Then Szalavitz met an outreach worker from San Francisco who was in Manhattan visiting a mutual friend. Though she wouldn’t learn her name for many, many years, Maureen Gammon changed Szalavitz’s life. Gammon didn’t convince her to stop using drugs. She taught her to use drugs in ways that would do less harm.

“I was not ready to quit, at that point. And in New York, 50 to 60 percent of injectors were already infected,” Szalavitz told Filter. “And then, though I didn’t know what it was called, at the time, somebody taught me to use bleach to clean my needles. And it saved my life.”

She was relieved and empowered. But she wasn’t happy.

That was Szalavitz’s introduction to harm reduction. Thirty-five years later, as an acclaimed journalist and author, she’s written the first history of the activist movement that is finally beginning to break into the mainstream. Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction hits bookstores July 27.

Ahead of its release, Szalavitz shared how she felt after that chance encounter with Gammon. She was relieved and empowered. But she wasn’t happy.

“When I learned about bleach, I was completely outraged,” she said. “The fact that something as common as household bleach could save you from a disease that was then almost 100-percent deadly, and nobody was even mentioning this, because they were afraid that mentioning it would encourage us to use drugs—as if we weren’t already using drugs. It was outrageous to me.”

She began to spread the word. From that day forward, whenever Szalavitz found herself in a public bathroom where she guessed people were injecting drugs, she left a message for them. “Use bleach,” she scrawled on every wall.

A Trip Through Harm Reduction History

In an alley adjacent to San Francisco’s “unlikely punk palace,” Mabuhay Gardens, drug users in the know kept a syringe hidden behind a brick, sharing it among an untold number of people on account of how hard it was to find clean needles in 1981.

Not far away, at the Haight Ashbury Free Clinic, epidemiologists tested one liquid after another, looking for a substance that would work quickly to kill HIV/AIDS and that was also cheap and widely available (eventually deciding on bleach, as Szalavitz would learn a few years later).

Meanwhile, in the port city of Rotterdam, the Netherlands, a group of Dutch heroin users established the very first “Junkiebond,” a group that American “junkies” would later replicate and call a drug users union.

On the East Coast, in a Brooklyn courtroom, the “Needle Eight” gave harm reduction its earliest day in court. Police had arrested the ACT UP activists for distributing clean syringes. On the stand, they delivered a fierce (and scientific) defense of their activities.

And to the north, in Canada, members of the Vancouver Area Network of Drug Users (VANDU) marched in the streets to demand authorities open the continent’s first sanctioned safe consumption site in response to an epidemic of overdose deaths that swept through the city in the 1990s.

Readers of Undoing Drugs meet an eclectic (and large) cast of characters. Edith Springer, the “goddess of harm reduction,” likely did more than anybody else to spread the word of harm reduction in its earliest days. Heather Edny was one of the first harm reduction advocates to speak openly about their own drug use. Keith Cylar brought the concept of harm reduction to housing, pioneering the collection of social policies that today we call housing first. Dan Bigg freed naloxone (Narcan) from emergency rooms and ambulances to make it available at needle exchanges and on the street. And Louise Vincent, a co-leader of America’s first national drug user union, demanded a voice at the federal level.

“We have the worst overdose crisis in the history of the United States. And we are not dealing with it well, because we haven’t learned the lessons of harm reduction.”

The story is one of empowerment, where a spirited collection of outcasts—many of them drug users themselves, as Szalavitz highlights—built a movement and then an entirely new paradigm for addiction.

Though Undoing Drugs deals mostly with the past, there is an unavoidable contemporary context: In 2020, an estimated 93,300 people died of an overdose in the US, up from 63,600 five years earlier.

“We have the worst overdose crisis in the history of the United States. And we are not dealing with it well, because we haven’t learned the lessons of harm reduction,” Szalavitz said. “Harm reduction has enormously advanced the rhetoric around what we should do, and the understanding that criminalization is a problem. But in terms of getting politicians to put that into actual action, that has been slower.”

Undoing Drugs covers a lot of ground, though not as much as Szalavitz would have liked.

“This is, basically, the first ever history of harm reduction, which meant primary sources, which meant interviewing hundreds of people,” she said. “And doing that in a context where a lot of people were criminalized and were not able to be open about their own drug use.”

“This book could have been 10,000 pages, and I easily could have done thousands of interviews. There’s an enormous amount that I had to leave out,” she continued. “I feel guilty about everyone who ended up in the footnotes or who I was not able to mention … It kills me. It was really torture.”

Despite Szalavitz’s misgivings, the book more than succeeds in its overarching purpose. Undoing Drugs leaves readers with a deep understanding of what activists are fighting for.

“Harm reduction is the idea in drug policy that we should stop people from getting hurt, rather than stop them from getting high,” Szalavitz said.

“The main goal should be, let’s make everything safer and less harmful. And that is in conflict with the War on Drugs, which makes things more dangerous and deadly. My book traces the movement to put harm reduction first, from its birth in the 1980s, to its current status as a genuine threat to worldwide prohibition.”

Image of book cover and top photograph of Szalavitz, by Ash Fox, courtesy of Hachette Books

The post “Undoing Drugs”—Maia Szalavitz’s Profound History of Harm Reduction appeared first on Filter.

“There were a couple of different counties in Ohio that were using refrigerator trucks to store the bodies of people who had overdosed and died,” Shuler began in a telephone interview. “That was the narrative coming out of Ohio. But it wasn’t what I was seeing on the ground. I was meeting lots of people who were trying their damnedest to figure out how to fix this problem. So that’s where I started.”

A couple of years later, the end result is This is Ohio: The Overdose Crisis and the Front Lines of a New America (September 2020, Counterpoint Press)—a book that sets itself apart from the pack with a focus on both harm reduction and the larger economic factors that Shuler argues comprise crucial yet oft-overlooked context.

“There was no singular dramatic moment of industrial loss,” the book reads. “Instead there was a steady decline—new technologies supplanting old, locally owned businesses being bought out by larger ones, factories shuttering via cutbacks and layoffs. The story of Newark is the same as in many places—as the world became more connected, local companies were gobbled up by bigger ones.”

The effect has been to leave residents in pain, Shuler argues. There were an estimated 4,280 overdose deaths across Ohio in 2019, up from 4,004 the previous year, according to preliminary data released by the Centers for Disease Control and Prevention last July. These numbers rank Ohio among the states affected worst of all by the crisis.

From economic decline, Shuler explains the overdose crisis and Ohio harm reduction programs with a beginner-friendly style that makes controversial topics easily digestible for people who might never have heard of these concepts, or who oppose them outright.

“I wrote the book from my perspective, as someone who was kind-of learning this stuff as I went along,” Shuler said. “So the book starts in a situation where we have someone who is abstinence-only. People are familiar with that … Then I take them from abstinence-only to see that there is a reason for SSPs [syringe-service programs]. And then maybe I can get them to see heroin-assisted treatment and see that it actually works…. If you can get people to make that leap, then maybe I can get them to rethink the War on Drugs.”

Shuler has found a gang of heroes who have taken matters into their own hands.

Shuler holds readers’ interest with a colorful cast of activists who are on the ground in Ohio today, pushing back against the fentanyl-driven overdose crisis and the wider drug war.

Among them are Trish and Billy, a mother and her son who struggles with his own addiction. The pair appear everywhere in Newark’s harm reduction scene, working both sides of the law to keep people alive.

“I’m trying not to let it totally control my life,” Trish says in the book. “But with all the activist work, if it saves one life … there might be another mom out there who saves Billy.”

For his part, Billy shares his story frankly in the hope of combating stigma.

“I’m a ten-year IV drug user,” he says at one community meeting recounted in the book. “What we’ve been doing for so long with the war on drugs is not working. In fact, it’s cultivating addiction. We gotta start looking at other pieces to the puzzle. There’s no one fix to the opioids crisis in America.”

At another gathering, Billy openly offers supports for drug users that at the time were still illegal in Newark’s home of Licking County.

