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We Gotta Start Associating Harm Reduction With Tobacco and Vaping More

The phrase “harm reduction” is most often associated with drugs and, to a much lesser extent, sex work — specifically, street prostitution and escorting as opposed to web-based, non-contact sex work — here in North America.

So much of our struggle as harm reductionists comes from trying to get our fellow laypeople rolling with SS Harm Reduction. Really, most of us who want to help drug users are interested in drug policy reform, drug user advocacy, and harm reduction, but most of us tend to lump it all under the umbrella of “harm reduction.”

Like damn. Those three are wayyy too fuckin’ long to say together just to identify ourselves.

Anyways.

I live in a rural, largely-right-leaning area that has virtually no HR infrastructure. You can imagine how few people are on board with harm reduction in bum-fucked-Egypt — in this case, BFE is Northwest Tennessee; my fellow injection drug users aren’t used to being able to source syringes in an above-ground manner. We’re used to the social services-criminal justice alliance not treating us right — why would we trust anything that seems too good to be true?

When it comes to my efforts in “drug stuff” — the aforementioned trio of things that help drug users — I feel like I’m responsible for making sure HR itself (i.e., mentioned by name) and HR-positive ideas thought of by people who don’t label their actions “harm reduction.”

We Gotta Normalize HR

People in the largely-right-leaning areas that dominate the United States by land mass are averse to ideas that seem overly left-leaning or excessively politically correct.

The modern American political landscape is more divisive than ever — check out this minute-long video that uses imagery to show just how discordant (yes, fancy word, I have big brain) we are in these times.

Social media also contributes to divisiveness among Americans. I don’t know what characteristics of social media lend themselves to this gross argumentativeness, though I know it’s true.

Also, I think largely-right-leaning people are all but averse to “radical,” high-level harm reduction applications like supervised consumption sites or safe supply; however, they are, in my opinion, likely to see the merit in switching to vaping largely-harmless nicotine solutions from smoking tobacco, which exposes smokers to dozens, if not hundreds of carcinogens. Hell, I’d think that many Americans wouldn’t even be down with syringe exchanges.

With such barriers in mind, it’s absolutely essential that we actively start involving tobacco and vaping in general harm reduction messaging. And, I’d go as far to say that harm reductionists, as individuals, should strive to associate entry-level harm reduction applications — or low-hanging fruit on the proverbial harm reduction tree, in other words — like switching to vaping from smoking or making sure to pace alcohol consumption and drink water in between every alcoholic drink, for example, with the phrase “harm reduction.”

In other words, if it’s appropriate for you to mention these entry-level ideas alongside “harm reduction,” do it! If more of us adopt this habit, we’ll undoubtedly improve the spread of harm reduction.

Not-So-Guilty by Association

Although tobacco so reliably causes cancer and other often-fatal health problems, since the drug is legal and has long been socially accepted by Americans from Fairbanks to Miami, it’s viewed many times more favorably than just about all illicit drugs.

The most widely-recognized application of harm reduction here in the United States is — and this is whether people actually think of it as “harm reduction” or not — switching from dip, chew, or another form of tobacco in favor of vaping.

Already, I can see how some people might not want to mar together the two worlds of (a) “hard” drugs that are viewed as inherently bad or high-level, “radical” ideas like supervised consumption sites and (b) basic, common-sense strategies that the American public is generally already on board with. Admittedly, it does seem disingenuous to associate non-radical, non-“hard”-drug-related ideas with what we’ve come to accept as “harm reduction.”

However, isn’t our cause as harm reductionists to help as many drug users as we possibly can to the greatest extent achievable? I think it is. Wanting to actively avoid easily-achievable, entry-level applications of harm reduction in favor of their way-more-advanced counterparts isn’t based upon solid reasoning — there’s nothing wrong with working smarter, not harder.

Well, at Least a Little Guilty

Vaping doesn’t have a smooth, buttery-soft image, unfortunately. Throughout 2019, people across the country developed often-serious pulmonary injuries, dozens of which died. News reports incorrectly linked the injuries to regular-ol’ vaping — the vaping smokers and dippers use to get clean of tobacco, that is — to the lung injuries. In actuality, the bulk of the injuries, if not all of them, were caused by counterfeit cannabis concentrate cartridges.

With legalization and regulation, states’ cannabis industries have become just like any other consumer goods market. Rather than, for example, cannabis concentrates being made in unregulated, illegal, often-unsafe makeshift labs and packaged in whatever’s convenient, these legal state markets offer branded products to customers.

You likely know that legal cannabis markets’ wares are often super duper pooper scooper mooper super fuckin’ expensive. Many people have eschewed the legal, well-regulated state cannabis markets in favor for the black market cannabis they’ve grown up with. With these two factors comes a perfect storm for tons of counterfeiting — and that’s exactly what caused the 2019-2020 vaping lung illness outbreak (that’s not my name for it; I ripped the name from Wikipedia), or so we think.

Admittedly, I’m not a vaping expert — I’m pulling this info essentially straight from Wikipedia. Centers for Disease Control and Prevention believes that patients who presented symptoms of vaping-associated pulmonary injuries were often exposed to cannabis concentrate cartridges that used abnormally-high proportios of vitamin E acetate, a thickening agent that’s regularly used in cannabis concentrate cartridges.

Usually, such cartridges wouldn’t contain more than 20% vitamin E acetate. Many illicit cannabis concentrate cartridge sellers were using vitamin E acetate to the point that cartridges were made up of at least 50% vitamin E acetate.

Vitamin E acetate is used because, to the untrained eye, it closely resembles THC oil, the most common cannabis concentrate.

Most Americans, so it seems, aren’t aware of the fact that counterfeit cannabis products were widely associated with observed vaping-related pulmonary injuries.

Ultimately, the vaping lobby ended up taking a net loss in terms of reputation. Still, it’d be beneficial to us to associate our cause with entry-level HR applications like this.

Associating Harm Reduction With Protective Measures Against COVID-19

Of course, global pandemics don’t come around too often. Like all of us, I hope the threat of catching COVID-19 goes away super soon.

However, while the pandemic is still very much in full swing, we should seize the opportunity to associate “harm reduction” with any and all entry-level, common-sense applications (e.g., wearing face masks or respirators, offering free novel coronavirus test facilities) that virtually everybody will recognize as effective.

And, just so we don’t get confused, potentially-controversial measures like forced stay-at-home orders shouldn’t, in my opinion, be linked to “harm reduction” — it seems like right-leaning people are responsible for much of the stay-at-home order protests; since we already desperately need to involve right-leaning people (especially those in rural areas) as harm reductionists, distancing ourselves from supporting such stay-at-home orders might be a good idea.

In Other Words, Let’s Make Harm Reduction Not Necessarily Drug-Related

If we could collectively brand “harm reduction” as a collection of common-sense, practical strategies for reducing all sorts of harms — not just drug-related harms — we’d be so, so much better off.

And, to be clear, I’ve already seen people associating the phrase “harm reduction” with the measures mentioned herein. But these harm reductionists are the exception, not the rule.

Lastly, since the vaping/smoking thing isn’t exactly in most harm reductionists’ wheelhouse, a lot of us — me included — might have to educate ourselves before we start making these associations publicly.

I want to hear what you have to say on this issue. And, no, this isn’t some generic call-to-action I close all my articles with; I really, really do value the community’s insight on this issue.

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Let’s Start Using “PWLE” in Place of “People With Lived Experience”

We’re all familiar with “people who use drugs” (PWUD) — a person-first phrasing now-often used in place of once-more-common alternatives like “addicts,” “junkies,” and even “drug users.” I actually prefer “drug user” to PWUD, but that’s not important.

