One Year Later: The State of Harm Reduction

"The losses do not become easier to bear over time. Instead, we channel our grief into our work, to try to prevent more loss and pain."
A black and white illustration of a solid, black circle with black needles injecting into it around the entire circumference. We can only see the bottom end of the needles. and it resembles the shape of a viral pathogen. Illustration by Luke Howard.

While the novel coronavirus spread through the United States, a second deadly pandemic continued to devastate the country. Overdoses and overdose deaths have increased through the novel coronavirus pandemic, killing tens of thousands of people in the last year, though overdoses are preventable. Throughout the pandemic, Trystereo and other Louisiana-based harm reduction organizations have worked alongside people who use drugs to keep them and their communities alive.

Harm reduction is a philosophy and movement premised on the fact that people do use drugs and will continue to do so, and therefore we should not work to eliminate or reduce drug use but rather support efforts to reduce any negative consequences that may be associated with drug use. Harm reduction centers drug users and those with a history of drug use as active agents of change in creating policy and harm reduction program development. Harm reduction is an anti-moralizing, anti-stigmatizing movement that recognizes the compounding oppressions of drug use with class, racism, poverty, trauma, gender and sexuality-based discrimination, and other experiences and identities. Syringe Service Programs (SSPs) are a cornerstone of harm reduction, providing people with sterile drug use supplies (like syringes, cookers, cottons, ties, and wound care kits), links to social services, and above all, community and solidarity.

Due to the pandemic, over the past year the potentially deadly threats to people who use drugs have increased by orders of magnitude. Due to rampant job loss, New Orleans’ existing housing instability crisis deepened. The New Orleans Police Department (NOPD) conducted sweeps of encampments that disturbed and displaced our unhoused neighbors, with reports that NOPD was taking safer drug use supplies along with other possessions. HIV and Hepatitis C testing and care were disrupted. Public health and harm reduction workers are concerned by modeling studies that indicate that the pandemic’s disruptions to testing, prevention programs, and linkage to care may have led to an increase in both HIV and HCV infections—we won’t know the extent until more data is gathered and analyzed. Economic stressors, social isolation (causing people to use alone), lack of access to services, and traumas (old and new) have all contributed to an increase in overdose deaths.

Though overdose deaths were rising nationally in the months before the pandemic, the fatality rate accelerated between March and May 2020the first months of the coronavirus pandemic in the United States. The increase in overdose deaths can be partially attributed to the increase of synthetic opioids like fentanyl and research chemicals like xylazine in the national drug supply, and a mainstream narrative might have you believe that was the sole factor. However, we can’t understate the fact that decreased access to medical and harm reduction services played a major role in this preventable loss of life.

According to data from the CDC, in the 12 month period ending in August 2020, there were over 87,000 reported drug overdose deaths in the United States—a total 27% higher than the year before. In Louisiana during the same 12 month period, drug overdose deaths increased by 52.4% (from 1,162 deaths in 2019 to 1,771 in 2020). As overdoses often go unseen and underreported, these figures are likely undercounting the true death toll, which the CDC estimates to be approximately 90,000 nationwide.

In the CDC’s own words: “SSPs should be considered by state, local, territorial, and tribal jurisdictions as essential public health infrastructure that should continue to operate during the COVID-19 pandemic.” The CDC recommended increasing the amount of Narcan carried by first responders, lowering barriers to treatment and medically assisted treatment (MAT), and expanding fentanyl test strip distribution and use. Narcan, or naloxone, is an overdose reversal medication available in intranasal and intramuscular formulations. It has no contraindications, is easy to administer, and is effective when paired with CPR.

The Biden administration recently issued a statement on drug policy priorities that supports harm reduction. Echoing what advocates have been saying for decades, it acknowledges that harm reduction work is “evidence based”the data consistently indicates that harm reduction programs reduce HIV and Hepatitis C transmission by 50%, reduce overdose deaths, and connect people to essential health care services. The statement claims that the administration will work to improve funding accessibility for SSPs, “support research” for harm reduction, and recognize that harm reduction programs reduce death and disease.

