With naloxone access programs, two Arkansas groups are trying to put the overdose reversal drug in the hands of people who need it.
Central Arkansas Harm Reduction Project and a partner organization, The Matt Adams Foundation for Opioid Recovery, now are operating naloxone hotlines in the central and northwest areas of the state, which anyone can contact to ask for a free naloxone kit. The kits include the medication, tools to administer it and instructions.
It's part of a strategy called harm reduction, whose proponents argue that drug use is a fact of life but injuries and deaths shouldn't be.
Advocates work to mitigate danger from behaviors such as substance use or sex work, viewing related issues -- for example, HIV or hepatitis C spreading via shared syringes -- through the lens of public health.
"I try to talk about [naloxone] in a way that normalizes it ... 'You should have this, because anybody around you could be using,'" said Mackenzie Bolt, an organizer with Central Arkansas Harm Reduction Project.
"I do think that a lot of people are realizing that if we don't take a harm reduction approach, more people are just going to die."
Harm reduction strategies have gained traction nationally in the wake of widespread opioid abuse, which has sparked infectious disease outbreaks and an opioid-related overdose death crisis that killed more than 47,000 Americans in 2017.
The approach isn't new. Similar programs in the United States date back to at least 1988, according to a white paper by the nonprofit Center for Innovative Public Policies, but recently it's attracted more notice from public health professionals.
Some government health agencies, such as the Maryland Department of Health and several local health departments in West Virginia, have experimented with harm reduction tactics.
Such services generally are offered for free or via a sliding scale and can include testing drugs for contaminants, HIV screening, condom distribution, naloxone training and distribution, and syringe exchanges -- in which people swap used syringes for new, sterile ones. (The latter is prohibited in Arkansas.)
Advocates say it's a more realistic and humane approach to social problems, chipping away at stigma and acknowledging systemic factors, like poverty, that contribute to drug use.
"We can't separate [substance use] from the pressures that are put on people to survive," said Clay Kasper, founder of Central Arkansas Harm Reduction Project.
Both Arkansas groups doing harm reduction work around opioid addiction are small, volunteer-run organizations founded after organizers' personal experiences with overdose deaths.
Central Arkansas Harm Reduction Project was started by Kasper with a friend in 2017 after seeing heroin use in her peer group and being in "social proximity" to several fatal overdoses.
The Matt Adams Foundation for Opioid Recovery, which began adding harm reduction to its work in March, honors Matt Adams, who accidentally overdosed in 2017 after two years of sobriety.
Heather Starbuck, Adams' fiancee, and Brittany Kelly, his sister, are among its co-founders.
Organizers from both groups spend part of their time approaching bars, churches, shelters and other gathering places to offer naloxone, which they've used donations to purchase from manufacturers, to add to first-aid kits.
They provide educational materials, such as a flyer that identifies the symptoms of an opioid overdose: loss of consciousness, slow or interrupted breathing or pulse, choking or throwing up, and blueish or grayish skin or fingernails.
They also meet with people directly, offering naloxone kits with no questions asked to people who contact their hot lines. Those meetings are confidential and "judgment-free," Kasper said, meaning they don't involve coercive conversations about sobriety.
Since starting naloxone distribution this spring, The Matt Adams Foundation for Opioid Recovery has given away close to 400 kits.
"It's booming, we have not slowed down. People need it," Kelly said.
"Until the system catches up with this epidemic, we need to keep people alive," added Starbuck.
Arkansas' prevalence of opioid use is high, with U.S. Centers for Disease Control and Prevention data noting the state as having the second-highest rate of opioid prescriptions in 2017. In the state, 188 people died from an overdose involving opioids that year.
Naloxone has been available through pharmacists in Arkansas since 2017, and several recent initiatives and grant programs have made it more widely available to local law enforcement agencies and to first responders.
Organizers from the harm reduction groups, while supportive of over-the-counter availability and state-run naloxone programs, say that access may not go far enough.
They point out that the drug can be relatively expensive -- averaging about $142 retail for two doses of naloxone nasal spray, according to a December presentation from a U.S. Food & Drug administration official -- and that people who are involved in drug use may not want to call on police.
"When it comes to the overdose crisis, the first responders are going to be the people who use drugs ... and their friends and family," said Kasper.
Health officials have linked the recent national uptick in overdose deaths to the presence of fentanyl in street drugs such as heroin and cocaine. The synthetic opioid can be as much as 100 times as powerful as morphine.
For harm reduction advocates, fentanyl upended calculations about the riskiness of substance use.
"People have always been using drugs, but now our drug supply is tainted," said Bolt.
The groups say they've received a largely positive reception from individuals and organizations they've approached about naloxone distribution.
That's ranged from enthusiasm from a bouncer, who said he had wanted to carry the overdose reversal drug while working on Dickson Street in Fayetteville, to emotional receptions from people who have lost loved ones to overdoses.