“If you or someone you know is out there still actively using, see me after the meeting to get some Narcan,” he tells a full room. “If you need clean syringes, I can help you. If you are using, don’t get high alone in a bathroom. Use with somebody … Do half. Wait thirty seconds and do the other half. It’s unrealistic to say that everyone here is completely abstinent. If you’re using, don’t be ashamed. Don’t let anyone in these rooms shame you.”

Shuler remained on the sidelines through his year researching This Is Ohio. While not an activist himself, he did however pick up a few things hanging out with people like Trish and Billy.

“To convince people on any complicated or controversial issue, you have to start with where that person is at.”

“In rural America, and in the Rust Belt, and in places that have fewer resources, try to figure out who are your allies, and work with those allies,” Shuler said. “Who are the people that you can bring along? Who are the medical professionals that you can bring along? You have to figure out who your allies are, first.”

He offered a second tip that will ring familiar to veteran harm reduction advocates.

“I once had the opportunity to meet Sister Helen Prejean,” Shuler said. “And I’ll never forget this, she said to me, ‘To convince people on any complicated or controversial issue, you have to start with where that person is at. So if they are more concerned about the economy, then you start there and you make that argument. If they’re more concerned about safety, then you start there. If they are more concerned about health and community health, then you start there.’ You figure out where people are at.”

In reading This Is Ohio, Shuler said he hopes people will share the experience that he had writing it. “The narrative arc of the book is really chronological, but it’s also an arc that takes me from being a newbie to maybe understanding a whole lot more than I did before,” he said. “And hopefully, I will take readers with me on that journey.”

In the sort of middle-America town where news reports too often only focus on the bodies, Shuler has found a gang of heroes who have taken matters into their own hands.

“Trish’s story is the story of a lot of people’s; she’s doing this because her son has his own struggles [with addiction], and because she would hope that while he is struggling, that there will be someone there to support him and to meet him where he is at.”

“I can’t even tell you how in awe I am of those people,” Shuler continued. “There are lots of people around the country who are doing something just like that. This is just one story.”

Photograph of Gary Lee Price’s sculpture “Family Outing,” in Newark, Ohio, by Chamberednautilus via Wikimedia Commons/Creative Commons 4.0

The post “This Is Ohio”—Economic Pain and Harm Reduction in the Rust Belt appeared first on Filter.

A man walks toward them and the journalists spot an ankle bracelet, monitoring his location electronically. Several members of a group across the street are on probation, and Schenwar and Law visualize numbers floating above the mens’ heads, counting down the years until they’re free from the ever-present threat of incarceration. Behind Schenwar and Law, inside an apartment building, a woman stares out the window, confined under house arrest.

Down at the other end of the street, a pair of beat cops whistle as they walk. They look friendly enough but, as Schenwar and Law explain in their new book, Prison by Any Other Name: The Harmful Consequences of Popular Reforms (The New Press, 2020), the officers represent a violent expansion of policing that is widening US authorities’ net to control ever-greater numbers of people.

“Other reforms that we talk about in the book, they’re less visible,” Schenwar told Filter in a telephone interview. “They’re about hiding people away.”

“We’re expanding the number of people under the physical control of the state.”

These include mandated-treatment facilities that house people arrested for drug possession, for example, and psychiatric hospitals that hold people apprehended for mental health crises. “All of these things that abolition activist Mariame Kaba calls, ‘the Somewhere Else,’” Schenwar continued.

“We’re expanding the number of people under the physical control of the state,” Law said in the same interview. Without the options of the Somewhere Else, “They might have been given some kind of sentence that was looser and that maybe did not involve as many requirements,” Law added. “And so this [push for out-of-prison alternatives] is actually expanding the number of people who are caught.”

Schenwar, the editor-in-chief of Truthout, and Law, a freelance journalist (who has written for Filter) and cofounder of NYC Books Through Bars, have written a spiritual successor to Michelle Alexander’s The New Jim Crow: Mass Incarceration in the Age of Colorblindness. It includes a foreword by Alexander. Focusing less directly on race—but maintaining a required awareness of systemic racism—Prison by Any Other Name loosely picks up at the prison walls where The New Jim Crow left off.

The book details an ever-creeping expansion of the prison-industrial complex, beyond barbed-wire fences, into people’s communities, schools and the very homes in which they live. It notes that the number of people in America under electronic monitoring increased from 53,000 in 2005 to 125,000 in 2015.

This would not be okay even if during the same period, the numbers of people in jails and prisons had decreased (they did not over the whole period, despite declines toward the end). The goal of reforms should be fewer people caught up in the system and indeed, its total transformation, not the same number transferred from one form of “correctional control” to another.

“These varying manifestations of the criminal punishment system raise the question of what defines a prison,” Schenwar and Law write in the book. “There is unique gravity to an actual prison sentence, the violence of locking a human being in a cage. Yet the system is broader than the buildings called ‘prisons.’ Manipulation, confinement, punishment, and deprivation can take many forms—forms that may be less easily recognized as the violence they are.”

“Drug courts are trying, sentencing, and confining people who in many cases wouldn’t otherwise be incarcerated.”

Take the example of drug courts.

As the opioid-involved overdose crisis of the 2000s replaced the “crack epidemic” of the 1980s and early ‘90s, the impacted populations in the spotlight initially shifted from Black people to white. That’s resulted in a so-called kinder, gentler War on Drugs, and encouraged politicians, like Democratic presidential nominee Joe Biden, to embrace drug courts as a treatment-based alternative to prison. But the extent to which drug courts are less violent than incarceration is highly debatable, the book argues.

“Instead of simply providing an alternative for people who would otherwise be sent to prison, drug courts are trying, sentencing, and confining people who in many cases wouldn’t otherwise be incarcerated,” it explains.

“The existence of courts designed to handle minor drug-related charges has been shown to encourage police to make those types of arrests—a kind of ‘if you build it, they will come’ phenomenon,” the book continues. “Police know these courts exist to handle an increase in small-time drug cases, and so they are more likely to make small-time drug arrests. As Denver district court judge Morris B. Hoffman stated, ‘It is clear that the very presence of drug courts is causing police to make arrests in, and prosecutors to file, the kinds of ten- and twenty-dollar hand-to-hand drug cases that the system simply would not have bothered with before.’”

And then there’s this: “Approximately half of people sentenced to a program through drug court don’t finish—and the ones that don’t often end up with harsher jail or prison sentences than if they hadn’t gone the drug court route in the first place.”

Schenwar and Law place this effect—“widening the net,” they call it—at the center of everything wrong with the current trajectory of prison reform.

“They [politicians] love the idea of diversion,” Schenwar said. “But you still arrest people for drug offences, you still criminalize drugs, you still criminalize all kinds of actions that may result from drug use or addiction. But instead [of prison], you funnel people into this alternate system because somehow it will help people by providing quote-unquote ‘treatment.’”

“And then when people violate the terms of their drug-court sentence—which happens so often because those terms are very rigid and very strict—then often the penalty is incarceration, and often it is the maximum sentence,” she continued.

Prison by Any Other Name was released against the urgent backdrop of the Black Lives Matter movement’s second wave. Both Schenwar and Law advocate for the abolition of the entire penal system—arguing that what’s needed for the creation of a more just society is wider access to quality education, improved options for employment, a drastically better healthcare system that includes mental health services, and other holistic reforms.

“When she died of an overdose, she was in an abstinence-based drug court program.”

Lending authority, they both come to the book’s topics from personal experience.

“Victoria, or Vikki as she’s known to friends, was once on probation,” the book reads. “At sixteen, Vikki was arrested for several counts of armed robbery and gun possession, all of which are violent felony charges … She was ultimately sentenced to five years of probation.”

Schenwar told a different story. “For me, this issue is very personal because my sister was in and out of jails and prisons for about 15 years and then in and out of all kinds of alternatives: electronic monitoring, drug-treatment centers and all kinds of things,” she said.

“She was in drug court in February when she died,” Schenwar continued. “When she died of an overdose, she was in an abstinence-based drug court program.”

Schenwar explained that her sister was mandated to remain abstinent or risk jail time. She did remain off drugs, for a while. But then, when she eventually relapsed, her tolerance was lower than she realized. If her sister had been offered something better tailored to her as an individual, maybe the outcome would have been different, Schenwar said, anger audible in her voice.

