“I think the way the health care system is developed is not necessarily with a harm reduction approach,” Evelyne Piret, one of the paper’s authors, told Filter.

The paper was published on March 28 in the Harm Reduction Journal. It studies outcomes for 1,168 Vancouver-based participants who had asked to be prescribed pain medication—of any kind, such as opioids, gabapentin, muscle relaxants, over-the-counter medicine like tylenol, cannabinoids or unspecified drugs—between 2012 and 2022. The pain that people hoped to treat was related to situations including surgery, injuries and various types of chronic pain, among others.

This data came from three ongoing studies with PWUD in the city: The Vancouver Injection Drug Users Study, the AIDS Care Cohort to Evaluate Exposure to Survival Services, and the At-Risk Youth Study. All participants in these projects were using banned drugs at the time they joined.

People’s self-management of pain prior to seeking formal treatment for pain was a factor associated with denial.

Conducting a statistical analysis of health care visits across 4,179 six-month observation periods, the team found 907 reports (21.7 percent) of a person being denied a prescription for pain medication.

Their analysis showed that factors positively associated with denial included: having experienced a non-fatal overdose; accessing opioid agonist therapy; and daily use of opioids from unregulated markets. Being younger was also positively associated.

In something of a Catch-22, people’s self-management of pain prior to seeking formal treatment for pain was another of the factors associated with denial.

Participants who reported self-managing pain variously did so with unregulated drugs; with prescription drugs which hadn’t been prescribed to them; with cannabis or other regulated drugs; with over-the-counter medicines; or, less frequently, with exercise or heat therapy.

This all illustrates some of the likely elements—whether decisions are based on prejudice, or on medical professionals’ perceptions of risks—behind denial of pain medications to PWUD, according to Piret, who is a graduate student at the University of British Columbia’s School of Population and Public Health, and works at the British Columbia Centre on Substance Use.

Being denied pain medication can leave people to suffer mental and emotional pain, as well as physical pain, she pointed out.

These outcomes could also worsen an already-difficult relationship between PWUD and the health care system by adding to stigmatization of drug use and potentially fostering adversarial interactions. This, in turn, could hinder opportunities for health care professionals to provide care for PWUD beyond pain management, Piret said.

The study also examined what PWUD did after being denied pain medications. Among the 895 reported actions taken post-denial, 53.5 percent saw a person turn to unregulated drug markets instead, and 6.1 percent involved a person going to a different doctor.

Piret noted that the paper cannot be taken as proof that being denied pain medications directly causes people to self-medicate with non-prescribed drugs. The connection has been widely drawn elsewhere, however.

“We’ve known this for a long time.”

The paper’s overall findings come as no surprise to John Braithwaite, a board member and supervisor for the Vancouver Area Network of Drug Users. “We’ve known this for a long time,” he told Filter. He’s experienced being denied pain medication himself, he said, and many people constantly go through this.

Braithwaite also described how the body language and attitude of a medical professional can suddenly shift, once they become aware that a patient is on a methadone program, for instance.

“Everything kind of changes. They’re reluctant to give you any kind of real painkiller,” he said. “Well, it’s frustrating … just to see someone change so drastically just because you’re on a doctor-prescribed medicine.”

Braithwaite said that this has become more common since 2016, when the College of Physicians and Surgeons of British Columbia (CPSBC) released a legally enforceable set of guidelines to reduce prescribing of opioids and certain other drugs.

“The College expects physicians to use their own professional [judgment] to make treatment decisions in the best interest of their patient,” the CPSBC emailed in response to Filter’s request for comment. “The College practice standard Safe Prescribing of Opioids and Sedatives does not prohibit prescribing; it provides principles to make prescribing opioids and sedatives, which carry risk, safer.”

“I would really love to see guidelines specific to the management of pain among people who use drugs.”

Piret said that the new research didn’t seek to evaluate these prescribing guidelines—and the study notes that the guidelines did not seem to change denial rates. But she added that they do provide important context to what’s happening.

The paper stated that these guidelines, and others released in 2017 by the Canadian government, “may be mismatched with the realities of PWUD.”

“I would really love to see guidelines specific to the management of pain among people who use drugs,” Piret said. These, she envisages, would cover “all of the special considerations around drug use and drug interactions and access to care.”

Photograph by Karolina Grabowska

The post A Close Look at Denial of Pain Meds to People Who Use Drugs appeared first on Filter.

BC’s overdose crisis has continued, with 2,511 suspected drug-related deaths recorded in 2023. That’s the highest number the province has seen, and up 5 percent on 2022. Harm reduction advocates have always argued that decriminalization alone isn’t sufficient to curb death rates, but point to other benefits of the policy.

Yet opponents have used the increase in overdose deaths to argue against the efficacy of both decriminalization and harm reduction efforts in general.

In response, a group of harm reductionists penned a post on the Canadian Drug Policy Coalition (CDPC) website to mark the one-year anniversary of decriminalization. They wrote that in some ways, decriminalization is meeting its goals, though other measures are also badly needed.

Lovegrove and her coauthors wanted to “counter the warping of facts and reality” surrounding decriminalization.

The authors of the post included Sarah Lovegrove, a registered nurse and member of the Harm Reduction Nurses Association. She and her coauthors collectively agreed that they wanted to “counter … the warping of facts and reality” surrounding decriminalization, she told Filter. 

One of its key goals is to decrease arrests and incarceration in cases of drug possession. By that measure, decriminalization seems to have had a positive impact: For the period from February-July 2023, BC reported that the number of “possession offenses” had fallen by 76 percent compared to the four-year average.

That said, according to reporting by the Maple, drug seizures in amounts at or below 2.5 grams increased by 34 percent in BC’s biggest city of Vancouver in the first six months of 2023. The discrepancy might be explained by the difference between city and province, and also by the fact that police seize drugs in cases where drug possession is not the primary reason for arrest.

