H A R M R E D U C T I O N C O A L I T I O N   F A L L 1 9 9 9   N O . 9

H A R M R E D U C T I O NC O M M U N I C A T I O N

BY ANONYMOUS

The last time I over-dosed I was revived

with Narcan. While itwas a terrifying experi-ence, I am extremelygrateful to both theperson who found meand the paramedic whosaved my life. I over-dosed because I usedtoo much dope in tooshort a time period,and because I hadtaken a large quantityof viks, percs and ben-zos1 within the last 24 hours. Even as I didrepeated shots, I knewI was using too much.But at the time thatfact was irrelevant; themost important thingto me was to get out ofmy head! Looking back,I can say that I wasstupid, acted irrespon-sibly and put a lot ofpeople at risk for get-ting busted, or havingto deal with a deadbody upon arrivinghome. But that’s in ret-rospect.CONTINUED ON PAGE 9

2

H A R M R E D U C T I O N C O A L I T I O NAllan Clear, Executive Director

Danine Hodge, Director of Finance & AdministrationDonald Grove, Director of Development

Suzie Ko, Assistant to the Executive DirectorAlvaro Arias, New York Office Manager

Nankhat Felock, California Programs Assistant Chris Lanier, Director of Community Organizing

Andre Robertson, California Programs CoordinatorPaula Santiago, National Community Organizer

Teresa Vega, Community Organizing Systems ManagerDon McVinney, Director of Education & TrainingVanessa Brown, National Training CoordinatorAmu Ptah, Assistant Training CoordinatorMaria Quevedo, Administrative Director of Training-CaliforniaAlessandra Ross, Staff TrainerEdith Springer, Senior TrainerPaul Cherashore, Resources & Publications Coordinator Orlando Roman, Treatment Advocate

Main Office 22 West 27th Street, 5th floor, New York, NY 10001, tel.212.213.6376 fax.212.213.6582, e-mail: hrc@harmreduction.orgWest Coast Office 3223 Lakeshore Avenue, Oakland, CA 94610, tel.510.444.6969 fax.510.444.6977, http://www.harmreduction.org

he Harm Reduction Coalition (HRC) iscommitted to reducing drug-related harmamong individuals and communities by initiatingand promoting local, regional, and nationalharm reduction education and training,resources and publications, and communityorganizing. HRC fosters alternative models toconventional health and human services anddrug treatment; challenges traditional

client/provider relationships; and provides resources,educational materials, and support to health professionals anddrug users in their communities to address drug-related harm.The Harm Reduction Coalition believes in every individual’sright to health and well-being as well as in their competencyto protect and help themselves, their loved ones, and theircommunities.Editorial PolicyHarm Reduction Communication provides a forum for theexchange of practical, “hands on” harm reduction techniquesand information; promotes open discussion of theoretical andpolitical issues of importance to harm reduction and themovement; and informs the community through resourcelistings and announcements of relevant events. HarmReduction Communication is committed to presenting the viewsand opinions of drug users, drug substitution therapyconsumers, former users and people in recovery, outreach andfront-line workers, and others whose voices have traditionallybeen ignored, and to exploring harm reduction issues in theunique and complicated context of American life.Since a large part of harm reduction is about casting a

critical eye toward the thoughts, feelings, and language wehave learned to have and use about drugs and drug users,Harm Reduction Communication assumes that contributorschoose their words as carefully as we would. Therefore, we donot change ‘addict’ to ‘user’ and so forth unless we feel thatthe author truly meant to use a different word, andcontributors always have last say. The views of contributors to Harm Reduction Communication

do not necessarily reflect those of the editorial staff or of theHarm Reduction Coalition. Any part of this publication maybe freely reproduced as long as HRC is credited.Editor: Paul CherashoreGraphic Design: Dolly MeieranPrinting: Alpina Printing, NYC© HRC 1999

tOverdose! by Anonymous . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Letter from the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

After the Fall by Gale Miklo . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

New Jersey: A Grassroots Groundswell by Chris Lanier . . . . . . . .6

Understanding Heroin Overdose by Kristen Ochoa, et al . . . . .10

Rescue Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Heimlich Maneuver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Naloxone Availability: Yet Another Positive Change by Dan Bigg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Naloxone Availability: Not a Silver Bullet by Robert Swarner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Drug Users Tools of the Trade by Ro Giuliano . . . . . . . . . . . . . .18

Turning Blue by Dante Brimmer . . . . . . . . . . . . . . . . . . . . . . . .24

Witches’ Brew by Donna Odierna . . . . . . . . . . . . . . . . . . . . . . .26

On the Ground by Delaney Ellison . . . . . . . . . . . . . . . . . . . . . .28

Gimme Shelter: Drug Users Need Housing by Sandra Fuentes and Daliah Heller . . . . . . . . . . . . . . . . . . . .30

Cover illustration by Eleanor Herasimchuk, reprinted fromJUNKPHOOD PRESENTS: THE UFO STUDY

Please write in with your comments, feelings, responses—wewant to hear from you. Send them to: The Editor, Harm Reduction Coalition, 22 West 27th Street,5th Floor, New York, New York 10001, hrc@harmreduction.org

H A R M R E D U C T I O NC O M M U N I C A T I O NF A L L 1 9 9 9 N O . 9

This issue of Harm Reduction Communication isdedicated to the memory of Angela Daigle, 1973-1999

“W hen I make the choiceto use by myself, it isusually because I want

to get as high as I can and not have to beaccountable to anyone, or it means Ihave a habit—which would make it phys-ically impossible to use with someoneevery time I do a shot. It is not because Iwant to kill myself, and not because Idon’t understand how to avoid overdos-ing, but because I am depressed and be-cause I am bored. For a lot of people, Iknow it is either deeper than that, or itisn’t. Some people are on a suicide mis-sion every time they use. Others justwanna get off.” It is this description of the drive to

use, from the cover article, an anony-mous account of the author’s overdose,that resonates for me—not the psycho -babble and judgments of physicians andpsychotherapists, researchers, and socialworkers, public health officials and poli-cy makers. And I assume for most users,it is as simple as the above sentence,“Others just wanna get off.” I remember the subject of overdose

coming up at HRC’s Second NationalHarm Reduction Conference. I said then

that it was a kind of litmus test; if peoplein the movement really cared about thelives of users they would be addressingthe issue. Communicable diseases im-pact all of us, but overdose kills onlydrug users. There does seem to be a crit-ical mass of interest coalescing aroundoverdose prevention and response: a fewgrass roots agencies around the countryhave begun devising strategies for ad-dressing what had been up to very re-cently a silent problem, and a majorconference on overdose convenes inSeattle on January13th.This issue of the Harm Reduction Com-

munication focuses on the subject of over-dose, particularly opiate-induced ODs.In addition to the cover article (anony-mous) there is Dante Brimmer’s not-so-anonymous OD story, Kristen Ochoa andcolleagues’ overview of the heroin over-dose problem, Dan Bigg and RobertSwarner’s arguments on the pros andcons (respectively) of distributing nalox-one (aka Narcan) to users and Ro Giu-liano’s instructions on how to use it,along with a great deal of practical infor-mation to assist users in responding toheroin overdoses. Why the emphasis on opiate-induced

ODs? Because opiate ODs are eminentlytreatable, are usually more apparent asoverdoses when they do happen and be-cause they appear to be more approach-able as a topic than other types of drugODs, especially among heroin usersthemselves. As Kristen Ochoa and hercolleagues point out, the topic of drugoverdose has until recently received littleattention. In the US, when the issue doessurface, it is usually centered on heroinoverdose, possibly due to the fact thatheroin ODs often come in clusters,which can make for dramatic news cov-erage. Our approach is pragmatic here;given the opportunity to address theproblem of heroin ODs, we must re-spond. Tackling one type of overdosewill make it easier down the road to takeon another. In fact, we want our readersto take this information and modify it tosuit their own situations, whatever drugis being used. What counts is saving lives.If you want to create effective over-

dose prevention and response programs,you must do as Delaney Ellison suggestsin the first installment of his new On theGround column, “ask the experts”—theusers we see day in and day out. Other-wise, such programs will wind up justbeing further examples of “the narcoticsof self-serving political agendas”….thoseof the other “experts,” the well paidones. This is the responsibility we harmreduction providers agree to take on—working with users to take the strategiesthey use to survive, and converting theminto effective services that can be dupli-cated by other providers or made readilyavailable, as is, to other users. So whenthe “official” experts get together to for-mulate a planned response to this long-neglected killer, overdose, we must bevigilant to ensure that they don’t com-plicate things in their zeal to appearpolitic or scientific. If they do so they runthe risk of devising programs that are in-effective at best and life-threatening atworst, and if we sit back, proud of our-selves for just getting overdose on theagenda, then we become complicit inthe creation of misguided and danger-ous policy.

On a different note, HRC has under-gone a few staff changes. Sara Kershnar,well known to many and one of HRC’soriginal two staff members, has movedon to collect her Masters in PublicHealth from Harvard. We wish her muchluck and love. She’ll be sorely missed. Wewelcome Don McVinney as the new Di-rector of Training and Education. Don isa top rank professor, educator, clinicianand hard core harm reductionist. Wealso welcome Amu Ptah, Alvaro Arias,Nankhat Felock and Maria Quevedo (seethe masthead for their respective posi-tions). Allan Greig has also left his parttime post as editor of Harm ReductionCommunication. This is my first issue re-placing him, and it’s been a trip. I hopeyou enjoy it.

—Paul Cherashore

3

DISCLAIMER HRC has included fiveinstructional pieces on overdose response: two areplanning tools—Calling 911 and Make a Plan— andthree are instructions for reviving an overdosedindividual—Drug Users’ Tools of the Trade (includingMeasurement Math), Rescue Breathing andHeimlich Manuever. Although some of the materialhere describes possible responses to specificmedical situations, HRC is providing this material forinformational purposes only. HRC distributes it withthe understanding that we are not in the business ofrendering medical, legal or other professionalservices, and we believe that it is always best toseek professional medical help in the event of anoverdose. That said, we also understand that untilusers are able to call 911 without fear of arrest orother repercussions, they will continue to avoiddoing so. Although the resuscitative material herecannot be a substitute for training received fromprofessionals, until such training is universallyavailable it may be the best we can offer. In themean time, ask your local needle exchange programto set up an overdose prevention/response course ifthey don’t have one, or contact your local red crossor health department for CPR training.

Thanks to Dan Bigg for use of material thatappears in Make a Plan, and Van Asher and TheLower East Side Harm Reduction Center formaterials appearing in Rescue Breathing andHeimlich Manuever.

letter from the editor

4

BY GALE M IKLO

New Brunswick, N.J. here, trying togive you a perspective after thefall of the Chai Project’s needle

exchange program on September 29,1998. I’m writing not only from thepoint of view of an injection drug user(IDU) but also from that of a programparticipant, supporter and member ofthe Chai Project’s staff as a peer educa-tor/street outreach worker. It’s funny,looking back now on the police raid, onthat particular Tuesday evening, realiz-ing how naive and complacent we hadbecome.Diana, our Executive Director, and I

were sitting on the back of the Chai Pro-ject’s van shootin’ the breeze, paying noparticular attention to the streets. Sud-denly, out of no where, a dark nonde-script van pulled diagonally across ourpath, and men jumped out, shouting,“this is a raid, don’t move, put yourhands where we can see them.” It wasn’tthe local New Brunswick police butrather Middlesex County Prosecutor’s

Office Narcotics Task Force detectives.Oh, and one New Brunswick police offi-cer just to cover the bases. Talk about arude awakening.We had become all too comfortable in

our situation. After all, here we were op-erating an illegal syringe exchange pro-gram out in the open. We even advertisedthe locations of our exchange sites, spec-ifying the days and/or nights and hours.The local police had been aware of ourservices for quite some time (years, infact), plus we’d been receiving a lot oflocal and statewide press including somenational media coverage as well. MichaelBeltranena, New Bruns wick’s Director ofPolice Services, had gone so far as tomake a statement to the press expressinghis admiration at our efforts and deter-mination to save the lives of a segment ofNew Jersey’s population that is usuallydiscounted, discarded and totally dis-missed. This irritated the hell out of ourillustrious governor, Christie Todd Whit-man, to the point where she “targeted” usfor extinction (sounds archaic, doesn’tit?) and she succeeded—to a degree—by

shutting down our needle exchange pro-gram. However, much to her chagrin, wereceived a plethora of press, 95% of it inour favor. Even her own appointed AIDSAdvisory Council came out in favor of sy-ringe exchange.The negative effects of New

Brunswick’s loss of the exchange pro-gram are truly sad and disheartening.Within one week, IDUs were sufferingthe results of Whitman’s revenge: theywere out of clean syringes and sharingwith other IDUs. Within one month theywere picking used and dirty syringes upoff the ground and using them. By thistime their syringes were so old, dull andbent that they were not only causing ab-scesses, they were breaking off in users’arms, too. Within a couple of months,Diana received a request for collabora-tion from the Police Director’s Office. Itseems that the streets, alleys, vacant lotsand even backyards of New Brunswickwere littered with discarded syringes.This was never a significant problem be-fore—in the year prior to our being shutdown, we took in approximately 47,000used syringes for proper disposal. SinceWhitman had us shut down, we’re nolonger able to operate in this capacity;therefore most of the used syringes endup reappearing in New Brunswick,whether it be in the streets, the parks, va-cant lots or even in the river. There is cur-rently no way to properly dispose of themwithout risking arrest and prosecution.The Chai Project agreed to help—afterall, our business is harm reduction—goout into town, with a police escort, toclean up in and around the city’s local“hotspots.” Once wasn’t enough, so thisis something we still do with police co-operation.The risk to the everyday, average citi-

zens’ children caused the establishmentto look for a possible solution to the sy-ringe disposal problem. But neither thepoliticians nor the public gives a damnabout the user, or how the exchange pro-gram’s closure affects us. Nor do theycare that our lives are more at risk nowthan ever before, or that the lives of ourfamilies and children are also affected.Our lives and those of our childrenmean nothing since we are just “drug-gies.” This monthly clean up is not a solu-

AFTER THEFALL

5

tion; it’s part of the problem. If syringeexchange programs were allowed to op-erate as before, IDUs would have accessto clean, sterile syringes. This has beenproven to cut the transmission rate ofAIDS and hepatitis. Used syringes wouldonce again be properly disposed of in la-beled hazardous waste containers, thusreducing the risks to the community andits residents. It would also eliminate theillegal sales and distribution of syringeson the streets, making our streets, parksand yes, even our own backyards, saferand cleaner.Implementing the return of the (Chai

Project’s) needle exchange program isreally the only feasible answer. Unfortu-nately, sad to say, that’s not going to hap-pen anytime soon, at least not as long asChristie (a/k/a Witless Whitman) re-mains in office. She’s condemned us all,not only the drug users but the families

and the community of New Brunswickalso, to risk exposure to a long, lingeringillness almost always ending in death.I’m sorry to say this, but she’ll never un-derstand until AIDS hits her family. Justbecause they’re not IDUs doesn’t givethem any special immunity. I hope andpray her family stays healthy and safe.Why can’t she do the same for ours? n

The impact of this story would be more dra-matic if it ended with the Chai Project discon-tinuing services. Thanks to the dedication ofour staff and participants, nothing could befurther from the truth. The New Jersey AIDSPartnership has funded a peer-based outreachproject targeting women at high risk for sexu-ally transmitted infections and HIV. Supportfrom the Tides Foundation helped us to estab-lish a community organizing group that hasas one of its goals the utilization of partici-pants’ networks to disseminate information

and supplies. (Indeed, it was the efforts of themembers of this group that made the April 29,1999 Trenton rally in favor of syringe ex-change a success. They recruited more than 50rallyers, and several spoke publicly about theirown drug use, their HIV status and the im-pact the injection-related AIDS epidemic washaving on their families and communities.)The Chai Project is still a struggling, grass-roots organization. It has continued to sur-vive and in some ways we are doing betterwork than ever before. However, the results arestill devastating; despite everyone’s best efforts,drug users in New Brunswick are, again, atvery high risk for needless and preventable dis-ease and injury. —Diana McCague

Executive Director, Chai Project

Gale Micklo is full-time Junkie, part-timeHooker, Peer Educator, Outreach Worker andPrevention Case Manager. She has been withthe Chai Project for two years

Within one week, IDUs were suffering theresults of Whitman’s revenge: they were outof clean syringes and sharing with others.

