’ve got what you need, but you must meet us on our terms! And don’t bring no change… that’s right, one for one.” He knew that the propaganda of the war could affect even us, and insidiously, the people who we serve! He knew that users could think of themselves as sick, weak people. He knew that people could be made to feel like they are worthless because they don’t want to “get clean,” instead of being treated like the people they wanted to be! Larry knew that providers, faced with the HIV health emergency, were capable of drawing lines and retreating in the face of funding restrictions, government guidelines and the politically correct precedence. He was willing to do something about it. Larry Dean helped us all by managing the secondary distribution occurring in shooting galleries and people’s

had heard all kinds of safe injection conversations and participated in trainings. He didn’t care about his tolerance levels. Larry hit a lick, copped and slammed a bag of excellent quality heroin into his acupital. We watched him do this a hundred times before; this time he died. What was important to him was real essential. It has to do with his friends dying horribly, needlessly, alone... because no one cared about them, or because many had the idea reinforced that they were too damaged and dangerous.

e didn’t pay attention to what I’d learned watching him change from stinking homelessness to having a stable apartment and taking regular showers. It didn’t seem to matter to him that consciously or unconsciously I treated him differently, better, as he changed. (Yeah, you right, I’m guilty.) I experienced a subjective lesson in the phenomenon of harm reduction. I’d silently opposed the outreach team’s

nomination of smelly Larry. It was their decision; I don’t vote. We have the conclusive evidence that harm reduction is practiced by all of us, all the time, as I watched Larry offer his knowledge and safe injection tools to the ones no one wanted to be bothered with, while he took better care of himself. Threatened with long and brutal incarceration, suspected and coerced by boy/men playing law enforcement, excluded from providers and treated like shit, users play this intricate game. When it works, there’s nothing sweeter— and they don’t stop copping! Larry changed clothes and became a street corner activist, the most effective kind. This is not a story of loss. We have been de-sensitized to loss. This is about how we, front line workers, need to learn to take care better care of each other. We ought to be able recognize that doing the work is the most rejuvenating, rewarding thing we may ever do! We can reject those notions about needing to “take a break” from the work! We’ve been challenged to participate in the effort to address the reasons why people use drugs. The list includes racism, poverty, stigmatization, homelessness, sexism and homophobia. Our response must be relentless! We can take the examples from those of us who live and breathe this life-saving effort and learn a better way to live and interact with those on the fringes. To accomplish this we must do what Larry knew to do: we need to ask the experts! We have to go into the environment uninvited asking, “Where are the problems and how can we help?” This is not a memorial. No, these words are written to awaken us to the narcotics of self-serving political agendas. This is about the, seamless, wrap around brutality of the hunches inherent in the rigid, white, male, middle-class, disease model for understanding and treating users. It becomes self-defense when we advocate for control of services that are supposed to help, but continue to harm. This is about Larry Dean, La La, Tracy, LC, Abba Dabba, these experts and all of us... ultimately. Here on the ground. n

HRC’s THE STRAIGHT DOPE education series meets your need for accurate, practical and nonjudgmental information in straightforward language on drugs and drug use. H is for Heroin, C is for Cocaine, and S is for Speed each describe their respective drug and the forms in which it comes; how it is used; its physiological and subjective effects on the body and the mind; tolerance, addiction, and withdrawal; detoxification; overdose prevention and management; legal issues; and stigma. Written by users themselves, each gives an honest account of the benefits that users report as well as the risks, dangers, and negative effects of their use. 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. Hepatitis ABC describes the latest scientific knowledge on the differing forms of hepatitis: their respective causes, symptoms, and prevention and treatment options. Getting Off Right is a plain-speaking, how-to survival guide for injection drug users. Written by drug users and service providers, it is a compilation of medical facts, injection techniques, junky wisdom and common sense that aims to provide the necessary information to keep users and their communities healthier and safer. STRAIGHT DOPE brochures can be bulk purchased at 15 cents each. Orders of more than 50 brochures add $3.00 shipping ($5.00 international). Getting Off Right is available at $5.00 per copy for 1-10 copies, $4.00 per copy for 11-50 copies, and $3.50 per copy for more than 50 copies. Add $3.00 for shipping ($5.00 international). Please send me: Description H is for Heroin Overdose C is for Cocaine S is for Speed Hepatitis ABC Brochure Shipping—US/Canada Brochure Shipping—Internatl Getting Off Right (1-10 copies) Getting Off Right (11-50 copies) Getting Off Right (50+ copies) Getting Off Right Shipping—US/Can. Getting Off Right Shipping—Internt’l

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Delaney Ellison is the Harm Reduction Coordinator at Community AIDS Resource and Education Services, Kalamazoo, Michigan.