In an emailed response to Filter, a spokesperson for BC’s Ministry of Mental Health and Addictions wrote that the province aims to treat drug use as a health issue, not a criminal one, “so more people struggling with addiction feel comfortable reaching out for help.”

They added that “early data indicates that the program is working as one part of our work to address the toxic drug crisis by saving lives, connecting people to care, and supporting people through their recovery journey.”

The email also noted that factors separate from decriminalization contribute to deaths, including the crisis growing “more complex and unpredictable” since the pandemic. 

The fact that decriminalization does not directly address the volatile drug supply explains why the Vancouver-based Drug User Liberation Front continued to operate an unsanctioned compassion club, giving participants a consistent supply of tested drugs to keep them safe. Two DULF co-founders are currently facing prosecution for this. 

The BC spokesperson stated that the provincial government is not interested in ending decriminalization: “Ending this measure will not save lives, but rather would increase fear of criminalization, making it harder for people to feel comfortable to access care. As the toxicity of illicit street drugs continues to increase, more people are at serious risk.”  

Lovegrove noted, however, that critics of harm reduction are using some of 2023’s numbers to argue in favor of BC’s Bill 34. This would ban drug use in various public spaces such as parks, playgrounds and bus stops, permitting arrests, searches and the seizure of any recovered substances. BC’s Supreme Court previously shot down the bill, but it’s still receiving support, including from some mayors in the province. 

There’s precedent to suggest narratives around visible drug use can see positive efforts rolled back, Lovegrove said. For instance, a harm reduction service including a pop-up safe consumption site in Nanaimo, BC, run by the Nanaimo Area Network of Drug Users, closed down in 2023 after local residents registered complaints. At the time, the organizers attributed the closure, in part, to the spread of “a narrative about how terrible” the service was, Nanaimo News Now reported. 

Conservative news outlets have also worked to place the blame for an increase in overdose deaths in Oregon on the state’s decriminalization of drug possession, approved by voters in 2020. A 2023 peer-reviewed article found no connection, while drug arrests have decreased. But legislative and ballot efforts are underway to roll back Oregon’s Measure 110.

“People use openly and in public because they don’t want to die.”

Using perceived flaws in BC’s decriminalization to justify something like Bill 34 would cause many issues, according to Lovegrove. She said parts of the bill are “quite redundant,” when the decriminalization framework already prohibits drug use in some public spaces, such as playgrounds. But Bill 34 would extend this to other spaces, including some public streets. Pushing people who use drugs completely out of public spaces, she said, could result in more deaths, as it would make them harder to find when an overdose occurs. 

“People use openly and in public because they don’t want to die,” Lovegrove said. “They don’t use … in public because they want to expose other people.”  

The narratives represented by Bill 34 also increase the stigmatization of people who use drugs, she added.

Lovegrove said that decriminalization is only “one piece of the puzzle” when it comes to reducing overdose deaths in BC, and that different major variables drove the rise in deaths in 2023. She cited the cost of housing as one of the biggest issues, when BC has the highest rental prices among Canadian provinces. 

More affordable housing would help people find stability, and recent research has detailed how reducing homelessness could reduce drug-related deaths. Other needs Lovegrove listed include stronger health care supports, the creation of more supervised consumption sites (particularly in rural areas), and increasing the quantities of drugs people can carry under BC’s decriminalization rules.

That last point has been a source of contention ever since BC’s decriminalization plans were announced. As Filter previously reported, harm reduction experts expressed strong concerns over the threshold amounts covered by decriminalization—generally 2.5 grams of cocaine formulations, opioids, meth and others—and the role of police in setting these limits.

Increasing the thresholds would make people in possession of larger quantities feel more comfortable accessing drug-checking services, Lovegrove said, by removing the fear of being arrested or having their drugs confiscated. She noted that people often buy drugs for personal use in larger quantities, much like a person would buy groceries to last a week. 

Natasha Touesnard is the executive director of the Canadian Association of People who Use Drugs (CAPUD). In this capacity, she often travels to BC to witness the impacts of decriminalization, and has heard more from CAPUD members based in the province. 

Touesnard said that the decrease in total drug charges in the province is a positive, but asked, “What about the other individuals that may have had a larger quantity?”  

Touesnard also agreed with Lovegrove’s assessment of the impact of housing issues in BC. Rents have “skyrocketed,” she told Filter. Plus, when affordable housing developments are built, they are often located away from many of the harm reduction services that people who use drugs may rely on. 

Couch-surfing isn’t even “really a thing now because most people just don’t have homes,” she said.

Both Touesnard and Lovegrove told Filter that to effectively combat overdose deaths, the province should consider legalizing and regulating drugs.

Touesnard added that supports like a universal basic income project, providing everyone with enough money to live on, could also help reduce deaths in the province. Currently, social services don’t provide nearly enough, she said. 

Other changes she would like to see going forward would be decriminalizing the possession of benzodiazepines, which aren’t included in BC’s decriminalization framework but are appearing more and more—often unexpectedly, for people making purchases—in the province’s drug market. 

Both Touesnard and Lovegrove told Filter that to effectively combat overdose deaths, the province should consider legalizing and regulating drugs, a big step beyond decriminalization. 

Lovegrove noted that when 80 percent of overdose deaths in 2023 occurred indoors, regulation would remove the unpredictability of the current drug market, meaning people who use drugs in their homes —potentially with no one at hand to help in case of overdose—would be at much lower risk.

And taking that next big step, Touesnard said, would effectively combat the stigma around drug use. With legalization, “People may feel more comfortable to access services, harm reduction services—to reach out to somebody if they have an issue.”  

Photograph (cropped) by British Columbia Emergency Photography via Flickr/Creative Commons 2.0

The post A Year Into BC Drug Decrim, Opposing Narratives Clash appeared first on Filter.

