Threading the Needle in Canton, GA

When I first read of Pastor Gary Lamb’s desire to bring a needle exchange program to Cherokee County, admittedly, my first thought was, “Holy s***, someone’s actually going to do it.” Then, in a lapse of social medial judgement, I read the comments. Never read the comments.

I have wanted to begin a needle exchange program in Cherokee County for several years. My main concern was whether Cherokee County was ready for a needle exchange program. I know people from this area who sometimes make the trek down to the Atlanta Harm Reduction Coalition (an 80 mile round trip), to exchange used needles for clean. When they can’t find a ride or afford the gas, they make due with what they have, or what they can find.

The first needle exchange program was implemented in Amsterdam in 1983. Within two years, most other industrialized nations had implemented their own programs. The United States was one of two exceptions. As a nation, we were a few years into the crack, “epidemic,” and the war on drugs was being sold as our most important fight (Those fighting the war on HIV were not as fortunate). Our administration was pushing for CIA and U. S. military involvement in interdiction efforts and needle exchange programs were seen as promoting rather than condemning substance abuse and illegal activity. Today, there are needle exchange programs across America, but progress has been slow due to difficulty locating funding and support.

Initially, the official reason for not promoting these programs was insufficient evidence demonstrating effectiveness in reducing disease without increasing crime and substance abuse. Thankfully, today we don’t have that problem. There is no shortage of evidence establishing the effectiveness of needle exchange programs in two important areas: reducing infectious disease and connecting typically hard to reach individuals with mental health, physical health, and substance abuse resources. There is no evidence that providing access to clean needles increases drug use or crime. My impression, however, is that this is one of those arguments that is not responsive to research and information.

Although I am now primarily in a private practice setting, I began my career with a Suboxone/methadone treatment center. I continue to be a tireless advocate for medication assisted treatment, and, through work in that field, I have grown accustomed to two types of arguments typically used in harm reduction debates.

The first type is philosophical, and typically involves deeply held beliefs. In this type of argument, there is often some variation of, “I don’t believe in _________,” or “___________ isn’t right (“right,” usually being some form of, “morally acceptable”).” Because this type of argument involves deeply held beliefs, positions may rest on subjective and often misinformed interpretations of both the issue itself, and what constitutes right and wrong. Notably, in philosophical arguments, whether the initiative actually accomplishes what it set out to do can be irrelevant, as can the question of the rightness or wrongness of the product of the initiative.

A few years ago, I decided to stop engaging in this type of argument. Not because it isn’t interesting, but because, in many applications, the argument is irrelevant to the actual saving or improving of lives, and because arguments involving these types of beliefs rarely result in change of opinion (if inclined to further study, the question is rooted in the ethical theories of deontology and consequentialism).

Deeply held beliefs are extremely resistant to change. In fact, there is a considerable amount of research demonstrating that when a person is presented with information irrefutably contradicting a deeply held belief, not only will that person fail to relinquish the belief, he/she will actually cling to it even more fervently, and the belief will become more entrenched and resistant to change. If you’re interested in finding out why that is, this is one of the best books on the subject.

The second type of argument is an empirical argument grounded in research and application. For example, if someone asked me why I am a proponent of harm reduction initiatives I would say, “I became involved in harm reduction initiatives because research has consistently demonstrated the efficacy of those initiatives. I continue to be involved in those initiatives because each day I see their effectiveness”.

The two types of arguments are themselves examples of what moral philosophy calls, “normative,” and “descriptive,” claims. Normative claims are rooted in ideas of morality and assertions of what is, “right,” or “wrong.” Descriptive claims are simply descriptions of the way the world actually is. Put another way, normative claims describe what, “should be,” and descriptive claims describe what, “is.”

In the “should be,”camp is the idea that dispensing clean needles encourages or enables negative behavior, and resources dedicated to dispensing should be mobilized toward the goal of getting the person, “clean.” That idea reflects a belief in the way recovery initiatives should be, and in a perfect world, would be. The issue we have to get past, however, is that this is not a perfect world, and research has demonstrated again and again that addictive disorders do not respond to prescriptive pressures of what others believe, “should be.”

In the, “is,” camp is the recognition that addiction is a complex behavior that unfortunately does not typically respond well to time-limited, unilateral, abstinence based intervention. In addition, the, “is,” camp recognizes that denying autonomy by coercing people to change in ways they do not themselves choose, typically results in ineffective treatment, if not refusal of services altogether. This refusal (in reality a socially implemented exclusion), results in the individual remaining distant from any sort of ameliorative or palliative care.

In a nutshell, this means that the triumph of moralistic, “should be,” arguments may result in negative outcomes for both the individual and the local community. As a therapist who works daily with addictive disorders, I have witnessed the ease with which proclamations can be issued from a moral high ground, but once down in the trenches the view changes. Providers in the trenches recognize that a good bit of substance abuse treatment is not about recovery; it’s about keeping someone alive for one more day.

