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The numbers are now frighteningly familiar: More than a million Americans dead from a drug overdose in the past two decades. More than 100,000 of those deaths came in 2021, in the middle of a global health crisis.
Americans are now more likely to die of an accidental opioid overdose than in a car accident. But cars would kill 15,000 more people a year were it not for seatbelts – something required by the federal government to be placed in every new car since 1968.
Seatbelts, helmet laws and airbags are what are known as harm reduction strategies. They reduce the negative consequences of risky behavior and have been almost universally accepted in the U.S. as ways to save lives.
For decades, drug policy experts have recommended that we embrace the seatbelts of drug use: overdose-reversing medicine like naloxone, kits that make it easy to test drugs for fentanyl – a synthetic opioid estimated to be up to 50 times stronger than heroin and now found in everything from methamphetamine to weed and crushed into pills – and clean syringes that reduce the spread of deadly diseases associated with intravenous drug use.
Joe Biden is the first president to embrace harm reduction as an essential part of the nation’s drug policy. He put $30 million into the American Rescue Plan to support community-based overdose prevention programs, syringe services programs and other harm reduction services. Last May, the Department of Health and Human Services promised $1.5 billion for state and local initiatives to combat addiction, including harm reduction services.
Harm reduction doesn’t abet drug use, says Judith Feinberg, a professor of infectious diseases and behavioral medicine at West Virginia University. “It’s about reducing the attendant harms of drug use, supporting people in the community and trying to keep them alive and healthy.”
“If you’re not breathing,” Feinberg says, “you’re not getting into recovery.”
“The science is conclusive,” harm reduction services save lives, says Feinberg’s WVU colleague Robin Pollini, a substance misuse and infectious disease epidemiologist. Research shows that naloxone access laws have resulted in a 14 percent decrease in opioid overdose deaths nationwide. And a Seattle study of people who used injection drugs found that new participants in a syringe exchange program were five times more likely to enter treatment than those who weren’t in the program.
Syringe service programs are also proven to reduce transmission of HIV and hepatitis C.
Notably, some of the best data we have on just how effective harm reduction can be was facilitated by former Vice President Mike Pence. In 2015, rural Scott County, Indiana, was experiencing one of the worst recorded outbreaks of HIV among injection drug users – an incidence rate more than 50 times the national average. Then-Gov. Pence reluctantly approved the state’s first syringe exchange program.
A team of epidemiologists worked with Scott County’s department of health on a study gathering local data and found that discontinuing the program would result in an increase in HIV infections of nearly 60 percent. Nevertheless, in 2021, local officials voted to shutter it.
Nationwide, the promise of a new era of drug policies is being countered with similar conservative backlash – this despite the fact that it was Republicans, including Kentucky Sen. Mitch McConnell, who advocated in 2016 to remove a federal ban on funding for syringe exchanges.
Heightened hysteria took root in 2022 when conservative media ran with a story that the government planned to use American Rescue Plan money to “distribute crack pipes.” Though research indicates glass pipe exchange is a solid harm reduction strategy, the Biden administration’s flat-footed response to the stigmatizing report ignited a media firestorm. During the ensuing outrage, Sen. Joe Manchin – a Democrat from West Virginia, the state with the nation’s highest rate, by far, of fatal overdoses – joined with Republican Sen. Marco Rubio to introduce a bill prohibiting the use of federal funds for syringe and other exchange services.
Central Appalachia has suffered disproportionately from our crisis of addiction. But over the past five years, politicians throughout the region have put policies in place that counter the research in addiction science, limiting communities from implementing proven policies.
Against this backdrop, photographer Stacy Kranitz and I visited particularly hard-hit communities to document three initiatives to save lives and change minds. We hoped to capture “the humanity and the generosity of spirit” that Feinberg says we all need to really understand our country’s ongoing addiction crisis.
A 45-minute drive northwest of Asheville, Hot Springs, North Carolina, is an iconic Appalachian Trail town – in fact, the trail weaves through the heart of downtown. Hot Springs is rarified air in a Blue Ridge Mountain valley, open armed, embracing.
But as the temperature rises on a mid-June Saturday morning, in the back parking lot of the Dollar General, corner of Bridge and Lance, a litany of interactions is conducted with utmost discretion.