In the world of harm reduction, we support things like drug-involved organizations hiring active and former drug users — oftentimes, particularly-problematic drug users — and involving them in decision-making responsibilities; employing current and former sex workers in sex worker-centered outreach efforts; putting LGBT people to work in LGBT-related capacities; and so on.

All of these people have what’s called “lived experience.” But why, exactly, is preference often given to people with lived experience?

I see two big reasons for doing so:

Here’s the Dealio, Steelio

We call drug users “people who use drugs,” right?

But… get ready for a total shower thought… why don’t we refer to people with lived experience as just that — “people with lived experience,” or PWLE for short?

Why We Needa Get Wit Da God Damn Program, My Fellow Bruhs

First off, it seems like much harm reduction-related communication takes place online. Social media often’ isn’t conducive to typing things out in full. Although we don’t go into full-on “text lingo” a la an out-of-touch 65-year-old — wat u gng 2 b dng l8r? — on social media, we certainly do use initialisms like PWUD to refer to the long, drawn-out, fucking-clunky phrase that is “people who use drugs.”

What other concise — hell, even halfway-concise? — wordings do we have to refer to people with lived experience, particularly Alphabet Gang members, sex workers, people who’re temporarily without a reliable, regular living space (or, to be more specific, without both a bed and a private bathroom, two things that are often used to determine whether someone is “homeless” or not), formerly-incarcerated people, drug users, etc.?

I’m aware of PWLE, but the phrase is criminally underused. Just to clarify, while my idea for PWLE was entirely original, I am not the first person to use this compact initialism to refer to people with lived experience. A quick google search uncovered a 2013 blog post that brought up the idea — though the author was very much against using the compact alternative to “people with lived experience” or any of its many hella-longer alternatives.

For example, I found this one description on a harm reduction-related job opening posted online and it’s nothing short of long and drawn-out — it’s a clunky-fuck, that’s for sure:

People with lived or ongoing experience with drug use, incarceration, homelessness, and/or sex work; people of color, women, and members of the LGBTQIA+ communities; and people living with HIV/AIDS and/or hepatitis C are …”

This leads me to define benefit — watch out, Spanish master Daniel Garrett here! — numero uno: We’ll be better able to convey our ideas online.

This is especially important because, at least in rural, largely-right-leaning areas that lack even a semblance of harm reduction infrastructure — like where I live — most people are learning about harm reduction online. I think this will remain the norm for at least five to 10 years.

Although it seems silly that a single initialism — PWLE isn’t an acronym because you say the letters one-by-one, which is an initialism; NASA, on the other hand, is an acronym — could help us communicate better, but it really could.

Who knows, maybe it might open up people to write or otherwise communicate about PWLE and PWLE-related issues — plain and simple, I bet the grossly-expanded, wholly-unnecessary phrasing used above discourages people (especially people who write, even if it’s just to compose a personal social media comment) from discussing PWLE.

I know it’d deter me from doing so.

Time for Benefit Number Two

We need to claim the initialism “PWLE” before another community or discipline takes it for themselves and popularizes it.

I often wonder why harm reductionists don’t refer to harm reduction as “HR.” In the past few months, I’ve been doing just that — placing “(HR)” behind one of my first uses of “harm reduction” to save myself time and, hopefully, at least, make my message easier to interpret.

Yeah, yeah, we all know the lousy-ass business function of human resources has taken the two-letter abbreviation of “HR” for themselves, but if we can’t beat out the world of human resources for the right to widely take “HR” for ourselves, what the fuck are we doing, anyway?

So, while I’m on the subject, I think we should start using “HR” as an abbreviation for “harm reduction” — the phrase is SUPER FUCKING CLUNKY AND I HATE IT!

I don’t hate it, necessarily, though I’d much rather use a single word — or any other phrase that’s got fewer than four syllables, for that matter — to refer to what we harm reductionists recognize as “harm reduction.”

And What’s Behind Door Number Three?

All considered, PWLE will likely get more attention — or, I guess a better way to put it is “more advocates who’re down for their cause” — just by adopting the abbreviation.

And — quick disclaimer — who knows if adopting the no-frills alternative of PWLE would have any material benefit for people with lived experience? I’m sure a big chunk of us harm reductionists would argue that adopting PWLE on a community-wide basis wouldn’t be worth the effort.

Spongebob Squarepants, “Something Smells,” Season 2, Episode 22a

What do we lose if we do make the change and our efforts don’t bear fruit? I don’t see us losing anything. How hard could it be to make the swap, after all? Should be easy like a Sunday morning…

Something Else…

I’ve looked at a few job postings from large harm reduction-related organizations here in the United States and almost always find disclaimers that encourage Alphabet Gang members, sex workers, and drug users to apply, as members of these groups are given preferential treatment.

Alphabet Gang, if you haven’t already figured it out, means “LGBT.” Before you get your panties in a wad, I’ll have you know I’m in the in-group for all three of these classes — not just the Alphabet Gang, so, therefore, my ideas are unequivocally better than members of the out-group. Hmph! Bow down, out-group plebeians!

But, seriously — I worry that, in some (if not many) cases, out-group members may run into trouble applying for sex work/drug use/LGBT-related positions. What if inferior in-group candidates are awarded positions over better, more-qualified applicants simply because they’re queer, cam models, or active drug users?

This idea isn’t relevant to the “Let’s adopt the abbreviation ‘PWLE’ in place of ‘people with lived experience'” thing, though I’d feel irresponsible if I left it out.

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Why’s Heroin the “Devil’s Drug”? Unpacking This Crock of Horseshit

I admit — haven’t got anything revolutionary here. Really, in this piece, I’m thinking out loud more than anything.

Growing up, I remember viewing heroin as among the worst of the worst drugs. I didn’t know why — I wasn’t familiar with any of the ins and outs or the specifics of heroin. Also not apparent to me was the similarity between the widely-illicit heroin (diacetylmorphine, a.k.a. diamorphine) and pharmaceutical opioid painkillers (e.g., oxycodone, morphine).

People, in general — at least where I’m from, southern Middle Tennessee, and where I live now, Northwest Tennessee — accept the consumption of diverted prescription opioid painkillers as “better” (whatever that means) than heroin.

Yeah, I know, modern American street heroin is significantly more dangerous thanks to the all-pervasive fentanyl and the inherently-uncertain nature of goods on the black market — but, in terms of the drugs themselves, they might as well be the same damn thing!

Anecdotal reports across the Interwebs, in my experience, at least, generally say that heroin feels significantly different from prescription painkillers.

I should note that heroin is a prescribed, pharmaceutically-available drug in some countries. Keep in mind I’m talking about the home of the free and the land of the brave, the single world superpower, the best country in the world — hell naw, I don’t like getting free healthcare and I fuckin’ LOVE going to jail for drug use that doesn’t bother a n y — f u c k i n’ — b o d y — which is, of course, the currently-more-divided-than-ever United States of America.

Anyways, Enough of the Bullshitting

Here’s what I came here to say: It’s silly that heroin is viewed as leagues “worse” — in terms of social standing or stigma, that is — than prescription opioids. And, again, heroin is hella dangerous… like, Hot Fire OXYCODONE 30 mg 30mg Roxy blue Roxycodone Roxicodon blues HOT FIRE FREE SHIPPING LEGIT PHARMACY NO BS blueberries. Tell me that ain’t fuckin’ fire.

Yeah, I Know Everybody Already Knew This

Daniel brings no revelations today. Not even close. Just a pile of horse shit on this clear-skied springtime day.

You welcome. Big pile of dookie coming right up. Oh wait. You just read it.

But, Seriously

Heroin’s got this D O U B L E — W H A M M Y effect, where we get the shit end of the stick for:

  • It’s unregulated, you never know what you’re getting.
  • People who use heroin need more help than people who use pharmaceutical opioids. Due to the greater social toll that heroin brings to the table, they aren’t able to get that help.

I don’t know what, exactly, we can do to fix this.