They do sometimes run into resistance, which they connect to a broader stigma around people who use drugs. Kasper has encountered people who say harm reduction work is "enabling."
But she said the alternative is to stand by and let people who use drugs die, "which is horrible."
She works hard to make sure volunteers aren't holding on to similar beliefs, observing that there are plenty of well-accepted resources for people with alcohol issues.
"There's so few people who are stood up for less than people who use drugs in illicit ways," she said.
A SOUTHERN SPREAD
Historically, harm reduction groups have been more prevalent on the west and east coasts than they have been in the South, but the Arkansas groups are part of a scattering of related organizations in the region.
That includes harm reduction groups in Tennessee, Louisiana and South Carolina, among others.
Between 2012 and 2015, Kentucky Harm Reduction Coalition founder Donald Davis estimates that the number of people using opioids in that state grew twenty fold, especially in rural areas.
The group, which began as a naloxone training program in Louisville, now works across the state and has done trainings at sites such as Catholic high schools and auto plants, where people would sometimes overdose on the job.
It is now receiving state support, purchasing naloxone with funds specifically allocated for that purpose from the local health department.
"People found out we were doing naloxone training, they would call us and ask, oh, can you come to Bowling Green? Can you come to Elizabethtown?" Davis said.
Kentucky also has numerous syringe exchange sites, which Davis attributes in part to a high number of local counties that are at high risk of an HIV outbreak.
Russ Read, another founder of the group, links a recent plateau in overdose deaths in the Bluegrass State to an increased harm reduction presence.
He says the group has garnered some support from fiscally conservative politicians, who note the high price tag of a lifetime of care for a person who has HIV.
"Some of them are looking at that, and then accepting [harm reduction]. And then you still have some people that don't accept it," he said.
"[I tell them] 'You're absolutely right, we are enablers.' We're enabling people to live, we're enabling people to get another chance."
In Georgia, executive director Dr. Mojgan Zare said Atlanta Harm Reduction Coalition is "in the trenches" working on health and wellness, especially for people who already have or are at risk of contracting HIV, hepatitis and sexually transmitted infections.
Earlier this year, their work expanded to include a syringe exchange after the Georgia legislative session yielded a law legalizing the service.
"We meet people where they are, understanding that substance abuse is probably always going to be an issue, because there's so many factors around it," Zare said.
"We cannot have the expectation that everyone become sober [before receiving help]."
She acknowledges an uphill battle in terms of public acceptance of the group's programs, mentioning a recently published study that found a majority of Americans opposing harm reduction strategies, such as safe injection sites (places where people can use drugs without fear of arrest) and syringe exchanges.
More education about harm reduction is needed to change minds, she said.
Zare encouraged new harm reduction groups to accept offers of technical or operations help, as organizations run by volunteers often lack experience writing grants, doing accounting work or increasing their access to unrestricted funds.
She said the appearance of such groups in Arkansas was encouraging.
"It's very exciting that they're there, and it's very needed, so I wish them a lot of success in their route," she said.
NEXT STEPS
There's some recent evidence that favors harm reduction-type programs.
A 2017 paper looking at a safe injection site in Vancouver, Canada, found declining HIV infection rates, a falling rate of overdose mortality in the immediate area and fewer ambulance overdose-related ambulance calls.
In a study published this month in The Journal of the American Medical Association, researchers linked broader naloxone access laws, especially the empowerment of pharmacists to prescribe it, to statistically significant decreases in fatal overdoses.
However, naloxone isn't the end of the work that the Arkansas harm reduction groups have in mind.
As well as offering free condoms and fentanyl testing strips, Kasper and Bolt say Central Arkansas Harm Reduction Project organizers are working toward having a mobile outreach unit and are interested in starting a 24-hour drop-in center.
In the future, Kasper wants to expand Central Arkansas Harm Reduction Project's geographic reach to include the entire state, as well as step up its focus on sex workers and formerly incarcerated people, who are vulnerable to overdose after detoxing in jail.
She's also looking toward legislative advocacy around issues such as HIV decriminalization, needle exchanges or safe injection sites.
"I don't know how long it will take us to get to the point where we can do something like that, but it is the goal," she said.
The group also is in initial talks with an Arkansas Department of Health branch about collaborations, a spokesman confirmed.
Starbuck and Kelly say they want The Matt Adams Foundation for Opioid Recovery to add naloxone to most area first-aid kits, but they also hope to someday offer funding for residential treatment for people experiencing addiction.
They say one overall goal of their organization is to change the frequency and tenor of conversations around addiction, especially within families who find the subject difficult to discuss.
"We want to change that -- we want people to talk about it," Kelly said.
"It's not a reflection of the person struggling in any way, shape or form. Addiction doesn't discriminate. It could affect anybody."
A Section on 05/28/2019