EXECUTIVE DIRECTOR SOUGHT

Harm Reduction Services of Sacramento, CA, isseeking a qualified person to direct agencyactivities. Must advocate for harm reduction.

© Master’s degree in health, mental health,psychology, or social services preferred.Progressively responsible experience maysubstitute.© Demonstrated experience in related healthor social services program administration.© Experience in administrative and businessmanagement including planning, budgeting,accounting, and personnel.© Experience working with a governing board.© Excellent written and verbal communicationskills. Demonstrated success in grant writing.© Knowledge of drug treatment programs andthe criminal justice system.

Send Letter of Interest and Resume to:Executive Director Ad1400 S Street, Suite 100Sacramento, CA 95814

(Please include salary requirements in yourletter.)

WE WANTYOUFORHRC MEMBERSHIP

Becoming a member of the Harm Reduction Coalition is one of the most significant ways youcan support our organization’s work and mission. As a coalition of harm reduction practitioners,providers, and consumers, HRC draws its strength, diversity, and expertise from the nationwidenetwork—people and organizations like you—that is HRC. As a member, you will receive regu-lar reports about HRC activities and events; a one-year subscription to Harm Reduction Com-munication; and discounts on HRC conferences, trainings, publications, and merchandise. Sodemonstrate your support of harm reduction and the Harm Reduction Coalition by becominga member today.

_____ $35 Individual_____ $100 Organizational_____ $150 Senior Member_____ $500 Core Member_____ $1000 Harm Reduction Partner

Name: _________________________________________________________________

Organization: ____________________________________________________________

Address: _______________________________________________________________

City: _______________________________ State: _________ Zip Code: ______________

Phone: ( ) _______________ Fax: ( ) _______________

E-mail: _____________________________________________________________

Send all membership subscriptions to: Membership,Harm Reduction Coalition, 22 West 27th Street, 5th floor, NY, NY 10001

phone: (212) 213-6376; fax: (212) 213-6582; e-mail: hrc@harmreduction.org

*

6

BY CHRIS LANIER

New Jersey is a more dangerousplace than you may think. Ifyou live in New Jersey, you have

a better chance of contracting the HIVvirus than in 44 other states. If you are awoman living in New Jersey, you aremore likely to contract HIV than any-where else in the nation. Newark (#5)and Jersey City (#2) are among the topfive US cities for percentage of the pop-ulation living with AIDS.Nearly two decades into the AIDS epi-

demic, New Jersey remains the only statein the Northeast U.S. without a provisionfor legal syringe exchange. The result isa public health meltdown: over 50,000people infected with HIV—37,000 ofwhom have AIDS—and 23,000 of whomhave already died as a result of the virus.Over 70% of the AIDS cases are amongpeople of color. While IDUs account foronly 28% of all AIDS cases nationwide,47% of New Jersey’s AIDS caseload is di-rectly related to needle sharing, with an-other 25% of the cases caused byunprotected sex with IVDUs or thosewith a history of intravenous drug use.That adds up to a total of over 70% of in-fections directly or indirectly related tointravenous drug use.According to a recent report by the

New Jersey Alcohol and Drug AbuseData System, New Jersey meets less thanone third of the need for heroin drugtreatment, with 25,665 admissions lastyear out of a need for over 70,000 slots.This means that the average user’s re-quest for treatment takes weeks to meet.In New Jersey, if you can’t quit dope by

yourself, and you’re not wealthy enoughto afford the Betty Ford Clinic, you sureas hell won’t get access to the tools youneed to prevent catching and spreadinga disease.

Where is the Needle Exchange?NJ Governor Christine Whitman oppos-es needle exchange, stating that it sendsthe wrong message to children: “Gov-ernment cannot on the one hand saythat drug use is bad and illegal and onthe other provide the tools for this de-structive behavior in the name ofhealth.” The intransigence of the cur-rent administration led to the hostileshutdown of the state’s only openly op-erating NEP, the Chai Project in NewBrunswick. Fortunately, some State legislators

have more public health–oriented views,but since 1995 conservative resistancehas continually blocked the passage ofpending legislation to create needle ex-change programs. The inflexibility of thecurrent administration has led to cyni-cism among many of the legislators, whoavoid discussion of needle exchange,fearing Whitman’s vehement opposition.HRC’s New Jersey Campaign to SaveLives Now! (NJCSLN!) does not sharetheir cynicism, and has shown that thereis substantial constituency support forneedle exchange that has never beenmobilized.NJCSLN! is a statewide public educa-

tion campaign designed to build aware-ness about needle exchange programs,and develop consensus among the lead-ership of the most hard-hit communitiesin support of needle exchange. Since

January of this year, HRC organizershave worked with members of city coun-cils in Jersey City, Paterson and Newarkto build a dialogue on needle exchangeand drug treatment, with the goal ofgenerating supportive action amongelected officials. NJCSLN! is a growing coalition of ser-

vice providers, health professionals, com-munity leaders and faith leaders,advocating for pending NJ state legisla-tion which would allow a three-year pilotneedle exchange as part of a compre-hensive HIV prevention program.

The StrategyMost needle exchange programs started“underground” and built public supportby demonstrating their efficacy. Bold ac-tivists in New Jersey took this traditionalroute of starting exchange under-ground, but the results did not followstandard history for other parts of thecountry: a series a vicious arrests led totheir total shutdown. Until a more sup-portive governor presides in Trenton,the pending legislation is the only thingthat will allow drug injectors to keepthemselves and their families free of HIVinfection.In other eastern states, such as New

York and Massachussetts, health depart-ments have focused exclusively on out-reach to injectors, never acknowledgingthat general community support for nee-dle exchange is crucial to the success ofprograms. Instead, the programs areforced to fend for themselves in re-sponse to hostile groups and self-pro-moters. In New Jersey, with no place tolook but UP, NJCSLN! is targeting entire

NEW JERSEY:A GRASSROOTSGROUNDSWELL

communities. NJCSLN! uses grass rootsoutreach to New Jersey’s urban commu-nities of color, offering the facts on HIVand its prevention, and the importanceof legislation to create legal needle ex-change. The strategy combines basicpublic health education and awarenesswith political advocacy. In the same waythat injectors reduce their HIV risk byimplementing safer injection practices,communities reduce their HIV risk byimplementing civic action.NJCSLN! hosts community forums,

offers street-based HIV risk awareness ed-ucation, organizes constituent visits tocity councilmembers and state legislatorsand conducts petition and voter regis-tration drives. The work is done by ateam of peer educators and volunteers

from over 80 different New Jerseychurches, AIDS service organizations anddrug treatment programs. NJCSLN!hopes that these efforts can be replicat-ed in other parts of the country.The legislation includes a require-

ment for municipal resolutions of sup-port before a program could be openedin any area. NJCSLN! has focused ongaining passage of these resolutions inthe urban areas of New Jersey hardest hitby HIV. NJCSLN! takes the lead fromFrank Fulbrook (a South Jersey-basedAIDS activist), who successfully lobbiedthe Camden City Council to unanimous-ly pass such a resolution last year.The NJCSLN! team researched the

positions of city councilmembers in sev-eral cities and developed a “vote count”

of those for, against and undecided.Armed with this information, the teamconducts intensive outreach to con-stituencies in key selected areas to turnout support for needle exchange. Inevery case, the support has been there.NJCSLN! created the impetus for a hear-ing on needle exchange with the JerseyCity Municipal Council, and with theHealth and HIV Committees of theNewark City Council.A victory for HIV prevention was

scored in April of this year, when the Jer-sey City Municipal Council passed a reso-lution supporting needle exchange andthe legislation. Introduced by Coun-cilmember Rev. Fernando Colon, Jr., theresolution passed the council 8-0, withone abstention. Numerous people with

NEARLY TWO DECADES INTO THE AIDS EPIDEMIC, NEW JERSEY REMAINS THE ONLY

STATE IN THE NORTHEAST U.S. WITHOUT A PROVISION FOR LEGAL SYRINGE EXCHANGE.

AIDS and family members, as well as theHudson County HIV/AIDS PlanningCouncil, testified at hearings held by thecouncil. Rev. Colon, a Pentecostal minis-ter, explained his advocacy for needle ex-change by saying, “maybe if we had hadthese programs ten years ago, I would stillhave two of my sons with me. I would havegiven them the needles myself had Iknown this would keep them alive.” This resolution has already changed

the mood of some legislators, as they areaware that their constituency may havemore sophisticated views on AIDS thanthe governor. State legislators, particu-larly those legislators from the Jersey Cityarea, cannot claim that the public sup-ports the status quo. To date, 13 state leg-islators have met with concernedcommunity representatives and NJC-SLN! to discuss passage of the legislation. The work in Newark and Paterson con-

tinues. NJCSLN! is building support in thefaith community, community based orga-nizations and city government. NewarkCity Councilmember Luis Quintana is de-termined to pass a pro-needle exchangeresolution before the end of the year, andis planning a large public forum on No-vember 20, 1999. This forum, at City Hall,will honor Wynona Lipman—sponsor ofthe original State Senate needle exchangebill in 1995—who died earlier this year. InPaterson, activists continue to collect sig-natures, register voters and organize meet-ings with city council members. Over 3000signatures have been collected on peti-tions supporting needle exchange inNewark and Paterson. A major event planned for World

AIDS Day 1999 (December 1) is a giant

“syringe pickup” in Newark. Volunteers,trained in hazardous sharps pick-up, andarmed with bio-waste containers, will goto the streets and alleys to collect used sy-

ringes. This action will be supported by apress conference, a speak-out at the citycouncil and demonstrations. The mes-sage will be clear, “Would you rather havethese on your street, or safely disposed ofat an NEP?” (If you want to try this inyour area, be careful. Not only are usedsyringes hazardous, but their possessionis illegal in most states. Be well-preparedfor the risks. The more overtly carefulyou are about handling the waste, thebetter you make the point that syringe ex-change reduces risks for everyone). n

Chris Lanier is the Harm Reduction Coali-tion’s Director of Community Organizing. Foradditional information about the NJ Cam-paign to Save Lives Now! contact Chris at212 213 6376 x17 or Paula Santiago at ourNewark office: 973 596 6066.

8

THE BILLSThe bills, A. 1807 (sponsored by Assemblypersons Reed Gusciora, D-Trenton, and Rev.Alfred Steele, D-Paterson) and S. 453 (sponsored by Senators Vitale and the late WynonaLipman), call for a three-year pilot needle exchange program, implemented by theDepartment of Health and Senior Services, within a context of comphrehensive HIVprevention, and with available referrals to drug treatment. You can read these bills online atthe following addresses:Assembly bill 1807:http://www.njleg.state.nj.us/9899/Bills/a2000/1807_i1.htmSenate bill 453:http://www.njleg.state.nj.us/9899/Bills/s0500/453_i1.htmSenate bill 267:http://www.njleg.state.nj.us/9899/Bills/s0500/267_i1.htm(Deregulates the sale and possession of hypodermic needles and syringes.)You can also request these pieces of legislation by fax or mail by calling NJCSLN! at 973-596-6066NJCSLN! office: Newark: 604 Martin Luther King Blvd., Newark, NJ 07102

HOW CAN YOU HELPIf you are a resident or work in New Jersey, and would like to know how youcan support the New Jersey Campaign to Save Lives Now!, please contactus at 973-596-6066.

For municipal resolutions of support for needle exchange in NJ:• Get a list with contact information for members of your city or towncouncil; get a calendar of council meetings. If possible, get the rules forintroducing legislation.• Put together a package of needle exchange information for distribution tomembers of your city or town council. Include a cover letter requesting ameeting. Make lots of copies, because you will have to distribute them morethan once. NJCSLN! has sample materials, and can help you get started.• Make appointments with each councilmember. Be persistent, but don’tget mad. Get to know everyone’s secretary! Councilmembers may try toavoid you—that’s OK, decide not to give up.• Get a group of people together who can join you for meetings withcouncilmembers: people infected/affected by HIV, doctors, someone whoruns an AIDS service agency and/or local clergy.• We also urge you to contact your state legislators. You can find out whothese people are and how to reach them online at:http://www.njleg.state.nj.us/html98/njmap.htm. Or call us and we’ll findthem for you. Ask your legislators (every district has two assemblypersonsand one senator) how they would vote on the needle exchange bills.• If you would like to collect signatures in support of the legislation, we cansend or fax you a copy of the petition. Over 3,000 signatures have beencollected as of August 1st, 1999.• Also check out the NJ Medical School chapter of STAR (Student ActivistResponse) which has an online sign-on for the petition, and otherinformation: http://students-njms.umdnj.edu/Organizations/Star/.

NJCSLN! tactics can be duplicated by anyone. Many legislators ignore theissue of needle exchange because they don’t think people are talking aboutit. Change their minds!

CONTINUED FROM COVER

One of the things outreach workersalways tell us is not to use drugsalone. This is an excellent idea

but not always a viable one. Being strungout is more about day to day survival andless about partying and being social. Fur-thermore, we often use drugs in isolationbecause of the social stigma. All of thismakes it difficult for each of us to inter-act with other users.From experience, I understand why it

is safer to use with someone else. For in-stance, I know I am using too much if theother person is doing one shot for everyfive I do, or vice versa. Dangerous thingscan still happen, but at least you have asounding board. Also, if you are usingwith someone else or a group of people,this would imply that you want to bearound others (or have to because youhave no choice) and therefore have tointeract on a social level to some degree.If you are using by yourself, the implica-tions are completely different. At leastthey are for me. When I use alone it isbecause I want to get as high as I can andnot have to be accountable to anyone, orit means I have a habit—which wouldmake it physically impossible to use withsomeone every time I do a shot.When I make the choice to use by my-

self, it is usually for the reasons I statedabove. It is not because I want to kill my-self, and not because I don’t understandhow to avoid overdosing, but because Iam depressed and because I am bored.For a lot of people I know it is eitherdeeper than that, or it isn’t. Some peopleare on a suicide mission every time theyuse. Others just wanna get off. I am pret-ty clear about my intentions before andafter I use, and yet that still does not pre-vent me from repeatedly overdosing.Going back to the last time I ODed, I

was alone all night, while my husbandwas at work. The agreement was to waitfor him to get home so we could get hightogether, but I was bored and decided Iwanted to get a few shots in before he re-

turned. In the five hours he was gone Idid a ton of dope, and the fact that I wasgoing to be gowed2 when he got backdidn’t seem to matter all that much. Infact, when he finally came home, I wasmore than gowed—I was unconscious.Despite having fears about calling 911,he realized he could not revive me on hisown. We were fortunate in that the copsdid not respond to the call along withthe paramedics.Like all users, I have heard horrible

things about Narcan. But, as I said in thebeginning, I am grateful to the para-medic who administered it because ifshe hadn’t, I wouldn’t be alive. The

paramedic who gave me the shot did nothate junkies. After I had been revived,she was decent enough to explain to methe steps she’d taken to bring me back.First, she took care of my breathing so Ididn’t die while she was waiting to seehow much Narcan was needed to reviveme. Second, my breathing was moni-tored for over three hours to seewhether I needed additonal shots. Get-ting hit with Narcan is fucked up. Oneminute you are unconscious, and thenext minute you are completely straight.The main thing I remember about it isthat I really wanted to get high again,and I couldn’t stop shaking or get myteeth to stop chattering. I was also superagitated, a feeling I spend a lot of time,energy and drugs trying to avoid. Nar-can is scary; even the name makes me

nauseous. (I’ve been with people whohave been brought back from an ODwith Narcan and just hearing the word“Narcan” makes them stand up and boltfor the door.) But no matter how fuckedup it felt, if it had not been given to meby someone who knew what they weredoing, I wouldn’t be writing this today.