Published in Letters in Biomathematics in December, the research deploys a mathematical model called a Markov chain. Provided with data, this model is used to project the movement of people in a city between different “states”— such as “Not Currently Using Drugs,” or “Using Drugs (in an OPS)”—as well as fatal and non-fatal overdoses depending on the presence of OPS and other factors.

According to the paper, the model allows “quantitative predictions of the benefits of harm reduction strategies such as overdose prevention sites, enabling policy makers to make data-driven decisions.”

The model showed that if San Francisco, as an example, had 25,000 people who use drugs and set up 10 OPS, each able to accommodate 30 people, there would be 176 fewer overdose deaths per year. It also found that 668 of the total would be in treatment or recovery after one year under this scenario.

The researchers are aware of how many variables, some of which they sought to account for, could impact effectiveness. Ami Radunskaya, a mathematician at Ponoma College in Claremont, California, and one of the authors of the paper, said the work suggests that OPS are most helpful in conjunction with other harm reduction strategies, such as helping people find work and housing, programs offering medications for opioid use disorder, and others.

“What could you say about the effects of not just, say, safe injection sites, but also putting resources into harm reduction programs that involve counseling or helping people get jobs?” she asked Filter.

Radunskaya added that this is something that California, among other states, could keep in mind, considering the influx of settlement money it’s receiving from pharmaceutical companies that manufactured various opioid painkillers.

“We wanted to delve more deeply … into the mathematical possibilities of such a model.”

According to Radunskaya, the model can also be used to gauge the effectiveness of other interventions. For instance, some of her students used it to look at buprenorphine treatment in San Bernardino County, California.

As the US overdose crisis continues, opposition to safe consumption sites hinders their rollout. For instance, the government of Colorado recently blocked efforts that would have allowed the sites to be created.

The authors of the recent paper had written a previous article specifically modeling Philadelphia. Published in the Harm Reduction Journal in 2021, it showed that an OPS would, indeed, help reduce deaths in the city. According to Radunskaya, the team involved members of the city’s public health sector, meaning they had access to a “lot of very specific data” about factors such as the number of people using drugs, providing the model with enough information to work.

At the time, the city was mulling over allowing a safe consumption site to open, though both the municipal government a long-running federal lawsuit have since blocked efforts to establish OPS.

From this first effort, the team learned more about other factors they wanted to include in the second paper. “We wanted to sort of delve more deeply … into the mathematical possibilities of such a model,” Radunskaya said.

“The first thing [a city] should do if they have a pile of money is to set up the safe injection sites and spread them around so they’re accessible.”

For the new model, they added new data from sources such as the cities of Seattle and Vancouver (which has OPS), and various jurisdictions in Europe. From these places, they had surveys about how likely people would be to attend an OPS given certain conditions (how close it was, etc.). Combined, this information enabled the team to look at how OPS could impact different US cities.

However, Radunskaya noted that all models have their limitations. Going forward, she said that she hopes to fine-tune this one, including by calibrating it for different types of behavior, such as for people who have only recently started using drugs.

“The first thing [a city] should do if they have a pile of money is to set up the safe injection sites and spread them around so they’re accessible,” she said. “And then, hold on to some of the resources and use them to have these social services.”

Photograph by Photo Claude TRUONG-NGOC via Wikimedia Commons/Creative Commons 3.0

The post Mathematical Model Illuminates Potential of Safe Consumption Sites appeared first on Filter.

Due to numerous factors which they could only control for to some extent, the researchers warn that their work mustn’t be read as a definitive measure of stimulant purity in the United States. What they can say is that their findings run counter to the narrative that “fentanyl is in everything,” Colin Miller, community liaison with the University of North Carolina’s Street Drug Analysis Lab and a coauthor of the paper, told Filter.

Fentanyl appeared in 8.9 percent of meth samples, and 21.5 percent of cocaine samples. However, there were many caveats.

The researchers tested 718 samples of cocaine and methamphetamine from 77 harm reduction organizations and clinics in 25 states between May 2021 and June 2023. The samples were initially sent to the UNC Street Drug Analysis Lab, where gas chromatography-mass spectrometry was used to check for the presence of fentanyl.

Fentanyl appeared in 8.9 percent of meth samples, and 21.5 percent of cocaine samples. However, there were many caveats to these numbers. Deploying statistical adjustments to account for them, the team then arrived at 6.2 percent for meth and 12.6 percent for cocaine—or roughly one in 10 overall.

Karla Wagner, a professor at the University of Nevada, Reno’s School of Public Health and a coauthor of the paper, explained to Filter that the team adjusted the numbers to account for various confounding issues that could have made fentanyl appear more frequently. (Again, she cautioned, even after these adjustments, the numbers are not meant to be representative.)

Some of these confounding issues are fairly simple. For instance, people would probably be more likely to send in samples for testing if they suspect they contain fentanyl. This might be because they used a fentanyl test strip—which has a chance of producing a false positive—or, in some cases, because after using some of a batch of a stimulant, they felt tired or passed out.

However, the nature of different meth batches, in the absence of fentanyl, might sometimes explain this, described Phillip Fiuty, another coauthor of the paper and technical advisor for adulterant checking programs in New Mexico for the global public health organization Vital Strategies.

“I think there’s a whole confluence of things kind of feeding the situation.”

Other confounding factors the researchers tried to account for include, for instance, the fact that samples only came from around half of all US states.

“I think there’s a whole confluence of things kind of feeding the situation,” Fiuty, who has lived experience of drug use, told Filter.

Miller, who also has living experience with drug use, noted that the number of organizations sending drugs in for checking has grown to more than 160 across more than 30 states since the team performed the research, which should bolster future understanding. He added that there are, of course, cases in which fentanyl appears in batches of stimulants, but that the belief it’s extremely common isn’t necessarily justified.