Ainsley Bryce is here, as she or a colleague is each Saturday morning, to distribute life-saving assets. Bryce has arrived well stocked. The free items she offers include:
syringes, naloxone, fentanyl test strips, COVID-19 test kits, saline, vitamin C, Band Aids, cotton, condoms, Epsom salt, soap, antibiotic ointment, Tegaderm, medicated patches, gauze, sharps containers, Pedialyte, heating pads, alcohol, gum, lip balm, information, referrals, a smile, a hug, non-judgment, kindness.
Bryce is the director of Holler Harm Reduction, based 15 meandering-mountain miles southeast in Marshall, a town of just under 1,000 tucked into the eastern bank of the French Broad River.
Though these interactions are entirely legal, discretion is wise. Most of the folks visiting Bryce are, after all, in active drug use; they’d prefer to remain unobserved by law enforcement and the judging eyes of their community. Many struggle with shame. Among Bryce’s objectives is easing it.
Twenty-five miles northwest of Hot Springs is the town of Newport, Tennessee, home to most of those who’ve traveled here today. Choice Health Network used to operate a syringe exchange in Newport, but the owner of the property on which it was held rented it to someone who doesn’t support harm reduction. Holler is now the closest option. And for these folks, it’s a godsend.
Business is brisk this morning. Bryce dispenses her wares from the back of her truck. Folks linger a while to chat. Many are her regulars and now friends. By the end of the day, she will have handed out more than 2,000 syringes.
Jack, 44, of Del Rio, just outside Newport, found Holler on the internet and connected his community. (Jack’s name and the names of other active drug users in this story have been changed to protect their privacy.)
“Thank god for these people,” he says. Jack lost his wife to an overdose; she died on the bed beside him. He believes his drug use is now manageable and takes every possible safety precaution. He rises each morning and heads to work.
Jared, 35, is a Newport resident. He’s carpooled down this morning with several members of his immediate community, folks he refers to as brothers and sisters. He found his dad hanging in the backyard at age 19 and began self-medicating with drugs soon after. “I thought, ‘Well, if I do some kind of drug, it will erase that vision in my head.’ But it didn’t.” He began injecting at 22 and has since.
Asked what it would take to quit, he says, “I wish I knew. … A lot of support. A lot of support.”
Holler Harm Reduction operates on a tight budget, one grant through AIDS United, another from an Asheville-based health trust. They haven’t applied for a grant through the federal Substance Abuse and Mental Health Services Administration. With a staff of three, two of whom are part time, they just don’t have the resources to slog through the federal application process, Bryce says.
Meanwhile, they experienced a 4,000 percent increase between April 2021 and April 2022 in the number of people they serve, partly due to the closure of the syringe exchange in Newport, but also to growing awareness that their services are available.
In addition to scheduled drop-in days, they deliver supplies anywhere in the county, assisted by a few people in active drug use who extend Holler’s reach.
Bridget, 33, is among them. She lives outside the town of Mars Hill with her boyfriend and a menagerie that includes her goats – Big Dote, Alice (because he looks like Alice Cooper) and Wenne (Wednesday Adams and Winifred Sanderson mashed together) – on a peaceful plot of land in a snug valley.
Bridget grew up around addiction. “My dad, that’s all he wanted was a needle,” she says. “He picked it over me and picked prison over me for years.”
She was diagnosed with ADHD as a kid, and she self-medicates the disease. She says small doses of meth allow her to function. “I could put it down, but I’d have to really want to put it down.” For now, she doesn’t. Bryce says she’s a careful user. “She really takes care of herself.”
“They’re my friends,” Bridget says of Bryce and Holler coworker Alonza Lasher. “They’ve pulled me out of places that I’d been stuck in for a long time.” They listen to her and answer her questions. “I like to ask questions. I want to know it all.”
Fifty-five-year-old Daisy also provides outreach. She tried cocaine at 18 – “Scared the devil out of me” – and then nothing more till she was 42, in the course of a very bad year in which she got divorced and lost custody of her kids. She was suddenly alone. Then it was “cocaine, methamphetamine, pills” to cope with the overwhelming sense of loss.
Daisy overdosed on heroin three times in August 2012, was in recovery for five years, then started using again after contracting lung cancer. She no longer injects, but she smokes meth. “I don’t get high anymore. It’s more like just maintaining the feeling of being okay.”