Irealize that within the harm reduc-tion movement there is a debateamong service providers surround-

ing the pros and cons of the distributionof Narcan. Until we understand the ef-fects of consistent, widespread Narcan dis-tribution, the debate should continue,without hindering users’ access to thispotentially lifesaving tool. However, as anopiate user, I also feel it is imperative tolet other opiate users know that a shot ofNarcan will not revive someone from anoverdose every time. Every overdose I havebeen involved in where Narcan was nec-

essary has required more than one dose,administered over several hours. In fact,it has required repeated injections, andmore importantly, someone who knewhow to perform resuscitative breathing.Users have learned how to do thisthrough their own self-education andthrough needle exchange programs thatoffer CPR training and overdose preven-tion groups. When you throw Narcaninto the mix, you are merely providingan additional tool to prevent a lethaloverdose. But it should not be used ex-clusively in the absence of a more exten-sive program of overdose prevention andlifesaving tools. n

1 Ed: Vicodan, Percodan and benzodiazepam,like Valium or Xanax

2 Ed: loaded

9

One of the things outreachworkers always tell us is

not to use drugs alone. Thisis an excellent idea but not

always a viable one.

10

BY KRISTEN OCHOA,HEATHER EDNEY-MESCHERY AND ANDREWMOSS

O verdosing is probably the mostimmediate life-threatening healthissue facing injection drug userstoday. It is a major cause of excess

mortality among heroin users in theUnited States,1 and in many countries,deaths attributed to overdose are equalto or greater than deaths attributed toHIV.2 Despite the number of personswho overdose, the issue has received lit-tle attention. In the U.S., very few studiesof overdosing exist and few programs arefocused on overdose prevention. Theissue is only just beginning to emerge.Perhaps the advent of better treatmentsfor HIV has allowed us the space to con-sider the risks of overdose more careful-ly, or perhaps the deaths among ourpeers and co-workers have become fartoo common.For heroin injectors, overdosing is an

occupational hazard. It’s hard to avoid—the fact is that heroin overdose will con-tinue to happen as long as heroin userscontinue to use. What can be done?While we may not be able to completelyprevent overdoses, we can prevent over-dose fatalities. No one should ever haveto die from a heroin overdose—we haverescue breathing (CPR) and we have theantidote (naloxone). However, there aremany barriers that stand between usersand these lifesaving measures. Under-standing the barriers may be the first steptowards breaking them down.

Dispelling Myths About Who Overdosesand WhyContrary to widespread views, we found

in our recent study of San Francisco in-jectors that overdosing is just as commonfor the seasoned injector as it is for thenew initiate.3 Just because someone hasa long-time habit does not mean they aresafe from overdosing. It’s also just ascommon for women to overdose as it isfor men. Another misconception is thatheroin overdoses are often suicide at-tempts. This is actually very rare. Few in-jectors intend to kill themselves whenthey overdose; more often they attributethe cause to just wanting to take toomuch. Intention falls into a gray area,where there are no plans to OD, butthere is a kind of ambivalence about thepossibility. The most concise explanationcomes from a participant in our study:

“Tolerances go up and down, some drugsare more cut than others, someone accidental-ly can do more.... From what I’ve seen, peoplewho overdose, they don’t have intentions ofdoing it; their intentions are just getting real-ly high.”

Obstacles to Seeking Help in the Eventof an OverdoseThe primary barrier to seeking help dur-ing an overdose is fear of police involve-ment.4 For this reason injectors areusually apprehensive about calling 911.Most, in fact, will try several things tobring the person back before calling 911.Real or perceived, the threat of arrestgreatly impacts decision-making at theoverdose. According to our participants,using with others, which is commonamong young injectors in particular, isnot necessarily protective, given this fear:

“A lot of people freak out and just runaway. I’ve made so many friends in the parkby finding them blue and bringing them backbecause everybody just flips out, ‘man, I can’tcall the cops because I’m holding and I don’t

want to get caught.’ It’s really stupid becauseyou can call from somewhere way across thescene, but if you did survive it’s because some-body called 911.”According to our study, 71% of injec-

tors have witnessed at least one overdose,so there is great opportunity for inter-vention because others are often presentand can take action to keep the personalive. People need skills to effectively in-tervene, including CPR training. It is alsoimportant for people to know location-specific details about how to make a 911call. What you say to the dispatcher, de-pending on the city and county, willsometimes elicit a police response in ad-dition to an emergency medical re-sponse; other times it will not. (Seesidebar, Calling 911, p.12.)

Policy and the PoliceThough education about calling 911 isneeded, it is not enough. Since we beganour study, we have learned of injectorsbeing arrested in different cities as a con-sequence of their overdose or someoneelse’s overdose. In Santa Cruz, officersissue citations to program participants atthe hospital where they are recoveringfrom an overdose. The problem of po-lice involvement in overdoses is probablythe largest barrier to preventing fataloverdose.Many needle exchanges have come to

agreements with law enforcement, keep-ing the police from arresting people inand around their exchange sites. Simi-larly, we must work collaboratively withthe police to insure that they will not ar-rest, search or charge drug users whohave made a 911 call. If this can be ac-complished, programs should spread themessage to injectors that punitive actionswill not be taken if they do call for help.

Understanding Heroin Overdose

11

The cost-benefit analysis of minimizingpolice involvement at drug overdosessaves both officer time and court costs. Ifwe don’t work with the police, we con-tinue to limit injectors’ access to para-medics and the emergency room, and wecontinue to lose lives.Though there is still much work to be

done in San Francisco, the police gener-ally do not seek prosecution of those pre-sent at an overdose. Unfortunately,because users have had bad experiencesin other cities, many still do not havefaith that it is safe to call 911 here. A par-ticipant in our study explains what goeson in San Francisco:

“We’ve all experienced when a friend goesout and they don’t want you to call 911, butthe police aren’t there to arrest you. The onlytime they will arrest you for a drug overdose isif you refuse to go with them to the hospital,and they only do that so you will seek medicalcare. If you have a problem with the cops com-ing, let the paramedics know and they will lis-ten to you.”

Recognizing and Defining the Problemin the U.S.One of the major barriers to solving theoverdose problem is recognition. Evenwhen programs and researchers ac-

knowledge and work on overdose, it isusually due to their own interest and ini-tiative. Government and private fundingset aside specifically for overdose scarce-ly exists, if at all. As a result, overdoseand ways to prevent overdose are not aswell understood in the United States asthey are in Europe and Australia. Hero-in, the heroin epidemic, the relationshipbetween drug users and the police andbetween drug users and health careproviders, are all very different in theU.S. For this reason it is hasty to con-clude that findings in other countries ac-curately reflect the overdose epidemichere. We must work to better understandour own epidemic in order to create ef-fective prevention strategies at home.

Preventing OverdoseA comprehensive overdose interventionwould include direct service organiza-tions, hospitals, emergency services, police and research. Educational cam-paigns, CPR and basic life-saving coursesas well as grief and loss support shouldbe major components. The distributionof naloxone (the opiate antagonist-akaNarcan) to drug users as part of a largerprevention program should also be ex-plored. Since opiates usually stay on

board after naloxone has been adminis-tered, more than one dose may be re-quired. Following up with a call to 911 ora visit to the emergency room may there-fore still be necessary in order to com-pletely bring the person out of danger.Naloxone may buy time for some, but itwill not solve the problem for peoplewho inject alone—only an educationalprogram can do that. Outreach and

The primary barrierto seeking help

during an overdose isfear of police

involvement. Real orperceived, the

threat of arrestgreatly impacts

decision-making at the overdose.

ARE HIV+ USERS MORE LIKELY TO OD?In Baltimore, the ALIVE cohort study has found that overdose deaths in injection drug users were more common in HIV seropositiveindividuals than in uninfected injection drug users. (For a description of the study, see note at end).

In HIV-positive drug users, AIDS accounted for one half of the deaths. When looking at deaths before AIDS, HIV-positive users weremore likely than uninfected drug users to die from sepsis, endocarditis and drug overdose. (Drug overdose was recorded on deathcertificates, but also confirmed by autopsy from the chief medical officer.)

The researchers examined why HIV-positive drug users were more likely than uninfected users to die from overdose. Although thisstudy did not track co-factors that might have been immediately responsible for death, such as the use of alcohol or tranquilizers withheroin, some important trends were noticed, notably that the risk of overdose death increases with duration of drug use.

Two plausible reasons are: 1) as HIV-positive drug users become more ill with HIV, they tend to reduce or even stop drug use for awhile, and when they start up again, it is possible that they might have reduced tolerance for the doses they may have taken previously,and 2) drug users with late stage HIV infection who have recently had pneumonia might have reduced lung capacity to tolerate heroin(which has the side effect of reducing breathing rates). One possible factor that has been ruled out is the money study participantsreceived for both participating in the study and getting tested for HIV. Time since last study visit was tracked, but individuals who had justparticipated did not differ in rates of overdose deaths from those who hadn’t been seen in some time–suggesting that the extra moneyearned from participating in the co-hort (or learning HIV test results) did not lead to doing more heroin, and, in turn, overdosing.

More attention needs to be devoted to understanding the causes of overdose, and the interrelationship between injection drug use andHIV. Specifically, additional investigation needs to be initiated to explore these particular findings. Confirmation that HIV+ IDUs are truly athigher risk for death from overdose will hopefully lead to attempts to gain a better understanding of the other factors that may be involved.

Note: This is a new finding, but the Alive study uses different protocols than previous studies: it looks at comparisons of drug users by HIVserostatus within the same city, during the same calendar time, rather than solely looking at trends over time.

The ALIVE study has been following 3,000 out-of-treatment injection drug users every six months since 1988. The population was 90%African-American, 80% male; 90% were active injectors at baseline with 45% injecting more than once a day. The overall mortality ratewas 2.8% per year in a population where the average age was 34 years old. Deaths increased with age, over time, and were more commonin men than women.

Information supplied by David Vlahov, Ph.D., Director of the Center for Urban Epidemiologic Studies, New York Academy of Medicine.

education can also offer tools for dealingwith less severe overdoses that do not re-quire naloxone, as many people are re-vived simply with rescue breathing or bytheir friends keeping them awake.One of harm reduction’s strengths is

its pragmatism and realism. Harm re-ductionists are generally aware of theneed for integrative approaches and arewary of single solutions. If naloxonealone were provided to injectors, wouldit prevent people from accessing emer-gency services? More work must be donebefore we understand the complexitiesof naloxone distribution. Only one Aus-tralian study has evaluated the accept-ability of naloxone among drug users,but there is no published study of nalox-one use itself. It is a more difficult task toraise consciousness and create changeamong drug users and emergency au-thorities than it is to simply give out vialsof naloxone. Programs that can do bothare likely to provide a longer lasting,more fail-safe method of curbing theoverdose problem. n

Kristen Ochoa (kochoa@itsa.ucsf.edu) is Pro-ject Director and Andrew Moss is PrincipalInvestigator for the University of California,San Francisco’s UFO Study. Heather Edney-Meschery (scnep@got.net) is Executive Direc-tor of the Santa Cruz Needle ExchangeProgram. The UFO Study is a collaborationbetween UCSF, the Haight Ashbury YouthOutreach Team and the Santa Cruz NeedleExchange. The Santa Cruz Needle Exchangeroutinely provides overdose prevention train-ings to participants and high school studentsin Santa Cruz County. The UCSF Depart-ment of Epidemiology and Biostatistics hasbeen studying overdose in young injectiondrug users for three years.

1 Heroin Abuse in the United States. Rockville,MD: U.S. Department of Health and HumanServices; 1997.

2 McGregor C, Darke S, Ali R, Christie P.Experience of non-fatal overdose amongheroin users in Adelaide, Australia:circumstances and risk perceptions. Addiction1998 93 (5): 701-711.

3 Ochoa K, Hahn J, Lum P, Page-Shafer K,McLean R, Moss A. Overdose commonamong young injection drug users. AmericanPublic Health Association 127th AnnualMeeting, Chicago, IL, 1999 (abstract).

4 McGregor.

12

CALLING 911: PARAMEDICS & THE COPSMany of us are afraid to call 911 when someone weknow ODs. You may have had a bad experience withcops or paramedics, or heard horror stories fromothers. But if you don’t know how to do rescuebreathing and/or CPR (or don’t want to), and youdon’t have naloxone or Narcan, calling 911 may bethe only way to save the person’s life.

Here are a few tips, some suggested byparamedics, some by other users, that can help youget through this stressful situation with a minimum ofgrief. Some of the suggestions appearing below mayseem obvious upon first glance. But after conductingfocus groups on heroin and overdose it’s becomeapparent to me that a public discussion on thesetopics can both reduce the risk of get busted for those who choose to intervene at an OD and help save lives—which is, of course, the object here. Remember, though, every locale has its ownprotocols. Just because San Francisco rarelydispatches the police doesn’t mean that it works thatway in your suburban community. In fact, in bothChicago and New York, police are usually dispatchedto overdose calls.1

THE CALL…l Lots of noise in the background, or yelling andscreaming, can cause the dispatcher to send thecops along for crowd control. Be as calm as possible(which I realize is often difficult given what’shappening—but try anyway), and before you speak tothe dispatcher tell anyone else in the room to bequiet.l Be clear and concise. Tell the dispatcher someonehas stopped breathing. That’s enough to get theparamedics zipping through the streets.l If you’re calling from a location that’s been thescene of prior calls for ODs, the dispatcher will oftenknow this. Most 911 systems—especially ones in bigcities—are computerized and keep records of thesekinds of things. (They may keep records of callswhere paramedics run into trouble, too.) If they askyou if it’s an overdose, don’t lie; it might make themmore suspicious. You can say you think the persontook something, but you’re not sure exactly what itwas.l If they’re asking too many questions, you canalways say you’re alone with the person and you haveto get back to doing rescue breathing. Just make sureyou’ve given them the address, phone number—ifthere is one—and instructions on how to get into thebuilding. (If you’re squatting, send someone out tothe street to wait, if you can.)