“Drug court played a role in her killing,” she added. “It was not her survival that counted in this system. It was whether she was following the law.”

Photograph by Jérémy-Günther-Heinz Jähnick via Wikimedia Commons/Creative Commons 3.0

The post Cages Don’t Always Have Bars: How “Reforms” Swelled the Carceral State appeared first on Filter.

There were an estimated 6,518 drug-overdose deaths across California last year, according to preliminary data released by the Centers for Disease Control and Prevention on July 15. That’s up from 5,626 in 2018—an increase of 15.9 percent.

The picture that emerges is one where California, until now largely spared from the tragedy of the opioid-involved overdose crisis, is beginning to catch up to so much of the rest of the United States. “We’re a little bit behind everybody else, but we’re still following the same timeline,” Michael Marquesen of the Los Angeles Community Health Project warned in 2018. “I’m sure it’s going to show up everywhere.”

California is one of the last areas of the country where “black tar” heroin remains available. The viscous consistency that characterizes black tar means it is difficult for suppliers to mix in fentanyl, the synthetic opioid responsible for the so-called “third wave” of the overdose crisis. Most of the country’s “China white” heroin—of varying consistency but always sold as a powder—was easily adulterated with fentanyl. But California’s black tar provided a modicum of relative predictability (if not security). At least until 2019, when it appears that began to change.

A February 2019 report by Insight Crime confirmed that Mexican cartels were steadily replacing heroin with fentanyl. And among states that saw significant increases in overdose deaths through 2019, California ranks among the top.

By 2019, California could have had safe consumption sites operating in several key cities.

Did it have to?

By 2019, California could have had safe consumption sites (SCS) operating in several key cities where large drug-using populations reside.

For years, Susan Eggman, assemblywoman for California’s 13th Assembly District, has patiently and repeatedly moved bills through the state legislature that would allow for the establishment of SCS—healthcare facilities where people can bring drugs to inject with clean equipment and under the caring eye of nurses.

Eggman came closest in 2018. By that September, Bill 186 was approved by both the state’s Assembly and Senate. Local agencies like the San Francisco Department of Public Health were ready to go with plans to open facilities with buy-in from local communities and without further delay. But just before Governor Jerry Brown left office, he vetoed the bill.

Today, legislators have State Assembly Bill 362 under their consideration. Eggman’s third attempt, it would allow for a six-year supervised-injection pilot program in San Francisco. The bill cleared the Assembly in May 2019 and last month received a second reading in the Senate.

The scientific literature in support of SCS is voluminous and widely available online. It says that they reduce the spread of infectious diseases like HIV and hepatitis C, and prevent overdose deaths. When deployed with complementary services, they also reduce crime in a neighborhood, move people into supportive housing, and connect users with mental-health services and other healthcare programs, including long-term treatment.

Most of the data on SCS pertaining to North America come from Insite, a Vancouver, Canada facility founded in 2003 and the only sanctioned site on the continent until 2016.

According to Insite’s operator, PHS Community Services Society, from March 2004 to December 2019, facility staff responded to 7,884 drug overdoses. Their success rate was 100 percent. Documents obtained under freedom-of-information legislation confirm that Insite has never seen one death.

A more recent and more relevant case study comes from Vancouver’s province of British Columbia. The region was the first in Canada where fentanyl sent overdose deaths soaring. In response, the provincial government declared a state of emergency and allowed for the establishment of a new class of SCS. Called overdose-prevention sites (OPS), these stripped-down injection facilities were deployed in affected communities quickly and effectively. Within a year, overdose deaths began to decline.

Through the winter of 2016, deaths across BC averaged 144 per month, according to the province’s coroners service. By the same period the following year, that number had declined to 115. And then in the same three-month period in 2018, average monthly deaths dropped to 100.

BC’s response to fentanyl was harm reduction. Although implementation could have been wider, it was beginning to work.

By that time, there were more than a dozen injection facilities operating in BC. The province’s response to fentanyl was harm reduction. And although implementation could have been wider still, it was beginning to work.

And then the COVID-19 pandemic swept into Vancouver, disrupting services and causing the adulteration of illicit drug supplies, and overdose deaths soared. According to the BC Coroners Service, there were 113 deaths across the province in March, 118 in April, 170 in May, and then a new record 175 in June.

All of this demonstrates that SCS are not the only solution to the overdose crisis, nor adequate in themselves. If people cannot access them, or do not wish to, their scope is clearly limited. Yet their pre-pandemic impact in BC illustrates what an important part of the solution SCS can be. Meanwhile, California, which, like all of the United States still doesn’t have SCS, just recorded, pre-pandemic, its worst year for overdoses. There are widespread expectations that national and state figures for 2020 will be worse still.

In response to North America’s overdose crisis, there’s one message that health authorities have pushed harder than any other: Do not use alone. Over and over again, officials have warned, if you use drugs, use them in the company of a friend. Should someone overdose, there is safety in numbers.

In response to the COVID-19 pandemic, authorities are instructing people to do the exact opposite. “Social distancing” and “self-isolation” are the precautions they are asking people to take today.

Authorities could soften the blow by finally allowing, with appropriate wraparound services and safeguards, the safe consumption sites that in 2018 both the state’s Assembly and Senate voted to support. A 2019 federal court ruling in Philadelphia that SCS would not violate federal law removed one potential barrier.

The first time I spoke with Eggman about her harm reduction efforts, back in 2017, she explained it like this: “Having a drug addiction should not be a death sentence.”

Photograph of Insite in Vancouver by Travis Lupick

The post California’s Huge Overdose Increase Didn’t Have to Happen  appeared first on Filter.

“People are so isolated right now and longing for connection,” Jess Tilley, co-director of the Urban Survivors Union, a national group of drug users, told Filter. “And then when you add being a drug user on top of that, or being a frontline worker or working in harm reduction, it’s worse. We’re sort-of the outcasts of society to begin with, so it’s so hard to find our community.”

A recent CNN report on an increase in overdose deaths across the Appalachian region coinciding with the spread of coronavirus used the phrase “pandemic’s-worth of triggers.” It’s a combination of anxiety, loneliness, stress, boredom and—for anyone who has lost someone to the virus or the burden it’s placed on the healthcare system—of loss and of trauma as well. Whatever one’s trigger might be for resuming use or using with greater risks, it feels like COVID-19 has brought it.

On top of it all, social distancing orders shut down mutual-support groups’ in-person meetings exactly when many people in recovery from addiction needed them more than ever.

Narcotics Anonymous (NA) meetings were relatively quick to move online, as were those of Smart Recovery and similarly large organizations. But the vast majority of such groups are based in the 12 Steps, only support abstinence, or come with other one-size-fits-all philosophies with which many people take issue. If COVID-19 has you using drugs in an unhealthy way, and if you’re not thrilled at the idea of surrendering yourself to a higher power or don’t want to quit completely, where can you turn for support?

“I used to utilize 12-step groups and I really missed that that community. And yet, philosophically, I’m feeling a little bit differently now.”

Meghan Hetfield, who works in family planning and peer recovery in Catskill, New York, told Filter that she found the answer just before the virus swept across North America.

“I used to utilize 12-step support groups at different times in my personal recovery and I really missed that human connection and that community that I had when I was attending those meetings,” she began. “I’ve really missed that aspect of my life. And yet, philosophically, I’m feeling a little bit differently now than the 12 Steps.”

Listening to the drug policy podcast Narcotica one night, Hetfield heard Tilley describe a new model of support group. With her nonprofit, HRH413, Tilley recounted experimenting with a model not dissimilar from NA. But instead of placing abstinence at the center of everything, it roots itself in harm reduction.

This sounded very interesting to Hetfield. Shortly after, she made the two-hour drive east to Tilley’s homebase of Northampton, Massachusetts, and attended one of HRH413’s meetings to see what Harm Reduction Works (HRW), as it had been named by this time, was all about.

Hetfield described finding what she didn’t know she had been looking for. “I wanted to provide the same space for people here [in Catskill],” she said. “It’s a way to build community around harm reduction in a way that I don’t think has been possible before. It is self-replicating and allows people to be in this space, whatever that looks like for them. Just come as you are.”

