An Ongoing Crisis
The overdose crisis continues to be a major public health concern and failure. Approximately 108,000 overdose deaths were reported in the United States in 2021, an increase of 15% from the number reported in 2020. According to the Centers for Disease Control and Prevention (CDC), annual reported overdose deaths in Louisiana increased by over 23% between December 2020 and December 2021, from 2,022 to 2,501. In New Orleans, Trystereo harm reduction collective participants reported reversing approximately 1,000 overdoses in 2021, and, according to unpublished data shared by New Orleans Syringe Access Program (NOSAP), their participants have reported 2,000 overdose reversals since November 2021. Of course, Orleans Parish is not the only location affected. The Philadelphia Center in Shreveport has lost three participants to overdoses in the past two months. In Calcasieu Parish, SWLA Do No Harm reports that 100 lives were lost to overdose deaths in 2021 (double the number from 2020). And as of June 14, 47 people in Calcasieu Parish have died due to overdoses in 2022; 80% of these deaths were fentanyl-related. These are not just dry statistics—each number is a person whose life mattered and whose death could and should have been prevented had better resources been available and policies in place.
It is important to note that reported overdose numbers are all underestimates; many overdose deaths are often initially reported with no cause of death, and non-fatal overdoses often do not involve a 911 call or visit to an ER. In addition, drug-related stigma and anti-drug laws make people less likely to report overdose information. Many factors have contributed to the rise in overdoses and overdose-related deaths, including: rising costs of nasal naloxone (the overdose-reversal drug) and a national shortage of the cheaper intramuscular version, an increase of fentanyl in the drug supply, economic instability and inequity, the housing crisis, social isolation and disruption to services caused by the COVID-19 pandemic, and structural racism. At the root of this all is, of course, the harmful and stigmatizing drug policy borne out of the racist War on Drugs.
Overdoses, HIV, Hepatitis C: all potential harms related to drug use are preventable. We have the knowledge and tools to protect people who use and inject drugs, most of which can be attributed to the tireless efforts of harm reduction advocates in Louisiana and beyond. As the harm reduction movement continues to be incorporated into mainstream public health and policy, it is imperative that this work not only centers but is led by the groups and communities who have been doing the work long before it was deemed acceptable or legal.
Harm Reduction in Louisiana
Harm reduction is both a movement and a philosophy which intersects with other social justice movements. It is based on the premise that drug use is a part of human reality; instead of focusing on eliminating drug use, we should instead work to make sure that people who use drugs have the resources and support needed to reduce any drug-related harms. Harm reduction is fully based on the concept of “Nothing About Us Without Us,” centering people who use drugs and those with a history of drug use as experts and active agents of change in creating harm reduction programs and policy. It is a spectrum of strategies, recognizing that drug use looks different for each individual. Though recovery is an option, it is not viewed as a necessity or the ultimate goal for everyone, contrary to more mainstream programs. Above all, harm reduction is an anti-moralizing and anti-stigmatizing movement which recognizes the compounding oppressions of drug use with class, racism, poverty, trauma, gender and sexuality-based discrimination, and other experiences and identities.
Founded in 2011, Trystereo is an all-volunteer harm reduction collective, which operates as a free, mobile public health resource for people who use drugs in southeastern Louisiana. Women With A Vision was founded in 1989 by a grassroots collective of African-American women in response to the spread of HIV/AIDS in communities of color. Their work spans everything from direct HIV outreach and harm reduction services to co-authoring legislation to decriminalize sex work. NOSAP is part of CrescentCare, which was founded as NO/AIDS Task Force in 1983. Among their many services, all of these harm reduction groups act as syringe service programs. Syringe service programs (SSPs) are one of the most important components of harm reduction outreach, providing people with access to sterile drug use supplies (syringes, cookers, cottons, ties, and wound care kits) and safer smoking kits to prevent infection with HIV, Hepatitis C, and other pathogens, as well as the overdose-reversal drug naloxone (brand name Narcan), fentanyl test strips, links to medical and social services, and, above all, community.