YOU HAVE WARRANTS, ABSOLUTELYCANNOT STAY AND NO ONE ELSE ISAROUND…l You can still call 911, using any of the above tipsthat are relevant. If you’re on the street or in a park,calling from a pay phone is pretty anonymous.l If you can do so without hurting your friend, draghim into the street, or the building doorway, if inside;

the easier it is for the paramedics to get to him, thebetter.l Keep up the rescue breathing for as long aspossible. It will give your friend extra time. Stick arounduntil you hear the sirens close-by.l If it’s happened on the street, or you brought yourfriend outside, before you leave try to get a passerbyto help.l If you can’t move your friend, you can stay until youhear the sirens get really close, then split. Just makesure help can get to your friend: leave the door open,put a note up, etc. A final suggestion: if it’s not yourplace and there’s a fire escape or back door, you canalways wait until the last minute and duck out theback way.

WHILE YOU’RE WAITING…l Continue rescue breathing. l If for some reason you can’t do rescue breathing,try to wake up your friend—shaking by the shoulders,yelling his name, etc.l If your friend wakes up, and you’re really afraid ofthe police coming, you can cancel the 911 call.Because a person can go out again after waking up,it’s a important to take your friend to the emergencyroom. This way, if he ODs again he can get propermedical care.

Another suggestion, which may already be standardpractice for many of you: hide your shit, especiallyanything that might have residue—like cookers,cottons, empty bags, etc.—before anyone comes. Andcoming up with a uniform story in advance may saveyou from getting caught in any lies to police orparamedics; I once went to jail because my friend toldthe cops stuff that contradicted what I said.

WHEN HELP ARRIVES…l If it’s just paramedics: The paramedics don’t carewhat someone has taken; they’re there to help. Withparamedics, saving lives is a point of pride. Givethem as much info as possible: what the persontook, whether they were already on anything else, anymedical conditions you know about, etc. (You canalways say you just got there, but the guy who just lefttold you what happened.)l If the cops come too: Generally paramedics arepretty smart and can figure out what’s happeningmedically on their own. Sometimes, though, when aperson is really overdosed, or has taken drugcombinations, it’s not as obvious. Even if you have topull the paramedic to the side to inform them of thesubstances taken, this can make a difference in theoutcome-especially if more than one drug isinvolved! The key here is to remain calm, not haveany attitude, be polite and be as honest as you canwithout getting yourself into trouble.

In the end, if you save a life, it will be worth it.

1 Oral communications by Dan Bigg and a NYPD public affairsofficer, respectively.

13

PREVENTING HEROIN OVERDOSE: PRAGMATIC APPROACHESJANUARY 13-14, 2000SHERATON HOTEL, SEATTLE, WASponsored and presented by: Alcohol and Drug Abuse Institute,University of Washington, Seattle; The Lindesmith Center, NewYork and National Institute on Drug Abuse, Washington D.C.

Heroin overdoses and overdose fatalities are increasing inNorth America and around the world. Many of these arepreventable, often with simple and inexpensive interventionsbased upon scientific research, epidemiological andethnographic insights and common sense.

This two-day conference brings together leading experts fromaround the world—scholars, service providers, users, outreachworkers and others who deal with and are affected by heroinoverdose—to present and discuss: Risk factors andepidemiology of heroin overdose; Treatment modalities;Outreach and education; Naloxone distribution; The roles ofresearchers, emergency medical services, law enforcement andfamilies and friends of overdose victims. For complete information and registration:http://depts.washington.edu/adai/conf/heroin.htm or email Nancy Sutherland, adai@u.washington.edu

THE FIRST INTERNATIONAL CONGRESS ON WOMEN & DRUGS SUNDAY APRIL 9, 2000HOTEL DE FRANCE, JERSEY, CHANNEL ISLANDS, BRITISH ISLESPresented by the International Network On Women & DrugsFor additional information:Email: women@hit.org.ukWeb: http://www.jersey2000.co.je/seminars.html#womsat

IITH INTERNATIONAL CONFERENCE ON THE REDUCTION OFDRUG-RELATED HARM APRIL 9-13, 2000HOTEL DE FRANCE, JERSEY, CHANNEL ISLANDS, BRITISH ISLESPresented by International Harm Reduction AssociationFor complete information and registration contact:International Harm Reduction Association c/o HIT ConferencesFirst Floor, Cavern Court8 Mathew Street, Liverpool UK L2 6RE Tel: +44 (0)151 227 4423Fax: +44 (0)151 236 4829Email: ihra@hit.org.ukWeb: www.jersey2000.co.je

NORTH AMERICAN SYRINGE EXCHANGE CONFERENCE XAPRIL 26-29, 2000PORTLAND, ORPresented by North American Syringe Exchange NetworkFor additional information contact NASEN at:Tel: (253) 272-4857Email: nasen@seanet.comWeb: www.nasen.org

12TH INTERNATIONAL CONFERENCE ON DRUG POLICY REFORMMAY 17-20, 2000WASHINGTON PLAZA HOTEL, WASHINGTON, DCPresented by Drug Policy FoundationFor additional information contact: Tel: Whitney Taylor, (202) 537-5005Email: conferences@dpf.orgWeb: www.dpf.org/html/conferences.html UP

COMI

NGCON

FERENC

ES

5th National Harm Reduction

ConferenceSponsored by theHarm Reduction Coalition

November 11-14, 2004New Orleans Astor Crowne Plaza Hotel

New Orleans, LAFor more information contact Paula Santiago, HRC Conference Organizer:

Tel: 212-213-6376, extension 15; email: santiago@harmreduction.org

14

If you are going to call 911, first check the person carefully for anydrugs on their person. It would suck to be resuscitated, only to bearrested. Note: These instructions are not a substitute for real-lifetraining; check with your local NEP or Red Cross for classes in CPR.

STEP 1: CHECK RESPONSIVENES1. First, tap then shake the person’s

shoulder. If that doesn’t work trypinching an earlobe or fingertip.

2. Ask “Are you O.K?” Shout theperson’s name; shout, “Wake up!” Ifno response, continue.

STEP 2: CALL 911 (get EMS in motion)1. Ask someone to call 911.2. If alone, yell for help. If no one comes,

call 911 and quickly return. SECONDSCOUNT!

STEP 3: ROLL PERSON ONTO BACK1. Do this as gently as possible to avoid

injury.

STEP 4: OPEN AIRWAY(Use head-tilt/chin lift method-seeillustration)1. Tilt head back with your nearest hand by

applying backward pressure to person’sforehead.

2. Place fingers of other hand under chinbone and lift. Do not use your thumb tolift the chin.

3. Tilt head back WITHOUT closing mouth.

STEP 5: CHECK FOR BREATHING(Take 3-5 seconds-see illustration)1. Place ear over person’s mouth and nose

while keeping airway open.2. Look at chest to check rise and fall:

listen and feel for breathing.

STEP 6: GIVE 2 SLOW BREATHS(See illustration)1. With head still tilted back, PINCH nose

shut.2. Take a deep breath; seal lips around

person’s mouth.3. Give 2 slow breaths, each lasting 11⁄2 to 2

seconds (take a breath after you give one).4. Watch chest to see if breaths go in.5. Allow chest to deflate after each breath.6. If neither breath went in, TRY AGAIN!7. If the 2nd attempt fails check for windpipe blockage, usually

caused by vomit obstructing the airway (see box on Heimlichmanuever on next page for instructions for clearing airway).

If this doesn’t work give 2 more rescue breaths!

STEP 7: NEXT, CHECK FOR PULSE(See illustration)1. DO NOT USE THUMB—It has its own pulse.2. Maintain head tilt.3. Feel on neck for pulse using 2 or 3 fingers

using hand nearest person’s feet.4. Take 5-10 seconds to feel for pulse.

Perform rescue procedures based uponfindings.

IF THERE IS A PULSE BUT NO BREATHING1. Give 1 rescue breath every 5-6 seconds,

10-12 a minute. Use same methods asSTEP 6 above, but only give 1 breath at atime.

2. Check to make sure there is a pulse, every minute.3. Continue until person revives, OR Trained help, such as emergency

medical technicians (EMTs), arrives and relieves you, OR You arecompletely exhausted.

IF THERE IS NO PULSE, GIVE CPR.

STEP 8: CPR: FIND HAND POSITION(See illustration)1. Slide fingers up ribcage nearest you to the

notch at the end of sternum.2. Place your middle finger on the notch and

index finger next to it.3. Put the heel of other hand next to index

finger.4. Remove hand from notch and put it on top of

hand on chest.5. Interlace, hold or extend fingers up.

DO 15 COMPRESSIONS(See illustration 9, below)1. Place your shoulders directly over your hands

on the chest.2. Keep arms straight and elbows locked.3. Push sternum straight down 11⁄2 to 2 inches.4. Do 15 compressions at a rate of 80 per

minute. Count as you push down: “one andtwo and three and four and five and six andseven and…fifteen and.”

5. Push smoothly; do not jerk or jab; do not stopat the top or at the bottom.

6. When pushing, bend from your hips, notknees.

7. Keep fingers pointing across person’s chest,away from you.

GIVE 2 SLOW BREATHS

Complete four cycles of 15 compressions and 2 breaths (takes about1 minute) and check the pulse. It there is no pulse, restart CPR withchest compressions. Recheck the pulse every few minutes. If there is apulse, give rescue breathing.

GIVE CPR OR RESCUEBREATHING UNTIL…Person revives, OR Trained help,such as emergency medicaltechnicians (EMTs), arrives andrelieves you, OR You arecompletely exhausted.

∂

∑

∏

π

∫

ª

º

Ω

æ

RESCUE BREATHING: THEY CALL IT THE KISS OF LIFE…

15

MAKE A PLAN TALK WITH YOUR PARTNERSTO WORK OUT A PLAN IN CASEONE OF YOU OVERDOSES.

Obviously, the time to talk iswhen all of you can talk. Amongthe questions to consider are:

ÁWhen should someone takeaction? (How slow should theperson’s breathing be? If whichpart of them is turning blue?)

ÁWhat’s prefered regardingcalling 911(Immediately, orshould resuscitation be triedfirst?), the use of CPR (If it’snot working, at what point is911 called or Narcan used?) andtrying Narcan (Where/howadministered? How much - 1mgor less, multiple doses?)?

ÁWhat should be done after theperson resumes breathing (Whatkind of support is desired? Willthe person go to the ER?)?

ÁWhat’s the plan when thenaloxone wears off (Do you goto the ER? Who will stay withthe person? What’s to be done ifthe person’s really dopesickafterwards?)?

ÁIs it OK to remove yourpartner’s ID, in case he or shehas outstanding warrants?

If you’re going to use naloxoneor Narcan, make sure you have akit made up, and put it in aplace where everyone can findit. It’s a good idea to have ashort instruction sheet,especially something writtenthat gives the proper dosageinfo. (Narcan/naloxone comes indifferent strengths andcontainer sizes, and syringesalso differ in capacity. It cansometimes get pretty confusing.)If you have a CPR cheat sheet,that’s even better, too.

REMEMBER, THE MORE YOUPLAN OUT IN ADVANCE, THELESS ROOM THERE IS FORERROR AND PANIC IN THEEVENT OF AN ACTUAL OD!

HEIMLICH MANUEVER:FOR THE PERSON WHO’S CHOKING

STEP 1: GIVE UP TO 5 ABDOMINAL THRUSTS (Heimlich manuever—see illustration)1. Straddle person’s thighs.2. Put heel of one hand just a few inches above belly

button and well below sternum’s notch (fingers ofhand should point toward person’s head).

3. Put the other hand directly on top of first hand.4. Press in and up—5 quick independent thrusts.

Note: For a pregnant woman or obese person considerchest thrusts—see below.

STEP 2: FINGER SWEEP (On unconscious person only—see illustration) 1. Use only on an unconscious person. On a conscious

person, it may cause gagging or vomiting.2. Use your thumb and fingers to open mouth and pull tongue

away from back of throat and away from object. You can dothis by grasping person’s jaw and tongue and lifting upward.

3. With index finger of other hand slide finger along inside ofone cheek deep into mouth, using a hooking action todislodge object.

4. If foreign body comes within reach, grab and remove it. DONOT FORCE THE OBJECT DEEPER.

If the above steps are unsuccessful…

CYCLE THROUGH THE FOLLOWING STEPS IN RAPID SEQUENCEUNTIL THE OBJECT IS EXPELLED OR EMS ARRIVES1. Give 2 rescue breaths. If unsuccessful, re-tilt head and try 2

more breaths. If there is no pulse, perform CPR too—see Step 8, Rescue Breathing, on preceeding page.

2. Do up to 5 abdominal thrusts.3. Do a finger sweep.

CHEST THRUSTS FOR PREGNANT WOMAN OR OBESE PERSON

UNCONSCIOUS1. Kneel beside the person, placing one hand on the center of the person’s breastbone and

then placing your other hand on top of it.2. Give 5 quick thrusts, compressing the chest 11⁄2 to 2 inches.3. Do a finger sweep (see above), open the airway with a head tilt and a chin lift and give 2

slow breaths. If air still will not go in, continue giving chest thrusts, finger sweeps and 2slow breaths until the object is expelled and air goes in. If there is no pulse, perform CPRtoo—see Step 8, Rescue Breathing, on preceeding page.

CONSCIOUS1. Stand behind the person, placing your arms under the person’s armpits and around his or

her chest.2. Make a fist with one hand and put the thumb side of the fist against the center of the

person’s breastbone.3. Make sure your thumb is on the breastbone—not the ribs—and that you are not near the

tip of the breastbone.4. Put your other hand over the fist and give quick inward thrusts.5. Continue giving thrusts until the object is dislodged.

If the person becomes unconscious while you’re doing this, use the method for unconsciouspeople.

ONCE THE OBJECT IS DISLODGEDIf the person is not breathing and has a pulse, perform rescue breathing. If the person is notbreathing and does not have a pulse, give CPR. (See Steps 7 and 8, Rescue Breathing, onpreceeding page.