“I think this model is going to be really attractive to a lot of people right now who are struggling for a sense of belonging that doesn’t have a million rules,” Hetfield added.

How the Meetings Work

So what is this model?

As the founder of the New England Drug Users Union and a high-profile name in America’s harm reduction movement, Jess Tilley is HRW’s de facto spokesperson, and her personal experiences helped inform its creation from the ground up. But the group is the brainchild of her HRH413 cofounder, Albie Park. In a telephone interview, Park conceded that for a support group that was originally conceptualized as an alternative to NA and the 12 Steps, HRW actually has quite a bit in common with them.

“HRW meetings are scripted,” Park began. They begin with a reading and end with a reading, and in the middle is a topic of the day and time for people to share. So the skeletal structure will feel familiar to the millions who have attended NA or AA. But from there, Park continued, HRW departs from NA in ways that some 12-steppers will disapprove of and others will find refreshing.

While most NA groups forbid “crosstalk,” HRW meetings place feedback and discussion at the centre of their meetings. Anyone sharing does however have the option to ask that the group only listen, Park noted. In addition, HRW lacks NA’s sponsorship structure and the pitfalls that can come with the sort of power that sponsorship gives one NA member over another.

Setting it apart from the vast majority of recovery-support groups, HRW has no requirement for abstinence.

HRW also declines to track participants’ “clean time.” There are no keychains for days abstinent and therefore none of the shame or stigma that abstinence-only groups can inflict on members who slip. What’s more, while many NA groups reject medication-assisted treatments (MAT) such as methadone or buprenorphine, or even view the availability of the overdose-reversal drug naloxone as enabling, HRW fully welcomes people on MAT and HRW meetings often distribute Narcan and syringes right in the same rooms where participants discuss aspirations for abstinence.

Finally, the most notable aspect of HRW, setting it apart from the vast majority of recovery-support groups, is that HRW has no requirement for abstinence. Attendees can express a desire for abstinence or share that they’re actually not interested in abstinence at all. Maybe they want to transition from injecting drugs to smoking them, or stop sharing needles and instead begin visiting a syringe exchange. Perhaps they are considering giving methadone a try. Or maybe a participant is simply looking for a shoulder to lean on.

“What 12-step has, is it is a redemption-story machine with that classic story arc,” Park said. “This [HRW] is just your life. There’s no demarcation point [around abstinence]. It’s not that clean. HRW makes room for things to be a little bit messy. It makes room for people to figure shit out….It was conceived for the person who is saying, ‘I don’t know what’s going on, I don’t know what’s happening, but I know I have to do something.’”

Through the second half of 2019, HRW was slowly beginning to gain traction outside of Tilley and Park’s hometown of Northampton, attracting chatter at drug policy conferences and clicks online. Then came COVID-19. It was more important than ever for people to feel support. And quite suddenly, in just the last two months, HRW rapidly grew online to seven virtual meetings held weekly on Zoom hosted out of five cities around the United States. (Anyone interested in checking out a HRW meeting on Zoom can find a list maintained on the group’s Facebook page. Additional information is also available at hrh413.org.)

Park said that he’s been pleasantly surprised. “If COVID had not happened, I probably would not have made the choice to go online,” he explained. “Then we started [online] and the meetings have been really, really well received.”

“I feel like I can finally talk about what my recovery really looks like.”

It was actually Hetfield who hosted the very first HRW online gathering. She said one of the most encouraging things she’s observed in their Zoom meetings is true honesty.

“Often people feel really good about not using heroin in five years but guess what, ‘I had a couple of beers over the weekend and I’m okay.’ It feels really good to say that out loud,” she recounted. Hetfield noted that HRW’s lack of an abstinence requirement means people can return to use without feeling like they’ve disappointed the group. That extra space can help people in recovery stop at a beer or two, whereas if they were NA, they might feel like a small slip with a glass of wine is a good reason to pick up an eightball, Hetfield explained.

“I feel like I can finally talk about what my recovery really looks like,” Hetfield said she’s heard participants say. “Somebody’s recovery or change process should be honoured and celebrated even if that doesn’t include abstinence,” she added.

Evaluation Under Way

It’s still early days for HRW and there so far exists no sort of data on how this harm reduction model might assist people with recovery or otherwise improve health outcomes. But a small team of addiction researchers has been commissioned by the nonprofit Rize to evaluate groups incorporating harm reduction into recovery, and one of the organizations they’re looking at is HRH413 and HRW. 

Jennifer Carroll, a medical anthropologist, is a member of that team. She emphasized she could not comment on a program under review, but spoke generally about a need for alternatives to 12-step and abstinence-only models.

If someone is coming from a situation of being abused, “the last thing in the world they need is a recovery platform that requires them to acknowledge their powerlessness.”

“The biggest problem with 12-step isn’t actually 12-step, it is that so many people believe that it is the end-all-be-all of personal change or wellbeing,” Carroll, an assistant professor at Elon University in North Carolina, told Filter. “If there is someone who is interested in 12-step, they absolutely deserve and need to have access to that tool….The challenge comes when people are shuffled into 12-step programs when that is an inappropriate form of care.”

For example, if someone is coming into a support group from a situation of being abused, Carroll said, “the last thing in the world they need is a recovery platform that requires them to acknowledge their powerlessness.”

The evidence of NA’s effectiveness in maintaining abstinence is indeed mixed, as the spirited debate around a recent high-profile New York Times article illustrates. Especially when assessing abstinence outcomes with different substances, 12-step groups do not work for everyone, the literature suggests.

Carroll added that there’s an obvious appetite for new models and philosophies for recovery. “My inbox blows up a lot with people who want a neutral source of advice. ‘This is happening with my nephew,’ ‘This is going on with my husband,’ ‘Do you have any thoughts or do you know anyone in this area?’” Carroll recounted. “And frequently, those requests are for any suggestion I can make about support groups or mutual-aid groups that are not 12-step oriented.”

Especially in the context of COVID-19 and continued requirements for people to remain in their homes, Tilley said there is one thing that HRW has borrowed from NA that inspires people to “keep coming back.”

“Those of us who were part of 12-step and who left, for whatever reason, whether it be the program, the people, or if we just felt we outgrew it or we started using again, the biggest thing that we miss is the community,” she said. “We miss the camaraderie. And that is HRW.”

Photo by Allie on Unsplash

The post Harm Reduction Works: An Exciting New Alternative to Narcotics Anonymous appeared first on Filter.

“The kids on the bus as it careered toward Yamhill each morning were sure that their world would be better their parents’ had been,” the veteran New York Times journalist writes with Sheryl WuDunn in their bestseller Tightrope: Americans Reaching for Hope (Knopf, January 2020). “Yet those kids ended up riding into a cataclysm, as working-class communities disintegrated, felled by lost jobs, broken families and despair.”

“About one-fourth of the kids who rode with Nick on the bus are dead from drugs, suicide, alcohol, obesity, reckless accidents and other pathologies,” the book continues.

Mike, Cindy, Jeff, Tim, Billy, Kevin, Sue and so on. They’re all gone. Others⁠—Chris, Mike, Bobby⁠—remain alive but are homeless, in prison or missing.

Kristof told Filter that the things that killed his childhood friends are not the problems per se, but rather are only indications of much larger, systemic issues.

Kristof and WuDunn—who is married to Kristof and who, with her husband, won a Pulitzer prize for their coverage of the 1989 Tiananmen Square protests—craft an intimate exploration of why so many of Kristof’s grade-school peers and so many more people across America are dying young.

Tightrope has won widespread praise. NPR called it “deeply necessary.” Newsweek said it “may well be the timeliest and most engrossing work of nonfiction this year.” The Washington Post’s review was mixed and hinted at a controversial reception, calling it “earnest and oddly endearing, but often slightly muddled; the authors want to speak to conservatives as well as liberals, but they can’t quite pull off their own balancing act.”

In a telephone interview, Kristof, who’s 60, told Filter that the things that killed his childhood friends are not the problems that the country grapples with today, per se, but rather are only indications of much larger, systemic issues.

“Drugs are a symptom of something much deeper,” the two-time Pulitzer winner said. “It’s a psychological crisis that manifests itself, not only in drugs, but also in rising alcohol-related deaths and in the highest suicide rate since World War II.”