Parts of the country are seeing more deaths where both stimulants and opioids were present. But Miller pointed out that this doesn’t demonstrate the opioids are appearing as adulterants in meth and coke, when polydrug use is the norm.

“You always have your sort of opiate purists, and sometimes your methamphetamine purists,” he said. “But for the most part, people are going to be using different substances simultaneously.”

At the same time, observers have argued, while accidental cross-contamination from sources selling more than one substance can happen, there’s no incentive for trafficking organizations to deliberately add fentanyl to stimulants. That won’t give the stimulant effects that some buyers solely want, wrote Jonathan Kirkpatrick for Filter, and most polydrug users prefer to measure their own combinations.

The narrative of deliberate contamination is “distorting the actual facts and our ability to respond sensibly with data-driven policies.”

Wagner said that the narrative of deliberate contamination is driving some parts of the US to implement harsher drug laws, such as increased penalties for fentanyl possession and drug-induced homicide laws.

This narrative is “distorting the actual facts and our ability to respond sensibly with data-driven policies,” she told Filter. She added that incarceration, and a drop in tolerance, can lead to more fatal and non-fatal overdoses—and that when drug markets can shift extremely quickly, regulations and policies that target specific drugs will end up obsolete.

Wagner acknowledged that a figure of roughly one in 10 stimulant samples containing fentanyl—while not representative—is concerning.

But taking a harm reduction approach which prioritizes safer supply programs, real-time drug checking services and overdose prevention centers is far better than crackdowns, she said. She recommended that people who use drugs test their batches as much as possible, and that they, their friends and family, and other members of the public get trained to recognize opioid-involved overdoses and to use naloxone.

Correction, December 20: This article has been edited to correct the description of Phillip Fiuty’s role with Vital Strategies.

Photograph of cocaine by Marco Verch Professional Photographer via Flickr/Creative Commons 2.0

The post How Common Is Fentanyl in Samples of Cocaine and Meth? appeared first on Filter.

These tools speak to the adaptability of the people making them. But though some homemade devices may be relatively safe, harm reductionists say the use of others can carry various added risks—such as inhaling plastic fumes or tiny shards of metal, mouth wounds and disease transmission.

This is particularly worrying considering the worldwide scarcity of pipe distribution programs and other harm reduction interventions that focus on people who smoke drugs. According to Harm Reduction International, only 16 countries offer safer smoking kits, compared to the 92 that host at least one syringe service program.

Mat Southwell, project executive with the European Network of People Who Use Drugs, has seen many homemade smoking implements first-hand in his time working in harm reduction. Over the years, he’s collected images of them from around the world.

“There were some that were somewhat elegant,” he told Filter.

Back in 2015, Southwell and some colleagues traveled to Afghanistan to speak with people who use drugs in the country. While meth production has become more commonplace in Afghanistan in recent years, Southwell recalls it was still early days for the drug at the time. Some people were taking 5-ml glass ampoules (tiny vials), heating them up with a torch and blowing them into meth pipes, complete with the distinctive chamber at the end. 

In the United Kingdom, which prohibits the supply of crack pipes, people who smoke the drug have come up with different solutions of their own. According to Southwell, who lives in England, a type of implement known as a nut-and-bolt pipe is somewhat common there. A hollow bolt forms the stem, with a nut screwed onto the top to serve as a mouthpiece. Often, material from metal scouring pads is placed in the pipes to act as a kind of filter. 

Other pipes used to smoke stimulants in the country include metal cannabis pipes, which are often extended with tape and various plastic containers in order to cool the smoke prior to inhalation.

Yet another kind of crack pipe previously found in the UK was made from a miniature bottle of Martell-brand cognac. These were chosen because they were made of “heavy-duty” glass, and the bottoms of the bottles had a small indentation, Southwell said. A hole could be punched through the bottom, making a mouthpiece. People would put a kind of filter in the neck of the bottle, along with the crack. Southwell said that these bottles were ultimately removed from the market in favor of plastic. Martell did not respond to Filter’s request for comment. 

Mostly there’s “just stigma and prison” for people who use stimulants in Latin America.

Ernesto Cortés is an activist from Costa Rica who has lived and living experience of drug use. He’s the executive director of the Costa Rican Association on Drug Studies and Interventions. Throughout his life and work, he has seen similar tools crafted, and can recall trying some homemade pipes himself. Some of these pipes are made from cans, he said, while others are metal tubes from TV or car antennae.

People in the United States are doing similar things, related Sheila Vakharia, deputy director of the department of research and academic engagement at the Drug Policy Alliance. Many will make their own smoking implements, and/or continue using the same one for far longer than is safe, after it cracks from heat or general wear and tear.

In many jurisdictions around the world, the prevalence of homemade smoking implements and related risks is driven by the illegality of pipes and safer smoking kit programs. Vakharia noted that each US state has its own rules about what is or is not considered “paraphernalia,” and which penalties, if any, apply to handing out or even possessing something like a crack pipe.

According to Cortés, safer-smoking harm reduction interventions are, primarily, illegal and/or unheard of across Latin America, though there have been some examples, such as a program in Mexico. Mostly there’s “just stigma and prison,” he told Filter.

Magdalena Harris, professor of inclusion health sociology at the London School of Hygiene & Tropical Medicine, noted that while safer smoking kit programs are illegal in the UK, people can still purchase pipes with which to smoke crack, as they are often marketed as being ornamental or for cannabis use.

However, Harris is part of an ongoing research project which, with government approval, is handing out pipes. Called the Safe Inhalation Pipe Provision (SIPP) study and based out of three locations across the country, it also surveys people who receive the pipes to measure changes in their use of homemade pipes and respiratory problems, among other things.

The homemade pipes represent “people doing their best within their situations, and the investment they have in their paraphernalia.” They may also pose health risks.