∂

∑

BY DAN B IGG

Naloxone is a miracle of a drug: itcan bring a person not breath-ing due to opiate intoxication

back to life very quickly. Naloxone avail-ability—ideally over the counter—and itslegal possession is a positive change crit-ical to our ability to effectively reducethe epidemic of opiate overdoses in theUS. In order to make this a reality, wemust confront biases and tendencies to-wards oppression of people using opiatesas well as our own limitations in harm re-duction thought.When administered properly, nalox-

one quickly reverses the respiratory de-pression associated with an opiateoverdose and lasts for a period of aboutan hour. If given to someone with a toler-ance to opiates it can also stimulate with-

drawal symptoms, as well as helping themstart to breath in the event they’ve usedtoo much. Naloxone has no impact of itsown other than the reversal of opiate ef-fect. It will not reverse an OD caused bynon-opiate drugs, nor automatically meanthat you will not die of an opiate OD, butit can seriously help to increase the oddsof survival and rapid recovery.The major benefit of widespread

naloxone availability should be fewer pre-mature deaths from opiate overdose. Ad-ditional benefits are also likely fromincreases in overdose awareness and pre-paredness, which in turn can lead to thegreater practice of overdose preventionmeasures (modulated injections, moreconsistent use of care partner injectingdyads, etc.) as well as increased capabili-ty and competence in preparing for andtreating ODs. The rationale behind this

16

NAL

OXO

NE

AV

AIL

AB

ILIT

Y Yet Another Positive Change

Not a Silver BulletBY ROBERT SWARNER

Proper response to opiate overdosecan be complex. Professional med-ical care is always the best option,

but there are several obstacles that standbetween opiate users and such medicalcare: fear of police, hostile attitudes fromemergency workers and hospital staff andminimal awareness among users of theimportant medical options available.1,2

There are also many avenues for im-provement on existing interventions toheroin overdose. With proper trainingother injectors, family and friends havethe ability to intervene when someoneoverdoses, and the attention from theharm reduction community to support-ing user-based interventions is well deserved. However, because perfect so-lutions do not exist, excessive attentionis given to the role of naloxone (or “Nar-can”) in reversing an overdose. The idea

of providing Narcan to the injectiondrug using community as a cure for over-dose is misleading and ill-conceived. Dis-tribution leading to broader access toNarcan wouldn’t pose any benefit in apreventative sense, and it is a dangerousmistake to offer access to this drug as analternative to professional emergencycare. Meanwhile, this discussion is ob-scuring the most crucial life-saving pro-cedures in overdose response: gettingoxygen into the overdose victim’s body is theaction which saves lives.Although almost universally pur-

chased in its generic form, Naloxone ismost commonly known by its tradename, Narcan. (The difference betweengeneric naloxone and Narcan is price,just like the difference between facial tis-sue and Kleenex.) Narcan was solely de-signed to compete with opiates forcertain receptor sites in the brain for usein treating opiate overdoses, and as a di-

is clear upon close examination of threepoints: 1) possession of naloxone in-evitably leads to thinking about overdose,and, of course, drug-taking practices thatlead to dangerous situations, 2) the useof naloxone is an unpleasant experiencefor most people—even if it is saving yourlife—and there is no desire to use itagain, and 3) having naloxone on handmeans that users potentially have a life-saving tool at their disposal for immedi-ate lifesaving intervention.The fear that by offering people

greater control over their lives—what Iwould call the essence of harm reduc-tion—leads to greater risk taking is falla-cious, as we have learned through yearsof experience with syringe exchange.Just as providing sufficient access to ster-ile syringes doesn't necessarily increasepeople’s drug use, having the antidote toopiate overdose hasn’t led to users doingtoo much and overdosing. Quite the opposite, in fact. Giving users access to a tool which can prevent unnecessarydeaths helps to develop and encourage

self-reliance; self-reliance which is ex-pressed in the form of more deliberatedrug-taking and strategies for preventingand dealing with overdoses. This onlygoes to show that the many distant andremoved fears of failure are more evi-dence of bias, and less powerful than asingle observed success in the practicalworld of the harm reductionist.There are potential risks arising from

naloxone distribution, including inef-fective use that might delay or preventsufficient OD treatment. However, nega-tive effects of naloxone use on a personwho’s no longer breathing are almost al-ways less harmful than the alternative:death that results from lack of oxygen. Inaddition, thorough knowledge aboutopiates, naloxone use and CPR/rescuebreathing techniques are excellent toolsthat can reduce potential harm from opi-ate ODs and prevent the aforemen-tioned incorrect use from happening inthe first place. Obviously, the more train-ing and assistance we can offer people asthey become more “overdose compe-

tent,” the better. However, this does notmean that we should deny access tonaloxone until someone achieves a cer-tain level of comprehensive overdosetreatment competence.Today it is hard to find anyone other

than paramedics and ER doctors who hasaccess to naloxone. These health careprofessionals sometimes use it in ways thatpunish opiate-dependent users—by ad-ministering too much in bringing the pa-tient out of an OD, thereby putting himor her into full withdrawal, or simply

17

agnostic tool in treating people who areunconscious or not breathing, when thecause isn’t known. Once there, Narcanoccupies these sites, keeping the opiatefrom binding to the brain. The opiatethen continues to circulate in the bloodsupply until it can be metabolized, andultimately excreted. Narcan will only in-terrupt the effects of opiates like heroin,morphine and the like. If the drug inquestion is not made from opium, normade to act like an opiate, then Narcanwill have no effect on an overdose. Narcan is generally thought of as one

of the safer emergency medicines. Some-times, though, Narcan has been found tocause sharp increases in blood pressure,allergic reactions, cardiac arrhythmiasand other peculiar side effects, includingdeath. Though these unwanted effectsare rare, and Narcan is used broadly, andwith a great safety record in overdose re-suscitation, like any drug it cannot bethought of as absolutely safe for every-one. One other problem with Narcan isthat most opiates last longer than Narcandoes. Therefore Narcan usually needs tobe administered repeatedly in order toget people through an overdose.

Narcan does not cure heroin over-doses. Narcan is an important tool, oneuseful part of an organized approach toresuscitating overdoses, which helps inthe overall management of the over-dosed patient. The cure for a heroinoverdose is oxygen, breathing supportand airway control, and anyone at thescene of an overdose has all of theequipment they need to provide thesethings to a person through mouth-to-mouth artificial respiration. These re-suscitations happen in a prioritizedorder so that no aspect of life support isoverlooked in favor of any other one.Any emergency medical treatmentevolves from the basic to the advanced.At the beginning of any emergencytreatment are the “ABC’s.” Anyone whohas taken a CPR class or first aid trainingknows that A is for airway, B is forbreathing and C is for circulation. Re-suscitation doesn’t progress until each issecured in its order, so any emergencymedical worker would make sure that A,B and C are being provided for beforeusing any tool like Narcan. Used prop-erly, Narcan restores a person’s drive tobreathe on his or her own, and allows

them to become conscious again. Givenwithout proper attention to the ABC’s ofresuscitation, Narcan may give thewould-be rescuer the illusion of a curewhen in reality the patient is still dying.Narcan is not necessary for reviving

an overdosed person in the strict sense.It isn’t uncommon that we begin breath-ing for an overdosed person and theywake up. Many overdoses are currentlytreated by the friends of the overdosedwho keep them awake and breathing bydoing painful things to them.3For people who are deeply overdosed

it is important to give Narcan at somepoint in the course of their resuscitation.However, the administration of Narcandoesn’t change the outcome of the re-suscitation at all. The moment when aperson’s life is saved or not comes beforeNarcan is administered. There are clini-cal studies that show that any patientwhose breathing was supported beforethe paramedics arrived lived throughtheir overdose, while those who diedwere the ones who had no breathingsupport, and weren’t breathing when theparamedics arrived.4,5In order to work, Narcan has to

18

BY RO G IUL IANO

THE SCENARIOYou and a friend score some dope (hero-in) and go get high. You’re fine, but yourfriend is beyond nodded and now blue.She has a pulse but is not breathing. Fab-ulous, you have an overdose on yourhands. But you are prepared—you havenaloxone (Narcan is the brand name;naloxone is the generic formula)—andknow how to do rescue breathing. Youwould like to avoid calling 911, due topossible police involvement.

THE EQUIPMENTHave an overdose kit ready. The kitshould include the following: •Muscle syringes…usually 1cc, 23 or 25gauge—but sometimes 2 to 5 ccs—with a 11⁄2 inch long point. (If nothing else isavailable an insulin syringe will do, butbe careful that the point doesn’t bend orbreak.)•Naloxone/Narcan…most commonlycomes in two different strengths:.4mg/ml or 1mg/ml, in either a single-dose glass ampoule containing 1ml, or amultiple-dose vial containing 10ml. Nar-can is more often found in the 1ml am-poules, naloxone in the 10ml multi-dosevials, but if you look carefully at the pic-ture on page 17 you’ll see they’re both inthe same size (10ml) vial. Because nalox-one/Narcan comes in differentstrengths and sized containers, includingsome not mentioned here, always checkthe label first. (Note: This drug needs tobe stored at room temperature and keptout of the light.)•Alcohol wipes are a nice touch, as is asmall sharps container. Written directions,like cheat sheets on rescue breathing andNaloxone/Narcan administration, are agood idea just in case you panic. Hope-fully the number 911 is ingrained inyour psyche!

THE PROCEDURE:You’ve tried shouting her name, shakingher, the head chin lift and the whole res-cue breathing trip. No luck. It’s Narcantime, baby. You are going to administer1mg of (1mg/ml strength) naloxone/Nar-can intramuscularly. (There is no time topoke around and try to hit a vein.) 1. Have one brand new muscle syringeready for action: the point must be 11⁄2inches long in order to reach the muscle.2. If using a 1cc ampoule, break off thetop, and draw up 1mg (1cc) of nalox-one/Narcan. If using a vial, insert theneedle in the rubber top and draw upthe naloxone/Narcan to the 1cc mark(see Measurement Math at right).3. Choose a site—upper arm, front ofthigh, hip/upper butt—and insert thesyringe and push down the plunger.4. IMPORTANT: Begin rescue breath-ing again. It will take 2-3 minutes for thenaloxone/Narcan to take effect. If youdon’t continue to breathe for the personshe could suffer brain damage, or evendie, before the Narcan takes effect.5. If the person has not begun breathingafter 2-3 minutes, administer another 1mg.You can safely administer up to 5mgs toget her breathing; if that amount doesn’twake her up she’s probably been put outby something other than an opiate.6. Naloxone/Narcan’s effects may onlylast 20-45 minutes, so when it wears offyour friend may slip right back into anoverdose. Be ready to re-administer thedrug. You must stay with her during this timeand monitor her breathing.7. Once the person is breathing decidewhether you’re going to take her to thehospital, call for an ambulance or see adoctor. Follow up care is needed.

IMPORTANT POINTS TOREMEMBERNaloxone/Narcan starts the breathingprocess by blocking all the opiates in theperson’s system. If the individual does

not have a habit they will not experienceany withdrawal or ill effects. If, however,they have a habit they can experience ex-treme withdrawal. This is why S.F.N.E.recommends the 1mg dosing. If you arereally afraid and freaked out and want tobring them around immediately—orthey haven’t been breathing for a fewminutes—then use 2mgs. Be prepared,though, to sit out the awful withdrawalwith this person, a withdrawal that mayeven include violent behavior. Most hos-pitals and paramedics use 3mgs, whichwe feel causes the OD victim undue suf-fering. The whole point of users admin-istering naloxone/Narcan to each otheris to have another tool that provides uswith the power to reduce drug-relatedharm—while remaining healthy and re-taining our dignity and compassion.Also remember they cannot get high

during this time. If they try it will just beblocked and come on when the nalox-one/Narcan wears off; this could sendthem right back into another overdose.One of the most dangerous situationsthat can arise is when you administernaloxone/Narcan in a situation youcan’t control, the person insists on usingmore after he or she has been revivedand a bit later, after the naloxone/Nar-can wears off, dies. If you’re unsurewhether or not you can prevent this kindof scenario, it may be better to call 911and let the paramedics take over.One last important point: NEVER,

ever use the same ampoule of naloxonefor more than one person, and alwaysuse a new syringe for each dose. You don’twant to revive someone only to discoveryou’ve transmitted HIV or hepatitis to theperson.

THE LAWNaloxone/Narcan is not a controlledsubstance, but federal law prohibits dis-pensing without a prescription. So, if youget jacked by the cops you’ll get cited for

DRUG USER’S TOOLS OF THE TRADE:NALOXONE AND NARCAN

19

possessing a prescription drug without aprescription. In S.F. the cops will justconfiscate it, maybe cite you and then itmost likely gets thrown out of court.

San Francisco Needle Exchange andHarm Reduction Services is a peer-based, community level intervention byand for young injection drug users in theHaight Ashbury district of San Francisco.S.F.N.E. provides the tools and educationthat our participants need to reduce in-jection-related illnesses, fatal overdosesand the spread of HIV and hepatitisB/C. We reduce drug-related harm byproviding easily accessible, non-judg-mental syringe exchange, medical care,abscess and wound clinics and safer-using education at our indoor site threetimes per week. Our goal is to empower

young injectors to protect themselves,educate each other and reduce drug-related harm within the community.

S.F.N.E. has been doing an overdosemanagement and prevention programfor 11⁄2 years with young (under 30yrs old)IDUs in the Haight. Young IDUs have re-ported saving 16 individual’s lives thanksto the knowledge gained from the S.F.N.E.trainings (rescue breathing/CPR). During 1998 and 1999, 30 young

IDUs received the OD management andprevention training prior to our intro-ducing the naloxone component. Thattraining consisted of the what, how andwhy of opiate, meth and coke ODs (pri-mary emphasis on heroin), 911 protocol,developing an OD plan with injectionpartners (or alone), plus rescue breath-ing and CPR training and certificationand OD prevention tools.Six months ago we incorporated the

naloxone administration training intoour instruction plan. We have taught 17young IDUs the new, naloxone-im-proved OD management and preventiontraining course. Currently the two parttraining consists of the causes of an OD;how it happens/stages of overdose; ODprevention tools such as letting thetourniquet off after you register (to tastethe shot), rescue breathing and CPRtraining and certification; 911 protocol;naloxone administration and most im-portantly—next to breathing for the per-son—developing an overdose plan.SHARE DRUGS NOT NEEDLES

Ro Giuliano is Co-executive director of SanFrancisco Needle Exchange & Harm Reduc-tion Services. Thanks to Dr. Dan Ciccaroni,Dan Bigg, Quijaun Maloof and Dr. PamLing for all their help.

