Kaia Sand | Harm reduction is a lifesaver

Opinion | Deaths due to fentanyl use are rising. We can, and should, use harm reduction techniques to mitigate risks.

by Kaia Sand | 19 Jul 2023

Vendor program director DeVon Pouncey and I walked through Old Town nearly every week for the past six years, but these walks changed the past couple of years. Now, as we discuss work, we also scan people’s chests to make sure they’re breathing.

Kaia Sand is the executive director of Street Roots. This column represents her views.

An opioid overdose takes your breath away — death by suffocation in open air. We ask people to show us a sign by moving, especially if we see a tiny piece of foil on their lap indicating they might have smoked fentanyl. They usually do move a little, often thanking us for checking on them.

On a recent walk, DeVon dashed across the street after spotting two men trying to revive another, and I followed him. DeVon grated his knuckle along the man’s sternum to see if he could startle him into a sound the way we had been trained. The man didn’t respond. I fished a syringe and a vial of naloxone out of my satchel. I tore the paper sheath off the syringe, tilted the vial, drove in the needle, drew up the liquid and plunged the needle into the man’s arm. His friend padded some blood from the injection site with a bandana, and we watched him. No response. I wondered if he needed more doses. I’d heard some people need multiple doses to emerge from a fentanyl near-death.

Then, suddenly, his eyes popped open. We were all cheering, and he mirrored us, thrusting both fists in the air, shouting, “I’m alive!”

At that moment, naloxone seemed like a miracle. The scorpion-shaped molecule not only latches onto opioid receptors in the brain but knocks off the opioids that have already affixed themselves.

Several Street Roots staff members have similarly administered naloxone to people on the streets in the last few months. We are in a window where, as long as we can bear witness to each other, we can save lives, but I fear other substances unphased by naloxone, like the horse tranquilizer xylazine showing up in other areas of the country.

When I first started working at Street Roots in late 2017, we released the 2016 death report for people on the streets, Domicile Unknown. No deaths connected to fentanyl were recorded. I recall talking to Haven Wheelock — Outside In’s harm reduction services manager — at the time, and she warned me fentanyl deaths were coming. Indeed, the most recent report found fentanyl contributed to 36 deaths in 2021.

Wheelock is a local legend, working for the past two decades in harm reduction. She has been a leader in the effort to use naloxone to prevent opiate overdose deaths. Her work is informed both by working day-in, day-out with people using drugs as well as a scholarly approach underpinned by her public health master's degree from Johns Hopkins University.

Fentanyl is so widespread that our daily work is suffused with people edging toward death, often despairing over the grip this drug has over their body. I decided to ask Wheelock more about what we are experiencing to help more Portlanders gain knowledge of fentanyl.

This is the first of several columns I will devote to this topic, including a future column on recovery options.

This conversation has been edited for length and clarity.

Haven Wheelock: I've been working with people who use the most stigmatized drugs for over 20 years now, and I have never seen our drug supply change as quickly and how people engage with the drugs they are using change so dramatically. There are people who are paying attention to this problem in a way now that is very different than they were a few years ago because it is so evident and so devastating.

Kaia Sand: How would you compare the intensity — or the risk of overdose — compared to maybe four years ago with someone who would be injecting heroin rather than smoking fentanyl?

Wheelock: So that's really, really hard to quantify. What we know is that fentanyl, pure pharmaceutical-grade fentanyl, is not what we're dealing with. Illicitly manufactured fentanyl, street fentanyl, gets really dangerous because it's not cut consistently, right? If people were doing pharmaceutical-grade fentanyl, even if it was 100%, it would be safer than what we're dealing with right now because, with opioids, you develop tolerance really quickly.

Let's say my tolerance is at a four — this is an arbitrary number, there's no actual numbers rating for this — I can handle that. If I get a two, then the chances of me taking two or three times more than I would otherwise goes up, which can be a higher risk for overdose. If I happen to pick up a six or an eight, then my risk of overdose is (higher). And what we're seeing is wide variability in the samples we are testing.

I think about it as I line up ten shot glasses. Four of them are Everclear. Four of them are water, and two are just plain vodka. And I have to pick three. They all look the same.