SSPs did not become legal in Louisiana until 2017 and must be authorized by local government. Orleans parish authorized SSPs in 2018. However, groups such as Trystereo, Women With a Vision, and NOSAP all provided harm reduction services in an “underground” capacity for years before then, despite the legal risks. These activists and advocates understood (and still understand) that it is worth breaking laws—especially those based in fear and discrimination—in order to save lives.
Though SSPs are legal in Shreveport, the fact that the surrounding areas have not passed such an ordinance has been a challenge. According to Hershey Krippendorf, director of development at The Philadelphia Center, “We are moving in the right direction [with SSP expansion] but [I] would like to see a blanket authorization to operate SSPs in [Louisiana]. It has been difficult to navigate jurisdictions outside of Shreveport to even begin harm reduction conversations.” Many Trystereo participants travel from outside Orleans Parish to pick up supplies and run the risk of having their supplies confiscated by law enforcement in their home parishes. There have been instances of people from these areas refusing naloxone or sterile injection equipment (cookers, cottons, etc.), supplies known to prevent infections and reverse overdoses, because they fear arrest under paraphernalia laws. Additionally, Trystereo has observed an increased demand for supplies not only within Orleans Parish but also the outlying areas. As a result, Trystereo has expanded its efforts to provide mail-order supplies to participants outside of Orleans Parish, in partnership with the organization NEXT Distro.
SWLA Do No Harm provides harm reduction services in what is known as Louisiana Department of Health’s Region 5 (Allen, Beauregard, Calcasieu, Cameron, and Jefferson Davis parishes), an area of the state where possession and distribution of syringes is still outlawed. This group, which is funded by Southwest Louisiana Area Health Education Center (SWAHEC) and partially sponsored by the Imperial Calcasieu Human Services Authority, is able to distribute fentanyl test strips, safer smoking kits, naloxone, and sterile injection equipment (e.g., cookers, cottons) but not syringes, the one item known to be effective in preventing HIV and HCV transmission and reducing the formation of abscesses. Peyton Boozer, the harm reduction program coordinator for SWLA Do No Harm, sums it up well: “We can advocate for our participants to use new sterile rigs [syringes], but it is not a realistic recommendation in an area where it is easier to purchase a gun than a sterile syringe… In the absence of such a service, it is only through underground resistance by people who use drugs that any collective care exists. This subversion gives me hope, but it is time for policy change that will protect the community.”
People who use drugs are the experts in their own lives and are among the first to report issues such as rising overdoses and changes to the drug supply. This is why it is so important to not only engage drug users and harm reduction advocates in conversations and program planning, but to let them lead the efforts. As harm reduction has become more widely accepted by the U.S. government and larger public health systems, there is a fear that the messaging will get watered down and the people who have been doing this work for years will be pushed out. This fear is not unfounded—one need only look to the whitewashing of the AIDS activist movement. As a recent example, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded $30 million in harm reduction funding in May 2022. The majority of the grant recipients are, unsurprisingly, larger institutions who lack the on-the-ground harm reduction experience but do have established infrastructure (e.g., grant writing teams), which the smaller, grassroots groups cannot compete with. Funding such as the SAMHSA grant also operates via a reimbursement model. Programs must be able to pay up front and are reimbursed by the funders later, meaning this type of funding is only really accessible to groups who already have large funding streams. This places individuals and institutions who lack lived experience or expertise in positions where they dictate messaging and program priorities, resulting in programs and policies that are not designed fully for the benefit of people who use drugs.
The Fentanyl Panic: A Direct Result of the War on Drugs
One of the catalysts for the rising interest in and co-opting of harm reduction is, as expected, the rise in overdoses and the increased amount of fentanyl in the drug supply. NOSAP reports that “In the past few years, fentanyl has become ubiquitous. Our participants no longer report using heroin; their primary drug is fentanyl, which may have heroin or some other substance cut with it. There are also many reports of people buying Xanax and Percocet that turn out to be fentanyl.” This corroborates reports from participants served by Trystereo, The Philadelphia Center, and SWLA Do No Harm. On estimate, 64% of the overdose deaths between May 2020 and April 2021 could be attributed to use of fentanyl or more powerful fentanyl analogs (e.g., acetyl fentanyl, carfentanil). According to unpublished data directly provided by NOSAP for this article, since the pandemic began the fentanyl overdose rate in St. Bernard Parish rose by close to 600% and in Orleans and Jefferson parishes by over 100%. In late May 2022, House Bill 212 was passed by the Louisiana legislature, which essentially legalizes fentanyl test strips by removing them from the definition of drug paraphernalia and which will go into effect on August 1, 2022. Unfortunately, this is tied to legislation that will increase the penalties for possession and distribution of this drug. This laser focus on fentanyl indicates a lack of understanding (or willingness to acknowledge) the structural factors that have led us to this reality.