MEASUREMENT MATH 1ml=1cc Syringes’ capacities are measured in ccs, but some syringes, like insulin and tuberculin, have a second setof markings for measuring the dosage of the medications they are made for administering. To avoid confu-sion, ignore those markings (called units) and concentrate on the cc markings; otherwise you may adminis-ter the wrong dose. (This is particularly true with insulin syringes. Insulin comes in different strengths—U-40,U-100 and U-500, with 40, 100 and 500 units per cc—and syringes are marked accordingly. With 1cc sy-ringes, 40 units on the U-40 syringe=1cc, but 40 units on the U-100 syringe=.4cc.) Tip: 1mg/ml Narcan/nalox-one is 21⁄2x as strong as .4mg/ml Narcan/naloxone, so you need 21⁄2x as much of the latter to equal the sameamount of the former. (Narcan—but not naloxone—also comes in a .2mg/ml strength; you’d need 5x as muchof it to equal the same amount of 1mg/ml Narcan.). The following chart should help:

DOSE STRENGTH OF NARCAN/NALOXONE AMOUNT NEEDED (CCs)1mg 1mg/ml 1cc1mg .4mg/m 2.5cc1mg .2mg/ml 5cc2mg 1mg/ml 2cc2mg .4mg/ml 5cc2mg .2mg/ml 10cc

Reprinted from JUNKPHOOD PRESENTS: THE UFO STUDY.

administering naloxone in cases of non-OD opiate intoxication. It has been sug-gested that no competence exists to usenaloxone outside of the realm of medicalprofessionals. This statement is short-sighted and paternalistic: if the medicalprofession, in all its wisdom and compas-sion, were able to handle opiate ODs bythemselves, then thousands of peoplewho currently die each year would insteadbe alive. I believe harm reduction theorysuggests that the improvements describedhere are possible—and essential!The serious alienation/isolation illic-

it drug users face from society in gener-al—and EMTs, health care providers andpolice in particular—as well as a medicalsystem which restricts users’ access tonaloxone, currently obstructs the poten-tial lifesaving impact of this drug. In cer-tain parts of Chicago (poor areas) andwith certain calls (illicit drug user-relat-ed) you might as well be on an islandwhen trying to get emergency medicalhelp. Similar situations apply to users liv-ing in squats and on the street. In Italy, to counter such problems,

thousands of vials of naloxone have beendistributed to opiate users by street out-reach workers. In the US, a very smallnumber of opiate users have been col-laborating with outreach workers to learnabout preventing and managing ODs.They have also been given naloxone aspart of this training. They appear to beusing it to increase their feeling of em-powerment, to care for others aroundthem and to save lives! There are peoplealive today who wouldn’t be if some non-medical opiate users hadn’t been allowedaccess to naloxone. Naloxone should bean OTC medication available freely or atminimal cost to everyone who wants it.As it is, limiting naloxone’s availability

to medical providers deprives opiateusers of hands-on access to an importantlife-saving tool. Its distribution would po-tentially prevent thousands of deathsfrom opiate ODs each year, and it wouldafford widespread opportunities to bringusers the information and practical skillsthey need to successfully deal with, whatare for them, relatively common life anddeath situations. The future role for

naloxone in harm reduction practice in-cludes over-the-counter availability andwide dissemination of instructions for itsproper use. Hopefully this empower-ment to manage opiate overdose will beintegrated into all places where opiateusers are reached and harm reduction ispracticed. Ideally, it would be part of atraining on naloxone’s benefits and lim-itations, as well as certification in CPR,rescue breathing, etc.As for calling 911 and solely using

CPR, the recommended intervention forlay people: does a typical heroin user havebreathing equipment, training, staminaor bottled oxygen and the necessary air-way tools to intervene successfully in a res-piratory arrest? Is there a medical personin the same circumstances who would beable to perform rescue breathing (with-out using special equipment) for thelength of time needed? I believe theemergency care system is very good, but itdoes not adequately address the problemsillicit drug users all too often encounterwhen using the system to get help for anOD: excessive response times due to prej-udice against drug-related calls, a punitiveapproach to overdose treatment and thefrequent coupling of police presence withEMT response. I am proposing thesechanges to make the system better than itcurrently is. Anyone who has lost a lovedone to opiate overdose should take noticethat these premature deaths can be easilyand cheaply avoided if we are willing toface the realities of opiate use and work togive people another tool to preserve life.Understanding and possessing nalox-

one is definitely part of “any positivechange” for opiate users. The more op-tions the user has to manage opiate ODs,the more capacity he or she has for re-ducing drug-related harm. Naloxone in-formation, training and availabilityincrease the options harm reductionistscan offer those looking to reduce drug-re-lated harm in their lives. Sterile syringes,naloxone education and access, betterveincare/safer injection information,CPR and first aid training, and as manyother options as conceivable should bepromoted and expanded as possibilitieswithin the harm reduction movement.Our greatest strength is our willingness toentertain improvements in spite of soci-etal requirements for perfection. I hope

20

Yet Another Positive ChangeCONTINUED FROM PAGE 16

NAL

OXO

NE

AV

AIL

AB

ILIT

Y

21

we do not lose this perspective as we moveto include naloxone or other medical in-terventions among the possibilities for re-ducing drug-related harm.I have heard some harm reductionists

say naloxone is not a good idea becauseit incorrectly promises to “solve the ODproblem.” I have always felt the beauty ofharm reduction is in its ability to learnfrom the past. Harm reduction haslearned that no single approach worksfor everyone, that any improvement isbetter than none and that the greaterthe level of user empowerment andnumber of options for improvement thebetter. Anyone who claims to solve everyfacet of a problem as complex as drugaddiction or misuse, overdose, etc. hasfailed to learn from the past and seemsunable to appreciate the power of “anypositive change.” Generating as manyoptions to handle overdose as possible isharm reduction’s work.Similarly, access to sterile syringes

does not “solve the disease problem”among injectors, as many opponentsclaim it should, but many of us havefought for the availability of sufficientsterile syringes to help reduce diseaserisk from injection. Criticism of this vari-ety is contrary to the recognition andpractice of improvements in a person’slife as they prescribe them for them-selves. Ultimately, the best criticism ofthe current approach to overdose treat-ment is the thousands of people who dieof opiate ODs each year in spite of themiraculous options available.It doesn’t seem like we can wait for the

medical system to respond. All of these is-sues—overdose, opiates, naloxone—havebeen around for decades and there is stillno medical solution offered beyond theemergency care system. Clearly, there’slittle difference from other take-home in-jectables like epinephrine for allergic re-actions, insulin for diabetes, etc. onceyou strip away the bias against drug users.What is novel is helping drug injectors to

reduce OD risk through medical meansas is done with allergics, diabetics, etc.—and such assistance is long overdue. Thephysician’s Hippocratic Oath would seemto dictate naloxone’s use, but apparentlybiases against people using opiates havekept it from progressing as a take-homemedical approach for years.Opponents of naloxone distribution

don’t answer the hard question of cost ef-ficacy, as most medical providers oftendon’t. Hepatitis B vaccination has beenmedically recommended for injectiondrug users since 1982 but is still largely ig-nored. Why? I would contend that biasesagainst drug injectors and high medica-tion prices have limited this interventionfar more than sensible public healthpractice would suggest. Only good re-search will answer the question of cost ef-fectiveness with the OD treatment issue.In the meantime we should do all that wecan with all of the options available to us.Certainly, our meager resources wouldmore effectively train and provide nalox-one use than CPR training. A 10ml multi-use vial of 0.4mg/ml naloxone (genericNarcan) costs less than $3.00, and the in-formation needed to use it well is easilyshared. CPR is very resource intensiveand generally not very effective for laypeople to do in cases of opiate overdose,primarily due to the difficulty in doing itcorrectly and for a sufficient length oftime without equipment.Ideal vs. reality. What is happening

with OD management today? It appearsthat if not for naloxone and injectionrooms (which have shown major reduc-tions in lethal ODs) as the lightningrods, little discussion would be happen-ing now. Many opiate users were talkingabout OD treatment after the Pulp Fic-tion thing. Imagine the talk on the streetif the movie had portrayed a real treat-ment for opiate OD: the priority ofbreathing and naloxone’s correct use.Hollywood screwed up this opportunity,and I can’t help but think that it did it soto avoid the charge that was leveledagainst the movie anyway: that it glamor-ized drug use. In the end, QuentinTarantino dissed the lives of drug users.(In Trainspotting naloxone was used in asadistic way only after the person wasdragged to the ER; this is reality but notall that is possible.)The people most excited about nalox-

one empowerment and provision arepeople using opiates. The enthusiasmamong many opiate users, resulting fromtheir awareness of naloxone’s possibili-ties, should be the most significant guidefor harm reductionists about its use. Fi-nally and ultimately, your struggle aboutnaloxone availability should include theultimate test of validity: if you were usingan unknown quantity of heroin (as is al-most always the case), would you wantyour injection partner to have naloxoneamong his/her other options for inter-vening in case of your overdose? Why nothelp show all your fellow brothers andsisters the same respect? n

Dan Bigg is the Director of the Chicago Re-covery Alliance and holds a CRADC addic-tions certification. Dan has been involved inboth the addictions treatment system and thepractice of harm reduction since 1984.

Naloxone’s…distribution wouldpotentially prevent thousands

of deaths from opiate ODs each year.

If the medical profession, in all itswisdom and compassion, were able tohandle opiate ODs by themselves, then

thousands of people who currently die each year would instead be alive.

NAL

OXO

NE

AV

AIL

AB

ILIT

Y

22

get to the patient’s brain. For a para-medic, getting it there is fairly simple.We either use IV dosing, or we use IM(intramuscular) or other types of injec-tions. We can even administer it via theirlungs if the situation dictates. Theprocess commonly takes time, and if thepatient’s breathing isn’t supported forthe duration, the Narcan is too little toolate. Even we see delays in the effects ofNarcan that last minutes. For the layper-son, getting Narcan to a person’s braincould be difficult or impossible. If thepatient has been down for any period oftime, their blood supply will be shuntedaway from their muscles. If they’re givenNarcan by IM injection, as might be thechoice by a layperson under stress, themedicine could sit in that muscle untilthe patient is dead. Also, you have toconsider that there may be some timespent searching for the vial of Narcan,etc., time that should be spent on oxy-genating the patient.It has been said that many paramedics

and other health care providers give Nar-can maliciously. While there may besome people in any profession who aremotivated to abuse people, I think thatmost of the harmful administrations ofNarcan can be attributed to inexperi-ence. Most experienced paramedics andnurses I know will see to the airway andbreathing needs of a patient, and thencarefully give enough Narcan to allowthe patient to be conscious, and tobreathe for himself. Typically, less expe-rienced workers give medicines exactlyas specified in a doctor’s order or in atreatment protocol. Such orders do nottypically prescribe a tailored approach toa particular patient’s problem. They aregenerally simple instructions includingthe name of the medicine, and the doseor dose range, along with the patient’sname and date and so on. Newer practitioners may not have the

sophistication, or may not have seenenough patient responses, to give a med-icine like Narcan in the most humaneway. Someone who finds themselves atthe scene of a heroin overdose with onlya vial of Narcan, and lacking proper firstaid training and the ability to provide

rescue breathing, would likely give Nar-can in a large dose, by the quickest routepossible. And, in a sense, people whohave little experience with overdose re-suscitation could not be faulted for giv-ing it by the quickest route available. Unfortunately, if used too aggressive-

ly, Narcan can drive a patient straightfrom heroin overdose to heroin with-drawal in a matter of several seconds,causing violent withdrawal reactions thaton their own can be life-threatening.This would be seriously harmful to any-one with a habit, and would create a dan-gerous situation where an individualwho’s been thrown into a state of agonyis suddenly able to walk and becomephysical. This is a terrifying situation forthe patient (not to mention the persongiving assistance), and can be dangerousfor anyone nearby. I frequently see friends of altered pa-

tients who are convinced that the patientis alert simply because they are able to talk,look them in the eye or get up. Without adefinite plan, situations like these couldget out of control quite easily. A patientwho seems alert could walk into traffic, falldown stairs, pick up a knife and hurt theirfriends (I have seen tremendous violenceprecipitated by the rapid use of Narcan)or disappear into the night and very quick-ly become re-overdosed. This is an impor-tant consideration, and should be part ofdiscussions about Narcan distribution tolaypeople and others.There are additional risks posed by

the elements of an overdose that can’t beaddressed by Narcan use in the field, andfor which the only available treatment isin the hospital. The aspiration of stom-ach contents into the lungs can oftenlead to pneumonia. Acidotic blood andtissues, caused by cessation of breathingfor a period of time, can lead to a few po-tentially lethal, delayed problems such ascerebral edema, or swelling of the brain,and non-cardiogenic pulmonary edema,where the membranes in the lungs be-come leaky and blood serum moves intothe air spaces of the lungs. Repeated useof Narcan can be fatal with the formercondition, and people suffering fromthe latter often need to be managed inan intensive care unit. Lastly, many med-ical problems cause unconsciousness,and could readily be mistaken for hero-

in overdose by a well-meaning rescuer. Insuch a situation, this confusion wouldlikely delay access to effective help whilethe rescuer is focusing on giving Narcan.Supporters of easy access to Narcan

have made comparisons with take-homeinjectible medicines prescribed for vari-ous medical problems. There are severaldifferences between most of these casesand the problem Narcan has been sug-gested to address. Take diabetes and beesting allergies for comparison. Both ofthese types of patients require medicinesthat need to be injected. In the case ofthe diabetic, the patient requires in-jectible insulin like non-diabetics requirewater or food. The patient makes insulininjections part of his/her daily routine.This patient is generally supported in theuse of this medicine and all the neces-sary testing equipment that goes with itby an ongoing relationship with a doctor.These patients require frequent follow-up for changes in their treatment strate-gy as they respond to changes in theirlives. While I would like to see a medicalestablishment that is willing to engage inthis type of relationship with heroinusers, I don’t think anyone has suggest-ed that Narcan distribution could be-come the cornerstone of such change.Rather, I believe Narcan distribution isbeing suggested as an alternative to cur-rently available medical care.In the patient who has a serious aller-

gy to bee stings, or other environmentaltoxins, epinephrine is prescribed in aneasy-to-use, spring-loaded pen that ac-complishes an injection when pressed to

You will set peopleup to fail if you

give them a vial ofNarcan withoutgiving them theskills to provide

breathing support.

Not a Silver BulletCONTINUED FROM PAGE 16

23

the patient’s thigh. These patients haveprecious few minutes to receive thistreatment, and they generally have oneof these epi-pens on their person mostof the time. One major difference be-tween this type of take-home treatmentand that proposed for Narcan distribu-tion is that patients allergic to bee stingsdon’t stop breathing. They remain con-scious, and identify the problem them-selves as their doctor has explained it,and as they have experienced it before.They use the epinephrine, and then goimmediately to the emergency room forfollow-up care. (As with heroin overdoseand Narcan, the problem of anaphylax-is doesn’t stop once the patient has usedhis or her epi-pen.)Patients with heroin overdoses imme-

diately become unable to help them-selves. This is a critical difference. Inpatients with diabetes or life-threateningallergies, the take-home treatment is pre-scribed to them, to be used by them, totreat their own illness by recognizingsymptoms they’ve experienced before.In the case of heroin overdose, Narcandistribution is more like take-home med-ical practice to be used by people whohave no experience differentiating be-tween heroin overdose and other causesof unconsciousness. These people wouldbe put in a position to make decisionsfor their friends, in essence practicingmedicine.I agree that access to the tools of over-

dose resuscitation does need to be in-creased. But the first step towardincreased access should be the elimina-tion of the fear of calling 911. This bar-rier is not insurmountable. By exposinghealth care workers to the philosophy ofharm reduction in their primary train-ing, and by educating police agenciesabout the effects of their enforcementpolicies, I think the fear of calling 911can be reduced. There may be situationswhere people are using in squats or inplaces that are otherwise far away fromhelp. For these cases it may be beneficialfor the people at this scene to have a vialof Narcan. However, if they choose touse the Narcan in lieu of breathing sup-port, or if they use the Narcan in a waythat precipitates withdrawal, they mayfind themselves in a situation just as dif-ficult as the overdose itself.