And not just mounting a call-to-action here because I’m planet Earth’s greediest self-promoter — I really want to hear y’all’s proposals for fixing this issue.

I’d like to hear real-world, practical solutions that could be implemented somewhere with virtually no existing harm reduction (HR) infrastructure — like the rural, largely-right-leaning areas that make up most of the United States such as Tennessee, North Dakota, Wyoming, or Missouri — in no longer than, let’s say, a year. If you think a more “high-level,” likely-viewed-as-“radical” HR approach is warranted, go ahead and hit me with that idea, too, even though it wouldn’t be able to work somewhere like Northwest Tennessee on a relatively short-term basis.

Aight den. Peace out. Girl Scouts. Boy I’m fuckin’ smooth — “peace out, Girl Scouts”… that’s an original saying I came up with ALL BY MYSELF! Gimme cool points.

+100 | Daniel Garrett Cool Account
+100 | Labor

See, I knew my accounting degree would pay off one day! ………….. ok I’m done with this POS article peace out bye. Dueces #cool #coolerthanu #buzzoffdweeb

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An Easy Guide to Understanding Why Fentanyl Is So Deadly

Want to finally understand why you hear about fentanyl all the time? Maybe without reading a novel or some complicated journal article written by doctors or college professors? Look no further.

What Is Fentanyl?

Fentanyl is a synthetic opioid available via prescription and the black market that’s about 50 to 100 times stronger than morphine.

Synthetic opioids aren’t inherently bad. Methadone is an example of another synthetic opioid that’s actually used in opioid replacement therapy or medication-assisted treatment (MAT) programs and to treat chronic pain.

Why Are People Dying From Fentanyl?

Opioid use is popular right now in the United States. Heroin is used by many in place of prescription opioids. Most heroin found in the modern American opioid supply actually contains a mixture and fentanyl and heroin. Fake prescription opioid tablets marketed as real ones are used similarly.

Both heroin and fake prescription opioid tablets that contain fentanyl are sold on an unregulated market. That means nobody ever knows what’s actually in their heroin, alleged prescription opioids, or other drugs.

Even if people are prepared to use fentanyl, it’s so potent that measuring out accurate doses is difficult. Also, because heroin, fake opioid pills, and other illicit drugs aren’t made in safe, regulated, pharmaceutical-quality environments, one customer could get sold product that has several times as much fentanyl as another. Concentrations of active ingredients like fentanyl are called “hot spots” among people who use drugs (PWUD) like me.

How Does Fentanyl Cause Death?

Opioid overdose causes death by making users super-duper sedated — or conked out, in slang terms — and losing the ability to easily breathe due to our airways becoming obstructed.

Oftentimes, fatal opioid overdoses result from a combination of drugs, not just opioids. Also, all opioids can cause death — not just fentanyl.

PWUD Don’t Know How to Stay Safe

I’m a long-term opioid user. My history includes over three years of heroin use — intravenous heroin use, that is — and three overdoses. Today, I do things like give out free, clean syringes and naloxone (the opioid overdose antidote) and educate people how to use drugs safely.

Why do I do this? Because dead people don’t recover.

Up until just three years ago, I wasn’t aware of how to stay safe while using drugs. All I knew was that drugs are bad and that I shouldn’t be using them in the first place.

There are many, many issues that plague modern American opioid users. The solutions below aren’t a cure-all in any way. If you know somebody who uses opioids — including yourself — these things can help keep you safe:

  • Enroll in a medication-assisted treatment (MAT) program immediately. In the United States, buprenorphine and methadone are prescribed as an alternative to other opioids. One way to find these programs is through this free tool.
  • Get naloxone (Narcan) immediately. In Martin, Tennessee, where I am, for example, you can hit up Melesa Lassiter, Northwest Tennessee’s Regional Overdose Prevention Specialist, for free Narcan. Live somewhere else? Visit naloxoneforall.org for state-by-state information about where people can access in-person naloxone and other free resources.
  • Use around at least one other person who knows you’re using, knows how to use naloxone, and isn’t also using at the same time as you.
  • Get fentanyl test strips. The ones I’m familiar with are the green-label “Rapid Resposne 1 Strip.” Find them from harm reduction organizations like FentAware (though only 6 at a time) for free, or from health product supply stores online. DanceSafe has got some, too.
  • Always assume any drugs you use contain fentanyl.

It’s always safer to not use drugs than to use drugs. Even if you follow the precautions above, it’s still possible to overdose. I don’t condone drug use. If you haven’t already started using drugs, please don’t use.

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Why We Need “The Big Book of Harm Reduction”

Since I first learned about and became interested in harm reduction — they virtually happened simultaneously some three years ago — I’ve long sought out a manual on building harm reduction (HR) infrastructure: Harm Reduction for Dummies, if you will.

I still haven’t found it.

Grassroots harm reductionists and fledgling HR-related organizations in places without any harm reduction infrastructure have no clue how to grow. We don’t know how to do this stuff. The only people who do are those in areas with better-developed HR infrastructure (e.g., New York, California, Canada, Portugal).

Even then, I feel like expanding harm reduction here in Tennessee — or, hell, the entirety of the (rural) American South — will require substantial deviation from what’s worked in other areas (again, New York, California, or Canada, for example).

Here’s What I’m Trying to Say

We need to collectively build “The Manual of Harm Reduction.” It’ll help mobilize grassroots harm reductionists like me and the many drug-related organizations that are held together with twigs and bubble gum — and that, unfortunately, happens to be a lot of them.

How can we go about doing this?

I’m not sure — I’m not even going to act like I’ve got the answers. However, I am willing to proofread and revise any harm reduction-related writing or resources you’ve got — yes, you!

One thing I think we need to do for sure is start talking about “The Manual of Harm Reduction” among fellow harm reductionists.

What Might “The Manual of Harm Reduction” Look Like?

Most likely, we’d have a collection of essays and articles as opposed to a textbook-type thing. In order to decide what issues and pieces of work are most important, we’d get together and decide what’d make a final, more-condensed version.

It also might behoove us to categorize “The Manual’s” content by location, if not come up with an entirely separate manual for places like the American South.

But Most Importantly…

You need to start talking about the idea for “The Manual of Harm Reduction,” or whatever the hell you wanna call it. It doesn’t matter what we call it — and it also doesn’t matter who gets credited for this idea.

In other words, don’t float this as Daniel Garrett’s idea — rather, consider it the entire (North) American harm reduction community’s idea.

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Why Tennessee Lacks a Harm Reduction Infrastructure

Here in Tennessee, we ain’t got shit in the way of harm reduction. We’ve got six syringe services programs (SSP). And other than the often-exclusionary 12-step programs, the outdated rehabs, and the entirely-bullshit drug courts, probation, and parole programs, that’s about it.

But why? Why is Tennessee — and much of the South, particularly the rural South, by extension — so ass-backwards when it comes to harm reduction or drug policy? Why don’t we have what New York, California, or Washington has?

Is it because we’re evil?

Maybe because we hate “druggies” like me, the stereotypical behavior of which I’ve exemplified hundreds of times?

Or is it for other, more practical reasons?

The “Radical” Nature of Modern American Harm Reduction

Person holding three used syringes giving them to somebody with an open hand.
Syringe exchange in action in Burlington, Vermont. (Robert Nickelsberg/Getty Images)

Things like syringe exchanges, widespread drug-checking, supervised consumption sites, and access to a safe drug supply have long been viewed as “radical.” Of course, I don’t think they’re radical, nor do anybody else who considers themselves a “harm reductionist.”

However, the majority of Americans, especially Republicans and other right-leaning people, definitely do consider some or all of these things “radical,” even though two-thirds of Americans don’t support the criminalization of now-illicit drug possession and only one-tenth believe the War on Drugs is a success.

