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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.

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Understanding Syringe Access in Rural Middle and West Tennessee

West Tennessee, a 21-county area home to roughly 1.56 million people over 10,650 squre miles, is home to two Syringe Services Programs (SSP). In comparison, Middle Tennessee is home to 41 counties, 2.68 million people, 17,009 square miles, and a lone SSP; East Tennessee, home to the most SSPs of any single Grand Division (3), holds 13,558 square miles with 2.4 million people.*

Outside of these two SSPs, which happen to be in the far southwestern extreme of West Tennessee, there’s essentially nothing good for drug users in terms of treatment programs, syringe access, or softer drug policies. I live about 125 miles from Memphis and 145 miles from Nashville — both are roughly two-and-a-half hour drives. No matter where you are in Northwest Tennessee, you’re at least, give or take a few minutes, an hour-and-a-half’s drive from your starting location to Memphis or Nashville.

It’s like this — if you aren’t already in Nashville or Memphis, you’re probably not participating in any of Tennessee’s recognized Syringe Services Programs. Even people inside those cities sometimes find it difficult to visit the physical locations where services are provided to participants; in other words, both Nashville and Memphis are all but havens for syringe access.

Here’s One Resource We Do Have — But It Sure Ain’t Syringe Access

The Tennessee Department of Health established the role of Regional Overdose Prevention Specialist in Oct. 2017. Currently, there are 21 Regional Overdose Prevention Specialists (ROPS) across 13 districts. ROPS are hold town hall-style naloxone trainings and distribute the lifesaving drug for free. According to the Volunteer State, ROPS primarily target three audiences:

  • First responders.
  • Entities that provide community-based resources, addiction recovery services, or treatment.
  • People who’re most likely to experience overdose, including their friends and family members.
Multi-color map of Tennessee broken down into counties. Each color represents one of 13 areas that the Tennessee Department of Health's Regional Overdose Prevention Specialists (ROPS) are assigned to.
Districts assigned to the state’s 21 ROPS. I’m in Region 6N.

From what I understand, a significant portion of attendees tend to attend ROPS training events to satisfy continuing education requirements. None of the 35 to 75 people I’ve given syringes, naloxone, and other harm reduction supplies to in my time as a practicing harm reductionist — virtually all of whom were long-term, often-problematic drug users; in other words, the most generally-disadvantaged drug users — have been familiar with Regional Overdose Prevention Specialists.

I’ve talked to some ROPS, all of whom admitted that they largely failed to reach regular often-illicit opioid users who are at high risk of overdose, as well as people who they’re close with. Yes, they inevitably reach some people at risk of experiencing opioid overdose, but not nearly enough.

Do Pharmacies Play a Role in Syringe Access?

In rural Middle and West Tennessee, if not elsewhere in the Volunteer State, injection drug users like me primarily get their syringes in black-market fashion. Pharmacies are given legal discretion to sell syringes without prescriptions, even if they feel that the sharps they sell will be used for injecting illicit drugs.

However, in actuality, very few pharmacists sell syringes without prescriptions. The relatively few active injection drug users who’ve tried buying syringes from pharmacies aren’t likely to keep asking pharmacists to sell them syringes; rather, it often feels like pharmacists are sworn enemies of people who use drugs.

I’ve heard that pharmacists in bigger cities are more willing to dispense syringes without prescriptions, though I don’t know this from experience.

Either way, it’s safe to say that pharmacies don’t play a role in expanding syringe access. Thanks to most local pharmacists’ unwillingness to provide injection drug users access to clean syringes, they actually do a good job of keeping disease transmission, likelihood to continue injecting drugs, and likelihood to not seek out drug treatment high.

But Seriously — What Resources for Drug Users Are Here?

We’ve got outdated, non-evidence-based drug rehabs, often-exclusionary 12-step programs, probation and parole, and drug courts, as well as medication-assisted treatment programs — though there’s just 19 physicians prescribing buprenorphine for opioid use disorder and two methadone clinics in Northwest Tennessee, a nine-county area that’s home to 254,000 people.

Outside of that, we’ve got absolutely nothing for drug users like me.

More About Sharps on the Black Market

As I’ve already mentioned, most sharps that local injection drug users source are from the black market. What does the “black market” for syringes consist of, exactly? The more popular sources of sharps are:

  • Fellow drug users, typically taking the form of injection drug users.
  • Illicit drug dealers.
  • Most importantly, family members who have prescriptions for syringes.

Drug Users Benefit From Performing Services for Fellow Drug Users

Due to drug laws, participants in illicit drug markets often face scarcity. Since a local market’s illicit drug vendors can’t openly offer their services, few end-users in any given area are familiar with all the dealers worth their salt there — buyers have a seller-finding problem.

Sometimes, end-users rely on fellow end-users to act as middlemen. End-users aren’t likely to give up their connections for two reasons: (1) dealers may not be comfortable with taking on new clients and (2) leveraging a relatively valuable connection by prospective middlemen. The nature of the black market makes opportunities scarce — that’s what ultimately makes these connections with dealers not always easy to come by and, therefore, valuable.

Family members seem more trustworthy than other sources of syringes. However, due to the nature of the black market, you can’t ever be sure family-sourced sharps have never been used. Still, I’d feel safer trusting a family source than a fellow user or dealer.

One time, I drove a well-connected fellow drug user to source drugs. She wouldn’t have been able to get there otherwise. Even though I regularly give her harm reduction supplies (e.g., syringes, naloxone, tourniquets) and she knew she would have still secured my transportation, whether she’s got a clean syringe to spare or not.

I understand she was incentivized and may have felt pressured to procure a syringe for me. What if I were less likely to turn to her as a middleman in the future as a result of her not giving me a clean syringe?

I’d asked her for a syringe upon getting the drugs, to which she obliged. Just before injecting, I found the barrel to contain a little bit of what looked like water.

Syringes never have liquid in them unless they’ve been used. At least never in my experience as a regular injection drug user.

Fortunately, because I’ve secured syringes and company from a free, mail-based harm reduction supply distributor for a year-and-a-half or two years now, I’ve never needed to hit the black market for sharps. I can only imagine how much more risk I could’ve faced without my long-time, super-safe supply source.

Dealers Aren’t Likely to Offer Syringes to Buyers

Now, I don’t know what things are like where you are, but dealers offering syringes, naloxone, and other drug-using supplies isn’t a thing here.

While I’ve provided two low-level dealers with syringes, naloxone, and company, they didn’t start a market trend where competitors felt forced to offer these same supplies.

If syringe access was better here, I feel like dealers here would more likely stock syringes for sale or as complements to the illicit drugs they sell.

It should go without saying, but dealers would be more likely to stock harm reduction supplies if we had better harm reduction infrastructure here.

The best shot we, as advocates of drug users, have at implementing this infrastructure is to become active in doing things that effectively promote harm reduction-positive ideas in a grassroots, self-motivated, lone-wolf manner.

Understanding Syringe Laws in Tennessee

Tennessee Code Annotated § 40-7-124 grants immunity to people who inform police they’re in possession of syringes or sharp objects that could be considered drug paraphernalia (a violation of T.C.A. § 39-17-425) from getting charged with or prosecuted for Possession of Drug Paraphernalia for those syringes or sharp objects.

Despite the fact this law came into being in 2015, it’s alarming that many law enforcement officers aren’t aware of the law. I’m sure many agencies across the Volunteer State do a great job of educating their members.

However, if law enforcement agencies here were on top of things, I wouldn’t have been arrested for Possession of Drug Paraphernalia for syringes despite the protection afforded to me by T.C.A. § 40-7-124, which I’ve seen nicknamed as the “Needle Possession Officer Awareness” law. What’s worse is that the syringes, albeit used, didn’t test positive for drug residue. I also didn’t admit to using them for illicit drugs. From what I understand, the syringes shouldn’t have been construed as drug paraphernalia based on T.C.A. § 39-17-425.

I’m not an attorney, but I’m intimately familiar with these two laws pretty well — I’d hope anybody else who’s been charged with and prosecuted for Possession of Drug Paraphernalia three times would be, too.

Lastly, I know many officers aren’t familiar with differentiating low-gauge, intramuscular-use syringes from their high-gauge counterparts that are common among injection drug users.

The former, usually ranging from 21 to 25 gauge, is included in naloxone kits.

Again, even though syringes themselves not used for illegal drugs aren’t illegal, people found in possession of naloxone kits containing IM-use syringes are liable to face unfair treatment from law enforcement, including ultimately getting charged with Possession of Drug Paraphernalia even though such a charge would be unfounded.

A local resident who I’ve given naloxone kits told me he’d been pulled over with at least one naloxone kit in his vehicle’s glovebox.

He told me the police asked to search his vehicle. In doing so, they found the naloxone kit and scrutinized him for the (albeit clean, unused) syringe it contained.

While it’s certainly possible to fight unfounded criminal charges in court, many residents of the Volunteer State, especially people living in rural areas and who are particularly-disadvantaged drug users, are unable to post bail or afford private legal representation.

They often prematurely, unnecessarily plead guilty to charges they’ve been accused of, even if defendants are confident they don’t deserve some or all of them.

I’ve been in that same situation. At the time of arrest, I was already on probation and arraigned 6 days out from my next scheduled report date. In court, I was told it’d take at least two weeks to be appointed a public defender and get back in court. Unable to post bail or hire a private attorney, I was forced to plead guilty — if I waited in jail, I could still end up getting charged, resulting in two potential violations since I wouldn’t have showed up on time; if I pled guilty, I could get violated because I caught a criminal charge, the cardinal sin of any probationary agreements.

What Can We Do for Syringe Access in Tennessee?

Tough question.

You can source clean syringes, naloxone, and other harm reduction supplies, then distribute them to illicit drug dealers and injection drug users.

You can try to inform in-state pharmacists of the benefits of selling syringes without prescriptions to suspected or potential injection drug users.

You can tell others about the state of syringe access in Tennessee and encourage them to support safe syringe disposal sites, syringe services programs, and the like.

I’m sure there are other ways you can advocate for improved syringe access in the Volunteer State, but I’m drawing blank. Whether you get engaged in syringe access advocacy or not, at least you’re now better informed about syringe access in rural Tennessee.

*Note that, since no official Tennessee Department of Health information regarding the number or location of Syringe Services Programs, there’s no way to be entirely sure of how many SSPs are up and running right now.

