Note: Since the publication of this article, I’ve been made aware of two Syringe Services Programs in West Tennessee. Both are in Memphis — A Betor Way and the Memphis Area Prevention Coalition’s SafePoint.
Northwest Tennessee (NWTN) is home to just as many drug users as anywhere else, though not nearly as many — if any — resources that other places have. Unfortunately, however, rural Tennesseans who use drugs, especially our injection drug users — note that I’ve been an injection drug user for about three years — largely suffer from a statewide lack of resources, among other issues, that lead to things like poor quality of life, shorter life expectancies, and so on.
This article is a follow-up to “Area-Specific Challenges in Northwest Tennessee,” an article I published in mid-November 2019 on my website, Northwest Tennessee Harm Reduction.
Note that this doesn’t contain all possible or appropriate solutions to the issues I posed in the aforementioned piece — which also isn’t a comprehensive guide to the area-specific challenges that we face here, though they apply to all of rural Tennessee, if not the entirety of the Volunteer State — though it certainly does cover several major points.
I assume all readers don’t know my personal history, though you can find it over at “Who Am I?,” another page on my website. I speak from the perspective of a long-term drug user who has spent the entirety of his life in rural Tennessee. I grew up in Southern Middle Tennessee’s Hohenwald, which is very much a hole in the wall, lived in Knoxville for all of four months, and have been in Martin — that’s in Northwest Tennessee — since May 2014.
I have used drugs nearly every day since Dec. 2011. Opioids have been my drug of choice since roughly June 2014. Like so many others, I used opioid painkillers at first — though I didn’t use them for pain, only recreation at first and later as self-medication for mental health purposes — that I purchased off the street. Some 3.5 years ago, I turned to heroin as a cheaper alternative. Between 2.5 and 3 years ago, I first injected heroin. I am now on Suboxone to satisfy my opioid dependency and have been since mid-September 2019.
I’ve been active in harm reduction for anywhere from 2 to 3 years now. I do this work for free and hope to eventually become gainfully employed in this field — I’d love it if I could satisfy this aspiration while living in rural Tennessee, preferably West Tennessee or Southern Middle Tennessee, the two portions of Tennessee that I believe are currently most underserved by government agencies, non-profit organizations, and community groups that help long-term drug users.
For what it’s worth, I’m low-income and always have been. I say this not because I think it makes me special, but because I very much understand the issues my fellow long-term drug users here in Tennessee also face.
Why Just Northwest Tennessee and Southern Middle Tennessee?
I mention these areas because I’ve lived and used drugs in these areas personally. I don’t want to speak on what I don’t know.
East Tennessee is filled with programs like syringe exchanges, also called syringe services programs by the state’s Department of Health. Nashville has at least one such program. There have been talks about Memphis getting such a program, but there is not such an operation — at least not yet — to my knowledge.
Look at a map if you need to, but Northwest Tennessee (NWTN) and Southern Middle Tennessee (SMT) are farther away from large cities and other areas that already have a relatively greater support system for drug users. The entirety of West Tennessee also fits this bill, except for Memphis, found in the southwestern extreme of the state. As such, and non-Memphis West Tennessee and Southern Middle Tennessee are more “stranded” than any other regions of the state.
Again, what follows largely applies to the entirety of Tennessee.
If you live outside of NWTN or SMT, the following information still is relevant to you.
1. Improving Trust and Reducing Discretion Exercised by Underserved Persons
Discretion, for the record, includes everything people do to avoid confrontation, keep from hurting themselves, and unveiling confidential information.
People don’t trust “the system” because it’s failed to protect underserved populations for so very long. Drug users can’t be honest about their substance use with law enforcement officers in fear of catching criminal charges, going to jail, potentially losing their jobs, and being separated from their families. People of color are less likely to be able to afford healthcare, including mental health treatment, even though politicians often swear to help these people; if they are able to afford it, they’re more likely to be discriminated against by treatment providers and therefore less likely to be honest with them about whatever issues they’re currently facing.
There are countless other examples of how people don’t trust the system. Here are two more specific examples.
In my efforts to distribute syringes, naloxone kits, and other harm reduction supplies throughout Northwest Tennessee, plenty of people have thought I’m either an undercover police officer or a confidential informant. People in the national harm reduction community have thought the same. I’m not a cop, a confidential informant, or otherwise working with law enforcement — I never have been any of these, either.
