The State of Harm Reduction in the South

“The south is intertwined with backward policies about drug use and people from those areas who use drugs especially IV drugs will suffer the consequences because of ignorant politicians and policy makers who think jesus christ will save them from humanities ailments.”

As the “Opioid Crisis” reaches a fever pitch across the United States, there are frequent reminders that no person or areas are immune to its deadly grasp. This includes sleepy Southern States that were previously known  more for rolling hills than pill mills, that is unless you speak with the residents. The dirty little secret of rampant opioid use is now impossible to sweep under the rug. The South is now the epicenter of a public health crisis. Opioid overdose is now the leading cause of preventable death in the United State. West Virginia and Kentucky both make the list of the top five states of deaths per 100,000 residents. Both the rise of Oxycontin, and the increased distribution of heroin into the sleepy centers of every major city has left leaders scrambling to tackle issues that were previously swept under the rug.

The failed “War on Drugs” has pushed society in a place where common sense drug policies were ignored in favor of punitive criminal justice “interventions”. Experts agree that substance use and abuse are a medical issue, not some type of moral failing. There are complex mental health components that influence decision making as well as a physiological cravings that occur as a direct result of repeated ingestion of these substances. Opioids are called “painkillers” for a reason. Not only can they relieve physical pain, their intense feeling of euphoria has been known to alleviate emotional pain as well. It is no surprise that many people that start out taking opioids whether prescribed or recreationally, go on to develop a dependence to them.

“I was picking up yesterday from two teenagers. When we finally got the goods, one of them asked the other for a rig (syringe). What he handed from the backseat was appalling. The needle was practically rounded off, and it was covered in blood. I passed both of them a 10 pack of fresh rigs (syringes) . Couldn't bear to see that happen.” (Texas)

Drug use has been part of the fabric of human history for thousands of years, yet in past decade, experimentation has turned into dependence and death. In the past few years,  clusters of a community can be wiped out in a matter of hours when the powerful opioid fentanyl is added into pressed into copy-cat pills or used to spike the rush of a bag of heroin. Unknowingly ingesting this drug can overpower the system quickly leading to a fatal overdose. Rates of HIV in sections of the country such as Miami have actually increased. The Hepatitis C virus (HCV) kills more Americans than 60 other infectious diseases combined, including HIV and yet this condition has been widely ignored by health professionals. In a recent switch, there has been building momentum around a movement known as “harm reduction”.

Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. The idea is that harm reduction provides education and tools to users of both legal and illegal drugs to improve their health and allow them to make positive, well informed choices. Until recently, harm reduction has been in direct conflict with the prevailing idea that users need to be locked up as a solution for both society and their poor choices. Southern states have traditionally outright banned harm reduction efforts including laws on the books that outlaw programs such as needle exchanges. Possession of an unused syringe without a prescription can lead to a criminal case. Not just for the people that use the services but also for the workers. Conner Adams from the Steady Collective in Western North Carolina explained “most exchanges in North Carolina live with some fear - because it is a Class 1 misdemeanor per syringe for someone over 18 and a Class 1 felony if the person is under 18.” In other words, any employee or volunteer can conceivably be charged for each exchanged syringe. The partnership between harm reduction agencies and public health officials is precarious at best, as these efforts are seen by some as “enabling” drug users. Yet advocates are setting up shop in even the deepest regions of the Bible Belt as locals search for solutions to the deaths of loved ones.

For those seeking assistance beyond the freely available 12 step or religious programming, the situation can be quite depressing. Private clinics that offer opioid replacement therapies such as methadone or suboxone can be both expensive and few and far between. Naloxone, the opioid overdose antidote, has been limited to hospitals. For those seeking education on HIV or Hepatitis C, the era of abstinence only education has created a culture of ignorance. The stigma of being an active drug user creates an insulated culture of isolation that drives users away from doctors and into relying on “junkie folklore” to resolve many common drug related health issues.

As a former heroin user who spent a year living in the South, I have been very interested in how the opioid “epidemic” has impacted various states. Rather than look on my computer to rehash new stories, I asked users to send in first hand accounts from their areas.

Tennessean here. Heroin has just exploded around here in the past couple years; before that, it was relatively rare. And from what I'm told, it used to be all tar, now I've seen plenty of powder as well. Some powder is cut with fentanyl, and some fake pills have floated around too, but overall the fent issue doesn't seem to be as severe here as in the northeast. Meth, crack, and painkillers dominated before then, and still do in some places. There's still a lot of opiate pills along with all the smack, though I'm sure the feds will start really cracking down on physicians eventually, whether or not they're actually doing anything wrong....

Thankfully needles and syringes can be purchased at pharmacies, but it's at the pharmacist's discretion, so some people might end up left high and dry. It's a shame. The state of harm reduction around here is rough, whether rural or urban. Absolutely no needle exchanges, hell, they're actually illegal in this state. They're considered paraphernalia, fresh or used. Though thankfully our neighbor to the north got some sense and started some. I know one dude who drives around giving people clean rigs, cookers, etc. and takes donations. I've seen houses where people had literal piles of used rigs on the floor, or grocery bags full. "I just give it a rinse of water before I use it again," ugh. Hep C rates have skyrocketed, for obvious reasons.