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Where Drug Users’ Unions May Fall Short

People who use drugs, especially their often-problematic counterparts, are given a bad name. Here in the United States, a campaign against drugs and drug users alike has been going strong for some 100 years — if not longer.

Drawing of five wadded fists held in the air. Two fists are red and three are black held together in a show of solidarity for drug user rights.
The Icarus Project NYC

We’ve been painted as — especially non-White and otherwise-disadvantaged people — “dirty junkies” by much of society for quite some time. Not very cash money, is it? This veil of being inherently bad — stigma, in other words — has directly made drug-related problems worse; because of it, we fail to deal with them effectively: criminalizing drug use or policing drug-related activity in general just doesn’t work.

On the other hand, drug users often give themselves a bad name — admittedly, I’ve made people who use drugs look bad countess times over my decade-long, ongoing career as a regular drug user. I still make us look bad today at times, even though I try to use responsibly — a relatively new development in my decade-long drug-using career.

Overall, the net positive done by modern drug user unions is unarguably beneficial to drug users as a whole, both current and future.

That’s What Drug Users’ Unions Are For

Drug user unions (DUU) — or “drug users’ unions,” since they’re both for and by drug users — can make themselves and, by extension, drug users look bad by inappropriately and excessively exposing such problem drug use to the public or by not being well-organized. For example, I looked at one well-known union that was reviewed by multiple people as bad because, at a protest or other public event, members couldn’t tell others what they were lobbying for or why.

I can’t say this without recognizing that DUUs can certainly imprint material, lasting outcomes in the arenas or spaces they’re advocating for fair drug user treatment in — and that’s something they often do.

Overall, the net positive done by modern drug user unions is unarguably beneficial to drug users as a whole, both current and future.

Being Badly Organized Hurts

If you look online for drug user union reviews, you’ll find reports of DUU members as being unable to tell others what, exactly, they were advocating for or why.

Although the idea that drug users should be given equal social footing is reasonable to understand, people are less likely to support drug users’ rights if members at protests or other public showings fail to sufficiently explain their purpose or reasoning.

Outsiders may feel that drug user union members, especially those who struggle to articulate solid reasoning in explaining themselves, simply want drugs to be legalized so they can use without repercussion.

We need to best appeal to opponents of drug users’ rights. How can we do that — by handing them shining examples of drug users living up to the “junkie” stereotype on a silver platter?

The vast majority of all drug consumers don’t often, if ever, exhibit problematic drug use. Very few of us fit the bill of “long-term, often-problematic drug users,” a term I use to describe myself.

Although we harm reductionists know this to be true and use this talking point — that few drug users actually experience serious negative consequences as a result of their drug use — in advocating for our cause, we can’t afford to run the risk of being perceived this way (read: perceived).

To best represent ourselves, I feel like we may benefit from putting our most-prepared, least-likely-to-make-drug-users-look-bad members on the front lines; in other words, every time drug user unions potentially show themselves to the public, they should be careful to avoid revealing anything that could reflect on harm reduction or its practitioners negatively.

Are Drug User Unions Worth Their Salt?

Again, drug user unions positively contribute to our shared cause of promoting equal treatment of people who use drugs, especially their often-problematic counterparts.

So, yes, drug user unions are most definitely worth their weight in salt.

However, we stand to lose footing or hold back our full potential in advancing harm reduction when drug user unions are poorly organized and their operations aren’t well-planned. I feel like we often don’t consider the public relations aspect of drug user advocacy.

While the “model minority” is a load of bullshit, I’m certain that showcasing active drug users in a way that doesn’t make us look bad is a reasonable, practically-minded suggestion.

Drugs cause us to feel different, lose inhibition, and impair our motor skills. When combined with long-unmet needs, which often serve as the basis for addiction, drug use can decay into problematic drug use that reflects poorly on all of us.

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“People Who Use Drugs”—Slow Your Roll on Person-First Language Like This

In recent years, harm reductionists have pushed to call drug users “people who use drugs” as opposed to “drug abusers,” “substance abusers,” or “drug addicts,” among other labels that hold considerable negative connotations. “People who use drugs,” or PWUD for short, is an example of person-first language, a self-explanatory convention that places people before things — things often viewed as holding people back, such as being physically disabled or having schizophrenia.

I worry that the use of “PWUD” among harm reductionists is excessive and paradoxically detrimental to our shared cause of helping people who use drugs. “People who use drugs” is often associated with political correctness and used in place of other, better-suited phrases like “drug user.”

And, Yes, I Do Have Skin in the Game

I like to call myself a “long-term, often-problematic drug user.” Having used drugs nearly every day for ten years, I’ve been kicked out of college and arrested thrice for my drug use, not to mention guilty of otherwise fitting the bill of the “junkie” or “druggie” stereotype countless times.

I also grew up around a super-problematic drug user of a mother for nine-plus years. She’s been arrested in front of all my middle school classmates for DUI, put me around generally-bad people — just a bunch of bullshit kids shouldn’t have to deal with.

Being Overly Politically Correct Hurts Us

Here in rural Tennessee, people are especially averse to anything that’s been singed by superfluous political correctness. This isn’t geographically specific, though — aversion to political correctness is common among nearly all largely-right-leaning people regardless of location. I should mention that even some left-leaning people aren’t fans of PC, either.

Largely-right-leaning politicians and stakeholders across Tennessee, for example, have supported prevention coalitions, often-exclusionary 12-step programs, and outdated, non-evidence-based rehabs. Yeah, they help some, but they fall short.

How can we best break through to those who are most likely averse to harm reduction? I don’t have the answer, unfortunately. However, one thing I do know is that we should avoid doing anything that can be viewed as overly and unnecessarily politically correct.

What is being overly politically correct, at least as far as drugs or drug users are concerned? I think avoiding “drug abuse,” “substance abuse,” and “addict” — at least when used excessively or as the first option to define what I like to call a “long-term, often-problematic drug user” or their behavior — isn’t overly politically correct; on the other hand, I think exclusively using the identifier “people/person who use/uses drugs” and never using other terms to refer to drug users, for example, could be seen as excessive and unnecessary.

It’s Not About the Number of Words

Choosing “drug user” over “person who uses drugs” isn’t at all about word count. It’s not that I can’t be bothered to type two extra words. This reasoning is nothing short of silly.

It’s about distancing ourselves from things potentially viewed as overly politically correct.

Let’s face it — “person who uses drugs” or, for example, “person experiencing homelessness who uses drugs” are clunky phrases. I’ve noticed that some harm reductionists never refer to drug users as just that — drug users. This leaves their writing and rhetoric prone to being clunky, difficult to read, and lacking good flow.

I prefer “drug user” — remember, I’m both a long-term and active drug user, so I very much have skin in the game — over PWUD, but I understand most harm reductionists want to avoid “drug user.” For those who prefer to use PWUD, please try to use at least a 25-75 blend of “drug user” to PWUD (“at least a 25-75 blend” means a 26-74 blend or better). I think “drug user” is the next-best option after PWUD in terms of identifiers that hold relatively few negative connotations.

For the record, I think — strictly from a literary, grammatical standpoint — that “drug user” is generally superior to “people/person who use/uses drugs.”

Associating Other Social Equity Efforts or Otherwise-Left-Leaning Ideas With Helping Drug Users

Many people who consider themselves harm reductionists view “harm reduction” as equal parts:

  • Helping drug users.
  • Advancing not-necessarily-drug-user-related social equity efforts (e.g., pro-LGBT, pro-sex worker causes).

Back when harm reduction was first applied on a major scale in the mid-1980s — which focused on the reduction of HIV transmission, which happened to be particularly likely among gay men who injected drugs — practitioners were forced to address the intersectionality between gay men, injection drug users, and HIV transmission. Based on its background, it makes sense that many harm reductionists view “harm reduction” as one-half helping drug users and one-half advancing auxiliary social equity efforts.

Also, considering the fact — although I have no hard evidence to support this, you’d be hard-pressed to argue otherwise — that most harm reductionists are largely-left-leaning people, it’s easy to understand why so many harm reduction supporters are also supporters of social justice interests in general.

Here’s my issue with associating (1) helping drug users with (2) social equity efforts or other largely-left-leaning ideas that aren’t directly related to drug use: Doing so detracts from our shared goal of helping people who use drugs.

First off, in rural Tennessee, most residents are averse to things like pro-LGBT or pro-sex worker efforts. Whether we actively promote these agendas in our harm reduction-related programming or simply mix our pro-drug sentiments with pro-LGBT or pro-sex worker ideas on social media for others to see, I think we make it less likely for Tennesseans to hop on board the SS Let’s Help Drug Users. They’ll be less willing to adopt harm reduction-positive ideas and, even if they do adopt such views, they’re less likely to become active, across-the-board supporters.

Second, according to the Harm Reduction Coalition’s (HRC) and the Drug Policy Alliance’s (DPA) definitions of harm reduction, helping drug users comes first. The DPA is equally dedicated to fighting “racialized drug policies,” which helps drug users at large — for example, even though I’m White, since I’m poor, I can’t afford to bail out of jail once arrested or hire a private attorney, both of which makes me more likely to unnecessarily plead guilty to charges and otherwise not defend myself like others who can afford to post bail following arrest or secure private legal representation.

Combating race-driven drug laws is undeniably directly related to helping drug users. Pro-LGBT efforts, for example, aren’t directly related to helping drug users. I recognize that, for example, we may need to adopt different strategies to help transgender people who use drugs, though modifying our approaches to help drug userstransgender drug users are, of course, part of the greater drug-using community — falls short of fully-fledged pro-LGBT efforts. The same holds true for pro-sex worker efforts, as drug use and sex work can very well overlap — and often do; however, advocating for sex workers in non-drug-related capacities should not be considered “harm reduction” because doing so doesn’t directly help drug users like me.

For the record, I’m bisexual and was an online-based sex worker for about four years. I reference pro-LGBT and pro-sex worker efforts here because I have skin in these proverbial games.

If I Wasn’t Already Clear

According to the HRC’s and DPA’s definitions of “harm reduction,” helping drug users is the primary objective of harm reduction. And, of course, this article is discussing harm reduction as it directly relates to drugs — not anything else, such as sex work.