Though this sounds promising, distribution of funds will likely be at the state level, enabling states to funnel the money to retrogressive abstinence-only programs. Without centering people who use drugs and harm reduction organizations, these policies may not reflect best harm reduction practices and the funds may not reach the agencies and people who need it the most. At worst, that funding could end up in contracts lining the pockets of the lucrative and exploitative recovery industry. As always, increased vigilance and advocacy are needed from those of us in the harm reduction community (and our allies!) to ensure that policies actually benefit people who use drugs, and that funding is awarded to the groups who have been doing harm reduction work long before it became palatable to the mainstream.

In late April, Hikma Pharmaceuticals announced the Food and Drug Administration (FDA) approval of a new, high-dose naloxone nasal spray known by the brand name Kloxxado. Kloxxado contains 8 milligrams (mg) of naloxone, twice the amount of a standard naloxone nasal spray, and is being marketed as a tool in addressing the rise in overdose deaths. While it is true that multiple doses of naloxone are sometimes needed to reverse overdoses, especially when fentanyl and other synthetic opioids have been used, there is no evidence that a dose of 8mg is necessary. In fact, providing a person with a single 8mg dose at once may cause stronger and more painful withdrawal effects, versus providing them with multiple 0.4mg intramuscular (what Trystereo distributes) or 4mg nasal doses spread out over several minutes. Naloxone sometimes takes a couple of minutes to work, which can be excruciating for the person responding to the overdose, who is likely anxious and focusing on giving CPR and/or seeking EMS help while monitoring the effects of the naloxone.

If higher doses are indeed needed, it is better to space out lower doses in order to reduce risk of stronger withdrawal symptoms—which can lead a person to want to use again sooner and increase their risk of overdosing once the naloxone begins to wear off. Proper training in Basic Life Support and overdose response—and free and easy access to naloxone—would help significantly more than expensive, higher doses; and as of yet there has been no discussion about making Kloxxado easily accessible. There is little to indicate that the development, FDA approval, and marketing of this drug is anything more than financially motivated, which makes sense because the pharmaceutical industry exists to generate profit (see also: their role in the opioid epidemic). It is also important to remember that the primary driver beyond the rise of synthetic opioids in the drug supply is the criminalization of drugs. By pushing drug use and distribution underground, there is no way to ensure that the supply is safe. Decriminalizing drugs, creating  supervised consumption sites, and providing people with the tools to check their drug supply would do far more to prevent overdoses than Kloxxado. The release of Kloxxado was, unsurprisingly, launched without insight from harm reduction groups. Again, this medication seems to be merely an attempt to capitalize on the current rise in overdoses (and government-funded public health programs that could result in lucrative contracts with pharma companies) than to actually save lives.

Doin’ the Work

Continuing harm reduction work during the pandemic has required rapidly changing distribution models, shifting programs outdoors, and moving to curbside or mobile delivery. Harm reduction groups developed new guidelines and shared them widely to ensure best practices. These practices included distributing more syringes to clients to minimize visits, screening clients for COVID-19, and working with other organizations to provide access to COVID-19 vaccines and other infection prevention resources. Trystereo has been coordinating with New Orleans Medical Reserve Corps (NOMRC) to begin distributing vaccines at our weekly drop-in sites. New Orleans Syringe Access Project (NOSAP) (CrescentCare’s in-house SSP) has begun administering walk-up vaccinations at their regular drop-ins.

Trystereo, like many of our comrades in New Orleans and elsewhere, mobilized quickly as stay-at-home orders were put in place last March. Because drop-ins—where volunteers set up at different community sites at fixed times to provide harm reduction supplies—were suspended from mid-March to the end of May 2020, we increased our mobile delivery, using our text hotline to schedule contact-free delivery with participants in New Orleans and surrounding parishes. Between March 21 and June 21, 2020 we made 220 deliveries.

Once stay-at-home orders were lifted, we resumed our weekly outdoor supply drop-ins. To ensure the health and safety of participants, we pre-packaged all supplies (sterile cookers, cottons, ties, bandaids, alcohol wipes, and wound care kits), distributed both COVID-19 safe CPR masks and N95 masks, and instituted social distancing requirements.

In the past year, Trystereo has distributed 582,100 syringes to our participants, an increase of over 28% from the 455,000 distributed in 2019. We have recorded over 730 overdose reversals from our participants, a 162% increase from the 450 recorded overdose reversals in 2019. Again, this is likely an underestimate, as our drop-in services were suspended mid-March through May 2020.