Send orders to: Brochures, Harm Reduction Coalition, 22 West 27th St., 5th fl., NY, NY 10001

GIMME SHELTER: DRUG BY SANDR A FUENTES AND DALIAH HELLER

Sharon and Cindy first met at a welfare SRO (Single Room Occupancy) hotel. They hit it off right from the start, being how they were both HIV-positive and addicted to heroin and smoking crack. Both got syringes from a needle exchange called CitiWide Harm Reduction, which went to SROs once a week. Both took turns making money on the hoe stroll and cashing in their food stamps. Cindy and Sharon shared the same dream: to get their own apartment. They felt with an apartment they could learn responsibility such as paying the bills, being able to cook and spending money on buying things for the apartment instead of drugs. Having an apartment would lead to being able to detox, because having an apartment was worth getting clean for. SRO hotels were all the same: small, roach-infested, drug-dealing and the majority of the time you got your room robbed. You also risked infection because of uncleanliness —sharing dirty bathrooms and showers. Well, Sharon was in a 21-day hotel, like Cindy, only her 21 days were up. She had to go back to Division of AIDS Services (DAS) to get re-housed at another hotel. So she got up and luckily saved some of her dope for the morning in order to go through the procedure to be re-located, which was an all-day process. She said goodbye to Cindy, and they figured they would meet up in the next hotel. You see, when you’re on welfare, you get shuffled around from hotel to hotel, and even if you find a permanent hotel you still have all of the above-listed problems, plus no medical care or case management. Sharon was lucky. Because when she got rehoused she was placed in another hotel where the program did outreach and needle exchange, she was able, through CitiWide Harm Reduction, to get into detox and eventually obtain an apartment. This allowed her to feel a sense of accomplishment. It wasn’t that simple, though. She went through brick walls in finding the apartment. She had to get welfare’s approval, then she had to wait for rent and security checks, and it wasn’t until losing two apartments that she finally got a case worker who processed her papers in time. Real estate agencies don’t like dealing with welfare because there are so many technicalities – it’s like

they try to make you lose hope or test your patience. But with a little help from a lot of friends, Sharon stuck it through to finally be in a place she could call home. Cindy, on the other hand, wasn’t as lucky as Sharon. Cindy missed her re-certification appointment because the hotel clerk didn’t give her her mail until a week later, so her room was closed, and she was told to go back to DAS. You see, in order to maintain an open case with DAS you have to show up for a re-certification appointment when they ask you to, which is usually every six months. But if you don’t get your mail wherever you’re staying, which happens pretty often at the hotels, then you don’t know when your re-certification appointment is. And if you don’t show up for that appointment, then they “close” your case, and the hotel management can throw you out into the street. So Cindy had to go to DAS to get back into the emergency housing system, only she was sick and needed to get straight. Except now, out in the street, she didn’t have access to needles, or the money to buy them. (Around the neighborhood where her hotel was at, there weren’t any street needle exchanges). She had to use used works or works she found because she was too sick and didn’t care how she got them—as long as she got straight. Stuck out in the street, Cindy was running again, taking each day as it came, trying not to get too sick so she could make enough money to get straight. She lost touch with CitiWide because she fell out of the hotel system, and she didn’t know where their office was because she’d left the map in her room when she was kicked out.

as a harm reduction intervention can provide an active drug user with the first step towards stability, towards use management, towards household maintenance, et cetera. The misconception that an active drug user cannot maintain housing smacks of the same prejudices and barriers which continue to prevent drug users from accessing adequate and appropriate services and support throughout the service world and beyond. In fact, in order for an active drug user to begin the process of stabilization, housing is of primary importance. Stable housing can help provide active users with opportunities to improve the quality of their lives. We have identified a number of positive situations supported by long term housing, which are far less accessible for active users who lack such housing. While some may disagree, it is important to consider that an active user who is living homeless on the streets has far fewer opportunities to fulfill certain basic human needs—a situation directly related to their homelessness, not their drug use (as many housing providers would have us believe). These opportunities are described below, in contrast to the common misconceptions that misinform traditional housing providers.

CINDY AND SHARON SHARED THE SAME DREAM: TO GET THEIR OWN F APARTMENT.

or many reasons related to their drug use, drug users are routinely denied housing. As harm reduction providers, we know that permanent (or, minimally, long-term) housing is a fundamental building block for individuals to gain some sense of stability in their lives. Without such housing, it is difficult for anyone to plan for the future, or to experience any personal sense of satisfaction, growth or development. The error in reasoning made by too many housing providers and housing placement agencies is that an active drug user cannot maintain housing because of their drug use. But we argue that housing

Therefore…

1. MISCONCEPTION: A drug user cannot maintain housing until they are clean, or at least until they have demonstrated long-term stability with their drug use, such as long-term methadone maintenance at a lower daily dose (i.e. lots of clean urines). If a drug user is not clean or “appropriately” stabilized when they obtain housing, they will not pay their bills, or they will destroy the apartment, or they will turn it into a spot for dealing or using, etc. In essence, they will wreak havoc in the apartment, the building and the neighborhood. REALITY: Drug users wishing to exercise/embrace some form of drug use management, even including abstinence, need to be situated in order to begin this process. After all, it is a process requiring, at the very least, some form of