People are sometimes unwilling to trust me, for example, for a few reasons. No harm reduction infrastructure exists here and what I do seems totally out of the ordinary. When people note things are unordinary or out of place, they’re trained to not trust those things out of a sense of self-preservation.
For these reasons, as well as several others, people are unlikely to trust social services workers, first responders, or law enforcement, even though these very people are often employed to protect them.
Time for another example. Meet Josh, a totally fictional resident of rural Tennessee. He works, but struggles to support his wife and child. Josh lacks reliable transportation. Due to his manual-labor job, Josh’s chronic pain is constantly acting up, causing him to source opioid painkillers from family members and friends. He also suffers from an anxiety disorder. Josh has no insurance and can’t afford to visit a doctor.
A local church offers to pay for mental health treatment on Josh’s behalf so he can seek help for his anxiety disorder. However, once he’s there, he quickly realizes he can’t be honest to the counselor or prescriber about his opioid use. Even though mental health professionals are supposed to be able to be trusted by patients, Josh can’t be honest.
If Josh could be honest, he could better receive the help he needs and stop self-medicating. He’d be less likely to turn to substance use thanks to having his anxiety disorder under control, too. This example illustrates yet another “trust” problem that’s all too common.
So, how can we improve trust and limit the barrier of discretion between drug users and the social services-criminal justice alliance in rural Tennessee?
Here’s the Solution
This is a multi-faceted problem. Due to the complexity of this solution, I’ll try to keep my explanation concise.
Part 1A — Law Enforcement and Drug Users Need to Have a Better Relationship
First, law enforcement officers need to establish trust with drug users.
Another example. In September, I was pulled over by law enforcement for speeding. Probable cause for a search was established by a K9 alerting on my vehicle, despite the fact I didn’t have drugs. Before I was searched, I informed the officer I was in possession of syringes. Despite the fact I spoke up, I was still charged with being in possession of drug paraphernalia.
T.C.A. § 40–7–124 is a law that prevents people in possession of syringes or sharp objects that have been used as drug paraphernalia from getting charged with or prosecuted for a violation of T.C.A. § 39–17–425, a.k.a. possession of drug paraphernalia, as long as the person being searched speaks up and tells the officer they’re in possession of such objects before a search is conducted.
Despite this, I was still charged with possession of drug paraphernalia. The officer obviously wasn’t aware of this law, even though it’s been around since no later than 2015.
People, particularly drug users, don’t trust law enforcement for this very reason — they’ll send your ass to jail in a heartbeat!
Here’s what I propose: law enforcement officers shouldn’t be able to charge anybody in possession of drugs or drug paraphernalia with criminal charges as long as they’re honest about it. Why? Doing so promotes bonding between the long-underserved population of drug users and law enforcement. Ultimately, this leads to things like greater long-term drug treatment outcomes and an ability to better solve crimes.
Ever heard of the whole “protect and serve” thing? Police could better protect and serve our society if drug users like me could actually trust them and be honest.
Educating law enforcement about laws such as T.C.A. § 40–7–124 would improve the relationship between drug users and police officers. A few more possible solutions include changing legislation so that honest, upfront drug users who come clean to law enforcement officers about being in possession of drugs or drug paraphernalia shouldn’t be given criminal charges, giving people who find themselves in trouble more options to seek out substance use treatment where appropriate, and getting law enforcement involved in distributing naloxone.
Part 1B — Promoting Alternatives to Criminal Punishment Used by Social Services Professionals
Second, social services-criminal justice alliance professionals should eschew traditional punishments for substance use in favor of evidence-based alternatives that improve the long-term outcomes of substance use disorder treamtent.
For example, who in their right mind would tell their probation officer they recently relapsed or otherwise used drugs? People go to jail for this stuff.
Here’s another example. Assume a couple gets arrested for child abuse. Although nobody wants parents to be using drugs, it’s unavoidable — some parents will have drug problems. The couple’s home is visited by a Department of Child Services representative who performs a test for methamphetamine residue in the home. The representative finds meth residue on a window in the parents’ bedroom, where their child is never allowed. No drug paraphernalia or drugs was accessible to the child.
This is actually a reason why parents get charged with child abuse.
These social services workers should be less willing to turn to the criminal justice system in dealing with clients’ substance use problems. There should be more government funding for committing people in the above two examples — as well as anybody else who deals with the social services system in any way, not just these two manners — to evidence-based substance use disorder treatment.