Helping drug users, at least per what two of the world’s leading harm reduction-related organizations think — the Harm Reduction Coalition and the Drug Policy Alliance, if you don’t remember — should be the number-one goal of harm reductionists. If this isn’t your goal, what you’re doing might not be best defined as “harm reduction.”

What do we do as harm reductionists? Things that are directly related to helping people who use drugs. We should avoid doing things that hurt drug users.

In places like rural Tennessee, where I live, people aren’t big on anything that’s pro-LGBT or pro-sex worker in nature. Also, residents of the Volunteer State aren’t already hip to harm reduction; obviously, they don’t support harm reduction-positive ideas, as they’re not even familiar with them.

How can we best appeal to the average Tennessean as harm reductionists? I think associating harm reduction with auxiliary social justice efforts or other largely-left-leaning sentiments can materially slow and geld our goal of helping drug users.

How Social Media Use Potentially Turns Off Newbies

Harm reduction is currently most supported by largely-left-leaning people, at least here in the modern United States. Largely-left-leaning people are almost always responsible for what’s considered by some to be “excessive political correctness.” Again, most Tennesseans aren’t fond of anything even remotely considered excessively or unnecessarily politically correct.

I was introduced to harm reduction online — specifically, on Reddit’s r/Opiates subreddit. In places without harm reduction infrastructure like rural Tennessee, most people who find interest in harm reduction will continue to be introduced to the idea via the World Wide Web.

How will largely-right-leaning or otherwise-not-largely-left-leaning people who haven’t yet been exposed to harm reduction welcome the idea of helping drug users — “harm reduction,” in other words — react upon being initially exposed to harm reduction when referenced in a way that’s seen as excessively politically correct?

Probably not well, at least not as well as if that exposure weren’t influenced by political correctness.

What Am I Getting At?

I worry that some potential supporters of harm reduction-positive ideas, efforts, and programs — even harm reduction resources, such as educational brochures — may be turned off by what they perceive as unnecessary, excessive, inappropriate political correctness.

Using “people who use drugs,” again, isn’t being politically correct, I don’t think; however, outright refusing to use terms like “drug user,” “addict,” or “drug abuse” — even though I think “drug abuse” shouldn’t be used outside of referring to excessive consumption of psychoactive drugs that unarguably constitutes “abuse” — may be considered overtly politically correct.

Associating harm reduction with things that are considered overly politically correct could inhibit adoption of harm reduction-positive ideas.

Does this serve as a well-defined, go-to guide for how not to be viewed as excessively politically correct? Hell no.

I think it’s most appropriate for each of us, as harm reductionists, to exercise discretion in doing things that may earn us an unwanted reputation.

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How Current Tennessee Laws Affect Drug Users

Without laws, uncivil action would permeate society. Laws are essential to maintaining order. Few of us would be willing to live somewhere that doesn’t have laws or an active law enforcement presence. 

Worn wooden gavel resting on a wood surface.
Wesley Tingey

Unfortunately, across the United States, existing laws unfairly treat people who use drugs. This is especially true in Tennessee — take syringe laws in Tennessee, for example. Further, law enforcement might not enforce more recent laws that treat people who use drugs more favorably. 

Here are several ways that Tennessee laws and law enforcement officers hurt Tennesseans who use drugs

Some Officers Just Aren’t Up to Speed

Here in Tennessee, we have a law known as T.C.A. § 40-7-124. It was codified — or written into law, in other words — in 2015. For pronunciation’s sake, that’s Tennessee Code Annotated, Title 40, Chapter 7, Section 124. 

The law doesn’t have an official nickname, though you may find it referred to as “Needle Possession Officer Awareness” — for ease of understanding, we’ll refer to it as the Needle Possession Officer Awareness law. 

Put simply, if someone gets apprehended by law enforcement and informs officers that they’re in possession of syringes or sharp objects before they’re searched, they can’t be charged with possession of drug paraphernalia, a violation of T.C.A. § 39-17-425, a Class A misdemeanor punishable by as much as one year in jail and $2,500 in fines.

This is one of the most common criminal charges Tennesseans receive — possession of drug paraphernalia, a violation of T.C.A. § 39-17-425. Law enforcement officers (LEO) are informed of these laws, as well as what constitutes evidence to actually charge people with criminal violations.

LEO are always on the lookout for syringes and sharp objects, as needlestick injuries can potentially lead to the transmission of blood-borne diseases like HIV or HCV (hepatitis C). 

People who inject drugs in Tennessee know all too well that being found in possession of syringes can land them in jail. As such, they’re incentivized to keep quiet about being in possession of syringes. Why, after all, would someone tell on themselves, potentially landing themselves in jail, on probation, or with expensive fines to pay?

This is a problem that LEO routinely face. 

This is the reason why the Needle Possession Officer Awareness law was written into state law by legislators in 2015. Their number one goal was to protect the police officers, deputies, and other LEO who protect civilians from criminals and maintain civility throughout Tennessee. 

Personally, I’ve been arrested for possessing drug paraphernalia, specifically syringes, even though T.C.A. § 40-7-124, the Needle Possession Officer Awareness law, should have protected me. I informed the deputy that pulled me over that I had syringes in my vehicle before I got searched and everything. Despite this, I got sent to jail for a night and had my vehicle impounded. Unable to afford bail or an attorney, I was forced to plead guilty, which resulted in me being put on probation, more commonly known as “11/29.” The probation costs are something like $700. The impound fee was about $250. I also put my loved ones through stress they didn’t deserve as a result.

Are all law enforcement officers here in Tennessee unaware of the Needle Possession Officer Awareness law? Surely not. However, the deputies that arrested me in September — referring to the incident above — weren’t aware. I’ve got a personal friend who works in law enforcement in Southern Middle Tennessee who wasn’t aware. 

I think it’s safe to say that countless other members of law enforcement across the Volunteer State also aren’t aware of this law. 

That doesn’t mean that they’re bad at their jobs, that we should launch a full-scale protest against them, etc. What it does mean is that we should strive to educate deputies, officers, and other members of law enforcement throughout Tennessee about T.C.A.§ 40-7-124. We should educate our friends and family members about this discrepancy, too. The more people who know about this, the more likely Tennessee law enforcement agencies will get on the proverbial ball and educate their employees about the Needle Possession Officer Awareness law and how to enforce it. 

Tennesseans Aren’t Incentivized to Get Medical Help for Drug Overdoses

I’m a long-term drug user and a lifelong resident of Tennessee. Having used regularly for about a decade now, I’ve heard countless stories of people not getting medical attention for others who experience drug overdoses. 

Why didn’t these people help their friends, acquaintances, or fellow community members seek medical help for suspected drug overdoses?

One reason rang true throughout all of these anecdotes: people were afraid of getting in legal trouble. 

Here in Tennessee, T.C.A. § 63-1-156, known by some as “Overdose Prosecution Immunity,” provides some protection to people who seek medical help for a suspected drug overdose, whether it be themselves or someone else. If you want to discuss this law with others, it’s pronounced as Tennessee Code Annotated, Title 63, Chapter 1, Section 156, for the record. Also, for simplicity’s sake, we’ll be referring to this law as the Overdose Prosecution Immunity law from here on out. 

I won’t be explaining the law in full. If you want to check it out yourself, here’s a link

It’s true that the Overdose Prosecution Immunity law does defend Tennesseans from legal trouble if they seek medical assistance for a drug overdose. This can’t be argued. However, the issue with the current iteration of this law is that it’s far too limited in scope. In other words, it doesn’t provide enough protection for Tennesseans who want to do the right thing by seeking help for people who are thought to be experiencing a drug overdose. 

Here’s what this law does: anybody who (A) calls 911, law enforcement, or a poison control center for or (B) assists someone in contacting these entities for or (C) directly provides care to someone who is thought to be experiencing a drug overdose “shall not be arrested, charged, or prosecuted for a drug violation.” They also won’t violate parole, probation, or any restraining orders or orders of protection in doing so. 

To be more specific about the term “drug violations,” Tennesseans are only protected against being charged with the Class A misdemeanors of possession of a controlled substance (T.C.A. § 39-17-418) and possession of drug paraphernalia (T.C.A. § 39-17-425). If people are found with a larger amount of a drug than what constitutes personal use, or simple possession, in other words, they’re not protected by the Overdose Prosecution Immunity Law. 

Here’s the Problem With This Law

Legislators did Tennesseans, in general, and Tennesseans who use drugs a favor by writing this law into state law books. However, they fell short in only allowing this law to protect people who are seeking help for the first time. 

To be fair, I understand why legislators made it this way. As a long-term drug user myself, I very much understand that drug use is risky. I’ve experienced opioid overdose at least three times, each instance of which could have killed me. Fortunately, I was given naloxone (Narcan) two of these times. Even though others might think that I “would have learned my lesson” after just one overdose, let alone three, people who use drugs and struggle with problem drug use or addiction often aren’t dissuaded from further drug use by an overdose. 

I know that I didn’t stop using after overdose. Few other people who use drugs stop immediately after they overdose and never use drugs again. 

I understand that legislators in the Tennessee General Assembly, where our state lawmakers meet, felt that giving people more than one “get out of jail free card” would encourage people who use drugs to keep using if they didn’t enact a strict limit on how many times Tennesseans would be provided legal protection by the Overdose Prosecution Immunity law.

Unfortunately, this just encourages Tennesseans to not seek medical assistance for people who are thought to be experiencing drug overdose. It also encourages them to not provide any help themselves, such as administer naloxone, the life-saving opioid overdose antidote. 

In the eyes of many people who use drugs here in Tennessee, the best thing they can do is get as far away from someone who is thought to be experiencing drug overdose.

Many Tennesseans Struggle to Afford Bail or Hire Attorneys — Here’s Why This Is an Issue

Law enforcement officers are incentivized to arrest people. It generates money for the jurisdictions they work in and may make the agencies they work for look better, thus finding themselves more likely to be awarded grants or otherwise favorable treatment. 

People charged with crimes who don’t plead guilty routinely experience better outcomes than those who do. Economically-challenged people are more likely to experience worse outcomes in court, getting longer jail sentences, more fines levied against them, longer probation time, and other unfavorable outcomes. 

The reason money sets low-income people back is because they can’t afford bail or to hire a private attorney. People who can afford private attorneys frequently experience better legal outcomes than people who are appointed public defenders by courts. People who can afford bail can better prepare themselves for court. 

