What Will the Anti-Overdose Drug Do for the Secret Needle Exchanges of the South?


The following article first appeared on Substance.com:

Every fourth Saturday, Alexander,* a tall, transgender 25-year-old, leads a team of volunteers to Raleigh’s notorious East Side, a place where poverty, crime and drugs collide. His motley crew of half a dozen current and former drug users, transgender people and college students hands out free condoms on street corners. They do short, on-the-fly trainings on drug overdose prevention and provide free rescue kits containing naloxone, a medication that reverses opioid overdose. And if people ask, they will furnish clean syringes for injection drug users–even though needle exchange is illegal in North Carolina.

Alexander has run a secret exchange since 2010, providing people who use drugs and transgender people with sterile syringes so that they won’t share used ones and potentially transmit disease. He and his team typically help 100-150 clients a month, operating under the harm reduction philosophy of “meeting people where they are at” in their drug use to encourage positive change. It’s a controversial practice in a Southern state where the public is quick to accuse anyone offering such services of “enabling” drug users.

North Carolina is home to five underground needle exchanges, and at least nine others exist throughout the South. In Florida, Georgia, Louisiana, Tennessee, Arkansas, Mississippi and Texas, harm reductionists are quietly distributing needles out of mobile units, vans, cars, garages—even from bicycles—because they believe it’s the right thing to do.

Recently attitudes in the South have started to shift. A burgeoning prescription drug crisis and the recent resurgence of heroin has forced public officials to rethink their hardline stance on drugs and even to grudgingly embrace some harm reduction practices—notably, providing naloxone to people who use drugs. The changes have allowed harm reductionists like Alexander to distribute the medication widely, and it has reversed over 115 potentially fatal overdoses in North Carolina alone over the past year. This surge in naloxone distribution has naturally led to greater contact with injection drug users and booming business for Alexander’s clandestine syringe exchange.

“Naloxone opens many doors,” says Alexander. “People who use drugs always have to be hyper-conscious of criminalization and stigma whenever they access any kind of service, so knowing that [naloxone] is safe and legal puts people at ease. Naloxone programs can provide people a safe starting point to engage in more open conversations about their health and choices, like seeking out and using clean needles, regardless of whether that is legal or encouraged.”

Ryan, a 35-year-old injection drug user from Garner, North Carolina, hadn’t heard of harm reduction or needle exchange until a friend told him about naloxone last month. Ryan immediately sought out a rescue kit from the North Carolina Harm Reduction Coalition and within days had used it to save a friend who had overdosed on heroin. “I’m glad I connected with the organization but I wish I had known about them sooner,” he says. “I could have saved a lot of people with naloxone.”

Naloxone (or Narcan) works by temporarily blocking the effects of opioids, such as prescription pain relievers or heroin. Opioid drug overdose causes respiratory failure, and naloxone restores a person’s breathing long enough for help to arrive. It’s so effective and easy to administer that across the country, over 10,000 laypeople have used it to reverse overdoses. Today approximately 250 community naloxone programs exist in 28 states that provide naloxone directly to active drug users and their loved ones. There’s also a rapidly growing effort to ensure that first responders such as police officers are equipped.

Kentucky offers a prime example of how naloxone’s sudden popularity has paved the way for conversations on harm reduction that were previously unimaginable in the South. Just a year ago, no formal harm reduction program existed in the state, though a few scattered advocates had been trying unsuccessfully to start one. Last year they finally had a breakthrough when a team of pharmacists, health care workers and doctors agreed to help them prescribe naloxone to parents of children who were at risk for opioid overdose. The new program has distributed over 100 kits and parents have already reported using them to reverse opioid overdose in their children. Kentucky advocates are now capitalizing on their new connections with the medical community to start conversations on other alternative health programs.

“Community naloxone programs are helping doctors and healthcare professionals to understand more about harm reduction,” says Kentucky harm reductionist Jason Merrick. “We even have a couple of physicians advocating for syringe access now because they see that with the recent increase in injection drug use, we are going to see an increase in hepatitis C and HIV as well if we don’t do something about it.”

It’s not just doctors who are rethinking their stance on harm reduction thanks to naloxone. Law enforcement and politicians are starting to talk about it positively, as are other groups and institutions with a history of hostility towards harm reduction .

“Abstinence-only treatment centers are starting to get involved [in harm reduction] because they want to reduce the risk of overdose in their clients,” says Texas harm reductionist Mark Kinzly—some centers are handing out naloxone to their graduating clients in case of relapse. Kinzly helps run a program in central Texas that distributes half a million syringes a year out of a mobile unit. Though syringe exchange is illegal in Texas, the local police have tolerated the exchange for over two decades because it helps to reduce the burden of disease in the community. Earlier this year Kinzly’s program added naloxone to its list of services and is already starting to serve many new clients.

While the flood of new converts to harm reduction is encouraging, some advocates see signs of trouble. Naloxone programs have created or boosted syringe access initiatives in some areas, but most of naloxone’s new proponents still conveniently ignore the fact that community naloxone programs actually originated from needle exchange.

The Chicago Recovery Alliance is credited with being the first organization to distribute naloxone directly to people who use drugs, and they did it by distributing to clients in an existing syringe exchange program. Since that first program launched in 1996, others have duplicated its success, also utilizing syringe exchange to get naloxone to people at high risk for overdose. Only recently have the two ever started to separate. Naloxone programs are now popping up independently—and many of those who run them are staunchly against needle exchange. It’s a major concern to some who fear that this new wave of “harm reduction lite” has strayed too far from its roots.

Kevin Irwin, a former Yale researcher and harm reductionist who now works in supportive housing in New Hampshire, says, “It’s exciting to have people talk about drug health in a positive way, but we can’t be afraid to talk about where community-based naloxone access came from. It came from syringe exchange programs and the idea that drug users care about their health and are good at acting on behalf of their own health.”

Naloxone programs and syringe exchange are both community interventions based in the belief that drug users can and do make positive health choices. So why is naloxone so popular, while syringe exchange remains illegal in most states? (A ban on federal funding for needle exchange programs also remains in place.)

“There is a sense of urgency around the drug overdose crisis, so people are more willing to try new things,” says Irwin. “To be cynical, people see white, middle class people dying of drug overdose and that spurs them to act. Combine that with a weakening belief in drug prohibition and we are starting to see national conversations around harm reduction that never would have been possible before.”

Irwin adds that arguably, it is harder for people to make moral arguments against naloxone because the consequence of drug overdose is death. On the other hand, the consequences of sharing syringes, hepatitis C and HIV, are easier for the public to dismiss as “deserved.” It’s another challenge for harm reductionists as their influence continues to grow: convincing the public that syringe access is just as important as overdose prevention. Most activists hope that the dialogue will also lead to bigger questions such as, why do people use drugs? And how can society respond to that without creating more problems with mass incarceration, widespread disease and death, and users who are stigmatized, criminalized and marginalized?

Alexander warns that as these conversations start to shift public policy, it is important for harm reductionists to stay true to their values. “I don’t want the harm reduction movement to lose sight of what motivated many of us to do naloxone access work before it was legal or fashionable,” he says. “Our belief in the rights of drug users, people of transgender experience, sex workers, etc. to dignity and self-determination around their health choices. I believe if we stay grounded in these core motivations, they will carry us forward to more positive change.”

This is a time of excitement and growing pains for the harm reduction movement. Naloxone has opened many doors. But we still have to decide which to walk through.

*Name has been changed.

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