SIPP also involves the pipe providers photographing homemade pipes people use. Some of the photographs in this article came through Southwell’s involvement with the project.

According to Southwell, the homemade pipes represent “people doing their best within their situations, and it also shows the investment they have in their paraphernalia.”

However, they may also pose health risks to the people who use them. In the case of the nut-and-bolt pipes seen in the UK, Southwell said, the steel scouring-pad filters can become brittle after repeatedly being heated, and end up breaking apart. Little pieces can then be carried into the lungs of the person using the pipe, damaging their respiratory system.

A different issue arises with homemade glass pipes like those Southwell saw in Afghanistan: Under heat, they can develop cracks. These cracks can cut people’s lips, which may increase the risk of transmitting bloodborne diseases like hepatitis C when people share pipes. 

In general, continuing to use a glass pipe after it starts developing jagged edges carries a risk of wounds to mouths and fingers.

A damaged pipe in the UK

Cortés mentioned a similar risk for the metal tube pipes found in some Latin American countries. With these, the hot metal may cause mouth wounds.

“In the absence of new, safe smoking equipment, people will rake together everyday materials, some of which should not be subjected to flame or high temperatures.”

Vakharia also noted that some homemade pipes include plastic. If heated over and over again, this plastic can release chemicals that are harmful to inhale. Additionally, some people will scrape leftover drug resin out of their pipes to smoke later; if they scrape it off plastic surfaces, they can end up smoking plastic along with the recollected stimulant.

“In the absence of new, safe smoking equipment, people will rake together everyday materials, some of which should not be subjected to flame or high temperatures,” Vakharia told Filter, and long-term, totally preventable health problems may follow.

Vakharia continued that one problem is how the ongoing overdose crisis, along with other factors like the HIV epidemic of the 1980s, has put far more focus on opioids than on commonly smoked stimulants. Yet another issue is that drugs like crack and meth tend to be more stigmatized than many others.

“There is this belief that safer smoking, in and of itself, is an oxymoron—that no form of smoking anything is safe,” she said, “without acknowledging [that] safety is a multi-dimensional, complex concept.”

All of the experts interviewed believe that government restrictions on safer smoking supplies are harmful. Last year in the US, conservative outcry over a historic-but-small federal harm reduction grants program—misleadingly portrayed as “crack pipes for all”—caused rapid backpedaling from the Biden administration, which hastily clarified that “no federal funding will be used … to put pipes in safe smoking kits.”

“Not providing pipes or the services … sends a message to people who use crack that nobody cares about them.”

Cortés said that governments should also provide more funding for drug-user network organizations, plus other services to improve the lives of marginalized people who use drugs, such as housing. Latin America’s US-funded drug war is hampering harm reduction in many countries, he said; ending it would surely help people who smoke stimulants stay healthy.

More work is needed to connect with and engage people who smoke stimulants, Harris said, adding that the SIPP study is doing just that: “What we’re seeing actually has some wonderful stories of engagement.”

Through its connections with people who use stimulants, SIPP is encouraging steps to address health risks, such as people getting tested for HIV or hepatitis C. But more broadly, Harris suggested, one of the biggest benefits of such interventions is that they show an underrepresented community that people are actually interested in their wellbeing.

“I think, to my mind, not providing pipes or the services … sends a message to people who use crack that nobody cares about them,” Harris said.

All photographs courtesy of Mat Southwell

Dr. Vakharia is a member of the board of directors of The Influence Foundation, which operates Filter. The Influence Foundation previously received a restricted grant from the Drug Policy Alliance to support a Drug War Journalism Diversity Fellowship.

The post Many People Left to Make Their Own Stimulant Pipes and Face the Risks appeared first on Filter.

For drug policy researchers at Open Society Foundations (OSF), there are right and wrong ways to spend this money. On August 31, to coincide with International Overdose Awareness Day, they published a call to action—urging state, county and other sub-national governments to allocate the funds to a variety of harm reduction interventions, rather than to policing and the criminal-legal system.

“If used inappropriately or inefficiently, it could be a real wasted opportunity, and could even make the overdose situation worse.”

“We wanted to use that day to draw attention to this huge issue because it’s billions of dollars, right? And if used appropriately, it could really change the way we treat addiction, addiction treatment in this country and really mitigate the overdose crisis,” Sarah Evans, division director of Drug Policy and Global Programs with OSF, told Filter. 

“But if used inappropriately or inefficiently,” she warned, “it could be a real wasted opportunity, and could even make the overdose situation worse.”

The call to action garnered more than 200 signatures from prominent researchers and advocates across the country.

It urges governments that receive settlement money to fund multiple areas of harm reduction. These include safe consumption sites (also known as overdose prevention centers); naloxone distribution; syringe service programs; drug-checking services; and low-barrier programs offering medications for opioid use disorder—with “special efforts” for people in prisons and jails, when overdose risk is acutely high after release.

It also urges funding for housing-first programs, which house vulnerable people without demanding abstinence or treatment engagement as a precondition. Research, the authors point out, has shown such programs reducing homelessness by 88 percent in US and Canadian cities studied—more effectively than programs that require participants to be “housing ready.” 

The document also outlines areas where it says settlement funds “should not be spent.” These include law enforcement agencies, jails and prisons, drug courts and abstinence-only treatment programs. 

The “family regulation system” is also named here, as the authors detail widespread harms arising from investigations that often relate to drug use. “Rather than putting more money into systems that disproportionately remove Black, Brown, and Indigenous children from their homes,” they write, “money should be used for supportive services that allow families to remain together.”

“We owe it to the people directly impacted to spend these funds in ways that will prevent further deaths,” the call to action concludes. “We encourage … stakeholders to consult with people who use drugs and their loved ones to ensure that these programs are implemented in ways that are respectful, appropriate, and effective.”