Areas that are more left-leaning than Tennessee have been more open to things like harm reduction-positive ideas, practices, and policies. These ideas have traditionally been a left-leaning thing — that’s the simplest way I can put it.

Politicians, Stakeholders, and Other Decision-Makers Have Pushed for Ineffective Approaches

Second, not only have right-leaning politicians and stakeholders failed to support effective strategies for dealing with drugs, they’ve actively campaigned for ineffective, largely-prevention-based strategies that actively hurt drug users like me.

Here in Tennessee, prevention coalitions are quite popular. According to the Tennessee Department of Mental Health & Substance Abuse Services’ “Substance Abuse Prevention Coalition Provider Contact List” — god damn what a mouthful! — there are 46 local prevention coalitions across the state, plus two statewide outfits.

We’ve got Prescription Drug Take Back Day, which raises awareness for dozens of secure prescription drug disposal bins around the Volunteer State, though they don’t accept syringes. This leads injection drug users like me to improperly dispose of syringes, sometimes throwing them on the roadside out of fear of being caught with them and catching criminal charges, having friends or family discover their injection drug use habit, or incur a work-related issue.

The Volunteer State is also home to 21 Regional Overdose Prevention Specialists, positions that were created in late 2017 to respond to the still-ongoing “opioid epidemic,” as many call it.

ROPS, as they’re known — pronounced “ropes” — hold public naloxone trainings and give out naloxone in Tennessee. The naloxone and the trainings are free, though ROPS systemically fail to reach active opioid users and others who are most at risk of opioid overdose.

I talked to one ROPS here in West Tennessee who told me they weren’t willing to distribute naloxone unless the recipients got trained to use it first — directly under their supervision, too. It’s easy to imagine how the long-mistreated, long-term, often-problematic drug users who the state claims to help aren’t too keen on visiting these trainings or accepting naloxone from ROPS.

Again, this isn’t to say ROPS are bad — our ROPS here in Region 6N, Melesa Lassiter, is great; she’s also laced me up several times over the past year or two, putting me on to tons of things I wouldn’t have otherwise learned. It’s just that, due to the distrust of resources that government agencies claim are for the most disadvantaged people, my fellow long-term, often-problematic drug users aren’t very open to the knowledge and naloxone ROPS provide.

I should note that naloxone is the lowest fruit on the proverbial harm reduction tree. Naloxone has no real contraindicationsdrug interactions, in other words — outside of causing precipitated withdrawal syndrome in opioid-dependent persons. Still, trading a second chance at life via naloxone-aided revival for an hour or two of peak withdrawal symptoms isn’t a bad deal.

Another note — naloxone doesn’t always cause withdrawal. I’ve had naloxone administered thrice — all in 2019 within a three-or-four-month period — and never experienced withdrawal as a result. A big reason for this, I think, is because my significant other, the person who administered the naloxone on all three occasions, never used a full dose of naloxone to bring me back. I know many people think you can’t reverse an opioid overdose without welcoming precipitated opioid withdrawal, but this isn’t true.

Third — We’ve Fallen Short, Ourselves

We harm reductionists haven’t done a good enough job of framing harm reduction-positive ideas in a way that most largely-right-leaning people will agree with — me included.

As I fleshed out in “How Outwardly Left-Leaning Harm Reductionists Hurt Our Cause,” people in the American South — rural Middle and West Tennessee, in my case — aren’t fond of things that seem politically correct or those that are associated with left-leaning values or ideas. Since many modern American harm reductionists are largely-left-leaning people, they tend to conflate our shared cause of helping active drug users like me with other things like non-drug-user-specific social equity efforts (e.g., pro-LGBT efforts).

I get it — some people want to bring about social change and level the playing field for traditionally-disadvantaged groups. This cause is worthy of merit — and I’m not just saying that because I’m bisexual and stand to benefit from pro-LGBT social equity efforts or because I was a sex worker for about four years and similarly stand to benefit from pro-sex worker social equity efforts. Oh, plus, I’ve always been low-income, so it’d help me triply if this playing field were leveled out. Just so you know I’ve got skin in the game — that’s all.

Regardless of what you, independently, value, we can’t escape the fact that most residents of Tennessee are averse to left-leaning or politically-correct things. If you want to expand harm reduction from states like Washington, California, and New York out to the completely-fucking-bare Volunteer State, you must be sensitive to the beliefs and attitudes of Tennesseans.

And, like I’ve mentioned, this isn’t just true for Tennesseans — it’s true for North Carolinians, Georgians, Kentuckians, and any other Southeastern state’s residents. Well, it also holds true for the largely-right-leaning states of North and South Dakota, Montana, and Wyoming, for example.

What’s the Solution for Tennessee and the Rest of the South?

I’ll be the first to tell you — I don’t know. While I know what Tennesseans don’t like, I’m not well-versed in Christian literature, values, or culture, which seem to be supported by the overwhelming majority of the Volunteer State’s residents.

People who understand these values and, by extension, how to frame harm reduction-positive messaging are vital to our efforts. Here in Tennessee, specifically, we don’t have any networks of harm reductionists or others who are interested in harm reduction-like things. I’ve looked through countless resources online with magnifying glasses and fine-toothed combs and have uncovered very few contacts.

For example, I went to the HepConnect Grantee Meeting in Raleigh, North Carolina, in March 2020 and met several Tennesseans who are active in harm reduction — not just interested in it — and have been for longer than me. I know there are several dozen others out there, too, if not more, but I just don’t know how to get a hold of them.

So, admittedly, it’s not like we Tennesseans have our shit together when it comes to harm reduction. We just — of course, I can’t speak for everybody in saying this, but every Tennessean harm reductionist who I’ve talked to largely agrees with these general sentiments — feel that we’ll need to modify the “harm reduction” that has worked for states like New York and California or countries like Canada and Portugal in order to effectively roll out harm reduction infrastructure in the Volunteer State.

Going Forward

If I haven’t already made this clear, I don’t have the answers for building harm reduction infrastructure in Tennessee.

However, I do know that we grassroots harm reductionists — many of whom, like me, are people who actively use drugs or are former long-term, often-problematic drug users — need to hop to action before the state does.

Right now, if you’re an active drug user, you can’t work as a Regional Overdose Prevention Specialist. From what a ROPS has told me, you’ve got to have something like a couple years’ clean time from regular drug use in order to hold the position. That person said regular drug users wouldn’t be able to work for the state in any capacity, unfortunately.

We’ve seen countless manifestations of seemingly-drug-user-oriented organizations that don’t hire active drug users or involve them in decision-making processes and, as a direct result, fail to do things that best help active drug users, especially “long-term, often-problematic drug users,” as I call them.

There will come a time when harm reduction goes mainstream. If we haven’t positioned ourselves well enough by then, I worry that the best interests of us active drug users won’t be kept in mind.

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Syringe Services Programs in Tennessee

Syringe exchanges, known as Syringe Services Programs (SSP) by the Tennessee Department of Health, aren’t very common in Tennessee. There are two in West Tennessee, one in Middle Tennessee, and three in East Tennessee.

According to the state’s Allison Wilhelm, as of April 21, 2020, there are seven current SSP sites — two in Memphis, two in Nashville, and three in East Tennessee (Chattanooga, Johnson City, and Knoxville). 

Memphis

The Memphis Area Prevention Coalition’s Safe Point operates each Wednesday from 2:00 to 4:00 p.m. It can be found at 28 N. Claybrook Street in Memphis, Tennessee. 

A Betor Way is also in Memphis, though at 1571 Sycamore View Road. It operates every Friday from 6:00 to 9:00 p.m.

Although it’s not an SSP, the Shelby County Health Department operates a Needle Disposal Program. Visit 814 Jefferson Ave.’s Central Laboratory, found in Room 258, between 8:00 a.m. and 4:30 p.m. to get a sharps container and to turn in used syringes. Note that, unlike every other SSP listed here, Shelby County Health Department charges a “minimal fee” for its syringe disposal services.