Fentanyl is a synthetic opioid that was developed and is still used as a painkiller during surgery. As it is an opioid and is cheaper and easier to produce than heroin, it has been used as an adulterant in the drug supply since 1979. When certain protocols are followed, it can be used safely, or at least properly mitigated. While it is understandable why there is much fear surrounding this substance—and the risks themselves are very real—it is important to not spread misinformation and distract from real issues. Over the past two years there have been increased reports across the U.S. of police officers ODing from simply touching fentanyl or even inhaling it in the air. This is, simply put, not medically possible and is reminiscent of the drug-related moral panic of the 1980s. Fentanyl has been used routinely in hospitals for decades, and harm reductionists are also sometimes exposed to the drug in their work, and yet no work or advocacy-related exposures have led to overdose. These lies restrict the access that surgical patients have to medical fentanyl during surgery, and also affect pain patients’ access to prescription opioids. Furthermore, this misinformation could lead to a reluctance of first responders and bystanders to administer naloxone and perform rescue breathing on people who have overdosed, due to the baseless fear that they could overdose from secondary fentanyl exposure.
There have also been increased unsubstantiated reports of people overdosing from smoking marijuana laced with fentanyl, most recently in New Orleans around (appropriately) 4/20, despite the fact that there is no reliable or verified data around fentanyl in the marijuana supply. Though it is possible that dealers may be packaging fentanyl and marijuana in the same area, leading to trace amounts of fentanyl in the weed supply, this is not the same thing as cutting weed with fentanyl. Even if fentanyl were present in marijuana, fentanyl burns at a lower temperature, meaning that the drug would no longer be active when it was smoked. And yet, this misinformation continues to be spread by law enforcement, for-profit rehab centers, and others who profit off the War on Drugs.
The increase of fentanyl in the drug supply, now including non-opioid drugs (e.g., methamphetamine, cocaine, pressed pills), over the past several years is a direct result of drug prohibition. Fentanyl is not the only adulterant in the drug supply; in fact, the moral panic around fentanyl will continue to lead to new, harder-to-detect chemicals being added to the supply. Xylazine (also known as “tranq”) is a veterinary tranquilizer which has been found in the drug supply across the U.S. While xylazine itself does not provide much of a high, it is often cut with fentanyl to give it “legs,” or extend the fentanyl high. In some places in the U.S. it has been found to be associated with over 20% of overdose deaths. Xylazine use is also associated with cardiovascular issues and an increased risk of developing necrotic wounds for those who inject drugs. Unlike with fentanyl, there are no test strips to test for the presence of xylazine or other adulterants. There are also no naloxone equivalents for xylazine and other non-opioid adulterants. Prohibition has only made the drug supply less safe. Policy makers, public health officials, and others in power need to step aside and let individuals and groups with lived experience and expertise take the lead.
Amidst the tragedy, there have been successes. In the five years since SSPs were legalized in Louisiana, services have grown and efforts are being made to not only expand these programs into other regions but to make them legal statewide, without local approval. Fentanyl test strips are no longer considered to be drug paraphernalia, and free naloxone is being made available across the state.
There is still much work to be done, however. Access to fentanyl test strips and naloxone is useful but will not solve the larger issues at hand. The U.S. desperately needs accessible, anonymous drug checking services, which allow people to see what is in their drugs without risk of legal repercussions. A safe drug supply would allow people who use drugs to be prescribed opioids and stimulants of pharmaceutical grade (uncontaminated) drugs. The expansion of supervised consumption sites is also greatly needed. Supervised consumption sites (SCS), also known as overdose prevention sites, provide people who use drugs a safe, judgment-free space to use pre-obtained drugs, with trained medical staff present in case of an overdose or other emergency. There are over 111 legal SCSs in over 60 cities and 11 countries. The first U.S. sites opened in New York City in late 2021. In the history of SCSs, not one life has been lost due to overdose. These spaces are also effective in preventing disease transmission, connecting participants to medical and social services, and providing community and solidarity.
