SMART Policy Podcast
Podcast by the UT SMART Initiative. Host Jeremy Kourvelas speaks with experts from across the recovery ecosystem - representing healthcare, prevention, law enforcement and more - about local, state and federal drug policy to find out what is and isn't working to make this fight against addiction a little easier.
SMART Policy Podcast
Harm Reduction
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Welcome to the Smart Policy Podcast, a production of the University of Tennessee's Institute for Public Service. Every month, we'll give you in-depth interviews with a wide range of experts on substance use disorder and the overdose crisis so that we can all have a better understanding of how we got here, how the state of Tennessee is fighting back, and what we might expect to see in the future. Harm reduction is a phrase that is popping up more and more frequently when people discuss the future of the opioid crisis. For example, in Beth Macy's Dope Stick, we learned about how the Stackler family got us into this bet, but her latest book, Raising Lazarus, she discusses where we go from here, and repeatedly we learn that the programs that have had the biggest impact are the ones that embrace harm reduction. So what is it? Broadly speaking, it is a policy framework that minimizes the negative healthcare outcomes of undesired behaviors by acknowledging that said behaviors are likely to persist, at least in the short term. In the context of substance use, this would mean reducing the impact of drug use before reducing the drug use itself. Crucially, harm reduction does not mean the drug use is condoned. It simply means withholding condemnation of this behavior while the consequences of the behavior are first addressed. So for opioids, this basically means keeping people alive so that you can treat them, which is how opioid abatement council chair Dr. Stephen Lloyd summarizes it.
SPEAKER_01You can't do anything uh without harm reduction up front because your patient is dead. It's such a simple thing. And I talk about it all the time. I said, Well, I'm against this, this, this, and this. And I said, Well, you know, those three things that you're against right there, what's going to keep our patient alive at first? And then after we keep them alive, now we can look into you know helping them improve their lives, whether it's you know GED, uh uh further education, job training, right? And and taking the steps for those long-term rewards of recovery, getting your family back, or starting a family, becoming a tax-paying citizen of our state.
SPEAKER_02Syringe service programs, sometimes called SSPs or needle exchanges, are important parts of harm reduction. Though they are often considered controversial, they are increasingly accepted due to their successes in keeping people alive, unharmed, and in recovery. Indiana was the first state to legalize them back in 2015, and they did this in response to a huge surge in HIV cases, which, alongside hepatitis C and other blood-borne diseases, spread right alongside IV drug use. In 2017, Tennessee passed legislation legalizing SSPs as well, joining dozens of other states. SSPs properly dispose of syringes, reducing accidental needle sticks experienced by first responders. Participants get clean syringes, which greatly reduces the risk of infection and transmission of bloodborne illnesses. They also dispense naloxone, which is used to reverse overdoses and save lives. And most importantly, they connect people to treatment. People that use SSPs are five times as likely to enter long-term recovery. Choice Health Network, originally an HIV prevention and treatment program, launched its own SSP in Knox County a few years ago, and this has already seen a tremendous impact. I spoke with Genoa Clark, their director of harm reduction, about what harm reduction is, the efforts in Tennessee, and what we might expect to see in the future.
SPEAKER_00But it's also a set of practical strategies that really let folks who provide harm reduction services meet people where they're at and uh provide that non-judgmental care that means we can help them uh stay safe, take care of each other, and hopefully get access to more services.
SPEAKER_02Are you finding and significant pushback in the climate here?
SPEAKER_00Yeah, absolutely. It's always a challenge. I think a lot of folks see what we do as enabling substance use, but one of the main tenets of harm reduction as a philosophy is that we know drug use does cause real harm in the world, but we also accept that drug use is part of the world, so why not give people options to help stay safe in the meantime?
SPEAKER_02Have you noticed any change in that? Um, are things getting better or worse in terms of uh the acceptance of the philosophy?
SPEAKER_00I think as as a philosophy, people are getting behind harm reduction more, even in the place we're at. Um, especially in rural areas, even we see folks are are getting more on board with it. I also think the harm reduction movement has been pretty co-opted. So I think lots of things call themselves harm reduction, but really what harm reduction is is supporting and uplifting people who use drugs and are marginalized, discriminated against, and oppressed in a lot of ways. So it's kind of a mixed bag. I think sometimes people are on board but in name only. Um, but I do think overall a lot more people are are familiar with our work. We just gave a presentation to students who knew what harm reduction was. Like that people's hands were raised in the room and we talked about it. And three, four, or five years ago that just wasn't the case. Nobody had even heard of it. So it's positive.