According to Evans, one of the biggest problems with funding allocation is that funded governments haven’t universally been transparent.

The document is part of OSF’s ongoing efforts in this area, which include its previously published Roadmap on Opioid Settlement Spending.

According to Evans, one of the biggest problems with funding allocation is that funded governments haven’t universally been transparent on where the money is going, though one website called the Opioid Settlement Tracker provides available data.

“There isn’t clear accountability in terms of setting up state- or county-level commissions that include people impacted by overdose in advising how the money should be spent,” she said.

But we do know of some notable cases, Evans continued, where either good or bad ideas have been proposed for the settlement money. 

Among those she condemns, County Commission President Blair Couch of Wood County, West Virginia, proposed using the money to reimburse the government for costs associated with law enforcement and the legal system. According to reporting by the News and Sentinel, Couch said: “The money is basically to reimburse us for our jail bill, for our sheriff’s expense, for our prosecuting attorney’s office expense and all the things that came into play over the opioids … We will see how everything comes out in the wash.”

A recent press release from the city of Brownwood, Texas, meanwhile suggested using the funds to purchase a law enforcement tool called the BolaWrap—a device that shoots out a length of Kevlar to wrap around suspects’ limbs from 10-25 feet away. 

And the state of Louisiana has proposed giving 20 percent of the funds it receives to sheriffs.

These and similar approaches, Evans said, are just “doubling down on the War on Drugs,” and will result in “sending more people to jail.”

“We know the solutions and we have the money. We just really need to be able to hold states and counties accountable.”

Some states are, however, providing funding to harm reduction efforts. For instance, Rhode Island has allocated $2.6 million of its settlement cash toward an overdose prevention center. 

North Carolina has also allocated $380,000 to a state-wide drug checking program using a mass spectrometer out of the University of North Carolina at Chapel Hill. The state is one of a few to be particularly transparent about where the funding is going, and runs a dashboard showing this information.

In all, the influx of settlement cash represents a “once-in-a-generation” opportunity, Evans said, and it’s vital to use it for evidence-based practices that reduce harms. 

“We know the solutions and we have the money,” she said. “We just really need to be able to hold states and counties accountable for doing the right thing with that money.”

Photograph via Pxfuel/Public Domain

The Influence Foundation, which operates Filter, has received restricted grants from OSF to support film production and promotion projects. Filter‘s Editorial Independence Policy applies.

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The paper, published in the Harm Reduction Journal, is based on interviews that Shoshana Aronowitz, assistant professor in the School of Nursing at the University of Pennsylvania, collected in July and August of 2020, close to the start of the pandemic. Immersed in harm reduction work herself, she recalls talking with colleagues about how the pandemic was impacting their work, and how they anticipated it would continue to do so.

Burnout came up again and again. “I was having these conversations constantly,” she told Filter.

From there, Aronowitz decided to collect qualitative data, by speaking with other people about their experiences of working in harm reduction and overdose prevention in Philadelphia, in both paid and volunteer positions. She and a team of researchers then examined the data provided by 30 harm reduction workers, substance use disorder clinicians and community organizers.

“With qualitative data, I feel like you really get into the heart and soul of what people are thinking and how they’re feeling,” Ijeoma Unachukwu, first author of the paper and MD candidate at Rutgers Robert Wood Johnson Medical School, told Filter.

The team coded the results against an existing model of burnout among physicians, which states: “Burnout is a syndrome characterized by exhaustion, cynicism, and reduced effectiveness.”

The model did not include some of the themes found, namely, “concerns about safety at work, lack of control over the work environment, and experiences of task-shifting”

The model includes various factors: workload and job demand, being able to find meaning in the work, control and flexibility, integration between work and life, the culture and values of a workplace or organization, resources and efficiency, and social support and community.

While the researchers’ results paired with many of these factors, the model did not include some of the themes they found, namely, “concerns about safety at work, lack of control over the work environment, and experiences of task-shifting” the paper notes.

Further, existing models don’t apply for volunteer workers, people with lived or living experience of substance use, social workers and “people outside of the traditional health care setting,” Unachukwu said.

Task-shifting was one commonly discussed theme. In traditional health care settings, tasks are regularly delegated to whomever is available during high-stress situations. This isn’t necessarily a burden or an issue, Unachukwu said. It can allow people to explore different roles.

That said, during the pandemic in particular, it became common practice for harm reduction workers to end up “picking up a lot of slack,” or “having undefined roles,” during periods of distress or uncertainty, she continued. “I think in our specific setting, it became a burden, but for all the reasons COVID was a big burden overall.”

Aronowitz added that task-shifting isn’t “in and of itself a bad thing, but I think it can become very burdensome for folks when they feel like they either don’t have the resources, or time to add more things to their schedule.”

Sometimes, workers won’t have been trained to do the things they’re being asked to do. Additionally, harm reduction or community organizations typically face significant financial limitations, and people working in harm reduction often aren’t compensated at the same level as those in other fields for performing similar tasks. All of this can contribute to burnout, Aronowitz said.

The researchers said that these findings could very well apply for other cities—and that certainly appears to be the case.

“You feel guilty for not feeling as sad as you should, or not having enough time to grieve.”

Brittany Graham, executive director and community developer with the Vancouver Area Network of Drug Users (VANDU), said that burnout is commonplace in the field. COVID was one thing, she explained, but the ongoing overdose crisis—claiming ever more lives in communities like hers—makes it increasingly hard to stave off burnout.

“As more and more people die … you feel guilty for not feeling as sad as you should, or not having enough time to grieve,” she told Filter. “But then, sometimes you feel all the emotions for the people. There’s not a lot of space or time for that work, or to remember people.”

In those circumstances, there’s still much work to do, and many people who need help. “It could be your best friend—you don’t have time to grieve,” Joe Raithby, VANDU’s vice president, told Filter. “You’re dealing with other people.”