USERS NEED HOUSING! stability, and housing provides that. 2. MISCONCEPTION: Active users who are housed with inactive users will cause the latter group to “relapse” in their “recovery” because of their exposure to the former group. Inactive users, or users choosing recovery, cannot control the urge to “pick up” drugs again when they are in contact with somebody who is using. Therefore, it is detrimental to house active users with inactive users, because this will place those users in “recovery” at risk for “relapse.” REALITY: Active and inactive users can actually relate to one another quite well, given the opportunity. They have had similar experiences, and have simply chosen different routes with their drug use. As harm reduction providers, we know that the spectrum of drug use can include “non-use,” and that active and inactive drug users can provide excellent support systems for one another if they are given the space, opportunity and support to communicate openly with one another about their issues and concerns related to drug use. Finally, to house active users only with other active users is like a direct invitation to “ghettoize” drug users—as if this isn’t already enough of a problem in our society! 3. MISCONCEPTION: Drug users don’t care about how they are perceived. They don’t have any self-respect because they only care about getting high, so they don’t really care how they are perceived by others, either. Based upon this premise then, providers don’t need to consider supporting and nurturing a drug user’s sense of self-worth. REALITY: Having one’s own housing contributes to one’s sense of self-worth. This is true for all humans, we believe, and active drug users are no different in that respect. 4. MISCONCEPTION: Drug users don’t want to reduce the harm that drug use may cause to themselves and to their communities. Drug users will get high whenever, however and wherever they want. They don’t think about safety related to drug use because they only care about getting high. REALITY: Housing allows an active user to practice harm reduction more effective-

ly, such as adequate and appropriate storage of syringes for exchange and personal space to use with somebody you can trust, thus making drug use a safer experience in all respects. 5. MISCONCEPTION: Whatever money they get, drug users will always spend all of that money on drugs. Drug users are unable to budget because to them, money equals drugs. Drug users are irresponsible with money. REALITY: Housing allows users to exercise personal responsibility. Budgeting becomes more relevant and important as bills need to be paid, items purchased for household maintenance, etc. Personal responsibility is exercised through household budgeting. 6. MISCONCEPTION: Drug users don’t eat. They don’t prioritize eating because they spend all their money on drugs, and they aren’t really interested in their nutritional needs because they only really care about getting high. A drug user with a kitchen will probably cause a fire when they try to cook, because they will be too busy getting high. REALITY: Given that permanent housing comes equipped with a kitchen, it is a great opportunity for an active user to be able to learn cooking skills, and to meet their nutritional needs. We know that nutrition is immensely important for drug users as an important health equalizer when an individual is using substances. 7. MISCONCEPTION: Drug users don’t care about their health. This is evident in that they choose to get high, which is detrimental to their health, and thus they are always risking their health to continue getting high. Therefore, drug users shouldn’t be trusted with medications, because they will not “adhere” to the regimen required for those medications because they will be caught up in getting high. Drug users cannot manage their time because they are too busy getting high, and this will contribute to problems they have in taking medications or “adhering” to a medication regimen. REALITY: With housing, more attention can be paid to one’s medical needs. Psych meds, HIV meds, etc. all require some space for storage, often including refrig-

eration, and these things are inaccessible to a user who is homeless. With housing, even time management for medications is now an opportunity, where formerly it was not even an option. 8. MISCONCEPTION: Drug users don’t care how they look or how they smell; they don’t care about their personal hygiene. This is evident in their indifference to how others perceive them, and in their drug use, which shows a lack of self-respect. And drug users deserve to have bad hygiene, because it is a testament to their problems with drugs. A drug user will really only develop good hygiene when they stop using. REALITY: Finally, housing provides active users with a basic opportunity for personal hygiene.

PERMANENT (OR, MINIMALLY, LONG-TERM) HOUSING IS A FUNDAMENTAL BUILDING BLOCK FOR INDIVIDUALS TO GAIN SOME SENSE OF STABILITY IN THEIR LIVES.

The story of Sharon and Cindy demonstrates the fundamental importance of housing for active drug users. Without housing, Cindy’s drug use spun out of control again, and we can only hope that she made contact with some friendly neighborhood harm reduction outreach program. Sharon was able to locate and move into permanent housing, although her need for support throughout this process was immense. As harm reduction providers, we know that the least we can offer to our participants is support—the least and often the most, too, particularly as the experience of being caught in a cycle of chaotic drug use can be extremely harsh and isolating. Even once they are in housing, support remains important. However, housing needs to be one of the first in a series of building blocks for the active user to gain and maintain stability. Shelter (adequate, appropriate and permanent) is a right, not a privilege—it is a public health intervention, it is a personal growth opportunity, it is one of the great stabilizers. Demand housing for active users! n Sandra Fuentes is a Peer Educator and Daliah Heller is Executive Director at CitiWide Harm Reduction in New York City. CitiWide provides harm reduction outreach and services to PLWAs living in SRO hotels in the Bronx and Manhattan.

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