Many Tennesseans are poor and can’t afford bail or to hire a private attorney. These people end up staying in jail longer after arrest. Their better-off, more wealthy counterparts are able to post bail just hours after being jailed, allowing them to return to their jobs, families, and lives nearly instantaneously. 

Here’s an example of how this comes into play. 

When I was jailed in September for possession of drug paraphernalia — again, even though the Needle Possession Officer Awareness law should have protected me from criminal charges — I felt forced to plead guilty the next day in court because I was on probation at the time and had to check in with my probation officer for a regularly-scheduled monthly meeting, like always. Waiting to be appointed a public defender by the court would have taken at least two weeks, I was told, causing me to not be able to report on time and likely ending badly for me. 

I also wanted to get back to work as soon as possible, as I can’t afford to miss work. As such, I pled guilty as soon as I possibly could, even though I knew I didn’t break the law and that T.C.A. § 40-7-124, the Needle Possession Officer Awareness law, would protect me from prosecution. 

This problem isn’t unique to me. Countless thousands of Tennesseans plead guilty to criminal charges they’ve been given, whether or not they’re actually guilty, to return to their normal lives as quickly as possible. 

Putting Everything Together

These aren’t the only ways that contemporary Tennessee laws and law enforcement officers unfairly influence people who use drugs. However, these three things are major problems that Tennesseans currently face.

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What Can You Do to Advocate for Harm Reduction and Drug Policy Reform Here in Tennessee?

If you’re reading this, chances have it you probably support harm reduction or drug policy reform, if not both. While you likely wish things were different, there’s only one way to actively accelerate social change other than the inevitable passage of time — advocacy. 

Google defines “advocacy” as “public support for or recommendation of a particular cause or policy.” Here’s one example of harm reduction advocacy: creating a brochure that explains the basics of harm reduction, describes examples of it, and tells readers why adopting harm reduction-friendly practices is a good idea; after printing the brochure out, copies are distributed to laypeople throughout the distributor’s local community. 

There are countless forms of harm reduction and drug policy reform advocacy. Few are objectively better than one another, though all have unique pros and cons. As such, all forms of advocacy can be better than others depending on how they’re being used — I think advocates should always be situationally sensitive.

Local News Agencies Are Valuable

Keep an eye on local news agencies’ most recent releases. You should keep tabs on at least several local news agencies, preferably those in and around your current area of residence. Subscribing to at least a few elsewhere is also a good idea.

When you find articles or broadcasts that favor the progression of harm reduction and drug policy either on a national level here in the United States, a state level, or even a local level, try reaching out to these agencies and identify whether you think they had a positive or negative effect on advancing harm reduction or drug policy. 

To define what I mean by “negative,” negative pieces include those that sensationalize drugs, spread misinformation about them, or damage our collective cause to advance harm reduction and drug policy reform.

Whether you’re looking to (reinforce/punish) the publication of harm reduction-(positive/negative) or drug policy reform-(positive/negative) pieces, you should always seek help from other advocates who you’re connected with. When one of your advocacy group’s members locates a piece that one of you wants to reply to, each of you should write a letter to the news agency in question for added effectiveness. 

The person who initially floated this idea to me said it may prove useful to send multiple replies from different identities. Of course, this isn’t illegal, but could very well contribute positively to our cause. Only you can determine if doing so is within your ethical boundaries — honestly, I’m still on the fence about it.

Coming Out as a Person Who Uses Drugs

Although sexuality and drug use are two entirely different things, just as people can out themselves as bisexual — I, too, am a member of the Alphabet Gang — widely outing oneself as a drug user can prove similarly difficult. Of course, there are many downsides to outing yourself as a drug user. If we all out ourselves as persons who use drugs (PWUD) — not that any such widespread, preplanned coordination would be feasible — the stigma associated with drug use is likely to start fading away. 

However, you should understand that everything you do will reflect on the other few people who have come out as PWUD. These people have already risked outcast, relationships, criminal justice problems, work opportunities, friendships, and much more. 

As such, you shouldn’t come out as a PWUD if you’re not in a good place to do so. Soon enough, fortunately, the stigma surrounding drug use won’t be as strong. The more people who do decide to come out as PWUD will make coming out easier, so, by coming out, we’re helping drug users as a whole.

This should go without saying, but you’ll be less likely to make others look bad if you’re responsible, well thought-out, maintain employment, and so on. 

Again — if you decide to do this, make sure you won’t make others look bad in the process. 

Realistically speaking, I know at least some drug users would take initiative, but those people would likely be of a more-responsible, go-getter nature. In other words, getting the people who most frequently and most intensively make us look bad — for the record, I’ve made us, as drug users, look bad countless times — would prove difficult, likely rendering our efforts better channeled via another effort.

Befriend or Get to Know the Following People and Places

Some people and entities are inherently more drug-friendly than other people and entities. These include law enforcement agencies, law enforcement officers, correctional officers, wardens, jails, drug rehabilitation facilities, prevention coalitions, churches, libraries, health departments, public defenders, parole boards, etc. 

By cultivating relationships with these people and places, you’ll generally be in a better position than most people to influence them. 

Understand you’ll get further with those who are already more drug-friendly or drug user-friendly. Still, I’d argue that our collective efforts would be better spent in areas that are more drug-averse or drug user-averse.

Never Spend Time Trying to Change Others’ Minds on Social Media

This is self-explanatory. Arguing with others doesn’t get you far, especially on social media. This is because people on social media are often set in their ways regarding hot-button issues like abortion, gun control, or how society treats drug use. 

Trying to advance your cause by attempting to persuade these people either wastes your time and gets you nowhere or results in people thinking worse about your cause. 

The unconventional measures that harm reduction-friendly policies propose don’t seem like good ideas upon first glance. Because social media doesn’t lend itself to answering complex, multi-faceted questions — or even hearing them out in the first place — spending time trying to change others’ minds, especially on social media, isn’t a good idea.

If you do try to attempt this, your posts should be placed in highly-visible areas, must be easy to understand, must be non-argumentative, and must not be placed in communities that are inherently or largely against such ideas already — sharing posts in more moderate areas may be a better use of your time.

Ultimately, the only reasons why I post on social media about harm reduction or drugs in general is to expand my network, relentlessly self-promote my writing, or boost my chances of finding gainful employment in this harm reduction space. I believe that posting to social media with the goal of changing others’ minds is nothing short of a waste of time.

Activating Drug Dealers by Giving Them Harm Reduction Supplies

Many people who use illicit opioids via injection, for example, like myself would much rather be able to source syringes from the same place they purchase their opioids of choice from than having to visit syringe exchanges, pharmacies, or — what often happens in rural Tennessee, where I am — elsewhere on the black market. 

Syringe, likely used, found on the ground with the plunger pulled roughly halfway back. The syringe itself is empty.
Syringe litter

Dealers who offer clean syringes to customers, whether it be for free or not, can cultivate and maintain a competitive advantage.

In areas where clean, free syringes are available, dealers aren’t likely to source syringes in an above-ground, legal manner. Rather, they’re more likely to accept syringes from below-ground resources, such as from one of their customers, for example. This is something I’ve done, myself.

Activating drug dealers by providing them with syringes, naloxone, and other harm reduction supplies is a good way to advocate for harm reduction because:

People who activate dealers in this way should also educate them, if possible, about the basics of harm reduction. Ideally, these aforementioned activators should provide dealers with hard copies of educational material in the form of brochures, pamphlets, or even single, printed-off, black-and-white sheets of basic harm reduction information.

In my experience, dealers aren’t as interested in learning about harm reduction as they are the prospect of building a competitive advantage. I’m not saying dealers are heartless, soulless criminals — I just think humans are more interested in capitalizing on opportunities that benefit them in the now rather than advancing abstract ideologies and the very-potential benefits that may come from them.

Also, even if dealers you come across are interested in the ideology of harm reduction, let alone adopting it and practicing it, they should be — at least I’d hope any business-minded person would be — averse to supporting something that would ideally cut them out of contention (i.e., harm reductionists generally support safe supply, which involves things like allowing doctors to prescribe pharmaceutical-quality heroin; this would unarguably harm any illicit drug market’s bottom line).

In Conclusion

Advocating for causes is time-consuming and often frustrating. Further, many people don’t advocate in effective ways. One of the number-one ways that people think is an effective way to be an advocate is by posting on social media. In most cases, this is simply ineffective, if not wholly counterproductive. 

These aren’t the only ways to advocate for harm reduction or drug policy reform. However, these five methods are all solid means of advancing our cause as harm reductionists or drug policy reformers — if not both.

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Proving Facts and Dispelling Myths About Drugs

We’ve all heard heard dozens of fellow users spout countless inaccuracies, misleading statements, and flat-out incorrect assertions about drugs, drug use, and drug laws as if they were all fact.  

There’s no way this article could even hope to cover a half of a percent’s worth of the myths, half-truths, and facts we’ve heard as drug users since 2010 — that’s when I first began using illicit drugs — and address them to help readers better understand them. 

Without further ado, let’s get started. 

Myth #1 — You Should Disinfect With Alcohol Swabs Before AND After Injection

A few weeks ago, I asked a fellow local intravenous heroin user whether she used alcohol swabs prior to injecting. She told me she used alcohol swabs both before and after injecting. This is actually worse for your health as opposed to just using an alcohol swab immediately prior to injection, no matter the type of injection used: IV (intravenous, or directly into the vein), IM (intramuscular, or directly into the muscle), or SC (subcutaneous, or under the skin).

Put simply, isopropyl alcohol — the active ingredient in rubbing alcohol and alcohol swabs — is an antiseptic, or something used on the skin to shrink the possibilities of infection.

Injections make small holes in the skin through which bacteria and other potentially-dangerous microorganisms can enter. Following an injection, blood rises to the surface and closes the hole made by the syringe. The faster this happens, the less likely foreign objects are to make it inside the human body. 

Using an alcohol swab after injection prevents blood from clotting. This is why it’s not a good idea to use alcohol swabs after injection.

Fact #1 — All Adults in Tennessee Can Purchase Syringes Legally

Many injection drug users in Tennessee struggle to get their hands on clean syringes. They usually are forced to hit the black market to source clean syringes, but, unfortunately, due to the underground nature of the black market, market participants can’t be sure that their sharps are fresh. 