The US is a rich country, but inequalities mean that many people don’t benefit, the book shows.

“The American economy has dazzled the world and its stock markets have created great riches,”  it reads, “but the median American household is actually poorer in net worth today than it was in 2000. America now lags behind its peer countries in health care and high-school graduation rates while suffering greater violence, poverty and addiction.”

The effect is profound. In 2017, the number of deaths attributed to drugs, for example, surpassed 70,000. Compare that to a rough average of 15,000 fatal overdose each year two decades earlier, through the 1990s.

Kristof and WuDunn

Yamhill is a white town, but Tightrope is more than another entry in the crowded cry-for-whites genre that exploded with 2016’s Hillbilly Elegy. The authors devote chapters to the earlier experiences of majority-black cities like Baltimore and Pine Bluff, Arkansas for example, where self-medication with drugs like crack cocaine—and the ugly political and law enforcement response—saw devastating outcomes.

“In many ways, I’d say that what Yamhill went through is something that a lot of African American communities went through about 20, 25 years earlier,” Kristof said. “In terms of life expectancy, in terms of job options and, to some degree, in terms of neglect, there are a lot of parallels.”

“Jobs left these urban areas⁠—places like Baltimore—and then people self-medicated as drugs came through,” he continued. “And then there was a very harsh crackdown. Men, in particular, then acquired criminal records that made them less employable and less marriageable. And then social fabric unraveled very quickly. That describes what happened in a lot of African American communities in the 1970s, say, and it also describes what happened in rural Oregon or Maine or Kentucky and white areas, a generation later.”

Kristof acknowledged, however, that the tone of the US response to the opioid-involved overdose crisis is dramatically different from its earlier response to crack—and he immediately named racism as a primary reason.

“In the 1990s and 2000s, there was a lot of pejorative, nasty commentary about suffering in African American communities, about how it was supposedly a reflection of black culture and deadbeat dads and bad choices. Meanwhile, the great Harvard sociologist William Julius Wilson said, ‘No, this is about jobs leaving’,” Kristoff said. “He was exactly right.”

If 2020 policymakers’ relatively compassionate response to overdose victims who are white is leading America to a slow erosion of the War on Drugs, that is racist. But the way Kristof describes it, a bad motive can be put to beneficial use.

“The fact that you have a lot of pain in red states, in white populations, has made the political system somewhat more responsive to these problems,” Kristof said. “It is hypocritical and it is a double standard, but it is a hypocrisy that may lead, belatedly, to more enlightened policies.”

Kristof and WuDunn note that in the US, a person’s income is roughly as inheritable as height.

Tightrope also emphasizes the long-term impacts of generational wealth disparities. Severely limited opportunities for the accumulation of generational wealth among African American families have produced a devastating racial-inequality gap today; “the median black family,” the book notes, “has only 10 percent as much wealth as the median white household.”

Quoting the Princeton University economist Alan Krueger, Kristof and WuDunn note that in the US, a person’s income is roughly as inheritable as height. “The chance of a person who was born to a family in the bottom 10 percent of the income distribution rising to the top 10 percent as an adult is about the same as the chance that a dad who is five-feet, six-inches tall having a son who grows up to be over six-feet, one-inch tall,” Krueger observed. “It happens, but not often.”

The book describes how, for white working class families, the post-World War II GI Bill of Rights made it easier for veterans to attend college, and housing initiatives greatly expanded home ownership. Black families were excluded.

The decline of such opportunities in recent decades saw suffering similar to that long experienced by black families increasingly experienced by white ones, too.

“This psychological crisis is partly driven by the loss of well paying, blue collar jobs,” Kristof told Filter. “If wages had kept pace with the economy than the average man in a non-supervisory job would now be earning, not $43,000 a year, but $90,000 … And then, when working class men began to earn less, that also diminished their marriage prospects. And so they’re less likely to have families to provide perspective and support. And loneliness is lethal.”

“Marriage and family” is a traditionalist’s remedy, and should surely not be a prerequisite for equality. At the same time, research has shown—for better or worse—that marriage is associated with better economic outcomes in the US, and that a stark racial gap in marriage rates has developed.

The similarity of black and white communities’ suffering does not extend, for example, to policing practices and incarceration rates.

The book provides valuable context for America’s overdose crisis, deftly explaining the economic factors that comprise many of its roots. But Kristof, who self-describes as a “progressive,” is a controversial figure in some left-wing circles.

That Tightrope’s central narrative unfolds in Yamhill reflects Kristof’s personal connection to these issues. But the fact that many black communities have been suffering for far longer will be uppermost in many readers’ minds, notwithstanding Tightrope’s chapters addressing the experiences of black populations. The similarity of black and white communities’ suffering does not extend, for example, to policing practices and incarceration rates. Some of the book’s language, such as “blacks,” also jars with 2020 progressive norms.

In addition, advocates for drug policy reform will be disappointed that Tightrope doesn’t include more on the roles that governments and policymakers have played in compounding the damage. The book has received criticism for centering the supply of illicit and prescription drugs, rather than the drug war, as a cause of misery.

Kristof and WuDunn do mention their opposition to the drug war and support for decriminalization, but merely a mention is about as much time as these issues get. The “solutions” section of the book focuses on very worthwhile ideas such as universal healthcare, improved family-planning programs and wage insurance. But I was hoping Tightrope’s pages would push for measures like amnesty for past drug convictions, for example, which would greatly help people with criminal records gain meaningful employment.

The authors also praise problematic approaches without mentioning that similar positive outcomes could be accomplished with far less collateral damage. For example, they correctly note that many people addicted to drugs find recovery following an arrest and time in prison. But of course there are ways to enter treatment—or should be—that don’t involve getting arrested, being locked up or spending the rest of one’s life with a criminal record.

Kristof and WuDunn also highlight (again, correctly) how the US military may steer someone from a small town with few opportunities to higher education and a better career. Here, at least, the authors acknowledge that youths could also find structure and purpose through programs that don’t involve PTSD and unjustified ventures in the Middle East.

Tightrope’s compelling narrative therefore has problems. At the same time, much of what it does, it does well. More people are using drugs, not just for fun, but in response to pain—and using in a manner, and under circumstances, that lead to overdose and death. With deeply human anecdotes, Kristof and WuDunn have illustrated a considerable part of this. There is much more to the story.

Photos of Yamill, from the cover of Tightrope, and of the authors courtesy of Knopf Doubleday Publishing Group.

The post Tightrope: A Powerful But Problematic Deaths-of-Despair Narrative appeared first on Filter.

And 66 times every day, an operator answers one of those calls, assesses the situation, and dispatches firefighters or paramedics (not police).

And then those professionals rush out and, nearly 66 times every single day, they save a person’s life.

“When BCEHS [BC Emergency Health Services] paramedics respond to a potential overdose patient, the patient has a 99 percent chance of survival,” reads an email from Shannon Miller, a spokesperson for the agency.

As a Vancouver-based journalist covering drug policy, one of the most common questions I’m asked is this: If Vancouver is so great with harm reduction, why are overdose numbers there so high? An analysis of relevant data can help explain.

With a population roughly the size of Colorado’s or less than half the size of Pennsylvania’s, there aren’t actually all that many people in BC. And yet Canada’s westernmost province is the epicenter of the country’s overdose crisis.

“The provincial rate of paramedic attended overdoses events (events per 100,000 BC residents) has increased 4 fold in less than three years, from 8 events/100,000 in January 2015 to almost 31 events/100,000 by March 2019,” reads a BC Centre for Disease Control (BCCDC) summary of the situation. “While the rate of events has steadied in late 2018, March 2019 saw the highest rate ever at 31 events/100,000.”

These are war-zone figures. And, more than five years after the synthetic opioid fentanyl arrived in the heroin supply and BC’s overdose crisis began, they are still only getting worse.

Last year, BC first responders answered more 911 calls for drug overdoses than ever before, according to new data that BCEHS has shared with Filter. There were 24,166 emergency calls for overdoses across the province in 2019.

That’s up roughly two percent from 23,662 calls in 2018 and 23,441 in 2017—and way, way up from 12,263 calls just four years ago, in 2015—according to additional statistics supplied by BCEHS.