Daisy plays an important role in Holler’s network: She’s a link to people otherwise unlikely to find their services. She takes in young people who have no place to go. “If they need somewhere to lay down, they sleep at my house – and if they need food or a shower or whatever.” She brings home Holler’s supplies and hopes that with her small interventions she might change the course of someone’s life.
“It’s wrong for somebody who’s making bad decisions when they’re young to have to deal with it for a lifetime when you can give them what they need to be safe, and hopefully get out of it and move on,” Daisy says.
Back at the Holler office (just a couple doors down from Madison County Republican Party headquarters), Lasher reflects on how so many of their participants “come to us carrying so much shame.” She and Bryce assure them, “You deserve an unused syringe, you deserve wound care, you deserve a friendly ear and love and support, regardless of anything.”
“And when they get that,” Lasher says, “it may be the first time anybody’s ever extended it to them.”
Today is Kiki’s 32nd birthday. It’s yet another blistering day in Knoxville. Several scores of people are gathered under an I-40 overpass to escape the sun. Many, Kiki among them, used to sleep here in an encampment, but now law enforcement doesn’t allow it. In fact, the state of Tennessee has made it a felony to sleep overnight on public property. And like most everywhere in the region – in the country – there’s a severe shortage of affordable housing.
Kiki isn’t sure where she’ll sleep tonight. She grew up in Georgia but has found community here in Knoxville. Tuesday is outreach day for Choice Health Network’s harm reduction team. Kiki’s always pleased to see them. Today she was tested for hep C.
Choice’s harm reduction services include syringes and other supplies, naloxone training and distribution, HIV and hep C testing and wound care. From its offices on Ailor Avenue and out in the community, Choice also connects people with other much-needed resources, including its own medical, behavioral health and pharmacy services.
Today, under this overpass, the team has set up a table of supplies. Out here, says Greg Stafford, Choice’s harm reduction medical coordinator, it’s largely about education – about HIV, for example, or basic wound care and the importance of rotating injection spots to avoid infection.
It’s also very much about building trust.
“The unfortunate thing is that so many folks we serve have been treated poorly in social service or health care settings, or both,” says Genoa Clark, Choice’s harm reduction director. A primary objective is “making sure they feel seen and heard.” Many health care providers make assumptions that people who use drugs or who are unhoused don’t value their health. Choice’s providers do not.
If a person tests positive for HIV, they’re immediately connected with a case manager who arranges for enrollment in the Ryan White HIV/AIDS Program, a federal initiative that provides HIV-related services nationwide, and helps launch treatment. Assistance is also provided, if needed, to get on a waitlist for emergency housing or for medical case management, food, gas cards and more.
Dee, 58, has been coming to Choice for about five years, exchanging syringes and getting regularly tested for HIV and hep C. These guys, he says, are “discreet and respectful.”
He’s dropped by the offices on a Wednesday for syringes, Band-Aids, antibiotic ointment and fentanyl test strips. He says, “They’re keeping me not only alive but healthy.”
Lesly-Marie Buer, who until recently was Choice’s research director and a member of the outreach team, says she would like for there to be a space to facilitate organizing and to help start both a drug users union and a sex workers union – “movement building,” she says, such that when the city or state makes decisions that aren’t in the best interests of its most vulnerable, there’s a unified response.
“That’s my vision for the future,” Buer says.
Success in harm reduction is keeping someone alive another day. There are then, of course, those who find their way into long-term recovery.
Misty is one such person. She’s the mother of small children who’d been receiving services from Choice Health Network for four years. She was regularly tested for HIV and hep C. Choice connected her to treatment. She’s now tapering off buprenorphine, a medication used to treat opioid use disorder, and is in recovery.
“I hate to sound corny,” says Jeff, 35, “but love and connection is definitely something that helps.”
On a Tuesday evening in June, Jeff has joined a few dozen others at Kanawha United Presbyterian Church for a monthly mutual aid meeting hosted by Solutions Oriented Addiction Response, or SOAR.
SOAR distributes naloxone and provides training in administering it. It offers testing for hepatitis C, referrals for medical care and access to legal services, and at these monthly gatherings it offers fellowship and food – and tonight, karaoke.