Nashville

Nashville is only home to one SSP, Street Works, which ran for years on an underground, illegal basis before earning an official title as one of the Volunteer State’s few Syringe Services Programs. In Madison, on 907 Gallatin Pike, Street Works operates from Monday to Friday from 9:00 a.m. to 5:00 p.m.

You can also call (615) 779-4840 for more information. 

Note: I claimed there were two SSPs in Nashville. According to the Tennessee Department of Health, both of which are operated by Street Works. One is located in Nashville at 101 Old Trail Court, the other at 907 Gallatin Pike in Madison. I don’t know the difference between these two locations — call Street Works at the aforementioned phone number to learn more.

East Tennessee

East Tennessee is home to three SSPs, two of which are run by Cempa Community Care, the other by Choice Health Network.

Chattanooga

Chattanooga’s SSP is run by Cempa and can be found at 1042 East 3rd St. It operates from 8:00 a.m. to 5:00 p.m. on Monday, Tuesday, and Thursday; an additional hour in the evenings on Tuesdays; and closes early on Fridays at 12:30 p.m.

Johnson City

The Tri-Cities’ area’s sole SSP, also known as the Syringe Trade and Education Program of Tennessee (STEP TN), is found at 615 North State of Franklin St. in Johnson City and runs Monday to Friday from 8:30 a.m. to 4:30 p.m., though is closed for lunch from 11:45 a.m. to 12:45 p.m.

Knoxville

Operated by Choice Health Network, Knoxville’s SSP is found at 701 N. Cherry St. and operates for two hours on Monday and Thursday, from 1:00 p.m. to 3:00 p.m.

Since publication, someone from Choice Health Network told me these times and this address are wrong. They asked me to include their phone number — (865) 208-7356.

Rural Areas

As of now, unfortunately, there aren’t any syringe services programs in rural Tennessee. This leaves most of Tennessee’s injection drug users shit outta luck.

I recommend visiting pharmacies — try independent ones — for syringes, though you may get turned down. If this doesn’t work, try out diabetes or medical supply websites or the free mail-based supply distributor NEXT Distro.

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How Online Drug Reporting Yields Better Harm Reduction

When I used to regularly browse Reddit’s r/Opiates subreddit, I’d sometimes see posts titled “Fentanyl Warning: (City, State).” Even though the site isn’t that active in hosting such warnings, sharing reports on drug forums like fentanyl warnings is an effective harm reduction practice.

Screenshot of the header of opioid-centered drug forum r/Opiates, a subreddit of Reddit.com.
r/Opiates’ header

The most recent fentanyl warning on r/Opiates is three months old. Looking back on other “fentanyl warnings,” they’re few and far between — there seems to be no more than two per month over the last year. Jynxies Natural Habitat is a Blogspot-based website dedicated to sharing the owner’s own stamp reports and relaying submissions from readers, though it’s been defunct for a half-decade. Reddit’s r/Glassine, too, was dedicated to stamp reports prior to its closure over two years ago. Free-standing sites like the now-defunct Opiophile, Drugs-Forum, and Bluelight have also been home to similar reports — though the latter two sites aren’t defunct, they’re not as active in subjective drug experience reporting as we’d like them to be.

While I’m not privy to all online subjective drug experience reporting platforms, something I am sure of is that we’d all benefit from having access to readily-accessible, active drug experience reporting websites.

The Need for Drug Reporting Sites Comes From the “Black” Part of the Black Market

All across the United States — hell, even across your county — the quality of illicit, unregulated drugs varies. As drug users, we never know what we’re getting.

Ever heard of that myth that fentanyl sometimes finds its way into the meth supply? It’s not a myth — it’s 100% true! Fentanyl has been found in non-opioid drugs like cocaine, and, of course, illicit opioids like heroin and counterfeit pharmaceutical opioid tablets.

Roughly 25 fake Mallinckrodt oxycodone pills, marked M 30, that contain fentanyl.
Fentanyl-laced counterfeit opioid tablets made to look like Mallinckrodt’s 30-milligram, instant-release oxycodone tablets. Courtesy of DEA.

We all know, as active American drug users, that fentanyl can very well be in any sack of dope you get. The concern with fentanyl is that there’s a relatively small threshold between an active dose and a potentially-fatal one. Another problem is that, due to the unregulated nature of the illicit drug market, manufacturers don’t use pharmaceutical-quality manufacturing processes — in other words, this results in “hot spots,” or areas of varied strength across batches of illegal drugs.

Keep in mind that we don’t need drug reporting websites or other platforms solely because of fentanyl. Rather, we need drug reporting sites because of the nature of the black market — without the often-pesky regulatory bodies that oversee commerce, the market lacks even a shred of accountability.

Dark Net-Based Illicit Drug Markets, in a Way, Act as Drug Reporting Sites

In the “real world,” of course, we don’t have to do any drug reporting. However you may get drugs, you’re not required to leave any reviews or reports of batches you come across.

On “the onions” — the phrase colloquially refers to dark net markets that can be visited via the Tor Browser, the logo of which is an onion — you’re incentivized to leave reviews.

With most modern platforms, the more, the better, and the more accurate reviews bring you more value in the eyes of vendors. Vendors like doing business with people who’re both motivated and thorough in leaving reviews, as better reviews stand the chance of boosting business.

If you didn’t already know, the path to success on any dark net market is to pull in great reviews on a consistent basis who are also well-reviewed themselves. On an above-ground peer-to-peer sales platform like eBay, for example, we can take accusations of theft to police and — who knows? — maybe even to court. We can leave reviews on other platforms, too, even if we have’t done business on them.

With dark net markets, you’re not taking any complaints to police or industry regulators — unless you like going to jail, not passing go, nor collecting $200 (yes, that’s a Monopoly joke). You might not be able to leave reviews on other platforms because the vendor might not be active on them. Also, with all dark net markets, you have to buy something from vendors in order to have the opportunity to review them. You can post on forums, naming-and-shaming vendors that’ve done you wrong, but that’s about it in the line of recourse.

The Importance of Drug Checking

If you don’t know what you’re consuming, you can’t truly be safe. Also, if you don’t know how pure your drugs are, you face similar safety issues. Drug checking helps people make better decisions.

Drug checking also gets people involved in harm reduction.

Here in Northwest Tennessee, most fellow drug users aren’t familiar with rapid fentanyl test strips — or, I should say, at least they weren’t familiar with them before I put them on game. These test strips are the most popular, in-demand supply I give out. I wish I had more, as they get more people interested in harm reduction in general. Hell, they make people more interested in taking care of themselves.

Thirdly, drug checking boosts “public health surveillance and response strategies to prevent harms associated with illicit drug use,” says a 2018 International Journal of Drug Policy study.

By extension, online drug experience reporting accomplishes similar results — it improves drug users’ decision-making, boosts involvement and interest in harm reduction, aids public health surveillance, and helps build well-rounded, effective public health responses.

Drug checking, defined by DanceSafe as “a harm reduction service that helps drug users avoid ingesting unknown and potentially more dangerous adulterants found in street drugs,” varies from drug experience reports in several ways:

  • Drug checking objectively, empirically determines what samples contain and (though not very often) in what proportions; experience reports don’t.
  • Experience reports are often entirely subjective in nature. Sometimes, reporters do use rapid fentanyl test strips or reagent tests, for example.
  • The primary focus of drug experience reports is on people’s personal experiences with drugs, not their guesses as to what to what they’ve consumed contains.
  • Lastly, drug experience reports are typically shared in real-time, whereas there’s often a several-day delay in the empirical chemical analyses reported by outlets like DrugsData.org.