Although pharmacists in Tennessee are legally required to ask everyone without a prescription for syringes what they plan on using syringes for prior to completing the sale, it is possible for all adults with valid identification to purchase syringes from pharmacies. However, at least in my experience, pharmacists in rural Tennessee routinely turn customers down.

It’s possible to purchase larger-diameter syringes without a pharmacy’s help — think of veterinarians, vet supply stores, or pet stores. However, these syringes are absolutely not intended for the injection of illicit drugs. 

Again, in actuality, injection drug users have one hell of a time trying to purchase syringes from pharmacies. Those who have tried to get syringes from pharmacies, especially in rural areas, often feel discouraged from trying other pharmacies in hopes of getting a “yes.”

I understand the rationale behind not wanting to feel responsible for helping an injection drug user shoot up, but people who inject drugs will get high whether or not they have access to clean, fresh syringes or not. As such, this idea doesn’t make much sense — shouldn’t pharmacists want to help underserved, at-risk persons from reusing sharps or sharing them with other users? Also, even if you purchase syringes off the black market, the only choice for most rural Tennessean injection drug users, there’s no guarantee they’re clean.

Anyway. To wrap this “fact” up, know that it’s legal to purchase syringes from pharmacies here in Tennessee without prescriptions but, in the same breath, understand you’re highly likely to get turned down.

Myth #2 — If You Have a Reliable Illicit Source for Diverted Prescription Medication, You’ll Never Come Across Fakes

Assume you occasionally consume prescription opioids (Norco, OxyContin). It doesn’t matter how often you take them. What does matter, in this scenario, is the source of the opioids. 

According to federal government statistics, beginning in 2015, the rate of opioid prescribing in the United States dropped for the first time in some two full decades. This caused major supply chain issues on the American illicit opioid market. 

People who were then able to regularly, reliably source prescription opioids from trusted sources had to do things like:

  • Start paying more for the same pharmaceuticals they were once getting. 
  • Go longer between their chances to source opioids since many people got completely cut off from opioids by their physicians. 
  • As time progressed past 2015, the likelihood of purchasing counterfeit opioid tablets off the American illicit opioid market drastically increased. 

These counterfeit tablets can either be made in a clandestine lab or in a fully-fledged pharmaceutical manufacturing operation would operate. The former is made possible by people selling small-time pill presses via the mail. They are usually sent part by part to avoid detection.

Their counterpart, the big labs mentioned above, are typically operated by Mexican drug cartels. Due to the widespread availability of pill presses, there are hundreds, if not thousands, of clandestine, one-room pill-pressing operations across the United States — but do we really know how active they are? Of course not — I’m just pointing out that pill pressing doesn’t just happen in big-time, Mexican-drug-cartel form.

Both are able to purchase pre-made mixes of inactive ingredients online. In most cases, these counterfeit opioid tablet manufacturers choose fentanyl as an active ingredient. Fentanyl has a lower threshold between the point at which consumers feel its effects — both analgesic and recreational — and the point at which opioid overdose symptoms manifest.

Another factor that makes counterfeit opioid tablets so deadly are “hotspots.” Hotspots are simply clumps of active ingredients. Fentanyl is much more potent than other opioids — extremely so. Because the volume of only a grain or two of salt can cause death in a human adult, it’s easy to understand why fentanyl “hotspots” are such an issue with counterfeit opioid tablets. 

Dude, There’s No Way My Pills Could Be Fake

Counterfeit oxycodone tablets seized by law enforcement that contain fentanyl
Counterfeit opioid tablets, intended to imitate Qualitest and Mallinckrodt 30-milligram instant-release oxycodone tablets

I’ve heard this rationale from countless drug users I’ve been around. I understand the thinking, especially from people who happen to have better connections to the diverted prescription opioid market, though it’s not a valid idea.

As you know, just one run-in with fentanyl-laced counterfeit opioid tablets can cause a potentially-fatal overdose.

Over the past few years, the quality of counterfeit pharmaceuticals — things like fake Xanax and pain pills, namely, not counterfeit blood pressure pills from India or anything, just to be clear — has improved drastically. It’s no longer possible to routinely tell fakes from their real counterparts just by identifying their characteristics.

How do we spread this message to people who use diverted prescription opioids — that they should view everything they come across as potentially counterfeit? I’m not sure. It’s often difficult to make the case to diverted prescription opioid consumers that their pills could be fake and contain the-super-easy-to-overdose-on drug fentanyl.

I think our best hope is to continually spread this message — that your pills could be fake and contain drugs with higher overdose potential like fentanyl even if you purchase them from trusted sources — to people who use drugs.

Fact #2 — Non-Opioids Can and Do Contain Fentanyl

We’ve all seen reports of non-opioid drugs like cocaine, methamphetamine, and even cannabis containing fentanyl. Although opioids are more likely to contain fentanyl than their non-opioid counterparts, other drugs can and do contain fentanyl — this isn’t just an over-sensationalized narrative pushed by news outlets.

There are a few reasons why batches of drugs on the American illicit opioid market contain fentanyl — and if you’d like to read more about why fentanyl is so deeply ingrained in the modern American illicit opioid market, check out this previous article of mine. They include the following:

  • Because fentanyl is much more potent than heroin, distributors don’t have to transport as much volume or weight when they adulterate their heroin with fentanyl. The more fentanyl in an opioid mixture, the easier distribution is. 
  • Fentanyl furthers people’s addictions and dependencies. Once the illicit opioid consumers in an area become dependent on fentanyl in addition to heroin — or another opioid like oxycodone, for example — the less satisfied they’ll be by batches of opioids that are fentanyl-free. 
  • Fentanyl-heavy batches effectively provide free marketing to dealers. Dealers have been known to push exceptionally strong or unevenly-mixed batches of illicit opioids that also contain fentanyl, causing more overdoses than usual — and potentially more deaths. Full diclosure — dealers are people, too, and they often don’t want to see their customers die. However, it’s undeniable that dealers stand to benefit by selling batches of “heroin” — really, almost all American “heroin” is a fentanyl-heroin mixture — that are more likely to cause overdose.
  • Fentanyl-positive “heroin” hits different. Even though opioid users know how dangerous fentanyl is — at least they should know for the sake of their well-being, and all — many report that they’d rather use heroin-fentanyl mixtures than just heroin, or whatever opioid-fentanyl mixture is at hand.
  • The last major reason is that fentanyl is much easier to manufacture than opioids like heroin. Heroin requires farmhands to cultivate broad, wide-open fields of Papaver somniferum, better known as the opium poppy. Fentanyl is manufactured with chemical precursors, meaning there’s no need for massive farming operations. Further, well over 90% of the world’s illicitly-manufactured fentanyl (IMF) actually comes directly from professional-yet-illegal manufacturers in China. These manufacturers use the Internet to sell high-quality, nearly-pure fentanyl and countless fentanyl analogues at low prices. 
Comparison of lethal doses of heroin, fentanyl, and carfentanil, a fentanyl analog.

As you can reason, there are plenty of reasons to add fentanyl to other opioids. But why would anybody include fentanyl in non-opioid drugs?

There’s no question that high-level distributors have made mistakes during the adulteration process that resulted in the cross-contamination of other, non-opioid drugs like meth with fentanyl. 

For example, assume a high-level distributor just got done adulterating their heroin with fentanyl. The distributor used a few blank credit cards/gift cards to mix the two opioids together. Rather than cleaning the cards off before attempting to adulterate their cocaine, for example, the distributor inadvertently contaminates their cocaine supply with fentanyl.

A personal anecdote from a Northwest Tennessee man — I’ve referred to him as Jonah before in one other article — is that, after he was court-ordered to go to rehab twice in two or three months, he ended up testing positive for opioids both times. Jonah never uses opioids and doesn’t like them. 

The one thing that stayed consistent between the two drug screens is his meth consumption. 

Further, other meth consumers in Jonah’s local area have also reported that they’ve tested positive for opioids following their consumption of local meth, despite the fact they didn’t otherwise consume opioids. 

Since fentanyl was — and still is — regularly found in the local illicit meth supply to which Jonah has access, I think it’s reasonable to assume that people higher up the supply chain intentionally cut meth with fentanyl. It’s not very feasible for high-level distributors to continually make the same cross-contamination mistake over, and over, and over, and over again. 

Here’s Jonah’s hypothesis as to why his community’s local meth supply contains fentanyl: after a few days of binging on meth, almost certainly bringing no sleep and — in many other methamphetamine consumers’ cases, too — an insufficient nutrient load into the mix, it’s not hard to reason that these people’s bodies would feel sore, worn out, or otherwise bad. Jonah feels as if the distributors who are responsible for adulterating methamphetamine with fentanyl provides the distributors with a competitive advantage because consumers’ aches, soreness, and lethargy would be better dealt with than by consuming methamphetamine without fentanyl included. 

Could Jonah be wrong about this idea? Yes. I think it’s a valid idea, however, and I haven’t seen it floated anywhere else.

What’s important to know is that all drugs, not just opioids, are liable to contain fentanyl. The problem with this is twofold: (1) users don’t know they’re consuming fentanyl and (2) since there’s such a low threshold between the amount of fentanyl needed to cause physiological or psychological effects and overdose, it’s easy for people to potentially die from unknowingly consuming fentanyl.

Myth #3 — You Can “Narcan” Yourself

Before Anything Else, Let’s First Understand Naloxone

Narcan nasal spray juxtaposed with its packaging
Name-brand Narcan nasal spray

First off, “Narcan” isn’t technically a verb — it’s a proper noun officially stylized as NARCAN® Nasal Spray — though you’ll inevitably hear it used as such somewhere. Narcan is a pre-loaded, single-use nasal spray that’s available over the counter in pharmacies across the United States. Drugs are available over the counter when they have little to no contraindications, or negative reactions to other medicines or people who have certain health conditions. 

Evzio naloxone auto-injector

Naloxone, the sole active ingredient in Narcan and Evzio — similarly styled EVZIO®, an auto-injector that talks users through the entire process — has no contraindications outside of people who are allergic to naloxone. 

Many people who overdose on opioids are opioid-dependent, meaning their bodies need to maintain minimum levels of opioids or else they’ll face opioid withdrawal syndrome, which shares many of the same symptoms of the flu. Although this isn’t a true contraindication — which means, according to Google, “suggest or indicate that (a particular technique or drug) should not be used in the case in question.” — opioid-dependent people experience precipitated opioid withdrawal for an hour or two following administration.