SPEAKER_02Um I understand it can take many forms. What would you say uh uh are the most common variants of harm reduction in terms of programs and projects here in Tennessee?
SPEAKER_00Well, for us, the harm reduction services we provide are pretty straightforward. We're providing access to uh new syringes, new injection supplies for people who inject drugs. We're providing access to testing, so HIV and hep C testing, because obviously HIV and hep C prevention are a big reason why it's important to provide folks with new supplies. Uh, and we're also providing access to things like overdose prevention education, uh, Narcanin and the loxone, navigation to PrEP and PEP, which basically are gonna prevent HIV or prevent it after people have been exposed to it. So I think there's a big network of options that harm reduction can include, but we provide some pretty straightforward healthcare services here in Knoxville.
SPEAKER_02As mentioned in the intro, harm reduction in Tennessee significantly expanded with the 2017 legislation legalizing syringe service programs with the intention of reducing the transmission of HIV and hepatitis C.
SPEAKER_00The 2017 legislation, I am very grateful for it personally. It's why I'm sitting here today. I'm so excited that Tennessee was a state that legalized syringe exchange because I think it uh is a long time coming, and I think probably was a surprise to some other states. And I think it is something that obviously we have a massive need for. Uh, the epidemiological data really bears that out. It's pretty obvious. Um, states that don't have legalized syringe exchanges obviously still see a lot of underground harm reduction work, and I know that a lot of the folks who are doing that work really feel that it's a calling and it's necessary, even um in the face of it not being legal where they are. But I'm very glad uh that Tennessee has an avenue for syringe exchanges to operate legally. My hope would be that people see the positive impact and are more accepting of the philosophy. But I really think that when we talk to folks who are hesitant or reluctant or even against harm reduction, one thing that really stands out to me is that there's kind of a shroud of mystery around what we do. And it really helps for people to actually just come see what we do every day. And once you talk to the folks who come see us, it's a much more diverse group than I think some people imagine. We see folks, folks who are coming in on their lunch break every single day. Once people can get past the stereotypes and see a lot of our work, that is probably the biggest thing that helps normalize and and create acceptance around harm reduction.
SPEAKER_02I understand there's uh a syringe service program out of a church uh in Claiborne County.
SPEAKER_00Yes, absolutely. Uh that has been amazing to see the progress in the past few years about folks that accept it. And I think we also have to look for people that we might not necessarily see as allies, and that's why rural communities can be so important that once you start talking to people who have a direct connection and maybe somebody they love, or maybe they themselves have an experience with substance use. I think it becoming personal means that people are much more willing to try something new. And for a lot of folks, we know harm reduction is new, but that's critical to getting that broad acceptance, is including people who we might not have reached out to in the past because they probably have been affected at this point in the opioid epidemic for sure.
SPEAKER_02You touched on this a little bit, but uh I think I might ask you a bit more directly. Uh, what resources uh do you provide to people who use drugs in terms of a harm reduction context?
SPEAKER_00Sure. Well, at our office here in Knoxville, so that's Choice Health Network here in Knoxville. We are historically an HIV service organization, so that means that we have lots of services for folks living with HIV and AIDS. Um, and we also have expanded in the past four years, so that means we have a medical clinic now that serves people living with HIV. We have and also folks who are on prep, so preventative services. We have case management and therapy for folks living with HIV, which is uh an incredible resource for people who are newly diagnosed. They do housing, food, transportation support. And then the third branch of our um office here is our harm reduction services, which is syringe exchange, uh, safer injection supplies, HIV and hepsi testing, prep navigation, PEP navigation, overdose prevention work, really. And a lot of what we do is also education in the community, which is critically important.