Prior to the pandemic, we increased the number of 0.4mg naloxone doses in our Narcan kits from two to three, based on participants’ reports that multiple doses were needed to reverse overdoses. With new funding, we soon increased that number of doses to four. Anecdotally, our participants have found this useful, and spacing out lower doses does not have the same harmful effects as administering one large, overpriced dose at once (as Kloxxado would).

Altogether we have distributed 29,850 doses of Narcan in the past year, compared to 9,500 doses the previous year. We also provided participants with 4,200 fentanyl test strips, which have increased in popularity and demand. Along with other harm reduction agencies in Louisiana and the United States, we understand too well the importance of making these supplies available. Each person we lose to an overdose is not a number—they are our friends and neighbors, every one unique with an unknowable, stolen future. Their deaths have a devastating impact on their families and our community. And the losses do not become easier to bear over time. Instead, we channel our grief into our work, to try to prevent more loss and pain. Each overdose death is preventable, and each is the result of structural violence and neglect. We need to remove all barriers to harm reduction services and demand an end to criminalization of drug use and the racist War on Drugs.

Comrades at Harms (Reduction)

The recent increase in demand for syringes and reported overdoses is not unique to Trystereo. We are always in touch with groups across the country doing similar work, and many individuals and organizations in our own state. We spoke to some of our colleagues across Louisiana to share their perspectives and observations on the year past.

Gjvar M. Payne, executive director of Capitol Area Recovery Program (CARP) in Baton Rouge, confirmed that demand for syringes surged during the first year of the pandemic. “While our staff and days were reduced, we saw numbers nearly triple during the pandemic [from 2019],” said Payne, adding that this increase has begun to level off. CARP also noted “significant” overdose increases reported by EMS and the coroner.

In Shreveport, the Philadelphia Center had only just begun providing harm reduction services in January 2020, the eve of the pandemic. They doubled the amount of syringes that participants could get per visit in their weekly program to minimize trips. Hershey Krippendorf, the Director of Development, said that the pandemic created additional hardships for their participants. “The pandemic has affected their mental health and at the beginning of the pandemic drugs were difficult to locate… some had to purchase drugs from unknown sources,” said Krippendorf. Some participants reported increased housing instability.

Krippendorf added, “Our area has been invaded by fentanyl. In 2020, we distributed 312 doses of naloxone… it was participant-reported that it was used 60 times. 2021, year-to-date we have distributed 207 doses and it has been participant-reported to have been used 38 times. We are barely in the fourth month of the year.”

Women with a Vision (WWAV), who have been organizing in New Orleans since 1989, says that the pandemic has changed their service model. “It’s still adapting,” says Christine Breland Lobre, the program director. “Before the pandemic, we had fixed site distribution at our office—Monday through Friday, 9am to 4pm, community based outreach two to three days a week along with three community elders that acted as distribution points in different neighborhoods.” WWAV set up a text hotline during the pandemic, and began offering up to a month’s worth of safe injection supplies at a time to minimize contact.

Now WWAV’s office is open Tuesdays and Thursdays, and the organization also directs participants to the drop-ins hosted by NOSAP and Trystereo. This collaborative harm reduction work has been critical for people who use drugs in New Orleans: WWAV’s participants have reported increases in overdoses, though the majority have been reversed by peers thanks to Narcan distribution.

WWAV has also been working during the past year to provide much-needed financial relief to sex workers impacted by the pandemic, launching a Sex Worker Advisory Committee. Lobre told us that “[hardships during the pandemic] are of course compounded by the stigma, discrimination and criminalization that SSP participants and other drug users face in housing, employment and medical and mental health care settings.” Pointing to barriers in access, Lobre said, “Most of our participants do not feel comfortable accessing medical care outside of an emergency, unless they have a healthcare provider that they trust.” These obstacles to care can have deadly results. “Participants still fear calling emergency services for overdose response because of fear of discriminatory treatment and criminalization,” Lobre said.

NOSAP also altered their operations. They moved services into their new garage to improve ventilation and allow for social distancing while people pick up supplies. NOSAP began screening participants for COVID-19 symptoms, changed from a 1:1 exchange—meaning that one sterile syringe is provided for each used syringe returned to the site—to 100 syringes per client, and added a secondary bulk distro day for clients disposing 300 to 500 syringes, which they will match with sterile syringes. During the pandemic, NOSAP also added a contact-free syringe disposal bin outside of their premises. “Our providers at CrescentCare have been moving towards lower barrier access to suboxone,” said NOSAP coordinator Nadia Eskildsen.