We do have naloxone available now; CVS sells it over the counter; training is available, and people who administer it are protected under a Good Samaritan law. All EMTs are licensed to give naloxone now (used to be only paramedics), and cops carry it as well in some cities”.

In West Virginia, the situation is more dire-

“I live near martinsburg, WV. place is occasionally referred to in the press as "little baltimore" due to the similarly severe opioid problems around. no naloxone is available over the counter as far as i know, i was planning a trip to a cvs in pennsylvania to acquire some. there's a bill to allow OTC sale in WV but it's locked up in the house at the moment...There's not a lot of sympathy for addicts in my circles. Suboxone  is viewed not as medicine but as "government drug dealing," I'd imagine they feel the same way about methadone”.

South Carolina:

“Suboxone and Methadone clinics are bringing in tons of new patients per day. The media doesn't really cover Opioid use in this state. I've only seen a couple news reports...The detox/mental health facilities in this state are all terrible. I've been to 2 of "the best" for detoxing in this state and they were absolutely horrible. ...The staff treat you as though you are sub-human and bark at you and give you orders... They were absolute shit-holes and the food was like left-over prison food, not to mention they strapped sick people down against their will. I'm definitely not going to another one of these "detox facilities".

Virginia checking in:

I'm from Virginia which we still consider the south. Harm reduction is basically nonexistent here while opioid use continues to grow rapidly. Pharmacies won't sell new syringes unless there's proof it's for insulin and narcan can't be purchased without a prescription. We have one methadone clinic in my mid-sized city and it's not worth the hassle for many addicts to go due to the high costs for intake and it's inconvenient location. There are very few suboxone doctors and that too costs too much to enter into a program if you can even get accepted into it due to their long waitlists. There are no rehabs and detoxes available unless you have the money or insurance, many people wanting to detox just go to the local hospital's ER to be admitted to their psych ward, which requires telling them you're suicidal to get in.

Overall there's no easy way to get help here unless you're loaded with money. I've watched heroin use explode locally over the past few years and yet all options for rehabilitation, maintenance, and harm reduction have stayed the same. Strangely enough the only improvements I've seen have come from our city police department. They've developed a program to get help for addicts they've arrested and are the only ones to have sounded off on the growing heroin problem and made an effort to help instead of just prosecute and send people back into the street. The situation here is terrible to say the least.

Alabama

“Clean rigs are about impossible to get unless you know somebody that has diabetes and can get them for you. I'd say 3/4 of the IV users I know all have Hep and in the last 1-2 years HIV is starting to pop up with a few of the younger users (21-25) I know”.

“ I can pretty much 2nd anything... The only "harm reduction" I'm aware of exists in the form of cops, civic leaders and parents having "drug abuse prevention summits" where everyone decries "ain't it terrible???" and they all hold hands and pray it goes away. There's no formal or informal exchange, Narcan is at Walgreen's now - so there's that. .. I think the majority of the population here is too overwhelmed by the magnitude of the problem and too undereducated to know where to even begin to know where to do any good whatsoever. A generation or two will unfortunately be sacrificed before something positive happens, and that's a huge "maybe" something positive will occur.”

Florida

“What is harm reduction? No seriously, there is nothing here.”

Kentucky

“Louisville -if you consider that the south. We have a one or two exchanges, narcan is legal to own "you don't have to be a trained professional" but I rarely hear about it being handed out, don't know if you can buy OTC. Now if you cross the bridge into Indiana (I know it's not the south), watch out. I'm a few weeks away from being a convicted felon, and possibly serve 6 months just for having a goddamn syringe”.

In collecting interviews for this article, one of the most frightening thing as a an advocate working in public health was the overall lack of information. In states that had syringe exchanges or some way to obtain naloxone, users seemed to be painfully unaware of it. While the mainstream media chooses to focus on the sensational elements of the Opioid “epidemic”, prevention services are lucky to get a small feature in a local media paper. Here is a comprehensive map of services and list of resources.

Insert Map here:

How to find naloxone:

http://www.overdosepreventionalliance.org/p/od-prevention-program-locator.html

How to find a syringe exchange:

www.nasen.org

Harm Reduction Agencies working in Southern States

• North Carolina Harm Reduction Coalition
• Macon County OD prevention (NC)
• Streetwork (Nashville, TN)
• Atlanta Harm Reduction (Atlanta, GA)
• Mississippi in Action (Jackson, MS)
• Women With A Vision (New Orleans, LA)
• The Ordinary People Society-TOPS (Dotham, AL)
• Asheville Recovery Group (Asheville, NC)
• Austin Harm Reduction Coalition (Austin, Tx)
• Urban Survivors Union (Greensboro, NC)
• Suncoast Harm Reduction Project (FLA)
• NAMA Recovery of Tennessee (TN)
• The Steady Collective (NC)
• Georgia Overdose Prevention (GA)
• Texas Overdose Naloxone Initiative (TX)
• Tennessee Overdose Prevention (TN)
• Radiant Church, Fayettteville (NC)
• People Advocating Recovery in Northern Kentucky (KY)

"The struggle" outside of Memphis