The legal barriers to distribution ofNarcan to untrained people are sound,and are not the first hurdle that theharm reduction movement needs tojump. Education about risk factors inoverdose, post-overdose counseling anda healthier relationship between the in-jection drug using community, the healthcare establishment and the police are farmore likely to have an impact on thenumbers of people dying of heroin over-dose. Even as part of our considerationof Narcan distribution, resuscitationtraining must come first. You will set peo-ple up to fail if you give them a vial ofNarcan without giving them the skills toprovide breathing support. Users andservice providers need to know that Nar-can is not a magic pill that fixes the situ-ation ala the dramatized resuscitationscene in the movie Pulp Fiction. The dis-tribution of Narcan will be harmful if itsuse is guided by such notions. It is un-fortunate that the focus of overdose in-tervention has shifted to Narcan. Whileit is a useful part of the resuscitation, it isone which gets used late in the game, andwhich should be used carefully, by some-one with experience administering it. An informed understanding of the

medical care one receives or has accessto is important, and this discussion willhelp to increase the harm reductionmovement’s understanding of the use ofNarcan. There is much to be done in theprimary and ongoing training of para-medics, nurses and doctors to exposethem to the philosophy of harm reduc-tion, and to highlight the risks of the im-proper use of Narcan by newerpractitioners. The addition of harm re-duction philosophy to training of practi-tioners will lead to more attention beinggiven to Narcan’s proper use, and even-tually to an improvement in Narcan’srole in health care.At best this discussion may help to in-

form our decisions as we try to deal withthe overdose issue. We could be desper-ate because people are dying, and itseems like every possible solution shouldbe tried until one works. We could bezealous because we think we’ve foundthe ultimate solution, and any effortspent on any other idea seems like awaste of precious time. And we could beregretful because we saw a situation, did

what we thought was best at the time andlater found out that our efforts hurt orkilled someone. Or we could invite allavailable expertise to a discussion that ul-timately will allow us to reconcile the des-peration, zeal and regret into ameaningful effort to deal with overdose.In my years as a paramedic I’ve felt thedesperation, I’ve been the zealot and, forthe rest of my life, I’ll deal with the re-gret. One situation at a time, over sever-al years and through thousands ofpatient contacts, I’ve learned that thereis nothing I do as a paramedic that is100% benign every time. The choice isours: either to be driven to action by des-peration or zeal beyond all considera-tions of unintended consequences, or toconsult expertise and learn from the in-vestigations and mistakes made by oth-ers before us, thereby avoiding the conse-quences of impetuous action. n

Robert Swarner is a paramedic field trainingofficer in Santa Cruz, and has spoken fre-quently on the topic of overdose at harm re-duction conferences. He has worked with theSanta Cruz Needle Exchange Program since1991, primarily doing overdose trainings andfundraising.

1 Hall, Wayne D. How can we reduce heroin‘overdose’ deaths? Medical journal ofAustralia 1996; 164:197-198.

2 Darke, Shane et al. Overdose among heroinusers in Sydney, Australia:II. Responses tooverdose. Addiction; 91(3):413-417.

3 Ibid.4 Sporer, Karl A, MD, et al. Out-of-hospitaltreatment of opioid overdoses in an urbansetting. Academic Emergency Medicine;3(7)660-667.

5 Bertini, Giovanni, MD, et al. Role ofprehospital medical system in reducingheroin-related deaths. Critical Care

The cure for aheroin overdose isoxygen, breathing

support and airway control.

24

25

Reprinted from JUNKPHOOD PRESENTS: THE UFO STUDY. JUNKPHOOD ’zine was started by and for young users of the Santa Cruz Needle Exchange Program (SCNEP).

For m

ore information about the UFO Study, or to order copies of JUNKPHOOD, call 831.425 3033 or check out their website, www.ufostudy.org.

26

Starting with this edition, Sara Kershnarwill no longer be writing Witches’ Brew.She will be missed here, but I am delighted

to be following in her footsteps as “Witch-in-Residence.” Like Sara, I am an herbalist inthe Western tradition, a harm reductionistand a health educator. I am also a holisticnutritionist, so I’ll be writing lots aboutherbs and foods that users and other folksmight find useful.

I love getting letters and email aboutwhat works for you. I am especially interest-ed in old family recipes—you know, the homeremedies your grandma made you drink orslathered all over you, or the plant your dadknew from the old country, be it Senegal orSicily or Southern California.

— Donna Odierna

This “Witches’ Brew” will focus on thechange of the seasons, and how to stayhealthy during the cold and flu season.As fall arrives, the light fades and the daysand nights cool down. Flu season ap-proaches, and your doctor or the healthvan folks may suggest that you get a flushot. Whether or not you choose to get

the shot, there is a lot more that you can doto boost your immune system and stay healthy

throughout the winter months. First, let’s take a look at foods that bolster the im-

mune system by enhancing the body’s virus-fightingabilities, or strengthen tissues so that microbes of allsorts have more trouble mounting a successful in-vasion. If you have a place to make your own food, ofcourse, it’s easier to control what you eat, but if yousometimes get prepared food, or even if you mostlyeat at free food programs, you may have a choiceabout your foods. You can also show this column tothe people who prepare your food, and ask if they canincorporate some of the suggestions.

FEEDING THE IMMUNE SYSTEMIn general, it’s best to eat heavier, warming foods dur-ing the colder weather. We tend to want more protein,and we like foods that are rich in fats and oils. Fats arenecessary—they keep cell walls strong and betterable to fight off invading germs. A little olive oil or but-ter is good, as are raw nuts and seeds, which also pro-vide protein. Autumn is nut harvest time,when nutsare cheaper and fresher. Go for walnuts, almonds,brazil nuts, filberts (hazel nuts) and seeds—sunflower,pumpkin and flax. Sesame seeds and cashew nutsshould be roasted before they are eaten, though. Tryto eat at least two tablespoons of nuts and seedsevery day, and 3-5 servings of cooked vegetables (aserving is about half a cup), and don’t forget to have

an apple (or other fruit) every day. Get plenty of vari-ety if you can—the more colors on your plate, the bet-ter!

GARLIC improves circulation, while keeping your tis-sues healthy and making you feel warmer. It also killsoff nasty microbes and boosts your immunity, if youeat it raw or lightly cooked. A clove or more of raw gar-lic every day should do the trick. Some herbalistsplace peeled garlic cloves in a jar, cover them withhoney and cover the jar, letting the garlic flavor thehoney. When a cold is felt to be coming on, the suf-ferer swallows a whole garlic clove, or takes a spoon-ful of the honey.

GINGER is another warming, stimulating herb. Whenyou’re coming down with one of those tight-chestedcoughs, hot ginger tea can loosen things right up.Make ginger tea by grating or thinly slicing about 1” offresh ginger root into a cup, covering with boilingwater and letting it steep for 10 minutes before drink-ing. Hot ginger tea can make you sweat, which isgood if you are in a warm, dry place (it can stimulateand break a fever). However, it is not good if you aresleeping outdoors or in an unheated building: if youare not warm enough after the sweating passes youcan become chilled.

CAYENNE PEPPER gets the circulation going,warms up cold hands and feet and helps the bodyget rid of toxins. If you put some red pepper powderbetween your socks and shoes it gets circulationgoing and makes your feet feel nice and toasty. In fact, GINGER, GARLIC and RED PEPPERS all

improve circulation and help to keep your veinshealthy and strong. Look for them in Asian, Mexican,Italian and Ethiopian food.

SHIITAKE MUSHROOMS, also called BLACKMUSHROOMS, are found in lots of Chinese food.You can also find them dried, in Asian grocery stores.If you eat a few of these several times a week, yourbody’s anti-viral defenses will be in good shape tofight off the cold and flu virus.

WINTER WELLNESS HERBAL SOUP 2 quarts water or broth (Chicken, beef or vegetable.Canned is fine.) 4 or 5 cloves of garlic 1-2 inches of fresh ginger, sliced thin, skin on 4-6 dried shiitake mushrooms 3-4 slices of dried astragalus root (from the herbstore or Chinese market. Astragalus looks like thetongue depressors you find in the doctor’s office). A handful of parsley Celery, chopped Carrots, chopped

WITCHES’

BRE

Hot pepper and salt to taste 2 T sesame oil or olive oil Put all of the ingredients into a pot. Heat to a low boil,reduce heat and simmer at least 45 minutes. Takeout the astragalus and the ginger slices. Drink thisnice and hot, 4-5 times a week, or every day if you like.Be sure to eat the mushrooms and garlic!

FALL TONICS Fall tonic herbs strengthen your system and keepeverything working in top form. Burdock root is myvery favorite fall tonic tea. It nourishes the liver, theskin, the kidneys and the digestive tract. It has a rich,sweet-bitter taste. Drink burdock daily for up to threemonths. One great thing about burdock is that itgrows like crazy in almost every urban area in theEast. Get someone who knows the plant to show it toyou so you can have your own supply. You have to beready to dig, and watch that the place you are har-vesting from hasn’t been sprayed with pesticides orrat poison, and is free from dog shit. Cut the roots upinto strips and dry them, or buy burdock root at thelocal herb store. Another great thing about this herbis that you don’t need to boil water to make burdockroot tea. It’s good as a cold infusion, and all you needis some dry burdock root, a quart jar with a goodcover and some clean water.

BURDOCK ROOT COLD INFUSION (no heatneeded) 1 ounce dried burdock root 1 quart of cool water Place the burdock in the jar, fill to the brim with water.Cover the jar tightly. Steep 8-12 hours, or overnight,shaking every now and then. Strain (or not) and drinkthe infusion (fancy word for tea) throughout the day.Make a fresh batch every night, especially if you don’thave refrigeration. Other good winter teas are mint, lemon balm, red

clover, oat straw and linden (also known as tilo or tilia,available in Latino groceries). These teas are all madethe usual way, with boiling water. Lots of folks report that they always get sick after

they kick dope, especially during cold and flu season.Whether or nor you have a detox planned, herbal teacan help you stay healthy during the colder months.

COLD SEASON/AFTER KICK TEA Mix together equal parts of any or all of the followingdry herbs: echinacea, Siberian ginseng, burdock, paud’arco, nettles, chamomile, hawthorn berries. Addlicorice root to taste (licorice is very sweet). Put an ounce of herbs in a jar, cover with boiling

water and cover the jar. Let it steep for at least 20minutes (2-4 hours is best), strain and drink through-out the day. If you do get sick after all of this, your symptoms

are less likely to be severe, and they won’t last as long.Your recovery time will be shorter, too.

TO FIGHT OFF A COLD OR FLU At the first sign of a cold—fatigue, achiness, tightchest or sniffles—try one or more of these things toboost immunity and stay healthy: —Vitamin C, 500mg every 4 hours, to bowel toler-

ance (if you get diarrhea, stop taking it or reduce thedose).—Echinacea, 30-60 drops of tincture, or 1 capsule,

every 2 hours until symptoms subside. If you do takeechinacea in tea, be sure to get “aerial parts,” be-cause the roots don’t make good tea. (Note: Echi-nacea stimulates white blood cell activity, and someunconfirmed research indicates that this may wors-en some auto-immune conditions like HIV. Peoplewith HIV infections, especially new infections, shouldtake this into consideration when deciding whetheror not to use echinacea.)—Ginger or linden or mint tea, 3-4 cups per day.—Drink lots of water—8 or more glasses a day, to

keep mucus thin and flowing. Thick mucus is a fa-vorite breeding ground for germs and microbes.—Stay warm and dry and get lots of sleep.—A Chinese remedy called “Yin Chiao” is great for

fighting off a cold. It’s inexpensive, and you can get itat Chinese herb stores and many health food stores. Fall is a good time to start turning our energy

inward, in preparation for winter. It’s a good time forcontemplation, and for self-assessment. By mid-De-cember the temperature has dropped, the nights arelong and the leaves have fallen. Growing things godormant and conserve energy in their roots. We canlearn from their example, and use this time to pay at-tention to our inner needs. What do we need fromour relationships, what can we do to keep ourselveshealthy and happy as we define those things, whatcan we do to start filling empty places and unmet de-sires? If we turn our thoughts inward now, we will be pre-

pared to take action in the spring, when the light begins to return and everything begins to moveagain—our energy flows much as the sap rises in thetrees to meet the warming sun.

Please send your comments and suggestions to: Donna Odierna c/o HRC/Witches’ Brew22 W. 27th St., 5th Floor, New York, NY 10001FAX: 212 213-6582EMAIL: hrc@harmreduction.org

Donna Odierna is a herbalist, nutritionist and health educator. She isin private practice and also works with IDUs at Casa Segura in Oak-land, CA.

27

BY DELANEY ELL ISON

Larry Dean was a Syringe Distrib-ution Outreach Worker and heoverdosed in Benton Harbor

last summer. He was up on what it waslike to be treated like shit. Larry Deanknew something about the drug policyand civil war on drug users that may benews to some. He knew, in the northamerikan nightmare, that most of theproblems faced by drug users stem fromthe way they are treated by drug treat-ment providers, the criminal justice sys-tem and society at large.He did not die alone. He died in the

arms of another outreach worker. I have

to hope if he were to choose, he’d havechosen this way.Larry knew, though he never said it,

that even the people he worked withcould have been bombarded so longwith the war on drugs propaganda thateven the most intelligent and sophisti-cated of us have internalized the lies.The most pervasive and basic of the lieshas to do with the way drugs/alcoholhave been carefully and historicallylinked to African American, inner-citymales to the exclusion of other groups.This paradigm allows criminal justice toviolate the constitutional guarantees ofall of this country’s citizens.Forgotten is America’s early history of

opiate use. At the turn of the century,white, middle-class men and women rep-resented the major consumers of mor-phine derivatives. This middle class gottheir dope from the pharmacist with aprescription from a doctor, not fromneighborhood kids! Ignored is the histo-ry of ever repressive drug policies wherethe illegal black market has turned mi-

nority neighborhoods into armed camps.Ironically enough, the current paradigmpervades the way we deal with peoplewho don’t meet our provider-centeredstandards. Larry Dean understood this.Usually, Larry would deal with those

individuals no one wanted to fuck with.Remember, he knew something aboutbeing treated like a sub-human! Heknew that sometimes even we, the harmreductionists, the outlaws, could ask thepeople we served to trust us without giv-ing them any reason to trust. We couldplace conditions, like pointless one forone exchange on the number of syringessupplied to them, without concern fortheir very real injection needs, or require

them to choose goals we thought wereappropriate. He realized that we oftenonly offer people the same compassionthey get in the dopehouse, from dealers:“Come to us, we’ve got what you need,but you must meet us on our terms! Anddon’t bring no change… that’s right,one for one.” He knew that the propaganda of the

war could affect even us, and insidiously,the people who we serve! He knew thatusers could think of themselves as sick,weak people. He knew that people couldbe made to feel like they are worthlessbecause they don’t want to “get clean,”instead of being treated like the peoplethey wanted to be! Larry knew thatproviders, faced with the HIV healthemergency, were capable of drawinglines and retreating in the face of fund-ing restrictions, government guidelinesand the politically correct precedence.He was willing to do something about it.Larry Dean helped us all by manag-

ing the secondary distribution occur-ring in shooting galleries and people’s

homes. He didn’t talk about it in de-briefings. He wouldn’t do that. He justmade secondary distribution work. Hetold us one day, “Nobody can sell sets inthe dope house, I got that covered!” Wedidn’t believe him, or we didn’t want tobecause we were supposed to be intouch with the street. But people beganto return 40-50 used syringes, capped,in the plastic bags he distributed. Whenthe subject of re-sale came up, he endedthe discussion with, “That ain’t none ofour business.”Larry Dean did not care that drink-

ing alcohol reduced vitamin k (clottingfactors) in the blood and acceleratedthe absorption of the drug, although he

had heard all kinds of safe injectionconversations and participated in train-ings. He didn’t care about his tolerancelevels. Larry hit a lick, copped andslammed a bag of excellent qualityheroin into his acupital. We watchedhim do this a hundred times before;this time he died. What was importantto him was real essential. It has to dowith his friends dying horribly, need-lessly, alone... because no one caredabout them, or because many had theidea reinforced that they were too dam-aged and dangerous.

he didn’t pay attention to what I’dlearned watching him changefrom stinking homelessness to

having a stable apartment and takingregular showers. It didn’t seem to matterto him that consciously or unconscious-ly I treated him differently, better, as hechanged. (Yeah, you right, I’m guilty.) Iexperienced a subjective lesson in thephenomenon of harm reduction. I’dsilently opposed the outreach team’s

28

On the grOund

nomination of smelly Larry. It was theirdecision; I don’t vote. We have the con-clusive evidence that harm reduction ispracticed by all of us, all the time, as Iwatched Larry offer his knowledge andsafe injection tools to the ones no onewanted to be bothered with, while hetook better care of himself. Threatenedwith long and brutal incarceration, sus-pected and coerced by boy/men playinglaw enforcement, excluded fromproviders and treated like shit, users playthis intricate game. When it works,there’s nothing sweeter— and they don’tstop copping! Larry changed clothes andbecame a street corner activist, the mosteffective kind.This is not a story of loss. We have

been de-sensitized to loss. This is abouthow we, front line workers, need to learnto take care better care of each other. Weought to be able recognize that doingthe work is the most rejuvenating, re-warding thing we may ever do! We canreject those notions about needing to“take a break” from the work! We’vebeen challenged to participate in the ef-fort to address the reasons why peopleuse drugs. The list includes racism,poverty, stigmatization, homelessness,sexism and homophobia. Our responsemust be relentless! We can take the ex-amples from those of us who live andbreathe this life-saving effort and learn abetter way to live and interact with thoseon the fringes. To accomplish this wemust do what Larry knew to do: we needto ask the experts! We have to go into theenvironment uninvited asking, “Whereare the problems and how can we help?”This is not a memorial. No, these wordsare written to awaken us to the narcoticsof self-serving political agendas. This isabout the, seamless, wrap around brutali-ty of the hunches inherent in the rigid,white, male, middle-class, disease modelfor understanding and treating users. Itbecomes self-defense when we advocatefor control of services that are supposedto help, but continue to harm.This is about Larry Dean, La La, Tracy,

LC, Abba Dabba, these experts and all ofus... ultimately. Here on the ground. n

Delaney Ellison is the Harm Reduction Coor-dinator at Community AIDS Resource andEducation Services, Kalamazoo, Michigan.