One last example. Opioids have been my primary drug of choice for nearly 6 years now. I turned to heroin in mid-2016, which is much more dangerous than pharmaceutical opioids due to its unregulated nature. Heroin users don’t know what their batches contain or, even if they did, the amount of heroin, fentanyl, or other drugs they contain. This makes it very easy to overdose from heroin — this ideology also spills over to counterfeit opioid tablets, which are already common all over the country. They usually contain fentanyl, a highly-potent opioid that has little threshold between the amount required to (A) make users feel high and satisfy their withdrawal symptoms and (B) cause overdose.
Cannabis has been shown to be a powerful tool in promoting long-term treatment outcomes in people like me, long-term sufferers of opioid use disorder. Although cannabis can certainly be misused, it’s silly that probation officers widely violate probationees for testing positive for cannabis, particularly where cannabis use helps people stay clean from other drugs that are typically more dangerous than cannabis, such as opioids.
Part 1C — Healthcare Providers Should Be More Accepting of Drug Use
Healthcare providers shouldn’t be forced to fire patients who test positive for drugs of abuse or otherwise admit to using illicit or unprescribed drugs.
For example, let’s say I relapse on illicit opioids. If I tell my buprenorphine prescriber that I’ve relapsed, he’s likely to fire me from the program. That leaves me without a legitimate source of Suboxone, a drug that’s helping me avoid using heroin; quite literally, I face death every time I use heroin. Although we’d like opioid users in these situations to refrain from relapsing, is it really a good idea to have such a low-tolerance view toward accepting recovering patients’ slip-ups?
I should note that, while the prescriber has some discretion in choosing whether he fires me or not, the state outlines rigid guidelines for buprenorphine prescribers in Tennessee that prevents them from keeping patients who’ve relapsed too many times.
Another example. Simone is prescribed a controlled substance (e.g. Xanax, Norco, Percocet, gabapentin) from a physician. The physician is required to provide drug screens on at least a quarterly basis, if not every month.
Physicians face serious scrutiny from regulators if they don’t fire people like Simone if they test positive for illegal drugs like meth, cocaine, cannabis, or other drugs that aren’t prescribed to them.
Let’s say Simone is prescribed Percocet for a serious, debilitating spine injury. She tests positive for cannabis according to a urine drug screen performed by her prescriber. Simone is now refused a prescription by the physician.
Every physician is different. Some allow a few slip-ups from such patients, while others have no-tolerance policies.
One thing’s for sure, however — prescribers shouldn’t be forced to stop rendering services to patients who slip up like Simone did. This is especially true with cannabis, an effective pain reliever that’s already been legalized for at least medical use by more than 30 states.
Part 1D — Doing Things That Help Drug Users
This might seem obvious, but it’s the most important thing that can be done to address regional area-specific challenges—actually doing things that help drug users.
These things can be carried out by non-profit organizations, government agencies, groups of like-minded people, or even individuals.
Here’s a quick anecdote: I pick up litter around Martin regularly, and I’ve done so in a few other local communities. In the past month, for example, I’ve picked up 3 syringes and had one other person in my neighborhood tell me they found a syringe littered near their home. In total, I’ve found syringes on 5 occasions on my own; with that other person’s report, that makes 6 total instances of used syringes being improperly discarded in my immediate vicinity.
I’ve talked to a few neighbors about this and the reaction is always the same — surprise; concern.
I always tell them that injection drug users are incentivized to throw used syringes on the ground because of law enforcement or not wanting family members, friends, or coworkers to know that they inject drugs. I follow this by telling them that injection drug users, such as myself, don’t have anywhere to dispose of used syringes around here.
This holds true for the entirety of West Tennessee outside of Shelby County, in the far southwestern extreme of the state, that is, as the Shelby County Health Department offers syringe disposal services for a small fee.
Even in cities that have such programs, injection drug users still improperly dispose of used syringes.
- We need gas stations to start putting sharps containers in their bathrooms. Doing this won’t welcome injection drug users to start shooting up there freely — we’re already using public bathrooms to do this! At least help us and everybody else on this planet, not to mention animals, stay safe by buying a sharps container for a few dollars and placing it in public bathrooms. This holds true for all other facilities that welcome the public: Walmart, other grocery stores, Family Dollar, Dollar General, restaurants, and so on.