Are There Any Widely-Used, Go-To Platforms for Finding and Leaving Drug Reports?

DanceSafe, for example, is one of the largest drug-checking entities in the world. The non-profit organization also creates and distributes educational material; at festivals and other events, the entity offers water, earplugs, condoms, peer counseling services, and event patrol oversight (i.e., making sure dance floors are clear of potential hazards). DanceSafe doesn’t publish its results, unfortunately, but the group said “we are hoping to when [Fourier-transform infrared spectroscopy] has been more widely introduced” in a Facebook message dated Monday, April 20th.

The Erowid Center runs DrugsData.org, which happens to be “the best option for test results right now,” according to DanceSafe. DrugsData.org’s list of samples of often-illicit drugs that have been tested via gas chromatography–mass spectrometry, or GC-MS for short.

While this organization is good at what it does, tests can be downright expensive, ranging anywhere from $40 for whole, pressed ecstasy tablets; research chemical samples, any non-pressed ecstasy, and blotter costs $100. Testing herbal supplements and pharmaceutical tablets, powders, and capsules costs $150.

To get an idea of how active the site is, it’s got two entries from April 17th, 15 from April 8th, 23 from March 22nd, two from March 20th, six from March 13th, 38 from March 9th, and four from March 6th. I believe this resource is the best publicly-available aggregation of empirically-tested drug samples on the Internet right now.

Just one glance at DrugsData.org and it’s easy to see that the Erowid Center project isn’t the type of resource to host drug users’ personal, anecdotal experiences — again, keep in mind DrugsData.org is for drug checking, not subjective drug experience reports. While Erowid, also an Erowid Center property, hosts these subjective drug experience reports, they don’t feature images or location.

At least in my experience, people tend not to turn to Erowid for location- or batch-specific drug experience reports — “stamp reports,” in other words. It seems like many drug users in my area, especially those that are the most disadvantaged or at the highest risk of experiencing drug-related problems, aren’t aware of web-based drug resources. Of course, they aren’t too keen on sifting through lengthy personal accounts of drug use.

Don’t get it twisted — Erowid is a solid resource. We just don’t have any active online platforms for sharing short-form, readily-digestible drug experience reports. Also, of those that do exist, none of them — to my knowledge, and please correct me if I’m wrong — condone location sharing. And I think location-sharing is very important in sharing drug experience reports and empirical drug-checking results.

The Importance of Location in Online Drug Experience Reporting

On Reddit’s r/Opiates subreddit, for example, community members aren’t allowed to share their location. Moderators are incentivized to discourage such sharing and actively censor such posts out of self-preservation. Reddit doesn’t want to help people find illicit drugs. By avoiding location, r/Opiates stands a much better chance of avoiding a swift banhammer strike.

For example, in March 2018, Reddit banned r/DarkNetMarkets for “a violation of Reddit’s policy against transactions involving prohibited goods or services.” Countless other drug-related subreddits have been dismantled for similar reasons. 

I agree, we’re better off with a r/Opiates subreddit that doesn’t allow location-sharing than without one at all. However, we need somewhere that facilitates location-specific sharing.

Batches of illicit drugs vary wildly by location — this is why location-specific drug experience reporting is so important. For example, in Philadelphialots of street heroin contains xylazine, known colloquially as “sleep cut.” Also, due to a lack of regulation, illegal drug markets’ batches similarly vary wildly.

The Issue With These Tests

Remember how expensive getting a DrugsData.org test is? The layperson can’t readily afford these tests.

Also, these tests aren’t performed instantly. In the real world, how often are drug users like me willing to wait after copping drugs?

Oh so often, we use drugs within minutes or hours of buying them. Many of us can’t afford to wait to use — well, it’s more appropriate for me to say that we’re not willing to wait to use, whether we’re just impatient or we want to send withdrawal symptoms packing.

Lastly, chemical analyses might not always match up with subjective drug experience reports. Although these breakdowns identify what substances drugs contain, we can’t always predict how people will react to them.

In other words, DrugsData.org-style analyses just aren’t practical. They’re important, yeah — don’t get me wrong. They’re just not readily available or practical for the vast majority of active drug users like me.

Virtually Anybody Can Get Involved

In order for an online drug experience reporting website to have utility, it needs to be readily-accessible. In other words, for it to be worth half a shit, it needs to be easy to access.

In my experience, people who use drugs in rural West and Middle Tennessee aren’t generally aware of web-based drug resources, whether it be Erowid, a drug-related subreddit, or a mail-based safe drug use supply distributor like NEXT Distro.

When People Get Active in Harm Reduction, They’re More Likely to Support Harm Reduction

Used rapid fentanyl test strips (FTS). One line, as shown in the left, represents a positive result, whereas two lines, as shown in the right, represents a negative result.
Used fentanyl test strips (positive result on the right, negative result on the left)

Like I already mentioned, around here, people are usually blown away by how “cool” fentanyl test strips are. Some people have been impressed by the small, already-balled-up, perfectly-sized cottons I distribute.

These people are more friendly to accepting syringes, naloxone, and other safe drug use supplies; solicit advice about proper injection practices and general drug-related best practices; and becoming interested in what we call “harm reduction.”

Platforms that allow people to share subjective drug experience reports will similarly get people, particularly active drug users, interested in harm reduction — even if they don’t know what “harm reduction” is.

Drug-Checking Websites Aren’t a Bad Thing

Don’t think that drug-checking result sites like DrugsData.org are a bad thing — they’re great!

What I am saying is that we don’t have a sufficient means of readily sharing subjective drug experience reports with others. And, while DrugsData.org is drug-related, subjective drug experience report-sharing is an entirely different thing.

What Does Sufficient Drug Experience Reporting Look Like?

I’ll be the first to tell you — I don’t know. I don’t know what the ideal drug experience reporting hub or framework would look like. I don’t know what problems might arise in creating or operating one.

I’d imagine that creating such a platform is risky because of its tie to illicit drugs. What if you get accused of helping people buy or sell illicit drugs? What if someone sources drugs from someone they met through your website and experiences a fatal overdose — don’t you think you could potentially be implicated?

Also, again, drug-checking reports from DrugsData.org and company are beneficial to our cause as harm reductionists. We don’t need to get rid of any existing sites to bring about a better world of subjective drug experience reporting.

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Current American Medication-Assisted Treatment Conventions Aren’t All Ideal

While medication-assisted treatment (MAT) programs across the country have reduced harm that enrollees otherwise would have experienced without enrolling, some feel that MAT hasn’t been expanded far enough throughout the United States. I can’t help but feel glad it’s legal here in Tennessee, though I also believe our current MAT system is far from ideal — I think we can all agree on that.

Refraining from future drug use would best serve my interests, as I’ve long proven myself to be an often-problematic drug user. Most people can moderate their drug use to avoid addiction and dependency, but I’m not one of those people. While I still use illicit drugs today, I’m in a much better spot now that I’ve reduced my overall intake and largely maintain myself with buprenorphine (Suboxone).

Medication for opioid use disorder (MOUD) prescribers — those are the physicians licensed to prescribe methadone or buprenorphine — are morally incentivized to not tolerate “dirty” urine drug screen results, as knowingly allowing program enrollees to continue illicit opioid use and be maintained using Suboxone could get prescribers in trouble. How would allowing a patient to “get by” with illicit opioid use reflect on a physician if the patient died of an opioid-involved overdose?

Wouldn’t be too cash money, would it?

On the other hand, I wish long-term, addicted/dependent — both in my case — opioid users could be maintained on Suboxone while still using illicit opioids. In my case, since I reduced my other-than-Suboxone opioid use big time, I’ve done myself a solid by seeking out MAT program enrollment. Before getting on Suboxone in September, I found myself in almost-entirely-mental opioid withdrawal every week for anywhere between two and four days.