We must address stigma, which influences our policy and harms our communities. “I would love to see stigma addressed on a higher level, including through hospitals, substance use treatment centers, and mental health providers. I would love to see more wraparound health care options serving the whole person that are gender-affirming, trauma-informed, and meeting people where they’re at,” says Boozer of SWLA Do No Harm. They add that “It is time for ‘Just Say No’ D.A.R.E. programs in schools to be replaced with evidence-based harm reduction education for youth. It is long past time for [the] decarceration of people serving time for drug-related charges and reversal of antiquated War on Drugs policies.”
Our policies around drug use and distribution are not working; at least, they are not working to the benefit of our communities. They have led to the disproportionate incarceration of people of color—particularly Black people—an extension of the racism inherent in all our systems. These policies have contributed to the ongoing overdose crisis and contamination of the drug supply. Drug prohibition has led to increased violence, directly and indirectly. These laws are killing us, and more direct action is needed by policy makers, progressive political organizations, public health institutions, and the medical field.
In Louisiana, harm reduction advocates are working tirelessly for SSPs to be legalized in the regions which have not yet passed an SSP ordinance and are pushing back against harsh and stigmatizing drug laws that are based in fear, not evidence. It is the unfortunate reality of our current system that, as important as the harm reduction efforts are, they need advocates outside the harm reduction sphere. Those of us who have any sort of platform in politics, medicine, or public health need to lend our support and time to advocating for this policy change, which will include lobbying our colleagues and local governments. Community members also have a role to play in showing up to local city council meetings and legislative sessions to push back against regressive laws and advocate for SSP ordinances and other harm reduction policy (e.g., legalization of safe consumption sites, drug decriminalization, lowering of naloxone costs). Finally, public health and medical professionals, and anyone with a platform, must educate their colleagues and the general public, pushing back against widespread misinformation spread in the media, the classroom, and the professional public health and medical settings.
This can seem daunting, particularly in this current political climate, when our rights are being taken away. However, it is important to remember that mainstream discussion of harm reduction, let alone decriminalization, safe supply, or safe consumption sites, was not a reality just a few years ago. There is greater funding, though we must work to make it more equitable. As small as it might seem, the statewide decriminalization of fentanyl test strips in Louisiana seemed too tall an order until recently. Legal SSPs were not a reality here until five years ago. The STD/HIV/Hepatitis C Program (SHHP) of the Louisiana Office of Public Health (OPH) has managed to fund, support, and expand SSPs across the state, and now has an official Harm Reduction division devoted to actual harm reduction practices. The successes achieved by the harm reduction community are not insignificant and have had a major impact. We now have a platform to enact broader policy change, should we as a greater community choose to put in the time and effort to support the harm reduction movement. This is not easy work, but it is necessary.
We need new policies and programs actually rooted in the philosophy of harm reduction—it is, without hyperbole, a matter of life and death. And this work must continue to be informed by advocates and people with lived experience: “Nothing About Us Without Us.” Financial and material support of grassroots harm reduction organizations must increase so that they can continue their work, no matter what the future holds. Harm Reduction groups in Louisiana and elsewhere have managed to subvert the systems in place for years and save thousands of lives. They have done this despite the stigma, despite the social inequities and legal barriers, and despite the devastating losses they have experienced in their communities. Though they will continue to do this work regardless of whatever laws and policies are in place, they need and deserve to have broader support and protections. Watered down, mainstream co-opting of harm reduction messaging and programs will not suffice. The harm reduction movement must be given the platform to dismantle the harmful structures in place and work to achieve a healthier and more equitable future. Hundreds of thousands of lives depend on this.
Mary Beth Campbell works in public health and is an active volunteer with Trystereo in New Orleans.
illustrations by Kate Lacour
photo by Foster Noone