Depending on what opioid an opioid-dependent person is reliant on, the peak of opioid withdrawal syndrome takes roughly 72 hours to be reached. Precipitated withdrawal, on the other hand, causes the full slate of peak opioid withdrawal syndrome symptoms to rear their oh-so-ugly heads in opioid-dependent people.

This is a small price to pay in exchange for having your life saved, though — an hour or two of pain to have another shot at this beautiful experience we call “life.” 

Naloxone acts as a powerful public health tool. Whether you think reviving someone who knowingly uses opioids and understands they can die from doing so is a good idea or not, since naloxone is cheap and has no true contraindications, naloxone is an effective tool for preventing death.

And, although off-topic, you may come across people who aren’t supportive of responding to opioid overdoses with naloxone. No matter their reasoning, I think the vast majority of all reasonable-minded humans agree that nobody should die while suffering. Many regular drug users — especially those suffer from drug addiction — use drugs to fill the gaps created by long-unmet needs not being fulfilled. I genuinely believe that every stint of problematic drug use comes to an end, however long it might take; this thinking lends itself to the idea that every addict will has a real, tangible shot at recovery.

Most people will get behind the idea of making sure people in active addiction don’t die in pain. This approach may be useful in educating laypeople about naloxone or persuading them to get on board the naloxone train.

Naloxone has been used extensively to reverse overdoses throughout the United States, especially recently.

According to the U.S. Centers for Disease Control and Prevention, more than 26,400 opioid overdoses were resolved from 1996 to 2014 through the administration of naloxone in the United States alone. Many opioid overdoses, as well as their reversals thanks to naloxone, go untracked, though.

For example, I had at least two opioid overdoses — I say “at least two” because I was given naloxone a third time when I was potentially just a few minutes away from experiencing overdose; I’m not sure if I can definitively count that as an “overdose” — in 2019. Both times, fortunately, I was revived with naloxone. Would I have died or experienced permanent brain damage without naloxone’s help? There’s no way to know.

I enrolled in a medication-assisted treatment (MAT) program after that third potential overdose, though not at all because of the overdose — rather, I was facing legal consequences as the direct result of my ongoing illicit drug use. My life is better now that I’m on buprenorphine (Suboxone, Subutex). It is impossible to get help for drug addiction, after all, if you’re dead.

When Should Naloxone Be Administered?

Knowing when to administer naloxone is the same thing as knowing how to recognize an opioid overdose. 

Bluish lips, fingertips, and toes are one of the most widely-reported symptoms of opioid overdoses, according to friends, family members, peers, first responders, physicians, nurses, and other medical professionals who’ve seen people experience opioid overdose.

While opioid users sometimes nod out, if an overdose is, in fact, present, they’ll be unconscious or very close to completely losing consciousness. Just like when people are unconscious for any other reason, people experiencing opioid overdose won’t be able to respond to any stimuli, even an air horn, a bright flashlight shined into their eyes from inches away, or a loud, blood-curdling scream.

The skin will turn a different color, though what color it turns depends on the person’s regular skin tone. Lighter-colored people, such as most White and Asian people, skin may begin turning hues of blue and purple. For darker-complected people, like most Middle Easterners and Black people, skin tones may start to become any one of a range of gray colors. Keep in mind that these aren’t scientific facts — just concerns we should play with.

If you’re unsure of what to look for or think you might not be good at recognizing these color changes, always first look to the lips for help. They’re the easiest to read, generally. Also, fingertips and toes may be of help, too. 

Assume you’re not sure of what to do. You see someone exhibiting one or more of these opioid overdose symptoms, but you also see that their current cohort of symptoms could very well be caused by another drug’s pattern of overdose symptoms. 

Here’s what we’re going to do. I’ll explain how to administer naloxone, as well as what signs you should look for to know when it’s an appropriate time to “Narcan” somebody. 

Once you’ve identified an opioid overdose, you should immediately call 911. If you have to move away from the person who’s overdosed to call first responders, you should place them in the recovery position, seen here.

This prevents them from breathing in a foreign object. Opioids, especially in excessive doses, are known to cause puking; the recovery position neutralizes the risk of asphyxiation by vomit — opioids, since they’re also known to cause unconsciousness, can make it difficult for people to clear vomit from their airways.

Now, it’s time to administer Narcan. Don’t worry about getting their body in a certain position; simply spray one spray in each nostril. Make sure the nozzle is firmly inserted inside each nostril before spraying.

If you’re using injectable naloxone, draw the naloxone solution into the syringe and inject it into the thigh or upper arm. To bridge the gap from now until paramedics alive, perform rescue breathing. There are several other best practices to follow in responding to opioid overdose, though I won’t list them here — I’m just trying to give you an idea of what administering naloxone is like, if you didn’t already know.

That’s how the naloxone administration thing works. But can you revive yourself with naloxone?

But Can You Revive Yourself With Naloxone?

Let’s Cover a Real-World Example, After Reading Which You’ll Determine the Answer Yourself

Opioid overdoses can happen anywhere from a few seconds to a few hours after opioids are taken; the fastest overdoses usually happen with intravenous administration, since no absorption barriers have to be passed.

Oral consumption, on the other hand, is sure to take the longest in terms of causing an opioid consumer to experience opioid withdrawal syndrome. One time — and it’s not like I’m proud to admit this; not at all — I experienced an overdose in 2014 that involved oral administration.

It was early June 2014. I won’t get into why, but I was angry at the time — very angry. I had almost never, ever used drugs in direct response to my emotions. I first took oxycodone — relative to my opioid tolerance at the time, I just took a standard dose; nothing special. Then, maybe 45 minutes later, I took alprazolam, and, relative to my benzodiazepine tolerance at the time, it wasn’t a large dose, either. 

I had actually combined alprazolam (Xanax) with oxycodone before several times, not to mention in larger doses than I did on this super-humid evening. About an hour after I took the Xanax, I decided I wanted to walk back to my room, as I wasn’t having any fun with the people I was hanging out with. 

Keep in mind that pretty much all students at this school had left a week or two prior, as the spring semester had just come to close.

On my way back to my room, I passed out. The only thing I remember is leaving the room. The room was no more than ~40 steps away from where I’d passed out, including a small flight of stairs.

Here’s what ended up happening: I stayed that way, collapsed in a lump on the carpeted hallway floor. All by myself. With nobody to help me. Not a soul. 

Everybody else had left campus just a week or two prior. I ended up coming to about three to four hours after I’d passed out. I was extremely disoriented, dehydrated, and confused. I felt more confused than I ever had in my entire life for about 15 minutes. I puked, and I puked, and I puked. And then I puked some more. 

I’m very lucky to be alive. 

Could I Have Administered Naloxone Myself and Prevented That Overdose?

Again, I don’t remember anything about falling out. Even if I knew what naloxone was and I had it with me, how would I have recognized the “point of no return”?

Therein stands the central issue with the prospect of naloxone self-administration in response to opioid overdose — you don’t know when you need to hit yourself with the life-saving drug.

I very well suspect that some opioid users could successfully prevent an impending overdose via naloxone self-administration. However, if you miss the mark just one time, game over!

Also, keep in mind that opioid users often can’t afford to ruin their high, which is exactly what naloxone does. Or, they might just not want to blow their high.

Put simply — and if you want to read more about my take on naloxone self-administration, check out my article on it — you can’t rely on yourself to administer naloxone in the event of overdose.

One last thing about naloxone — after I’ve been given naloxone, I’ve never experienced precipitated opioid withdrawal syndrome. This is because I just happened to be given enough naloxone to resume consciousness, though not enough to forcefully remove the opioids that were occupying my noodle’s opioid receptors from those receptors — that’s what causes precipitated withdrawal, if you didn’t know. I also still felt high after all three of my run-ins with naloxone.

Fact #3 — Kratom Is an Opioid

Many advocates of kratom, including the American Kratom Association, argue that kratom is not an opioid despite the fact it causes effects oh-so-remarkably similar to opioids, mitigates opioid withdrawal syndrome, and acts on the brain’s opioid receptors as its mechanism of action.

I wholeheartedly disagree — I think kratom is, in fact, an opioid.

What Is Kratom?

Kratom leaves in the wild

Kratom (Mitragyna speciosa) is a deciduous evergreen tree — the tree would lose its leaves if grown in a non-tropical area, though, since it’s found in tropical areas, kratom trees don’t ever shed their leaves for the winter, making it both deciduous and evergreen — that is native to Southeast Asia. People have used kratom for at least hundreds of years, usually by laborers to power through workdays thanks to its stimulating and analgesic effects.

Kratom contains a couple dozen alkaloids, or psychoactive compounds, that are responsible for its effects. People typically use kratom by swallowing ground, powdered kratom leaves, making tea, or chewing fresh leaves raw a la chewing tobacco.

Although the pro-kratom advocacy organization American Kratom Association considers kratom not to be an opioid, I disagree. There’s no single, widely-accepted definition of “opioid,” which makes arguing whether kratom is an opioid or not difficult — without agreeing on a definition, you can’t reasonably discuss whether kratom is, in fact, an opioid or not.

How Do Opioids Work?

Again, in order to make this case, I first need to define “opioid.” It’s reasonable to say, no matter which definition you’re using, that an opioid is something that acts on the brain’s opioid receptors and has morphine-like effects.

Why does morphine — and, of course, other opioids — relieve pain, cause analgesia, and potentially lead people to addiction or dependence?

We’ve got a few different kinds of opioid receptors. One of them is the mu-opioid receptor.

A 1996 study found that, by comparing humans to mice that lack the mu-opioid receptor, the mu-opioid receptor is responsible for both the “therapeutic and the adverse activities” of morphine. Mice without the mu-receptor gene are more sensitive to painful stimuli, don’t pull as much reward from drugs of abuse, and lack the same dependence, reward, and analgesia from morphine that mice with the mu-receptor gene.

Here’s Why Kratom Is, in Fact, an Opioid

Chemical structure of 7-hydroxymitragynine, also known as 7-OH, 7-OHM, and 7OHM
7-hydroxymitragynine (7-OH)

Two of the most prevalent and powerful alkaloids in kratom are mitragynine and 7-hydroxymitragynine (7-OH). Primarily, the effects of these alkaloids come from partial agonism of the mu (µ) opioid receptor.