“For the last three years the total number of overdose calls paramedics attend has remained steady–but this steady volume of overdose calls (now, more than 24,000 calls a year) is double what it was before the overdose crisis began,” a January 9 BCEHS statement reads.

Meanwhile, the number of fatal overdoses BC suffered in 2019 actually declined and, remarkably, declined by a lot.

There were 823 illicit-drug overdose deaths recorded by the BC Coroners Service (BCCS) during the first 10 months of 2019. That puts the province on track for a projected 988 deaths last year.

That’s down from 1,542 fatal overdoses in 2018 and 1,495 in 2017.

Graph showing illicit drug-involved death rates in British Columbia from 1993-2019. Credit: BC Coroners Service.

However, while a one-third decline in overdose deaths is good news, it comes with a major caveat.

Nearly a thousand deaths last year is a number that remains miles above what was once considered “normal” in BC. Five years ago, in 2014, BC recorded just 369 fatal overdoses.

From 2001 to 2010, the average number of deaths each year was just 204, barely one-fifth the “good news” number of 988 projected for 2019.

Overdose deaths are down, but overdoses are not. They are higher than ever before. What, then, accounts for the decline in the ratio of overdoses that turn to fatal overdoses?

“Without access to and rapid scale-up of harm reduction and treatment strategies, the number of overdose deaths in BC would be 2.5 times as high.”

BC authorities’ response to the opioid epidemic has primarily consisted of programs and services that fall under the umbrella of harm reduction—a field of health care that seeks to minimize the harms of drug use without necessarily eliminating the use of drugs itself.

The BCCDC has flooded the streets of neighbourhoods acutely affected by the crisis with the overdose-reversal drug naloxone. It’s made it free and widely available without a prescription and offers regular training sessions in overdose response that anyone can drop in to attend, also free of charge.

Regional health authorities have opened additional supervised-injection facilities (SIF) and established a new category of low-threshold supervised injection called overdose-prevention sites (OPS).

Still more de facto supervised-injection sites have been integrated into dozens of supportive-housing buildings in BC operated by nonprofit government partners.

Activist organizations like the Vancouver Area Network of Drug Users (VANDU) responded to the onset of the overdose crisis by forming teams of volunteers trained in overdose response and sending them out to patrol the alleys of the city’s downtown core. Inside private single-room occupancy hotels (SROs), marginalized citizens have organized amongst themselves to ensure naloxone is available within their buildings, and that as many residents as possible know how to use it.

Along back alleys in impoverished Vancouver neighbourhoods like the Downtown Eastside, it’s not uncommon to find naloxone kits clipped to chain-link fencing, left hanging there by persons or groups unknown, for anyone who might one night use it to save a friend’s life.

BC, and especially the city of Vancouver, continue to see an unprecedented number of 911 calls for drug overdoses. But, while authorities have failed to slow the number of overdoses occurring, they have begun to slow the number of those overdoses that end with a death.

“The rapid expansion of harm-reduction services in response to BC’s overdose crisis prevented more than 3,000 possible overdose deaths during a 20-month period,” reads a June 2019 media release summarizing a paper co-authored by the BCCDC’s medical lead for harm reduction, Dr. Jane Buxton.

During the period analyzed—April 2016 to December 2017—there were 2,177 illicit drug overdose deaths in BC, according to the BCCDC paper. “The study estimates that without access to and rapid scale-up of harm reduction and treatment strategies, the number of overdose deaths in BC would be 2.5 times as high,” it reads.

Rates for overdose deaths in Vancouver and across BC remain the highest in Canada. But without harm reduction, they would be far worse. And harm reduction may now be beginning to turn the tide.

Photo of naloxone kit hanging on Downtown Eastside fence in Vancouver by Travis Lupick.

The post Why Overdose Deaths Have Fallen Here—Despite More Overdoses appeared first on Filter.

Since the synthetic-opioid fentanyl began augmenting or replacing heroin across North America, controlling your dose has become increasingly difficult. Every bag of “heroin” purchased on the street is of an unknown purity. Amid sky-high fatality rates, fentanyl is making many bags stronger than anybody wants.

An older heroin user in Seattle who goes by the nickname JD told Filter that he struggles to achieve the milder high he’s after.

“So many people who hit that heroin, shooting it in their arm, they nod and they be so deep, they forget everything,” he explained. “I don’t want to do it like that. I stay on point.”

For six or seven years now, JD has visited the People’s Harm Reduction Alliance (PHRA) in Seattle’s University District. He was standing outside their office one morning with a few other guys, waiting for the door to open, and a friend told him about something new that PHRA was experimenting with. He suggested it might be what JD was looking for.

“It’s called the hammer,” his friend said. “It’s a heroin pipe.”

JD gave it a try.

“It don’t make my stomach all upset like the needle does,” he said. “It doesn’t make me sick. It doesn’t make me nod. So I like it.”

“If we could create something that was actually a better product, we could give North Americans a means to switch from injection.”

Many of the most effective responses to the drug war’s new era of synthetics have emerged from the minds of people who use drugs. Filter has covered how drug users are at the front of naloxone distribution, for example, and how groups in Canada are organizing “buyers clubs” to bulk-purchase opioids of a known purity.

Now Shilo Jama, a longtime organizer in Seattle, hopes to offer a tool that gives people who use heroin greater control.

“My feeling was, if we could create something that was actually a better product, we could give North Americans a means to switch from injection,” said Jama, who co-founded PHRA and has also written for Filter. “If we could find a pipe that worked well enough, that could bridge a gap.”

On a 2018 trip to Portugal, Jama noticed that many younger heroin users were reluctant to try needles and instead smoked their opioids using tinfoil. “But tinfoil always felt inefficient to me,” he continued. “With tinfoil, you’re getting the entire area around you high. Smoke is leaving every which way.” And this could be a disincentive to smoke, rather than inject. “So I felt like we could build a more efficient system.”

Jama began looking around. Small glass pipes specifically designed for the inhalation of crystal methamphetamine and crack cocaine have existed for many years. The former is typically a straight tube and the latter a tube with a bubble on one end. They can work for heroin for a short time but clogging is a problem.

“Mother of God, this is way more complicated than I thought.”

“Next, I started looking at old opium dens and opium pipes,” Jama said. Antique designs, however, proved prohibitively expensive. Working with a glass company that Jama asked should remain anonymous, he began experimenting with different prototypes and collecting feedback from members of the Urban Survivors Union, a national nonprofit run by people who use drugs that Jama also co-founded back in 2009.

“We went through a long design process,” Jama recounted. “Mother of God, this is way more complicated than I thought,” he remembered thinking. “There was a lot of trial and error and, eventually, we got to the final design, which looks like a little hammerhead.”

The resulting design.

PHRA’s heroin pipe can work for powdered “China white” but was designed for Washington State’s “black tar” heroin, which has a viscous consistency that’s just about impossible to snort. The pipe consists of a longer tube that feeds into a shorter tube connected at a right angle. At the bottom of the shorter tube is where the heroin goes in, and where you apply a lighter from underneath. A replaceable screen placed at the pipe’s junction prevents clogging.

Overdoses were at the front of Jama’s mind when designing the pipe. But, as with so many harm reduction programs, a number of unintended benefits are increasingly apparent.

McMahan said that the pipes are a less harmful way of ingesting drugs compared to syringes.

Vanessa McMahan is a researcher with the University of Washington’s department of medicine. Together with Tom Fitzpatrick, a PHRA co-founder and medical doctor, she’s working to evaluate Jama’s heroin pipes via a six-month study. It’s based on information that PHRA collected both before and after the device’s beta rollout in Seattle’s University District.

The numbers remain raw but, overall, said McMahan, the data look encouraging. Since the end of June 2019, PHRA has distributed roughly 4,400 of the heroin pipes.

McMahan said that the pipes are a less harmful way of ingesting drugs compared to syringes, for the obvious reason that syringes carry a heightened chance of infection. Because needles involve bodily fluids, it is easy for them to spread diseases like hepatitis C and HIV/AIDS plus bacterial infections that can lead to abscesses and cellulitis. With pipes, those risks are minimized.