Advocates say the $30 million Pres. Biden first allocated for harm reduction in the American Rescue Plan is a pittance. Joe Solomon, SOAR’s co-director and a newly elected member of the Charleston City Council, notes that, according to the West Virginia Center on Budget & Policy, the opioid crisis costs Kanawha County an estimated $30 million a week in law enforcement and foster care and to treat hepatitis B and C, HIV, endocarditis and neonatal abstinence syndrome.
SOAR once held health fairs at which it gave out up to 1,000 units of naloxone, exchanged clean syringes for used ones, offered HIV testing and treatment referrals, and much more. But state legislation and a local ordinance implemented in 2021 curtailed those efforts, and SOAR ceased distributing syringes.
Hillbilly, a longtime Charleston resident who prefers the nickname, can assure you that people are hurting. And she’ll tell you the word “SOAR” has a magical effect on her community.
Hillbilly has done a lot of things in her life. She’s been a live-in nanny, been unhoused, trained service dogs in prison. She can walk you through the intricacies of a riverside encampment – how those with the poorest mobility are allotted space nearest the entrance – and what it meant to be visited by a SOAR outreach team.
“They’d give you a bottle of water to drink, Gatorade,” she explains. “Table right here, you get tested. Table right there, you get taught how to clean your wounds. And over here, you get some [clean syringes] if you like – but it wasn’t all about giving out needles. It was informational. People don’t get that.”
“When we were still handing out syringes, that’s how I got the majority of my targeted testing done,” says Brooke Parker, a care coordinator with the Ryan White HIV/AIDS Program and SOAR’s board VP. “I could go anywhere and say, ‘Hey, you need some supplies?’” Or, “‘Here’s why I’m testing, and here’s why it’s important for you.’”
“I think that when we talk about what the remedy is for this crisis, and this experience of, you know, chaos, it’s connection,” says SOAR’s Stacy Kay.
Andy Barefield was among those who’d come to know the SOAR team. “He was a character,” Betty Stemple says of her son. Barefield died by overdose at 36 on April 24, 2021.
Stemple had connected with SOAR prior to her son’s death. In the days after, Kay was at her side. She and others in the circle – “my SOAR sisters,” Stemple calls them – embraced her. She’s now part of an extended family.
There are encouraging signs in the region of growing acceptance of at least some harm reduction measures.
In Tennessee, legislation went into effect in July 2022 that allows health care providers and community groups to distribute naloxone under standing orders. The hope is that this will make naloxone much more accessible in rural communities.
But advocates argue Appalachian communities must be more proactive.
Syringe exchange efforts have been stymied in West Virginia by changes to local laws. HIV continues to spread throughout Kanawha County, even after a 2021 Centers for Disease Control investigation called it the most concerning HIV outbreak in the country, warning that the reported numbers could be just “the tip of the iceberg.” Research indicates that the closure of syringe exchange programs will result in an increase in HIV infections.
As epidemiologist Robin Pollini put it, the “science is conclusive.” And, she added, “What the science also tells us is that when you open these programs, it does not result in an increase in syringe litter or a rise in crime.”
SOAR in West Virginia continues to press forward. The organization tripled the number of syringe disposal boxes throughout Kanawha County in 2021, according to Solomon, and runs “Appalachia’s largest drug user-led syringe-cleanup crew.”
Solomon believes the way to convince the broader community that the work SOAR strives to do is in everyone’s best interest is to underscore common objectives like these.
“[I feel] terrified that we won’t have the humanity and the generosity of spirit and the political will to see that this is somebody’s mother, somebody’s brother, somebody’s uncle, somebody’s son and daughter,” Judith Fienberg said.
On that day in Hot Springs, North Carolina, Nicole is Holler’s last arrival. She’s traveled over from Newport. Having gathered her supplies, she’s sharing with Bryce her hopes of soon entering treatment.
“Three months ago,” Nicole says, “this wasn’t in my heart. You couldn’t have made me stop if you wanted to. But it’s on my heart so strong.”
Nicole isn’t sure where she’ll sleep tonight. Bryce urges her to be safe.
“It’s good to see you,” Bryce tells her. “Can I give you a hug before you go? Thanks for coming, dear.”
Nicole knows where to find her.