29

HRC’s THE STRAIGHT DOPEeducation series meets your needfor accurate, practical and non-judgmental information instraightforward language on drugsand drug use.

H is for Heroin, C is forCocaine, and S is for Speed each describe their respective drugand the forms in which it comes; how it is used; its physiological andsubjective effects on the body and the mind; tolerance, addiction,and withdrawal; detoxification; overdose prevention andmanagement; legal issues; and stigma. Written by users themselves,each gives an honest account of the benefits that users report aswell as the risks, dangers, and negative effects of their use.

Overdose: Prevention and Survival discusses what overdose is;how it happens; how you can prevent it happening; how you canprepare for it happening; how to recognize if someone else hasoverdosed and what to do and what not to do in an overdose situation.

Hepatitis ABC describes the latest scientific knowledge on thediffering forms of hepatitis: their respective causes, symptoms, andprevention and treatment options.

Getting Off Right is a plain-speaking, how-to survival guide forinjection drug users. Written by drug users and service providers, it isa compilation of medical facts, injection techniques, junky wisdomand common sense that aims to provide the necessary informationto keep users and their communities healthier and safer.

STRAIGHT DOPE brochures can be bulk purchased at 15cents each. Orders of more than 50 brochures add $3.00 shipping($5.00 international). Getting Off Right is available at $5.00 percopy for 1-10 copies, $4.00 per copy for 11-50 copies, and $3.50per copy for more than 50 copies. Add $3.00 for shipping ($5.00international).

Please send me:

Description No. copies Price each Total

H is for Heroin _______ $0.15 _______

Overdose _______ $0.15 _______

C is for Cocaine _______ $0.15 _______

S is for Speed _______ $0.15 _______

Hepatitis ABC _______ $0.15 _______

Brochure Shipping—US/Canada $3.00 _______

Brochure Shipping—Internatl $5.00 _______

Getting Off Right (1-10 copies) _______ $5.00 _______

Getting Off Right (11-50 copies) _______ $4.00 _______

Getting Off Right (50+ copies) _______ $3.50 _______

Getting Off Right Shipping—US/Can. $3.00 _______

Getting Off Right Shipping—Internt’l $5.00 _______

Total Enclosed _______

NAME

ORGANIZATION

ADDRESS

CITY STATE ZIP CODE

COUNTRY

PHONE

Send orders to: Brochures, Harm Reduction Coalition,

22 West 27th St., 5th fl., NY, NY 10001

CINDY AND SHARON SHARED THE SAME DREAM: TO GET THEIR OWN APARTMENT.

BY SANDRA FUENTES ANDDAL IAH HELLER

Sharon and Cindy first met at a welfare SRO(Single Room Occupancy) hotel. They hit itoff right from the start, being how they wereboth HIV-positive and addicted to heroin andsmoking crack. Both got syringes from a nee-dle exchange called CitiWide Harm Reduc-tion, which went to SROs once a week. Bothtook turns making money on the hoe strolland cashing in their food stamps. Cindy andSharon shared the same dream: to get theirown apartment. They felt with an apartmentthey could learn responsibility such as payingthe bills, being able to cook and spendingmoney on buying things for the apartment in-stead of drugs. Having an apartment wouldlead to being able to detox, because having anapartment was worth getting clean for. SROhotels were all the same: small, roach-infested,drug-dealing and the majority of the time yougot your room robbed. You also risked infectionbecause of uncleanliness —sharing dirty bath-rooms and showers.

Well, Sharon was in a 21-day hotel, likeCindy, only her 21 days were up. She had togo back to Division of AIDS Services (DAS)to get re-housed at another hotel. So she gotup and luckily saved some of her dope for themorning in order to go through the procedureto be re-located, which was an all-day process.She said goodbye to Cindy, and they figuredthey would meet up in the next hotel. You see,when you’re on welfare, you get shuffledaround from hotel to hotel, and even if youfind a permanent hotel you still have all ofthe above-listed problems, plus no medicalcare or case management.

Sharon was lucky. Because when she got re-housed she was placed in another hotel wherethe program did outreach and needle ex-change, she was able, through CitiWide HarmReduction, to get into detox and eventually ob-tain an apartment. This allowed her to feel asense of accomplishment. It wasn’t that sim-ple, though. She went through brick walls infinding the apartment. She had to get welfare’sapproval, then she had to wait for rent and se-curity checks, and it wasn’t until losing twoapartments that she finally got a case workerwho processed her papers in time. Real estateagencies don’t like dealing with welfare be-cause there are so many technicalities – it’s like

they try to make you lose hope or test your pa-tience. But with a little help from a lot offriends, Sharon stuck it through to finally bein a place she could call home.

Cindy, on the other hand, wasn’t as luckyas Sharon. Cindy missed her re-certificationappointment because the hotel clerk didn’tgive her her mail until a week later, so herroom was closed, and she was told to go backto DAS. You see, in order to maintain anopen case with DAS you have to show up fora re-certification appointment when they askyou to, which is usually every six months.But if you don’t get your mail wherever you’restaying, which happens pretty often at the ho-tels, then you don’t know when your re-certi-fication appointment is. And if you don’tshow up for that appointment, then they“close” your case, and the hotel managementcan throw you out into the street. So Cindyhad to go to DAS to get back into the emer-gency housing system, only she was sick andneeded to get straight. Except now, out in thestreet, she didn’t have access to needles, or themoney to buy them. (Around the neighbor-hood where her hotel was at, there weren’t anystreet needle exchanges). She had to use usedworks or works she found because she was toosick and didn’t care how she got them—aslong as she got straight. Stuck out in thestreet, Cindy was running again, taking eachday as it came, trying not to get too sick so shecould make enough money to get straight. Shelost touch with CitiWide because she fell outof the hotel system, and she didn’t know wheretheir office was because she’d left the map inher room when she was kicked out.

For many reasons related to their druguse, drug users are routinely deniedhousing. As harm reduction

providers, we know that permanent (or,minimally, long-term) housing is a fun-damental building block for individualsto gain some sense of stability in theirlives. Without such housing, it is difficultfor anyone to plan for the future, or toexperience any personal sense of satis-faction, growth or development. The error in reasoning made by too

many housing providers and housingplacement agencies is that an active druguser cannot maintain housing because oftheir drug use. But we argue that housing

as a harm reduction intervention canprovide an active drug user with the firststep towards stability, towards use man-agement, towards household mainte-nance, et cetera. The misconception thatan active drug user cannot maintainhousing smacks of the same prejudicesand barriers which continue to preventdrug users from accessing adequate andappropriate services and supportthroughout the service world and be-yond. In fact, in order for an active druguser to begin the process of stabilization,housing is of primary importance.Stable housing can help provide ac-

tive users with opportunities to improvethe quality of their lives. We have identi-fied a number of positive situations sup-ported by long term housing, which arefar less accessible for active users wholack such housing. While some may dis-agree, it is important to consider that an active user who is living homeless onthe streets has far fewer opportunities tofulfill certain basic human needs—a sit-uation directly related to their home-lessness, not their drug use (as manyhousing providers would have us be-lieve). These opportunities are describedbelow, in contrast to the common mis-conceptions that misinform traditionalhousing providers.

Therefore… 1. MISCONCEPTION: A drug user cannotmaintain housing until they are clean, orat least until they have demonstratedlong-term stability with their drug use,such as long-term methadone mainte-nance at a lower daily dose (i.e. lots ofclean urines). If a drug user is not cleanor “appropriately” stabilized when theyobtain housing, they will not pay theirbills, or they will destroy the apartment,or they will turn it into a spot for dealingor using, etc. In essence, they will wreakhavoc in the apartment, the buildingand the neighborhood. REALITY: Drug users wishing to exer-cise/embrace some form of drug usemanagement, even including absti-nence, need to be situated in order tobegin this process. After all, it is a processrequiring, at the very least, some form of

30

GIMME SHELTER: DRUG

PERMANENT (OR,MINIMALLY, LONG-TERM)

HOUSING IS AFUNDAMENTAL BUILDINGBLOCK FOR INDIVIDUALS

TO GAIN SOME SENSE OF STABILITY IN

THEIR LIVES.

stability, and housing provides that.2. MISCONCEPTION: Active users who arehoused with inactive users will cause thelatter group to “relapse” in their “recov-ery” because of their exposure to the for-mer group. Inactive users, or userschoosing recovery, cannot control theurge to “pick up” drugs again when theyare in contact with somebody who isusing. Therefore, it is detrimental tohouse active users with inactive users, be-cause this will place those users in “re-covery” at risk for “relapse.”REALITY: Active and inactive users can ac-tually relate to one another quite well,given the opportunity. They have hadsimilar experiences, and have simplychosen different routes with their druguse. As harm reduction providers, weknow that the spectrum of drug use caninclude “non-use,” and that active andinactive drug users can provide excellentsupport systems for one another if theyare given the space, opportunity andsupport to communicate openly withone another about their issues and con-cerns related to drug use. Finally, tohouse active users only with other activeusers is like a direct invitation to “ghet-toize” drug users—as if this isn’t alreadyenough of a problem in our society! 3. MISCONCEPTION: Drug users don’t careabout how they are perceived. Theydon’t have any self-respect because theyonly care about getting high, so theydon’t really care how they are perceivedby others, either. Based upon thispremise then, providers don’t need toconsider supporting and nurturing adrug user’s sense of self-worth.REALITY: Having one’s own housing con-tributes to one’s sense of self-worth. This istrue for all humans, we believe, and activedrug users are no different in that respect.4. MISCONCEPTION:Drug users don’t want toreduce the harm that drug use maycause to themselves and to their com-munities. Drug users will get high when-ever, however and wherever they want.They don’t think about safety related todrug use because they only care aboutgetting high.REALITY: Housing allows an active user topractice harm reduction more effective-

ly, such as adequate and appropriatestorage of syringes for exchange and per-sonal space to use with somebody youcan trust, thus making drug use a saferexperience in all respects.5. MISCONCEPTION: Whatever money theyget, drug users will always spend all ofthat money on drugs. Drug users are un-able to budget because to them, moneyequals drugs. Drug users are irresponsi-ble with money. REALITY: Housing allows users to exercisepersonal responsibility. Budgeting be-comes more relevant and important asbills need to be paid, items purchasedfor household maintenance, etc. Per-sonal responsibility is exercised throughhousehold budgeting.6. MISCONCEPTION: Drug users don’t eat.They don’t prioritize eating because theyspend all their money on drugs, and theyaren’t really interested in their nutri-tional needs because they only reallycare about getting high. A drug user witha kitchen will probably cause a fire whenthey try to cook, because they will be toobusy getting high. REALITY: Given that permanent housingcomes equipped with a kitchen, it is agreat opportunity for an active user to beable to learn cooking skills, and to meettheir nutritional needs. We know that nu-trition is immensely important for drugusers as an important health equalizerwhen an individual is using substances.7. MISCONCEPTION: Drug users don’t careabout their health. This is evident in thatthey choose to get high, which is detri-mental to their health, and thus they arealways risking their health to continuegetting high. Therefore, drug usersshouldn’t be trusted with medications,because they will not “adhere” to the reg-imen required for those medications be-cause they will be caught up in gettinghigh. Drug users cannot manage theirtime because they are too busy gettinghigh, and this will contribute to problemsthey have in taking medications or “ad-hering” to a medication regimen.REALITY:With housing, more attention canbe paid to one’s medical needs. Psychmeds, HIV meds, etc. all require somespace for storage, often including refrig-

eration, and these things are inaccessibleto a user who is homeless. With housing,even time management for medicationsis now an opportunity, where formerly itwas not even an option.8. MISCONCEPTION: Drug users don’t carehow they look or how they smell; theydon’t care about their personal hygiene.This is evident in their indifference tohow others perceive them, and in theirdrug use, which shows a lack of self-re-spect. And drug users deserve to havebad hygiene, because it is a testament totheir problems with drugs. A drug userwill really only develop good hygienewhen they stop using.REALITY: Finally, housing provides activeusers with a basic opportunity for per-sonal hygiene.

The story of Sharon and Cindy demon-strates the fundamental importance ofhousing for active drug users. Withouthousing, Cindy’s drug use spun out ofcontrol again, and we can only hope thatshe made contact with some friendlyneighborhood harm reduction outreachprogram. Sharon was able to locate andmove into permanent housing, althoughher need for support throughout thisprocess was immense. As harm reductionproviders, we know that the least we canoffer to our participants is support—theleast and often the most, too, particular-ly as the experience of being caught in acycle of chaotic drug use can be ex-tremely harsh and isolating. Even oncethey are in housing, support remains im-portant. However, housing needs to beone of the first in a series of buildingblocks for the active user to gain andmaintain stability. Shelter (adequate, ap-propriate and permanent) is a right, nota privilege—it is a public health inter-vention, it is a personal growth opportu-nity, it is one of the great stabilizers.Demand housing for active users! n

Sandra Fuentes is a Peer Educator and Dali-ah Heller is Executive Director at CitiWideHarm Reduction in New York City. CitiWideprovides harm reduction outreach and servicesto PLWAs living in SRO hotels in the Bronxand Manhattan.

31

USERS NEED HOUSING!

Harm Reduction Coalition22 West 27th Street5th FloorNew York, NY 10001

NON-PROFIT ORG.U.S . POSTAGE

P A I DPERMIT NO. 569NEW YORK, NY

HARM

RED

UCTI

ON C

OALI

TION

HARM REDUCTION COALITION

22 West 27th Street, 5th FloorNew York, NY 10001Phone: 212-213-6376Fax: 212-213-6582

3223 Lakeshore AvenueOakland, CA 94610Phone: 510-444-6969Fax: 510-444-6977