But the pressures continue to mount. People who use drugs often don’t get adequate care in the formal medical system. Welfare payments in British Columbia are low, and housing costs—including subsidized housing—are increasing, Graham said. Many social services don’t operate at the same level as they once did.

This means that people who use drugs and/or are unhoused will sometimes come to VANDU, which is primarily an advocacy organization, seeking supports they can’t find elsewhere. “If we have a blanket, we’ll give them a blanket. But if we don’t have a blanket, we can’t help them,” Raithby said.

Harm reduction workers and community organizations need to be strategic about where they put their efforts.

In terms of task-switching, VANDU doesn’t have the funding to hire, for instance, a dedicated janitor to do cleaning, so that falls on already-overburdened workers. The same is true for human resources staff, Graham said. These roles simply “become informal tasks that everybody in the organization takes on.”

There are a great many things a person could be doing every day, Graham continued, but never enough time to do them all. So harm reduction workers and community organizations need to be strategic about where they put their efforts. When workers feel like it’s impossible to do their jobs at their best, she said, that can contribute to burnout.

Both the researchers and the VANDU workers said that increases in funding and resources would help address this issue, as it would allow organizations to hire and train more people, and increase their ability to buy supplies. Yet government funding for harm reduction organizations remains limited, Graham noted, and what little there is may be spread across several organizations.

Photograph by Brut Carniollus via Unsplash

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“We are very hopeful and optimistic that the Senate will see this issue as the crisis that we do and take action,” state Representative Rachel Roberts (D), one of the bill’s sponsors, told Filter.

Harm reduction workers in the Appalachian state also hope that the legislation progresses.

Fentanyl test strips are inexpensive drug-checking tools that enable people simply to find out whether fentanyl is present in the substance they intend to use. This knowledge informs people’s decisions about whether to use and the harm reduction strategies they may employ.

Currently, fentanyl test trips are considered drug “paraphernalia” in Kentucky. The designation includes many other items employed to facilitate safer drug use—such as other testing equipment, syringes, and “Objects used, intended for use, or designed for use in ingesting, inhaling” various substances, among others. Breach of this law can result in a misdemeanor charge, with a maximum sentence of one year in prison and a fine of $500.

The concern that police could charge someone with possession of these tools deters people from carrying them for personal use, Waldon said.

HB353 would remove fentanyl test strips from this list. Advocates say that this would be an important move in stemming overdose deaths in Kentucky. The state suffered 2,250 such deaths in 2021—73 percent of which involved fentanyl. While many people who regularly use opioids may expect fentanyl to be present in their supply, people taking counterfeit pharmaceutical pills, for example, may be much less aware.

The Kentucky Harm Reduction Coalition (KHRC), based in Louisville, has been able to hand out the test strips in the state since 2021 through an initiative that has federal government support. However, Shreeta Waldon, KHRC’s executive director, said there could still be large benefits from legalizing the strips generally.

She told Filter that in Jefferson County, where she operates, she has not heard reports of people being charged with the possession of fentanyl test strips. Nor has she received confirmation of it happening in other parts of the state. However, the issue is that there’s some ambiguity.

The concern that police could charge someone with possession of these tools deters people from carrying them for personal use, Waldon said. Some harm reduction providers, too, may be deterred, and barriers like this just make harm reduction work more difficult, she added.

Waldon, who has nearly 20 years’ experience of working in the field, has seen how fentanyl test strips can help people stay alive, wherever they are in their journey with drug use, substance use disorder, or returning to use after a period of abstinence. Misunderstanding and stigma are behind a tool like this being illegal in the first place, she said. “It’s a lack of knowledge.”

“Maybe, just maybe, we are moving in a direction of solutions.”

Rep. Roberts is the daughter of a substance use disorder counselor, so the bill is close to her heart, she said. “I think this is a great way for people to be able to make sure that they’re using what they think they’re using to try and prevent overdoses.”

Further, it would enable nonprofit and community groups around the state to be able to “step up” and “help people stay as safe as they can.”

“This is yet another tool in our arsenal,” she added.

Waldon expressed that it would also be valuable to remove other harm reduction tools from the list of prohibited “paraphernalia,” such as safe smoking or snorting equipment. Still, she’s hopeful about the current bill, both for what it does specifically and for what it could signal about attitudes in Kentucky.

“Maybe, just maybe, we are moving in a direction of solutions, and really focusing on healing our communities,” she said.

Photograph by Filter staff

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The team is currently exploring this idea and reaching out to various stakeholders. They hope to complete a document outlining how Alberta’s most populous city could potentially implement such an idea—and how other municipalities could also get on board.

Evan Watson, Angela Chen and McKenzie Tilstra began thinking about this last November, when their group of U of C classmates sought to come up with new ideas to help people who use drugs during the overdose crisis. They wanted to find a way to help save lives without pushing people into private rehabilitation facilities—which is the way the provincial government in Alberta is going, with its abstinence-oriented take on addiction. A number of Alberta SCS have been forced to close in this climate, leaving many people without safe spaces to use drugs.

“So, for us, it’s about trying to come up with a creative solution,” Watson told Filter.

Eventually, they settled on the idea of setting SCS up on municipal land near fire stations. Fire stations are located in many parts of the city, making them easily accessible, and they tend to have vacant land next to them. Another factor is that Alberta fire departments are already regularly called on to respond to overdoses.

The team drafted a proposal for the idea, and ended up receiving $2,500 in funding from the Social Innovation Initiative, an effort out of the U of C and various other organizations.

“What we have right now is a mandate to explore the possibility and the roadblocks.”

According to Watson, they’re now in the process of connecting with fire services, community organizations, various government bodies, harm reduction groups, people who use drugs, and other stakeholders across Canada. They want to collect feedback and get a sense of whether doing this would be possible, as well as the best way of going about it. “What we have right now is a mandate to explore the possibility and the roadblocks related to whether or not this can be something that can be implemented,” he said.