- Health departments and/or non-profit organizations and government agencies need to begin offering services that syringe services programs do, such as collecting others’ used syringes, referring drug users to evidence-based substance use disorder treatment providers, and distributing supplies that keep drug users safe (e.g. fresh syringes, clean tooters, alcohol swabs, tourniquets).
- Lifting federal regulations on buprenorphine prescribing. Like I’ve talked about in “Suboxone Is Too Hard to Get,” SAMHSA, the Substance Abuse and Mental Health Services Administration, a federal government agency, only allows physicians who specialize in addiction medicine, undergo specialized training, and pay hefty licensure fees to prescribe buprenorphine (Suboxone, Subutex) as an opioid replacement. Thanks to this legislation, the nine-county region that is Northwest Tennessee, home to some 254,000 people, only has 19 buprenorphine prescribers — and a whopping 2 methadone clinics, each of which is located at the westernmost and easternmost ends of Northwest Tennessee in hella inconvenient form.
- Requiring pharmacies to sell syringes to adults. Although I’m not a fan of authoritative governments and excessive market regulation, pharmacies throughout Tennessee, especially rural Tennessee, widely refuse to sell syringes to customers without insulin prescriptions. This encourages injection drug users like me to purchase syringes off the black market at best and share used syringes at worst. Revoking pharmacists’ ability to exercise discretion in choosing who they sell syringes to would increase access to clean syringes throughout all of Tennessee, especially chronically-underserved areas like Northwest Tennessee.
The more we do these things, the more likely people, particulary underserved drug users, will trust “the system.”
2. Educating Drug Users About Harm Reduction
I can’t speak for the entire drug-using population of Tennessee when I say this. However, here in Northwest Tennessee, drug users aren’t aware of things like the existence of naloxone (Narcan), where to find clean syringes in a legal manner, how to properly respond to opioid overdoses, or the recent state laws designed to protect drug users.
I’m dead-ass serious when I say that most drug users I’ve come across don’t know what naloxone is.
Even daily injection opioid users, who really, really, so very badly need naloxone largely don’t know what naloxone is. It’s not like they just don’t know where to get it; they don’t even know about it in the first place!
Here’s the Solution
Part 2 — Educate Drug Users, in Particular, About Harm Reduction
Like I mentioned earlier, even though the state has hired 20 Regional Overdose Prevention Specialists to promote harm reduction, reduce stigma, and boost public awareness of things like naloxone administration and how addiction actually works — these are the three things the state’s Department of Mental Health & Substance Abuse Services claims to do via its ROPS — they largely fail to reach people who actually are at risk of opioid overdose and other drug users.
This isn’t an empirical fact. Rather, it’s just my experience. Remember how I talked about people aren’t willing to trust “the system,” let alone people?
We need to do a better job of educating drug users, especially those who are most at risk of serious injury or death stemming from drug use (i.e. homeless populations, people of color, low-income individuals, those with lengthy criminal histories) about harm reduction.
Yes, both society and the greater cause of advancing harm reduction and improving the lives of people suffering from substance use disorder benefit from educating the general public about harm reduction.
However, long-term injection drug users and other underserved, problem drug users are harder to reach than run-of-the-mill drug users. After all, the majority of people are drug users, which includes cannabis, alcohol, and tobacco.
- We need to reach these people and tell them about naloxone and how to use it, as well as provide them with Narcan or generic naloxone kits.
- Educate them about how to properly inject drugs.
- Inform people like me about what blood-borne diseases (e.g. HIV, Hepatitis C[HCV]) are and how they spread. Make clear how diseases can spread through sharing paraphernalia such as syringes or tooters. Provide safe, feasible options for drug users to stay safe while using drugs without having to incur additional costs or losing any of their drugs in the process.
- Tell drug users why they should care about harm reduction. Getting end-users of drugs to adopt harm-reduction-related ideologies is the single most effective way to get them to practice it.
- Most importantly, we need to know where to obtain harm reduction supplies. This includes the mail-based national distribution organization NEXT Distro, based in New York, diabetes and medical supply websites that sell things like syringes without prescriptions at low costs, and potential in-state distributors such as syringe services programs — if and when they’re implemented in currently-underserved areas like NWTN or SMT.