If you’re against Preacher Lamb’s idea, and you’ve somehow hung in with me for this long, let me try to paint a holistic picture of how a successful program would work.

First, a needle exchange program is a way to bring people in and provide a needed service. This simple service in fact accomplishes two goals.

1. It is estimated that 20% of HIV cases and over 50% or Hepatitis C cases can be attributed to injection drug use. The lifetime cost of HIV treatment is estimated to be between $400,000 and $600,000 per person. Annually Hep C treatment runs around $25,000 per person. The newest treatment for Hep C (Harvoni) is $95,000 for a 12-week regimen. Much, if not most, of these costs are borne indirectly by taxpayers and health care consumers. In 2005, a CDC study found that needle exchange programs could dispense syringes at an average cost of $0.97 per syringe dispensed.
2. The simple act of bringing people in out of the shadows, and showing kindness and compassion where none existed before, begins to build relationships. My professional opinion, and there are those who disagree, is that addictive disorders are rooted in emotion and attachment. At it’s core, addictive disorders are relational issues. Any positive, non-judgemental interaction is an opportunity for connection.

 

Second, a needle exchange program is a way to educate and help prevent overdose. Georgia Overdose Prevention exists to reduce opioid overdose fatalities through education and advocacy. A large part of their program is the free distribution of Naloxone kits to anyone who wants one. Exchange programs provide a convenient point of access for these kits and, make no mistake, these kits save lives in Cherokee County every week.

Third, a needle exchange program is a means of connecting individuals with services. Testing for HIV and Hep C can be provided along with education and referrals to resources that provide treatment. Volunteer therapists or case managers can be onsite to provide counseling, crisis assistance, education, assessment, and referral to both individual and family resources.

I’d also like to add a few observations from 20 years spent as a drug addict, alcoholic, and criminal. In those 20 years, I never witnessed anyone decide against using drugs already in his/her possession because he/she didn’t have a syringe. If a syringe absolutely cannot be found, there are other ways to use drugs. I never heard anyone say, “Oh well, I don’t have a needle. Guess I’ll throw these drugs away and go to rehab.”

A more likely scenario, is that someone resorts to using a needle that has already been used 5, 10, or 20 times. I have personally witnessed people, “sharpening,” needles on matchbooks, emery boards, car bodies, and even outdoor air conditioner units (basically any hard metal surface that may improve the needle’s ability to achieve the desired outcome).

If one person doesn’t have a needle, however, there is usually an acquaintance who does. After a phone call, needles are being swapped, often appraised and then selected from many within makeshift Sharps containers, usually 20oz soft drink bottles. I’ve personally witnessed attempts to clean needles with Clorox, 409, Windex, Fabuloso, and just plain soap and water (If I’m being honest, I rolled the dice a time or two myself).

There is an often repeated assertion that nothing can be done for addicts until they hit rock bottom and want to get help. That is simply not true.  It can only be true if we continue to support the idea that anything short of permanent abstinence is a failure.  Harm reduction therapy, and all of it’s components, is built on the idea that numerous goals short of abstinence are worth pursuing. It is possible to reduce risk of infectious disease and overdose, achieve a reduction in use or symptom expression, improve emotional or interpersonal skills, provide links to physical and mental health care for co-occurring disorders, or provide links to social support systems.

Another core principle of harm reduction therapy is that each person is the best judge of what is best for him (or her). The best way to discourage people from opening up is to continually pressure them to do what you think they should do. Empathy is the ability to feel and understand another person’s situation from their perspective. It is the cornerstone of all helping professions and the key to establishing trust and building rapport. Heavy-handed, judgement based, abstinence only proclamations are one of the surest ways to ostracize those we’re trying to help.

Instead of labeling people, “junkies,” wagging accusing fingers, and giving them a good dose of, “what you should do,” we can meet them where they are and take what they’re willing to give. Several times over the past few years I’ve heard a client of one of our clinics say, “I’m only going to come here when I can’t find heroin.” I usually reply with, “Bud, that’s great. If that’s all you’re willing to give me right now, that’s ok. We’ll work with it.” At least I know that at some point that young man or woman will be sitting in front of me with access to medical care and support systems. That’s a good place to start, with the hope that we can build from there. Those are the types of people who are generally excluded from treatment. Is the individual and society better off, or worse off, if we deny them the opportunity, however infrequent, to experience something positive and come a little closer to a therapeutic atmosphere?

One of the difficult truths of working with substance abuse clients is that cure is not always possible.  Sometimes only for a time, sometimes for. . . well. . . forever. Some wounds simply will not heal, but if someone is alive, there is always hope.

As a community and as a society, we need to fully consider every initiative that attempts to bring the suffering out of the shadows and into relationships.

Maybe the question we should ask ourselves is, “What happens if we don’t do it.”

I believe the answer is nothing.

Which is exactly what most people are doing now.