Shilo Jama (left) with Vanessa McMahan and Tom Fitzpatrick.

Other benefits were less expected or are less obvious.

“These pipes are a way to include people who smoke opioids in our programing,” McMahan said.

“For a long time, needle exchanges have worked with people who inject substance. But people who smoke substances have not been able to get the same level of services.”

“Now there are people who come to the needle exchange for a [heroin] pipe and that might be the only place that they get any [health] service,” she continued. “So it’s not just a pipe program. It’s a way for people to connect with testing, referrals for treatment, or referrals for health-insurance navigation. First and foremost, having a pipe program is inclusive.”

PRHA’s heroin pipes have caught the interest of three broad categories of drug users.

Only a small percentage of Americans ever use a needle to inject drugs. But studies have shown that those who do are at a higher risk of adverse health outcomes. According to the US government’s Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 4.48 million people in 2018 had used a needle to inject drugs during their lifetime, up slightly from 4.44 million the previous year. Of those 4.48 million people in 2018, some 2.36 million had injected heroin in their lifetime. Meanwhile, an estimated 2.12 million had smoked heroin.

Jama said it appears that PRHA’s heroin pipes have caught the interest of three broad categories of drug users. The first is the relatively-new opioid user who has never tried injecting drugs. For them, the hope is that the heroin pipe will increase the length of time they refrain from injecting or prevent them from transitioning to injecting all together.

The second group is older drug users who have been using needles for a long time and who might struggle with health issues as a result. “They can transfer to smoking, let their body heal, and then they can make their own decisions,” Jama said.

The third group consists of people who are injecting drugs who might want to taper their use as a step toward abstinence. “If they can transfer to smoking, they might be able to reduce their use,” Jama said.

He described the pipe project as the definition of harm reduction. “At its core, it reduces harm.”

Around PRHA’s headquarters in Seattle, JD said the heroin pipes are beginning to attract attention.

“The ladies, they are really interested in it,” he noted. “They like that it’s clean, without all the mess of the foil paper. A bunch of them are trying to get away from the needle, even if they use the pipe and still use the needle sometimes. So it’s good.”

All photos by Shilo Jama, who retains the rights.

The post Heroin Pipes: How the “Hammer” Was Built for Harm Reduction appeared first on Filter.

Just kidding.

Fentanyl, Inc: How Rogue Chemists Are Creating the Deadliest Wave of the Opioid Epidemic (Grove Atlantic, September 2019) is the first book dedicated to the “third wave” of the overdose crisis, which claimed an estimated 68,000 lives in the US last year.

Author Ben Westhoff really does travel to China to infiltrate groups responsible for producing some⁠—though by no means all⁠—of the dangerous synthetic drugs that now dominate the crisis. But what he finds there is a far cry from Scarface.

“Two floors of the facility were crammed with salespeople, perhaps two or three hundred, most in front of desktop computers in cubicles that were red and gray on one floor, green and gray on another,” the book reads. “It was a bustling place, with cold-calling, deals being struck, and money being made. Salespeople offered to speak with potential customers on just about any app or platform they desired, fitting for a company that calls itself ‘the first e-commerce conglomerate in the chemical industry.’”

Behind fentanyl’s rise, there are no guns or street gangs—at least not at the top of the pyramid. Instead, there are corporations, and executives who insist their operations are perfectly legal.

“Just a normal day at the office. But this company was selling fentanyl precursors and, as far as I can tell, selling more than any other company in the world.”

These companies employ university graduates with chemistry degrees and pay them to cook both fentanyl precursors and the finished product. Then a vast sales team connects with customers in America, often on the dark web but just as often through regular websites with contact information clearly posted. When a deal is struck, a package is put in the mail and, a few days later, arrives on a doorstep in the United States.

Fentanyl, Inc makes clear that the drug war is over. America is still fighting but, without a doubt, has lost. Private companies are replacing the mafia. Powerful synthetics like methamphetamine and fentanyl are supplanting their weaker organic predecessors, cocaine and heroin. Drugs are cheaper, easier to get, and more potent than ever before.

After a tour of the fentanyl manufacturer’s sales floor and production facilities⁠—located in the bustling city of Wuhan, in Hubei Province, Central China⁠—Westoff, posing as a would-be purchaser, introduces us to the 2019 version of the cartel kingpin.

“Dowson [Li] said goodbye, repeating his recommendations for tourist spots,” Westhoff writes of the end of his visit. “It was still raining, and he insisted that I take his umbrella …. I soon stopped contacting Dowson, and he never pressed me about the order we discussed. Months after my trip when I was back home, however, he sent me a Skype message on my birthday with a cake emoji.”

In a telephone interview, Westhoff confirmed he was surprised by what he found in China.

“There were floors of salespeople working in cubicles,” he emphasized. “They are all recent college graduates in their 20s. It looked like a Western sales floor, with little plants on employees’ desks. It was just a normal day at the office, but this company was selling fentanyl precursors and, as far as I can tell, selling more of them than any other company in the world. And it was a normal office job for them.”

Fentanyl, Inc not only reveals the contemporary synthetic-drug industry that today is booming in China. The first third of the book is an informative and highly-entertaining story about the synthetic drugs that came before fentanyl. Westhoff recounts the developments of LSD, MDMA and other lesser-known substances such as mephedrone, BZP and the once-widely-available synthetic cannabinoid JWH-018. 

He also introduces us to larger-than-life characters from the world of synthetic drugs, including Orange Sunshine acid wizard Nick Sand, New Zealand “legal-highs” pioneer Matthew Bowden and, of course, PiHKAL authors Alexander (Sasha) Shulgin and Ann Shulgin.

From there, Westhoff takes us into the dark web, to massive online drug markets such as the Silk Road and AlphaBay (shut down in 2013 and 2017, respectively), and the many similar sites that have since popped up to replace them.

“With the dark-web dealers, it was surprisingly easy,” Westhoff told Filter. “It’s easy to contact them through their dark-web profiles and different [online] markets. I told them that I was a journalist and a lot of people were really happy to talk.”

The days of drug kingpins with names like El Patron and Chapo are coming to an end. In Fentanyl, Inc, the dark-web dealers Westhoff meets use the less-catchy aliases of “high_as_fxck_GER,” “Desifelay1000” and “U4IA.” They don’t live in seaside villas; they’re your next-door neighbors. Their products don’t move through tunnels under the US-Mexico border; they arrive in the mail courtesy of the US Postal Service.

“Prohibition has created a situation where fentanyl makes the most sense from the perspective of a dealer.”

Setting Fentanyl, Inc apart from most other books that focus on the supply-side of illegal drugs, Westhoff smartly avoids pro-drug-war narratives that push for an intensified law-and-order response to the proliferation of more potent synthetic drugs.

Most people who use opioids do not want fentanyl, despite its being the strongest opioid widely available. People still want heroin, or other less potent opioids like OxyContin. But prohibition has created a situation where it is fentanyl that makes the most sense from the perspective of a dealer. 

Compared to heroin, synthetic fentanyl is easier to produce, less risky to transport (because of its reduced bulk), and insanely more profitable. It’s a phenomenon known as the “Iron law of Prohibition.” The War on Drugs and misguided law enforcement efforts have not stemmed the spread of fentanyl, but instead have contributed to its takeover, Westhoff carefully explains in Fentanyl, Inc.

“That’s the main point of the book, in a way,” he said. “We empower the cartels through the drug war.”

It’s therefore the demand side of illegal-drug markets on which authorities must focus resources if North America’s overdose crisis is ever to come to an end, Westhoff said.

“People are always going to find a way to get their drugs,” he explained. “Drugs are always going to find a way. And so we need to focus on making people less vulnerable to those drugs, educating people about what these new drugs are, helping people beat their addiction, or, at worst, safely maintaining their addiction.”

Book cover courtesy of Ben Westhoff/Grove Atlantic.

The post Fentanyl, Inc: How Corporate Sales Floors Dominate the New Drugs Market appeared first on Filter.