The SCS they envision would be standalone sites outside of fire stations, potentially run through temporary structures like tents. This would be both for the sake of easing things for an overburdened fire service, and for the comfort of the clientele. Further, they would be operated by community groups that already provide services for people who use drugs.

At the end of the initial process, the team wants to create a longer document and a working model—materials that could be shared with other municipalities, so they could potentially replicate the plan. 

Normally, funding for SCS comes from provincial coffers—for example, the particularly busy one in Lethbridge, Alberta, from which the provincial government pulled its funding in 2020.

If the abstinence-oriented United Conservative Party remains in power in Alberta, the team’s proposal could potentially help make up the harm reduction shortfall—if other funding were obtained. And if a future government is more amenable to SCS, the project might work in conjunction with its priorities. However, Watson noted that “at some level, in order for this to happen, you’re going to have to be looking for broad support across the spectrum.”

Besides the basic goal of saving lives by reversing overdoses, the project could also theoretically reduce the burden on a health care system which is, broadly speaking, ailing across Canada. “We know that if we can keep people out of hospital by preventing overdoses before they happen, that’s an incredibly powerful thing,” Watson said.

“This group has a stellar team, a convincing plan to meaningfully co-create solutions with community members with lived experience, on a topic that’s affected far too many people for far too long,” Aleem Bharwani, cofounder U of C’s Pluralism Initiative—one of the groups involved in the funding—wrote in an email to Filter. “I’m hopeful and inspired by young medical students who seek to co-create durable solutions to improve our collective quality of life.”

Photograph by City of Calgary Fire Department via Wikimedia Commons/Creative Commons 2.0

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The United States’ alcohol Prohibition in the 1920s is often cited as an example of what happens when you remove regulation from a lucrative market. Groups operating outside the law are heavily incentivized to participate in the trade and to protect their market shares—by whatever means they can, in the absence of a rules-based system.

A century later, prohibition of many drugs by most countries continues to produce equivalent incentives. The resulting violence may involve rival groups competing with each other, or groups protecting their trade from law enforcement. Police, of course, directly enact violence in fighting the global drug war. In some countries, atrocities are perpetrated by a combination of official law enforcement and associated vigilantes. And drug enforcement has also been shown to contribute indirectly to violence: Arresting leaders of trafficking organizations creates volatility as others bid to fill the vacuum.

“In order to be legitimate, a policy that entails a large number of homicides must protect against more harm than what it causes.”

Petter Johnstad, the author of the new paper, is a high school teacher in Bergen, Norway, with doctorates in psychology and religious studies. His article cites various research on the topics of drug criminalization and violent crime, the harms associated with some drugs, human rights policies, and more. His analysis, matching others’ past findings, suggests that besides producing violence, drug criminalization does not appear to reduce the consumption of illicit drugs, and is a net creator of harms.

“It is obvious today that drug criminalization leads to violent crime. In order to be legitimate, a policy that entails a large number of homicides must protect against more harm than what it causes,” Johnstad wrote in an email to Filter, adding that this does not appear to be the case.

One of the main cruxes of his paper is that prohibition as a policy—when we know it inevitably causes violence, including against many people involved in neither law enforcement nor the drug trade—leads to a violation of basic human rights.

The rights in question are enshrined in Article 3 of the Universal Declaration of Human Rights (UHDR), which states: “Everyone has the right to life, liberty and security of person.” (The European Convention on Human Rights has one of many examples of similar stipulations.)

Johnstad notes that every country has signed onto the UDHR. Many countries regularly violate parts of it, of course; he cites Russia, though even a country like Canada has plenty of failures.

As such, the paper continues, governments and even voters who support prohibition can be considered as having endorsed breaking a human right to life and safety. And that could apply similarly to the United Nations Office on Drugs and Crime (UNODC), Johnstad said. The UNODC, which has a history of supporting global prohibition, did not respond to Filter’s request for comment by publication time.

“The drug criminalization regime is moving along a path of gradual dissolution and will be abolished sooner than most people think.”

Johnstad believes that international governments and the UN should abolish prohibition in order to end the violence and human rights violations—which disproportionately impact countries in the “Global South.” A human rights court, such as the European Court on Human Rights, could in theory, he said, consider a case that uses this kind of logic, “but I would not hold my breath for it.”

However, he added that he believes “the drug criminalization regime is moving along a path of gradual dissolution and will be abolished sooner than most people think. That remains to be seen, obviously.”

Emma Roberts, senior director of national capacity development at the National Harm Reduction Coalition in the US, agrees that the prohibition of drugs causes more harm than drugs themselves. “If we had a regulated drug market, then we would be able to save a lot more lives than we’re able to save right now,” she told Filter.

She added that there are several reasons politicians and voters may continue to support criminalization, however.

For one thing, the drug war benefits some people economically or politically. In the US, for example, unpaid or poorly paid prisoners make up to around $2 billion worth of goods each year and perform $9 billion worth of services in the upkeep of the prisons. Around 400,000 people are currently held on drug charges in the US alone. There’s private prisons, policing jobs, and profits for the companies that supply police and prisons. And profits for some Pharma companies are protected by the prohibition of rival versions of their drugs, among many other examples.

Politicians can also benefit from taking a hard anti-drug stance in places all over the world where such policies remain popular. “It’s about winning votes,” Roberts said. At the same time, many individuals may support criminalization simply because it’s all they’ve ever known or have been taught.

It’s in part a question, then, of finding ways to communicate the wealth of evidence for the harms of prohibition—like that compiled by Johnstad—to enough voters to make a difference.

Photograph of UN Human Rights Council session in 2016 by UN Geneva via Flickr/Creative Commons 2.0

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