Despite the fact I only labeled the above solutions as Part 1 and Part 2, there are actually five main solutions for addressing the area-specific challenges that drug users face here in Northwest Tennessee — remember, these solutions largely hold true for the entirety of the Volunteer State.
If you couldn’t be bothered to read the body of this article, that’s okay! Here’s a summary of the five solutions I proposed above.
These five solutions are summarized below, with the first paragraph representing Part 1A, the second paragraph representing Part 1B, and so on. The fifth paragraph represents Part 2.
Drug users and law enforcement need to have a better relationship. Law enforcement is directly responsible for improving this relationship. Benefits include officers having access to more information because more community members would be willing to proffer leads or direct evidence and improving long-term substance use disorder treatment outcomes.
Social services-criminal justice alliance professionals include probation and parole officers, judges, child custody social workers, and sheriffs, among others. These people are often keen on turning directly to traditional punishments (i.e. incarceration, strict drug court program enrollment) in dealing with substance use disorder. Members of the social services-criminal justice alliance should adopt other, more humane, evidence-based means of addressing substance use problems, including criminal charges that result from drunken behavior and parolees simply failing drug tests for illicit (or legal, in some cases) drugs.
Healthcare providers, whether because of personal preference, employer requirements, laws, or regulatory scrutiny, are too keen on discontinuing treatment as the result of patients’ unprescribed use of illicit (and sometimes legal) drugs. This even extends to treating long-term, dependent opioid users with buprenorphine, such as here in Tennessee, where prescribers aren’t allowed to tolerate many relapses and are forced to fire patients, leaving them without a legal source of reliable pharmaceutical opioids. Prescribers should ultimately be more accepting of patients’ consumption of unprescribed and/or illicit substances, ranging from primary care physicians, to mental health practitioners, to addiction medicine specialists.
It sounds silly, but we need to actually start rendering services that reduce harm to drug users, repealing existing legislation that works against the best interest of people suffering from substance use disorder, enacting new legislation that favors these persons’ lifelong treatment outcomes, and so on. This includes things like retail businesses adopting the use of sharps containers in their bathrooms, removing SAMHSA’s strict red tape around buprenorphine prescribing for opioid use disorder, and having non-profit organizations and/or health departments render services to local communities such as collecting used syringes, distributing clean ones at no cost, and referring problem drug users who seek help to evidence-based treatment providers.
Lastly, we should educate end-users of drugs about harm reduction. Simply educating the public about it isn’t enough. Despite the efforts of Regional Overdose Prevention Specialists in Tennessee, people paid by the state to distribute naloxone and reduce drug-related stigma, people who are most affected by drug use such as me are largely glossed over by the efforts of ROPS. ROPS fail to reach drug users themselves due to the population’s lack of trust in social support systems and their use of discretion. We need to develop and carry out new approaches to educating these people about harm reduction.
Putting It All Together
Yeah, this article is pretty long. There’s a lot of information to take in. I can hardly digest YouTube videos that are just a few minutes long, let alone articles that are 4,000-plus words long, like this one — hell, I usually can’t be bothered to read them in the first place, am I right?
And, again, this is by no means a complete aggregation of all the solutions to addressing Northwest Tennessee’s area-specific challenges.
There is no single way to address these area-specific challenges. To effectively, speedily integrate harm reduction — and not just grabbing the low-hanging fruit that is distributing naloxone — into Tennessean society, we need to explore all five of these avenues at minimum.
So, what can you take away from this?
We need drug users and law enforcement to get along. We need to develop and regularly use alternatives to criminal punishment to address problem drug use. Healthcare providers need to be more lenient in dealing with substance use. We need to actually do things that help drug users, like implement places for injection drug users to dispose of syringes without the threat of being slapped with criminal charges. Lastly, drug users, particularly those who are most damaged by how we currently deal with drugs as a society, need to be educated about harm reduction.
Also, existing members of the harm reduction community need to be active in laying down harm-reduction-related infrastructure in barren places like Northwest Tennessee. We’re not being helped by hardly anybody who knows what they’re doing!
Why haven’t people who get paid to do this — unlike me, unfortunately — in well-established areas such as California or New York focused their efforts on places like Northwest Tennessee or Southern Middle Tennessee?
I don’t know. But I sure hope this changes.
Even if I never get paid to do this for a living, even if I never have a part in implementing harm reduction on a large scale here in Tennessee, I sure hope some group, some organization, some government agency, or somebody makes change here and makes change quickly.