So you just grab three, and the effects could be very different. There's a reason you're required to put alcohol content on beverages and beers and wines, right?

Sand: That's a really helpful analogy.

Wheelock: I mean, that's why it's so dangerous.

Sand: Can you define harm reduction?

Wheelock: Harm reduction is a set of tools and strategies to help people who are using drugs stay safe and healthy, and alive. It's a philosophy of social justice movements like access to safer use supplies and naloxone that can really promote the health and dignity of human drug users while respecting their autonomy to decide what they do with themselves and their bodies.

Sand: And so, what does that look like when we're looking at fentanyl?

Wheelock: It can mean a lot of things. There's the individual-level harm reduction strategies, the community-level strategies, the policy-level strategies. For folks who are using substances, especially if they know they're using fentanyl, it’s about making sure they're not using alone, making sure they have naloxone on hand, that their friends have naloxone on hand, making sure they are checking their drugs.

When we look at who's dying of overdoses, it’s mostly people who know they're using. The media looks at stories about kids who are doing a pill that they think is something else. That is tragic and awful, and I don't want to downplay that, but that really is the minority when we look at overdose death data, and who's actually died.

It's mostly people in their 30s, 40s and 50s, people who have known substance use disorders.

A pet peeve of mine is so many people think harm reduction is about street outreach workers giving people stuff. So much of what we do is building relationships, fostering therapeutic trust in folks and helping folks understand the substances to make the safest decisions for themselves.

In terms of harm reduction on a community level, advocacy around overdose prevention sites is really important. Especially in our current housing crisis in the current climate where everyone is really mad about seeing people doing drugs.

There's a trade-off between public tolerance for public drug use and some safety. If I'm hiding behind a dumpster to use, and I fall out, I'm less likely to be seen. But if you and DeVon take a walk through Old Town and come across somebody who's not breathing (you can give them naloxone).

So I would love to give people a place where they could go and use and be surrounded by people who are trained to respond. That’s not to say we won't be traumatized having to respond to overdose events because we will be, but it's different, right? It's different when you go in knowing that that is something you will likely have to respond to in the day versus turning a corner and finding someone not breathing.

Sand: How do we do an overdose prevention site when folks are smoking rather than injecting? What would that look like?

Wheelock: A patio. In Vancouver (British Columbia), I went to one overdose prevention site where literally it was just a covered patio that had shades, so people weren't necessarily seeing it. But it’s just like many of the patios that people smoke on or the alcohol consumption sites that we have all over the city. In New York City, at the overdose prevention site at OnPoint, they actually have a ventilated room.

It’s important to be educated about the actual risks of fentanyl. There's so much mythology and so much fear that's being generated by law enforcement that’s not true.

Sand: Could you address a couple of those concerns about exposure, like police talking about overdosing by touching it, or breathing it in, say, on the MAX?

Wheelock: I don't want to say it could never happen — that you could get high walking by someone smoking. But realistically, if we are outside, or if there is ventilation in a space the size of a bus, smoke is dissipating in a way that is not going to be harmful or dangerous. It’s unpleasant because burning stuff smells bad. But in reality, fentanyl, in particular, is dangerous to people using fentanyl, whether they're using it knowingly or not, because it is in something or there's cross contamination in the pipe that they're smoking out (of). But it is not dangerous to the general community. If you are not doing drugs, you don't need to be afraid of fentanyl, and you don't need to be afraid to help someone using fentanyl in the event of an overdose. It can't be absorbed through your skin. Being in close proximity to it is not dangerous. There are journal articles on this.

Sand: How do we write about this and not fearmonger but attach the correct amount of gravity?

Wheelock: Making sure you center the people using drugs is really important. And so, acknowledging that yes, it is scary and yes, it is heartbreaking. It’s scary and heartbreaking for people using these substances. And for people who love them.

Street Roots is an award-winning weekly investigative publication covering economic, environmental and social inequity. The newspaper is sold in Portland, Oregon, by people experiencing homelessness and/or extreme poverty as means of earning an income with dignity. Street Roots newspaper operates independently of Street Roots advocacy and is a part of the Street Roots organization. Learn more about Street Roots. Support your community newspaper by making a one-time or recurring gift today.

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