Chemical structure of mitragynine, the chief alkaloid of kratom
Mitragynine

Mitragynine acts as a partial agonist at hMOR (EC50 = 339 ± 178 nM) and a weak antagonist at hKOR and hDOR. 7-OH acts as a partial agonist at hMOR (EC50 = 34.5 ± 4.5 nM) and as a competitive antagonist at hDOR and hKOR.

Some kratom fans may argue that, since kratom is only a partial agonist, it can’t be considered a true opioid. LSD and THC, for example, are both partial agonists of the 5-HT2A and CB1 receptors, respectively. LSD is still considered a classic psychedelic based on its effects; THC is defined as a cannabinoid for the same reason.

Myth #4 — Kratom Is a Deadly Drug

The other ideas I’ve addressed so far are likely more familiar to you than this one. While this might not be a widely-held misconception, I’ve come across a handful of people who think kratom is a deadly, dangerous drug.

The only people I’ve heard say this in real life were all involved with a medication-assisted treatment program in Jackson, Tennessee — two of them were physicians and the other was the program’s director and a registered nurse. I’ve seen people online say the same things, too.

These two physicians and the director-cum-registered-nurse told me kratom causes worse opioid withdrawal symptoms than buprenorphine (Suboxone). That could be the single most ignorant thing I’ve ever heard. I’ve taken kratom for three-plus years. Never did I have serious withdrawal symptoms.

Now, since I’ve been on Suboxone, I can’t even begin to feel the effects of kratom, even in high doses. Also, before enrolling in the MAT program, I never had a material physical dependency to opioids. Now, I do.

Comparing Kratom to Other Opioids

Opioids are notorious for causing respiratory depression, the most common direct cause of death stemming from opioid overdose.

Kratom has less potential for causing respiratory depression than classical opioids. It’s also less likely to be abused like other opioids, as it just doesn’t have the same recreational potential.

Kratom, Alphabet Soup’s Best Friend

The Centers for Disease Control and Prevention (CDC) have published research that fingers kratom as a direct cause of death in about 100 people after examining some 27,000 accidental drug overdoses across a 17-month stretch in the United States.

The U.S. Food and Drug Administration, as well as other federal government agencies, have used similar research as a tool to campaign against kratom. Ostensibly, officials hope to have the drug viewed as a deadly, dangerous drug by the American public.

I feel that the three aforementioned medical professionals — although they’re obviously incentivized to slam alternatives to opioids other than buprenorphine, considering they work for a medication-assisted treatment program, and all — may have been led astray by FDA and CDC reports.

Also, these reports have spurred news agencies around the country to write about kratom as a potentially-harmful or definitely-deadly drug, further pushing people to view kratom negatively.

Here’s the Verdict

Yes, kratom is a drug. Like all drugs, kratom can prove harmful. However, kratom doesn’t pose much of a threat because:

  • Kratom has little recreational potential.
  • It’s less likely to cause respiratory depression — or vomiting, for that matter.
  • Kratom is much, much safer than classical opioids, especially those sold on the black market, not to mention readily available and cheap.

Kratom, which is often used to curb anxiety, depression, chronic pain, and other health problems, can be used irresponsibly, especially by people who are self-medicating to deal with anxiety or depression.

Also, because the kratom market is largely unregulated, there’s no way to reliably enforce manufacturers to prevent kratom from being contaminated with pathogens, heavy metals, other active ingredients, bulking agents, or any other adulterants. Kratom needs to be regulated — at least if we want the kratom industry to be safer, that is.

Tying Everything Together

I hope I’ve been able to shed some light on commonly-held myths, misconceptions, and half-truths that are common among people who use or are otherwise involved with drugs.

Please do reach out to me if you think I got anything wrong.

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How Mailing Syringes to Drug Users Helps — The Merits of Mail-Based Supply Distribution

People like San Francisco’s Tracey Helton and organizations like New York City’s NEXT Distro have long distributed syringes, naloxone, and other harm reduction supplies via mail.

Mail-based supply distribution (MBSD) is so very helpful for people who live in areas where there isn’t much, if any, access to harm reduction supplies, drug-related education, or drug user health support. Although MBSD isn’t an equal substitution for in-person syringe services programs and other resources that help drug users like me, they’re unarguably the next-best alternative.

I regularly distribute supplies like these from mail-based supply distributors to fellow drug users and dealers here across rural Northwest Tennessee in an underground, unfortunately-illegal, grassroots fashion. Here, syringe access is nonexistent and finding naloxone is like pulling teeth.

Here are some insights on MBSD that I’ve gathered during my time as a harm reductionist.

Drug Users Often Lack Access to Necessary Supplies

Across West Tennessee, there are only two syringe services programs (SSP) overseen by the Volunteer State. Both of them are in Memphis, which is in the far southwestern extreme of Tennessee. No matter where you’re at in Northwest Tennessee, a nine-county area home to 254,000 people, Memphis is at least a solid 90-minute drive away, rendering legal syringe access essentially impossible.

Pharmacies can legally sell syringes, though pharmacists routinely turn down customers without prescriptions for syringes. The only access we have to syringes here in rural West Tennessee is the black market.

Here, there’s an objective, pervasive lack of access to supplies like syringes.

Even in areas where there is syringe access, many drug users get left behind for reasons like not having reliable transportation, having to work during program operation hours, not wanting others to know about their drug use, and fearing incarceration because they have outstanding warrants for their arrest.

Mail-based supply distribution circumvents these barriers and many others — though, just to be clear, MBSD isn’t a panacea.

At Least Here, We’re Trained to Exercise Discretion in Everything We Do

As drug users, we’ve been trained to avoid new people or things that seem too good to be true. In my own efforts to distribute syringes, naloxone, and other supplies to people who use drugs, I’ve been turned down countless times by people who simply don’t trust me.

The people of rural West Tennessee aren’t used having access to syringes, let alone getting free syringes — we’re used to buying them illegally from other users, family members, or dealers — which has made reaching out to people who use drugs and could stand to benefit from what I do difficult. As you might imagine, many here aren’t comfortable with the idea of receiving syringes through the mail, either.

In full disclosure, I’ve tried to turn people on to mail-based supply distributors, many of which offer supplies for free, but nobody’s taken me up on this offer. Once syringe access expands and rural Tennessean drug users become familiar with it, I know they’ll slowly come to trust such opportunities as legitimate.

Even if we did have open access to syringes here in rural Northwest Tennessee, the most vulnerable drug users likely wouldn’t be able to visit syringe services programs’ outlets or be comfortable with showing up in person. MBSD would help reach some of these people, assuming they’re housed or otherwise have an address to accept mail at.

Last thing — there will be a transitory period following the expansion of syringe services programs here in rural Northwest Tennessee in which drug users will slowly come to accept such resources as legitimate. Abruptly shaking us out of our discretionary habits, which, again, are so prevalent here in rural Tennessee, isn’t possible. During this period, I predict that some people who stand to benefit from access to syringes and other harm reduction supplies may only be comfortable participating in supply distribution programs if they can receive supplies via mail.

MBSD may prove useful during this transition. Maybe not.

Well-Served Drug Users Are More Likely to Support Harm Reduction Than Those We Haven’t Helped

It doesn’t take much thought to reason that a well-served drug user is more likely to aid in harm reduction than an underserved counterpart.

This is just an anecdote, but I only became active in harm reduction after I was given syringes, naloxone, and other supplies — they came by way of mail, too. We don’t have much access to things like that here.

Although you could, in theory, purchase syringes from pharmacies, pharmacists rarely sell syringes without prescriptions here in rural Tennessee — I’ve heard pharmacists are more lenient in cities, such as Memphis or Nashville — this rarely happens. Those who have tried to buy syringes without prescriptions usually don’t bother after a few tries, anyway.

One more anecdote — I’ve only been able to welcome aboard other drug users or dealers as secondary distributors after giving them supplies myself.

If We Drug Users Demonstrate Responsibility, We Stand to Gain More Support

Despite research that shows otherwise, most Americans — at least this is true for rural Tennesseans — don’t support expanding syringe access.

Many people think opening up syringe access simply enables injection drug users. While I understand this reasoning, the fact that regular injection drug users by the boatload who only have black-market syringe access suggests this idea falls short.

Let’s face it — often-problematic drug users like me have often lived up to the stereotype of “junkie” or “druggie.” I know this is true for me. And I’ve been around so many others who fit the bill, too.

If we drug users can prove ourselves responsible in handling syringes given to us, views toward improving syringe availability may brighten.

Of course, I’m sure syringe access will be portrayed negatively by local news agencies if syringe litter becomes prevalent or complaints arise even if most of us are, in fact, responsible with the supplies we receive. Still, we stand to improve our overarching reputation as drug users through proving responsibility. But this is something we should strive for, anyway.

For the record, if I wasn’t already clear, I’ve made myself — and all drug users, by extension — look bad countless times before. And, even though I try to act more responsibly now, I still find myself giving drug users a bad name from time to time.

Is it reasonable to expect everyone who uses drugs to act responsibly? No. Actively making drug users like me aware of this responsibility will, inevitably, encourage at least some of us to shape up.

Mail-Based Distribution Can Promote Safety During Pandemics

Times of pandemic don’t rear their ugly heads very often, to be fair, but MBSD reliably reduces pathogen transmission.

Although this is a very real benefit, I feel it’s auxiliary to other points expressed herein. Despite this, I think we harm reductionists could benefit from making the public aware of this benefit before the ongoing novel coronavirus pandemic slows down. Maybe not — admittedly, I’m not well-versed in communications or public relations.

Providing Opportunities to People as Potential Secondary Distributors Gives Them Purpose

I know a handful of people, one currently-incarcerated dealer and a few active drug users, who are willing to distribute the supplies I provide to others who use drugs.

The dealer, of course, was motivated by the prospect of selling syringes or increasing sales by offering supplies customers might not have access to. However, the others, I believe, are motivated by the prospect of helping others.

Long-term, often-problematic drug users like me often have less to live for than the general population. We are also less likely to actively pursue passions and hobbies. We lose interest in things we used to like.

Activating current drug users as secondary supply distributors gives them purpose, which can very well lead to outcomes like ceasing or decreasing drug use, securing gainful employment, or enrolling in college or trade school. Put simply, by giving people purpose, we improve their quality of life.