SPEAKER_02In 2019, Choice Health Network served almost 5,000 clients. They collected and disposed of over 450,000 syringes and delivered almost 24,000 doses of naloxone. Their clients reported that they reversed over 2,500 overdoses using that naloxone, which is more than the number of people that died of fatal overdoses in Tennessee that same year. These drug-related services were compounded with their traditional role in mitigating the spread of bloodborne pathogens. In fiscal year 2018 to 19, Choice Health Network conducted 494 HIV tests, 305 hepatitis D tests, and started 85 patients on PrEP, the HIV prophylactic medication. But as Genoa said, Choice Health Network has also addressed multiple social determinants of health. In fiscal year 2018-19, they also provided 754 clients with case management services, 353 with food assistance, and 195 with rental assistance, as well as providing 66,700 miles of client transportation assistance. You're offering services as well, like giving people food and and did you say clothing as well? I uh did I hear that?
SPEAKER_00No, but that's interesting. Actually, we we do provide some clothing just lately. We've been dipping our toes into that. We just see a huge volume of people who are looking for services through our syringe exchange, and we try and provide as many other resources as we can organizationally because our focus is on folks who are living with HIV. We have um Ryan White case managers and they're able to provide direct assistance as in gas cards, food cards, bus passes, things like that for folks who are diagnosed with HIV.
SPEAKER_02So you're you're doing not only just harm reduction, but you're actually addressing a lot of social needs.
SPEAKER_00Yes, I think once you dip your toes into what harm reduction is and you see the need in our community, uh often I think people are just really shocked when they come to see us by how many people are using our services. But once you're there, it's really clear that what people need is not just access to resources uh around their substance use, but access to resources that they need to live life. They need access to shelter, access to transportation, um, access to primary care. So it's pretty eye-opening to see how connected all those concepts are. COVID has really impacted our work in a major way. So the past two years have been a bit challenging to nail down how many, really, how many people we can see, what's the volume like. A lot of folks don't have consistent access even to get transportation to our services, which is huge. But we're regularly seeing, I would say, probably 300 plus people a week at this point, which is quite a few people. We have a really incredible staff that handles that volume. Um, but I also think it's important to note that we limit our volume and we're appointment only here in Knoxville. So I think if we had drop-in, we would see a much, much bigger volume of people. The last time we had you know, walk-in, drop-in hours, we were looking at about 200, more than 200 people a day lining up for services, and without the capacity to support that. I mean, we we are limiting how many people we see, which is why I think it's so important for other other folks and other agencies to really think about what it might take to integrate better services for people who use drugs because the need is huge in our community, and I think the big reason we don't see that is stigma. People are not gonna self-identify a lot of the time. But I think the numbers of people who need those services are much bigger than what we even imagine.
SPEAKER_02We just uh removed from the definition of drug paraphernalia phenyl test strips. Um what do you think the impact of that is gonna be?
SPEAKER_00I think any any legislation that helps the folks we see uh take care of themselves and keep themselves more safe uh is really positive. And I think that includes the fentanyl test strip legislation, that includes the Safe Syringe Act that originally passed in 2017. Um people we serve really don't have a lot of baked-in protections, and they also often have a lot of really negative experiences with the justice system. So anything that clarifies legally what they can and can't do is is really positive for us and for our programming.
SPEAKER_02What what are your thoughts on the future of harm reduction in general? Uh maybe not i i if in Tennessee would be perfect, but in general is fine.
SPEAKER_00The future of harm reduction in Tennessee, I'm hoping that I'm hoping we have enough really solid legislation to start passing in Tennessee. I think fentanyl test trips are a great start. I hope there's more to come. I I'm hoping that those things really encourage maybe people or agencies or agencies that don't exist yet to to start providing harm reduction services to folks. The need, like I have said over and over, is just so huge. And I hope if we make it easier and make it uh an easier pathway to providing services, that people will take that opportunity. The future of harm reduction generally, my hope is that uh I don't have a job, that I work myself out of a job, and that these services aren't needed for people because they just have better options. But I also think I'm probably not qualified to talk on the future of harm reduction generally. I would really love to see programs incorporate people that have direct lived experience, that people who have been injecting and faced a lot of the challenges that our clients face are the ones leading those programs and giving these interviews in the future. What I would love is that people with lived experience are recruited, encouraged, uh, and accepted as really viable candidates based on that lived experience without a caveat for sobriety, without a caveat for education, just people's experience alone is what gets them a job.
SPEAKER_02For more episodes on in-depth discussions on Tennessee policies related to substance use disorder by a range of local experts. Please subscribe to us wherever you get podcasts and visit our website at smart.tenst.edu. I'm Jeremy Corvellis. Thank you for listening. See you next month.