The State Legislature

In the midst of the work of day-to-day survival, the harm reduction community and allies in Louisiana have also been confronting an adversarial state legislative session. WWAV led efforts to decriminalize sex work through Louisiana House Bill (HB) 67. Though the bill was voluntarily deferred and will not move forward during this legislative session, having it heard in committee with sex workers giving testimony was itself a win, and WWAV has not given up on decriminalization.

At the time of printing, there remain three concerning bills. Louisiana House Bill 238, authored by State Representative Pat Moore (D), seeks “to create the crimes of felony and misdemeanor intentional exposure to a sexually transmitted disease.” This law, like all HIV and STI criminalization laws, is not based on medical or public health fact but rather stigma and outdated views of HIV and other STIs. It is outrageous that Louisiana is holding up a vote for an HIV and STI criminalization law in 2021, while other states are working to repeal or at least reform similar laws. Laws like HB238 discourage people from even wanting to know their status, and disproportionately harm people who use drugs, sex workers, unhoused persons, Black and Brown people, and other people who face institutional barriers to health care and basic human necessities.

Louisiana Senate Bill (SB) 69, authored by State Senator Beth Mizell (R), calls for people who distribute drugs containing synthetic opioids to be “imprisoned at hard labor for not less than five years nor more than forty years, at least two years of which shall be imposed without benefit of probation, parole, or suspension of sentence, and in addition may be fined not more than fifty thousand dollars.” Forced labor of prisoners is an extension of chattel slavery, part of its afterlife. The proposed language leaves dangerous room for interpretation about distribution and dispensing of drugs—it could create additional criminalizations regarding sharing drugs, and for  individuals unaware of the presence of fentanyl or other synthetic opioids (many people do not know precisely what their drugs contain, due to the absence of a safe supply and lack of access to testing).

The last in this trifecta of murderous Drug War bills is Louisiana HB166, authored by Representative Bryan Fontenot (R). Initially, the bill proposed to not charge, prosecute, or penalize a person who responded to an overdose even if they were in possession of a controlled substance at that time. However, in a bizarre echo of three-strikes laws (and… coupon limitations?) it was amended to state that this provision “shall not apply when first responders or law enforcement officers respond to the same residence two or more times for a person experiencing a drug-related overdose.” In other words, this bill does nothing to protect people who use drugs and would increase hesitation to respond to overdoses for fear of criminal charges.

Though these bills are certainly intimidating, we also see that our work is not in vain. Our collective advocacy efforts resulted in the City of New Orleans voting unanimously to decriminalize fentanyl test strips, an essential tool in preventing overdoses and overdose deaths. Though this action is not enough—all drug paraphernalia should be decriminalized, and, if we want to prevent further contamination of the drug supply, so should all drugs—it is a victory and one which we are choosing to celebrate! Allies interested in helping oppose SB69, HB238, and HB166 should contact their representatives to voice dissent. Keep an eye out for groups gathering in Baton Rouge to testify against these bills. We need your active allyship.

Looking Ahead

As with all disasters, the secondary effects of the pandemic have further illuminated the importance of harm reduction itself, and the need for harm reduction practice to be better integrated into society. This pandemic will not be the last catastrophic event that increases risk for people who use drugs and other institutionally-marginalized groups. We must recognize the role that social inequalities play in people’s capacities to deal with drug-related harm. And we must continue to center people who use drugs in all aspects of harm reduction. They should not only be included in discussions—they need to be leading at all levels.

Let us also remember and honor all the work the harm reduction community has already done to achieve a healthier and more equitable world. Trystereo and our comrades in Louisiana and beyond have increased our outreach and commitment to our communities, even in the face of a pandemic.

Despite the evidence that harm reduction practices should be standard public health practice, despite the evidence that stigmatizing drug use causes only harm, there are forces in power which blatantly ignore the evidence and push for archaic laws to further their oppressive agendas. And yet, despite everything, we are still here. And we are still doing our work to subvert death.A black and white illustration of a tall building and the ground underneath it is hollowed out and crumbling. Illustration by Luke Howard.

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illustrations by Luke Howard

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