This cycle got started because I’d have enough money to afford anywhere from three to five days’ worth of using opioids — I could never afford to use throughout the week without interruption — before regressing into a shell of myself until I got paid again. I lived each day during this cycle constantly tracking the time in anticipation for my next high. I wasn’t very psyched about living, either — I felt indifferent about the potential of experiencing overdose. In other words, I never once worried that life was whizzing by too quickly during the three or four years consisting entirely of my oh-so-depressing, constantly-repeating week-long cycle.

After starting Suboxone, I didn’t fiend for heroin — more like a fentanyl-heroin mixture knowing the modern American illicit opioid market — or other opioids as I used to. I also stopped contemplating an “accidental” suicide via opioid overdose. Life was better, in general.

I worry that medication-assisted treatment programs’ firing of patients who test positive for non-prescribed (often-illicit) drugs seems to stand in contradiction to the tenet of keeping patients on — or at least constantly offering them MOUD access — MOUD in favor of returning to the (often-illicit) opioid use they came from, which is typically more dangerous.

Here’s my issue: is it better for MAT programs to (1) allow enrollees to use other opioids and be maintained on Suboxone or methadone or (2) kick enrollees out after testing positive for other opioids an arbitrary one-too-many times?

I think number one is the better option. Here’s why.

What’s the Point of Medication-Assisted Treatment?

I don’t think there’s an objectively-true purpose of medication-assisted treatment. We must ask ourselves what we value most from MAT programs to formulate a worthwhile answer — only then can we hope to define the purpose of MOUD maintenance.

Here’s What I Value From MAT Programs

I think MAT program enrollees’ often-problematic opioid use should decrease as a result of their buprenorphine or methadone use — that’s one performance indicator we can use. Their exposure to risky or detrimental scenarios (i.e., visiting a high-crime area to source illicit drugs) should wane — the second metric we’ve got. And, most importantly, their quality of life should improve — albeit this third metric is considerably harder to quantify. These are the central values I want from medication-assisted treatment.

No, these are not the almighty three “values” I hope to get from MAT. You’re encouraged to pick and choose your own values — don’t just blindly follow mine!

Of course, I recognize MAT as a super-solid alternative to opioid use — and even alcohol use (naltrexone). Whether you have opioid use disorder per the DSM-5 or not, MAT can help you. Even though I didn’t have a physical dependency to opioids before I enrolled in an MAT program — I didn’t experience the same “flu-like,” for lack of a better word, opioid withdrawal symptoms that so many others do; dealing with the mental fallout of ceasing opioid use was the big issue for me, personally — Suboxone maintenance was still a good fit for me.

Again, I think medication-assisted treatment is great for dealing with opioid use disorder and otherwise-problematic opioid use.

What Does the Volunteer State Want From Medication-Assisted Treatment?

The Tennessee Department of Mental Health & Substance Abuse Services’ medication-assisted treatment page states, “The prescribed medication [Suboxone, methadone, or naltrexone] operates to normalize brain chemistry, block the euphoric effects of alcohol and opioids, relieve physiological cravings, and normalize body functions without the negative effects of the abused drug.”

While this definition outlines the physiological effects of suboxone, methadone, and naltrexone, it doesn’t address any higher-level, overall goals for people involved in medication-assisted treatment programs.

Many medication for opioid use disorder prescribers in Tennessee are weighed down by looming regulations. Some are more comfortable than others with regularly accepting “dirty” drug screens — a more-appropriate term might be “positive drug screen” — from patients without firing them. Others fear regulatory backlash if they don’t act in accordance with state guidelines, which encourage prescribers not to retain patients’ enrollment if they submit just four positive drug screens in a two-year period, among other stringent regulations.

What Does Tennessee Want From MAT Program Enrollees?

All MAT programs’ prescribers want to see patients exhibit abstinence from illicit drugs while taking their prescribed dose of buprenorphine, methadone, or naltrexone. Some programs are willing to let regular cannabis use slide, though not anything more than that. Programs also aren’t cool with alcohol use, either.

Due to pressure from the state, however, prescribers often are constrained to appease the state by doing things that aren’t conducive to successful treatment outcomes.

The state’s regulations state that any enrollees who test positive for illicit drugs four times — the text actually reads, “Upon a second/third/fourth positive drug test result within six months of the first/second/third positive drug test result,” which means four positive drug test results for illicit drugs could span a 24-month period at longest — are required to “address the on-going [sic] multi-drug use through increased group and individual counseling, intensive outpatient [sic] and residential clinical treatment.” Imagine getting kicked out of a MAT program because, after pissing dirty four times in two years, you refused to go to residential inpatient clinical treatment.

The aforementioned document is 44 pages long and is packed to the brim with strict guidelines that make it difficult for prescribers to best help MAT program enrollees.

Consider This Scenario

Assume Bob is a regular illicit opioid user who lives in Tennessee. Bob has proven himself to be an often-problematic drug user, having found himself in legal, financial, familial, relational, social, mental, and physical trouble from his opioid use.

Bob solicits a medication-assisted treatment program that prescribes buprenorphine and shortly after enrolls in the MAT program.

Bob’s frequency and intensity of illicit opioid use decreases thanks to his enrollment and regular dosing of Suboxone. However, he still continues to use — just not as often or as much at once. Bob also doesn’t go on binges like he used to.

While Bob will be allowed at least one slip-up, he faces inevitable termination from the program if he continues to submit urine for drug tests that test positive for opioids. Assume that Bob maintains this pattern of use, regularly taking both illicit opioids and the Suboxone he’s prescribed.

Ask yourself — what do you think will happen if Bob is dismissed from the program? Do you think he’ll be better off enrolled in the MAT program and allowed to continue his concurrent consumption of illicit opioids and the Suboxone he’s prescribed or better off dismissed from the MAT program?

Here’s What I Think

Often-problematic drug users continuing their illicit drug use is rarely a good idea. As a long-term, often-problematic illicit opioid user myself, I’ve faced all the problems Bob has and more — I know that continuing to use opioids is a bad idea, at least for me, personally.

The most ideal outcome for Bob is to ultimately cease his illicit opioid use, if not quit the use of all drugs, opioid or not.

Would it be better for Bob, assuming that he wants to continue using illicit opioids, (A) to remain on Suboxone and use other opioids less often or (B) to be dismissed from the MAT program and use illicit opioids on a daily basis?

I think, although not ideal, (A) is the better option.

People in Bob’s shoes could be fired from MAT enrollment if they tell their prescribers that they plan on continuing illicit opioid use. In order to hide evidence of illicit opioid use, they’d have to secure “clean” urine — that which only tests positive for buprenorphine and nothing else — and sneak it in the MAT program’s facility on a regular basis.

Responsibilities of MAT Program Professionals

How responsible is my Suboxone prescriber if he’s okay with me continuing my use of illicit opioids, even though I’d still be on Suboxone and I’d be using less than before beginning Suboxone maintenance?

I don’t think it’d be responsible of him at all. What if I overdosed or another negative outcome occurred?

Is it good enough to have an MAT program enrollee reduce illicit opioid use (i.e., Bob’s scenario above) or would a MAT program physician be settling for less by allowing a patient to do so?

Even the most forward-thinking harm reductionists can see the problems with drawing the proverbial line between these two situations.

The Effects of Buprenorphine on an Opioid-Dependent Patient’s Brain

Before I got on Suboxone, I used illicit opioids as often as I could afford them. I’d be able to spend anywhere from one to four days high in a row upon getting paid. The rest of the week, I’d lay in bed unable to concentrate, nothing short of depressed, and interested in nothing more than the next time I’d be able to get high.

This pattern of use went on for at least two years, if not three or four.

What a way to live, huh?