Just to be clear, I don’t think MBSD should be solely reserved for people interested in community distribution. Mailed harm reduction supply access certainly got me engaged in secondary distribution and harm reduction in general, though I think I’d have been less likely to seek out supplies if the senders considered me responsible for further distributing them.

In my time distributing supplies to other drug users and, less commonly, dealers, I’ve found that most recipients haven’t been interested in distributing syringes, naloxone, and company themselves. I do think, however, that people who seek out supplies from mail-based distributors are more likely to engage in secondary distribution than their counterparts.

They Help Kickstart Harm Reduction Efforts in Underserved Areas

I live in Northwest Tennessee. The closest syringe services programs are each two-and-a-half hours away. Syringes currently aren’t available anywhere else, as pharmacists — the only other legal source here — don’t usually sell syringes to people without prescriptions despite being legally able to do so.

I’ve only ever received harm reduction supplies from out-of-state, mail-based sources. These suppliers effectively advanced efforts to improve the treatment of people who use drugs by activating me as a harm reductionist, whether or not they had this in mind.

Mail-based distribution can inspire recipients to support future harm reduction-positive measures in grassroots form or, as in my case, encourage them to actively practice harm reduction in a tangible, hands-on manner (i.e., distributing supplies, educating others about safer practices in drug use).

One of the major challenges that American harm reductionists face, in my opinion, is expanding resources that help drug users to rural areas. MBSD is one of our most valuable resources in doing just this.

Tying Everything Together

MBSD isn’t just for reaching people in underserved areas. I think mailing syringes, naloxone, and company to people in areas where there aren’t currently any available resources is an effective way to reduce HIV and hepatitis C transmission, prevent injection drug users from potentially harming themselves by using worn-out syringes or other supplies, and connect people in active addiction with much-needed resources.

I also think health departments and state-sanctioned syringe services programs (SSP) can find utility in mailing supplies to areas that aren’t currently served. Mailing things isn’t free, plus, governments that allow SSPs to operate often require them to dispose of participants’ used syringes — mail-based distribution doesn’t lend itself to direct used syringe disposal by such programs.

Like all things in life, mail-based distribution isn’t problem-free. The altruistic distributors who send syringes and other supplies out of state often worry about legal action being taken against them. Some funding sources might not allow organizations to send supplies to out-of-state recipients, either, potentially resulting in loss of funding. There may be other issues, such as safety concerns.

All considered, mail-based supply distribution is a great thing—and something we need more of.

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Uproar Follows Philadelphia’s Supervised Injection Site—But Is It Well-Placed?

Taken from Philadelphia Magazine.

Philadelphia, Pennsylvania, has long been one of the heroin hotspots of the United States. Drug Enforcement Administration (DEA) reports have long indicated that Philly has the highest-quality heroin in the nation.

Philly has been hit quite hard by the opioid epidemic. Fortunately, state and municipal governments in places like New England, the Pacific Northwest, and California have implemented programs and resources designed specifically to help people who use drugs.

The City of Brotherly Love was — was being the keyword — set to break ground on a supervised injection facility, or a facility staffed with medical professionals trained to respond to drug overdoses on Thursday, Feb. 27.

Expressions of disappointment and disdain have littered social media, websites, and forward-thinking news agencies since then. The supervised injection site (SIS) would have been the first of its kind in the United States, becoming the 11th country to implement such a facility, following behind Canada, Switzerland, Norway, Spain, the Netherlands, Germany, France, Luxembourg, Denmark, and Australia.

Yeah, It Sucks, We All Wish Philly Got the Supervised Injection Facility

As fans of harm reduction, drug policy reform, etc., it’s safe to say we all wish Philly would soon be home to the long-planned Safehouse-brand supervised injection site. Wish in one hand, spit in the other — that’s how it goes sometimes, right?

It’s not like Philadelphia is flat out of resources to help people who use drugs. Philly is home to some of the most forward-thinking policies, programs, and ideas related to harm reduction and drug policy reform.

Living in rural Tennessee, home of essentially zero drug-user-related resources, I wonder, where’s the support for expanding such resources here?

Why aren’t people seemingly as worried about equalizing the playing field across the United States instead of building up Philadelphia with a stronghold of drug-user-related resources?

I think trying to take advantage of this “failed supervised injection site” wave of popularity might help spread word of area-specific challenges for rural West Tennessee.

What Resources That Help Drug Users Does Philadelphia Have?

According to the City of Philadelphia’s website, the city’s residents are privy to considerably more valuable resources than other cities’ populations, such as Police-Assisted Diversion, for example:

• People stopped by law enforcement for certain minor crimes (e.g. illicit drug possession, buying controlled substances, prostitution, retail theft) in only the 22nd, 24th, and 39th Districts OR people who ask for help from the police, even if they aren’t reasonably able to be charged with one of the aforementioned crimes are eligible for Police-Assisted Diversion (PAD). Put simply, PAD steers a high volume of people eligible to be arrested for petty crimes away from jail and into “supportive, peer-based social services,” says the Philadelphia Police Department’s website.

Some people have proven themselves to use drugs irresponsibly or in a self-destructive manner. These people, of course — at least if they want what’s best for them, that is — shouldn’t be using drugs. I very much fit this bill — even though I constantly experience problems resulting from my drug use, I still use drugs.

Many long-term drug users struggle to outright quit their drug or drugs of choice when it’s primetime for them to do so. Lasting physical and mental effects can seriously improve the likelihood of bad things happening, such as continuing to engage in criminal activity. People who are forced to kick their dependencies and/or addictions in lockup are highly likely to relapse upon release.

Providing medication-assisted treatment (MAT) to incarcerated populations can reduce violence, improve quality of life, prevent inmates from further accumulating any other charges, and reduce the chance of recidivism upon release. Here’s what the Philadelphia Department of Prisons did with MAT:

• Just over two years ago, the Philadelphia Department of Prisons rolled out medication-assisted treatment in the form of buprenorphine (Suboxone, Subutex, Sublocade), naltrexone (Vivitrol), and methadone. Although officials only tested a small portion of their entire female incarcerated population, now MAT is available for all females who are currently incarcerated in the Philadelphia Department of Prisons.
• Speaking of MAT, the city’s Department of Behavioral Health and Intellectual Disability Services operates an around-the-clock MAT treatment facility in the heart of the city. In some cases, opioid-dependent persons who are unable to secure buprenorphine or methadone maintenance right when they feel they need it most are liable to move back to illicit opioids that, as we all know, are much deadlier than naltrexone, buprenorphine, or methadone.

People suffering from opioid use disorder need to get not just referred, but delivered directly to treatment providers so as to reduce rates of relapse, overdose, and other bad opioid-related outcomes from happening. This concept is known as a warm handoff:

• The City of Philadelphia has long known that people suffering from opioid use disorder are disproportionately likely to end up in hospitals’ emergency rooms. Whether the opioid-dependent people end up there because of overdose, unbearable withdrawal syndrome symptoms, or something else, physicians who are currently in charge of patients with opioid use disorder are now given help by the city to assure that such patients end up directly in the hands of necessary treatment providers — whatever treatments that may be.

We’re all familiar with naloxone, the opioid overdose antidote. Although providing naloxone to a municipality’s or state’s populace is one of the lowest-hanging fruits on the harm reduction tree — this is so because naloxone has no real contraindications, has a long shelf life, requires no prescription many places, and is so highly effective against opioid overdoses — Philadelphia’s distribution of naloxone to its people has proven to be an integral part of its multi-faceted response to the opioid crisis, with naloxone-related programs including:

• Giving everyone who has been released from jail within Philadelphia a naloxone prescription.
• Every month, the city holds a free training event during which anybody can learn how to recognize opioid overdose, how to administer naloxone, and otherwise respond to opioid overdoses.
• Here’s another thing: in many places, first responders are the number-one target of the people, government entities, or organizations that have been tasked with distributing naloxone. However, in Philadelphia, city-wide naloxone distribution targets community members, too, in a major fashion.

I’m Sure Philadelphia and the Quaker State Have More Resources That I Haven’t Mentioned

People who live in Philly are obviously more likely to know about all major drug-user-oriented resources that exist than residents of rural Tennessee.

I picked the aforementioned resources from the City of Philadelphia’s website — in particular, a section titled “The City’s Response” — and am sure I mentioned all the major ones.

However, since I don’t live there and haven’t talked to anybody who does live there, residents of Philadelphia and elsewhere in Pennsylvania may have more resources or programs than I’ve mentioned here.

Now, It’s Time to Explain What’s Available to Us Here in Rural West Tennessee

In August 2019, West Tennessee welcomed its very first syringe services program (SSP), A Betor Way. Although, I suppose, it’s “cool” to say that West TN has an SSP in its jurisdiction, since Memphis is in the southwestern-most extreme of the state, only people who live in Memphis, just outside of its city limits, or within a 15 or 30 minutes’ drive to the Birthplace of Rock ’n’ Roll would even think about sourcing clean, free syringes, naloxone, and other harm reduction supplies from either of the two Memphis-based SSPs.

I live in Martin, about 10 minutes south of Kentucky and an hour east of Arkansas. I’m about 150 miles — two-and-a-half hours’ drive — away from Memphis. Even people who live in the southwestern-most extreme of Northwest Tennessee still are at least an hour away from the city, if not closer to 90 minutes.

Like many states, the Volunteer State distributes naloxone to residents of the state. But who ends up getting the naloxone, and who or what organization gives it out?

About two years ago, the state put 13 Regional Overdose Prevention Specialists (ROPS). They primarily give out naloxone to first responders, law enforcement, and, according to the state’s website, people who are at risk of opioid overdose. ROPS give naloxone out at regularly-held training events that are free to attend.

Here’s the bad thing about ROPS — illicit opioid users are highly unlikely to attend the highly-public, town hall-type meetings.

So, what do we have here in rural West Tennessee? Nothing outside of outdated rehabs, exclusionary 12-step programs, drug courts, and profit-minded probation officers, unfortunately. This also holds true for rural Middle Tennessee.

In Closing

After seeing the rash of people speaking out against Philadelphia canceling its plans to house the supervised injection site, I wondered why people weren’t as worried about expanding ground-level programs in places like rural Tennessee.

That’s all I want — resources and programs that help drug users like me in criminally-underserved rural Tennessee.