Drug testing conducted at various safer consumption spaces (SCS) confirms that fentanyl has all but completely replaced heroin. Worse, an even more toxic opioid, carfentanil, arrived in the winter of 2016. Overdose deaths in BC increased from 333 in 2013 to 1,489 in 2018. This February 2019 graphic from the BC Coroners Service illustrates the extent to which fentanyl-involvement has come to dominate overdose deaths:

In response, the province has invested heavily in harm reduction. Naloxone is available free of charge and without a prescription. In addition, there are now at least 15 sanctioned SCS in BC, where people can bring drugs to inject them under the supervision of staff trained in overdose response. Authorities attribute some success to these programs. BC’s chief coroner, Lisa Lapointe, has estimated that without harm reduction, BC would see close to triple its current number of fatal overdoses. However, while the stats have plateaued, they have not declined.

Now a group of researchers working with drug users in Vancouver has proposed a radical additional response. They want to make pharmaceutical-grade heroin available as a regulated, relatively safe alternative to illicit fentanyl sold on the streets.

“This model is inspired by cannabis compassion clubs and buyers clubs, both of which emerged in the 1980s and 1990s in response to the AIDS epidemic,” reads a white paper published February 21 by the BC Centre on Substance Use (BCCSU).

The prominent Vancouver research organization—which operates with strong ties to the BC government—calls the document a “blueprint for heroin regulation”.

“The compassion or buyers club would function as a cooperative (or ‘co-op’), as an autonomous and democratic enterprise owned and operated by its members,” the report begins.

“A member-driven purchasing cooperative is an arrangement among businesses or individuals whereby members agree to aggregate their demand in order to purchase a certain product at a lower price from a supplier,” it continues. “By aggregating their purchase orders and relevant resources, members are able to take advantage of volume discounts, price protection, shared storage and distribution facilities and costs, and other economies of scale to reduce their overall purchasing costs.”

How the Clubs Would Work

If you’ve seen the award-winning 2013 film Dallas Buyers Club, you have a rough idea of how a “heroin compassion club” might operate. The BCCSU’s report paints a more structured picture, however. To start, individuals addicted to opioids would receive a medical evaluation required for membership. Once accepted into the club, they would still have to pay for the heroin they used, but could do so with many advantages over purchasing drugs in the illicit market.

Members would not receive an unknown substance that likely contains fentanyl. Instead, they would have access to pure prescription heroin (diacetylmorphine) or, if the club chooses, a mixture of powdered heroin plus a known cutting agent, such as caffeine.

The drug would come from a legal producer in Europe. (The report doesn’t name potential partners, but a likely candidate is DiaMo Narcotics in Switzerland, which already has a presence in Canada via a Toronto-based distributor named Almat Pharmachem.) Then each compassion club member could inject the drug at a designated location—it would make sense to integrate the clubs into existing SCS—or take a small supply of the drug off-site for consumption at home.

The BCCSU recommends keeping barriers to joining these clubs low, arguing against any sort of medicalized model that would require regular meetings with health-care professionals. The report also suggests that each compassion club include complimentary services such as overdose-response training, naloxone distribution, and optional connections to detox, rehab and other treatment options.

Working Within an Existing Legal Framework

Dr. Evan Wood is the BCCSU’s executive director and a co-author of the report. He told Filter that his team’s goals were to find a way to make a regulated supply of heroin available as a relatively safe alternative to street fentanyl, and to do so without requiring changes to existing Canadian laws that forbid trafficking and possession of illicit narcotics.

They found two possible answers to this challenge, Wood continued.

The first is what’s known in Canada as a “Section 56 exemption.” Section 56 of Canada’s Controlled Drugs and Substances Act allows the federal government to exempt “any person or class of persons” from criminal penalties related to drugs if “the exemption is necessary for a medical or scientific purpose or is otherwise in the public interest.” (The same exemption has allowed North America’s first legal SCS, Insite, to operate without breaking the law since it opened in Vancouver in 2003.)

The second legal option is Canada’s Drugs for Urgent Public Health Need (UPHN) program. It allows health officials to request to import a drug that is not available through regular channels if there is an “urgent public health need for the immediate use of the drug”.

Wood said that either of these options could be combined with a research component to allow a heroin compassion club to operate without breaking the law.

“An evaluation creates an opportunity for British Columbia to go ahead with something like this without requiring a federal health minister to stand up and say, ‘We’re legalizing heroin’,” Wood said. “This is an opportunity to do something like this…with the federal government essentially just staying out of the way.”

Most Heroin Users Don’t Want Fentanyl

With supply theoretically covered, another question the BCCSU sought to answer concerns the demand side of the market. Would potential members of a buyers club want heroin?

In a separate interview, Erica Thomson, another co-author of the report, told Filter there’s a perception that people who use drugs always seek the most potent substance available, which, with opioids, means fentanyl or carfentanil. But Thompson maintains that is a bit of a myth.

She explained that in her work as a peer coordinator for a regional health authority, she speaks every day with people who use drugs. Most have consistently told her that the only reason they are using fentanyl is because it is the only opioid dealers are selling.

“This is the piece that worked for me. That comfort.”

Thomson said that anecdotally, there are key differences between fentanyl and heroin that have left many people addicted to opioids struggling with pain. Not physical pain or symptoms of withdrawal—fentanyl takes care of those issues just as well as heroin, Thomson said. Where fentanyl falls short is  is in situations where people are using opioids to self-medicate past trauma or emotional pain.

“I once had a woman weeping when they went back to old-school heroin,” Thomson recounted. “There were tears in her eyes. She said, ‘This is what I missed. This is the piece that worked for me. That comfort.’”

Several longtime drug users interviewed for this story similarly said that fentanyl lacks the “warmth” or “hug” that’s often associated with heroin. Kevin Yake is president of the Vancouver Area Network of Drug Users (VANDU), a grassroots advocacy organization established in 1997 and comprised entirely of people who use drugs. He said that fentanyl is generally not a drug of choice in Vancouver, and is only popular because there are so few alternatives available. “Even if they’re doing fentanyl, a lot of people don’t like it,” he emphasized.

The BCCSU has numbers that support such anecdotal reports. It recently surveyed 650 people in Vancouver who regularly use opioids, and found that 80 percent said they preferred heroin, whereas only 16 percent said their preference was fentanyl.

Unique Potential

Prescription heroin has already been available in Vancouver for some time, but only on a very limited basis. (It has also been successfully deployed in several other countries, most famously Switzerland, where it was introduced in the 1990s.) In 2014, an academic trial called SALOME transitioned into a regular opioid-substitution program that today sees roughly 130 patients receive either diacetylmorphine (in most cases), injectable hydromorphone, or slow-release oral morphine.

Called Crosstown Clinic, this program is a highly medicalized model that requires a standalone facility staffed by a full-time doctor plus an entire team of nurses. That means it is expensive to operate (though, as studies have shown, it still produces net savings for the government, thanks to lowered police and emergency-response costs that patients no longer incur once they receive opioids via the healthcare system).

In contrast, buyers clubs could expand across the country with minimal costs and relative ease, Woods said. “We believe that a cooperative model where people purchase heroin could essentially be self-sustaining without any ongoing taxpayer investment.”

“A cooperative could undermine the illegal market wherever it is set up.”

Finally, the report describes how the creation of drug-user cop-ops could gradually supplant much of the illicit market, therefore minimizing violence associated with organized crime.

“Fentanyl adulteration in the illicit drug supply is a predictable unintended consequence of drug prohibition,” it reads, reflecting the so-called “Iron Law of Prohibition.” “The same forces that pushed the market away from relatively bulky opium towards heroin, a more concentrated opioid that was easier to transport clandestinely, have continued to push the opioid market to increasingly potent synthetic opioids, including a range of fentanyl analogues.”

The document concludes: “A cooperative could undermine the illegal market wherever it is set up.”

Yake cautioned that a heroin compassion club would not solve BC’s fentanyl crisis overnight, but added that there is no doubt it would save lives. Even if it’s only a small number at first, Yake argued that makes the idea worth serious consideration.

“This fentanyl thing, how do you stop it? I don’t know,” Yake said. “But I think I do know how to prevent deaths. That’s by having other drugs available. Something that you know where it comes from, you know what’s in it.”

Image via the British Colombia Centre on Substance Use

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