When I got on Suboxone, I was actually able to finish Youtube videos to the end — not to mention feel joy from watching them. I felt more stable; on Suboxone, I’ve never acted like I would when I was super duper high, and, similarly, I’ve never felt as low as I used to after my binges were over — and that happened consistently… every… single… week.

Suboxone has also deterred me from using illicit opioids on several occasions because I knew I’d end up wasting my money thanks to buprenorphine’s opioid-blocking effects.

Also, although this doesn’t have anything to do with my brain, I’ve been around criminal activity much less than when I was actively using. That makes me feel better and reduces the likelihood of me being sent to jail or otherwise dealing with the criminal justice system.

Where Should We Go From Here?

Personally, I want be able to still use heroin and other illicit opioids on occasion and take Suboxone regularly without facing termination from the MAT program I’m enrolled in.

Going forward, I think patients enrolled in MAT programs should be able to use illicit opioids if they so choose without the risk of being kicked out. It’s safer for me to take Suboxone six days of the week and illicit opioids one day rather than me not use Suboxone at all and only use illicit opioids; I also feel confident that my quality of life is higher this way.

I don’t feel confident in asserting that my idea is the way to go. I certainly think what I proposed above is a good idea, but medical professionals, addiction specialists, mental health practitioners, social services workers, criminal justice system members, long-term illicit opioid users, and others need to spark up a discussion about this before we do anything. None of us know with certainty what’s best — but many of us feel we need change, and change is where we need to start.

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What Do Tennessee’s Regional Overdose Prevention Specialists (ROPS) Do?

Nestled deep inside the Bible Belt, Tennessee is big on tradition and conservative values. As you might imagine, harm reduction — reducing harm done to and experienced by drug users — isn’t very big here.

Here’s a good rule of thumb — the more left-leaning a state is, the more likely existing harm reduction infrastructure can be found there (e.g., California, New York). Places like Tennessee don’t have much in place; we’ve got at least six state-recognized Syringe Services Programs, at least one county health department-run syringe disposal program, and 21 Regional Overdose Prevention Specialists (ROPS).

Billboard from the Tennessee Department of Mental Health & Substance
Tennessee billboard promoting free naloxone.

ROPS are employed by the Tennessee Department of Mental Health & Substance Abuse Services to hold regular naloxone trainings and distribute the life-saving drug. Although the Volunteer State certainly isn’t the only government to employ people acting in such roles, Tennessee is unique in its use of “Regional Overdose Prevention Specialists” as a title.

Man holding a single unit of Narcan naloxone nasal spray still in its packaging.
Man holding Narcan (naloxone) nasal spray.

The Background of ROPS

In late 2017, the Tennessee Department of Mental Health & Substance Abuse Services released its “TN Save a Life Program.” Ostensibly, this four-pronged program was rolled out due to the rash of opioid use and resulting opioid-related deaths that initially broke out some 10 to 15 years prior.

The TN Save a Life Program was designed to deal with fallout from the opioid epidemic and consists of the following components:

  • The so-called “Project ECHO,” a project with Vanderbilt University touting the end goal of helping clinics, hospitals, and emergency rooms beef up access to medication-assisted treatment programs, a.k.a. opioid replacement therapy, through the provision of telemedicine services.
  • The creation of “regionally-specific resource guides.”
  • The staffing of 20 “Regional Overdose Prevention Specialists” throughout 13 regions within the Volunteer State. These people hailed from a variety of backgrounds, including “recovery, paramedics, and Certified Peer Recovery Specialists,” taken directly from the DMHSAS’s website. Now, there are 21 ROPS.
  • A state-wide media campaign.

Who Do ROPS Serve?

This comes from the same website mentioned above: ROPS primarily tend to first responders, entities that provide treatment and recovery services or community-oriented resources, and people considered at risk of overdose — including their family members and friends.

These aren’t the only beneficiaries of ROPS — “all interested community members” can be trained in responding to opioid overdose with naloxone.

Regional Overdose Prevention Specialists hold training sessions across the region they’re assigned to. There are 13 regions in terms of ROPS distribution. Northwest Tennessee, a nine-county area home to 254,000 people, is labeled Region 6N.

What Do Trainings Consist of?

Just as there are three primary audiences, there are three main topics that ROPS’ training events cover:

  • Raising public awareness for facts about the opioid crisis and the trends that currently define it, how addition works, and best practices for administering naloxone.
  • Attempting to nip drug-related stigma in the bud.
  • Spreading knowledge of harm reduction, why it’s important, and defining what the practice consists of.

A Real-World Example of a Regional Overdose Prevention Specialist

Melesa Lassiter, Region 6N's Regional Overdose Prevention Specialist, running a naloxone training seminar in Humboldt, Gibson County, Tennessee.
Melesa Lassiter holding a naloxone training event in Humboldt, Tennessee, on Oct. 2, 2018.

Melesa Lassiter has served as Region 6N’s Regional Overdose Prevention Specialist since Oct. 2017. She’s part of the Weakley County Prevention Coalition (WCPC), which oversees her role as ROPS.

Although WCPC engages in prevention-based drug use efforts, thanks to Ms. Lassiter’s status as ROPS, she stands out as one of the only prevention coalition employees in Northwest Tennessee to be active in harm reduction — even though naloxone distribution is the lowest-hanging fruit on the harm reduction tree, we very well can consider it “harm reduction.”

Via a local public housing authority office, Martin Housing Authority, name-brand Narcan is made available for pickup. She also holds naloxone training events, including specialized sessions designed just for law enforcement, among other intended audiences.

By no means are these all the things ROPS engage in, though everything mentioned here collectively acts as the meat-and-potatoes of their job duties. What each individual Regional Overdose Prevention Specialist does will vary based on the organizations that oversee their duties for the state.

Ms. Lassiter, for example, may be more likely than the average ROPS to carry out prevention-based programming at local schools — such messaging is a major focus of local prevention coalitions like Weakley County Prevention Coalition.

In Full Disclosure — Do ROPS Fall Short of Their Intended Goals?

Regional Overdose Prevention Specialists, due to the town hall-style nature of their trainings, often fail to reach the most disadvantaged regular drug users (e.g., injection opioid users). This isn’t to say they completely fail to train these people or meet them where they’re at with naloxone, though. As ROPS continue to make a name for themselves across the Volunteer State, more injection opioid users, for example, will come to perceive these state-sanctioned harm reductionists as legitimate and worthwhile.

Much like anywhere, people here — especially long-term, often-problematic drug users like me — exhibit discretion in assessing new or otherwise-too-good-to-be-true opportunities. I think the average level of discretion exhibited by the most disadvantaged drug user here in Northwest Tennessee is higher than average, nationally-speaking, that is.

People can be surprisingly unwilling to open themselves up to offers of free safe drug use supplies. One time, I visited an area of West Tennessee that was populated by a relative fuckton of people experiencing homelessness to have my help refused by all but one person despite the fact I shot heroin in front of them!

Here in Northwest Tennessee, for example, the overwhelming majority of locals who’ve received syringes, naloxone, and other harm reduction supplies from me weren’t aware of ROPS when I first met them — since then, little has changed.

The most disadvantaged people who use drugs — those who are cordoned off from society — are unlikely to trust opportunities like opioid overdose response training or free naloxone because people here aren’t used to having others provide them safe drug use supplies.

To reach these objectively-worse-off, often-problematic drug users is by continuing to advocate for harm reduction and the fair treatment of drug users.

In places like rural West and Middle Tennessee, where there’s little interest in drug user advocacy, activating drug users, illicit drug retailers, and laypeople alike as grassroots harm reductionists is arguably our best tool.

In Closing

All considered, Regional Overdose Prevention Specialists are a valuable resource in improving the treatment of drug users. Although they only pluck the harm reduction tree’s lowest-hanging fruit — naloxone distribution and training — I think we’ll look back at ROPS as being pioneers of modern-day harm reduction here in the Volunteer State.