Harm Reduction Beyond Narcan Part 2 (Nursing)

Harm Reduction… Beyond Narcan…Part 2

Ashley Shukait, MPH, CHES®

• Overview of harm reduction services including syringe service programs and overdose prevention centers (Part 1)

• Current drug supply and drug checking capabilities (Part 2)

• Struggles, Barriers, Solutions for harm reduction in Michigan (Part 2)

• Provide strategies to strengthen and build more positive relationships between patients who use drugs & their healthcare providers (Part 3)

Current drug supply and drug checking capabilities

Informed Decisions

• We use information to make decisions all the time when we select food and alcohol:

•

Purity in labels: What is in it and how much? Are there ingredients that people are allergic to in it? What about calories?

•

Potency: Alcohol is labeled with the volume of alcohol by percentage 3%-40%

• What if our food was a guessing game? What if we couldn’t eat in front of others and it was criminalized?

Current Supply

• Unregulated, inconsistent, uncertain and varies across regions & time & communities

• Powders like look alike, cross-contamination happens, people buy the wrong stuff

• Understanding the supply shift is helpful in understanding where your patients are coming from, any health complications that can occur, & how difficult it is to transition to Bupe etc

• Fentanyl is an expectation in the cut, no longer an adulterant in heroin; xylazine has become the adulterant now (regions vary)

(Ciccarone et al., 2017); (FDA Xylazine Alert, 2022)

Drug Checking Services (DCS)

PWUD have had various techniques to check drugs for decades of long -standing practice using their senses. Does it smell or taste different? Appear of the substance, sound when heated up also were ways to know if something was off

Fentanyl is sweeter than heroin and tasted different in the back of your tongue; Xylazine people said they didn’t get high, but had legs keeping them from being sick

PWUD are critical in the development, implementation, evaluation & interpretation of results-NEED TO BE IN REAL-TIME for PWUD

PWUD know local supply & know what is norm for their area- they can also push back against false ideologies -drug war hysteria

Drug Checking Services (DCS)

• Can use multiple instruments to determine a sample's main active ingredients, fillers or cutting agents, any unexpected drugs

• These can be done in person where results are given on the spot within 5- 20 minutes or with further analysis sent to a lab for concerning samples. Samples can be done online as well through various agencies

• Can be done by individuals like Test Strips, or done through harm reduction programs with equipment that provides more qualitative and quantitative information-each has specific abilities and limitations

• Dance Safe- Reagents & Festivals since the 90’s; DrugsData (EcstacyData) GCMS for mail in samples since 2001.

(Maghsoudi et al., 2021); (DanceSafe, 2022); (Drugs Data, 2022)

What’s in my drugs?

Test Strips

• Promote empowerment, health and dignity, and positive behavioral changes

• Most used by:

• Currently unhoused people

• People who sell/supply drugs

• Buying from someone they don’t know/trust

• Recently witnessed an OD

Credit: AS (Bathje et al., 2021); (Park et al., 2021); (Beaulieu et al., 2020); (Bardwell et al., 2019)

Fentanyl Test Strips

Fentanyl Test Strips are cheaper (~$1/strip); binary in results +/-. No % or other details provided

• Cannot differentiate between fentanyl analogues such as carfentanil, acetyl fentanyl, and methyl fentanyl, fluoro-substituted fentanyl, and Nitazenes

• Previous to DanceSafe’s new strips, high false positives with stimulants, especially MDMA and Meth*

There are Benzo and the newly created, overly -priced Xylazine Test Strips (in testing process)

(Ti et al., 2020); pending peer review studies for Dancesafe*

Fourier Transform Infrared Spectroscopy

• Nobel Prize-winning device invented more than a century ago and mathematical equations from a 1950s Ph.D thesis

• Measures chemical fingerprints by light without destroying the drug in the process (drugs are expensive)-

REAL-TIME INFORMATION

• Provides information on a range of fentanyl and other substances like Xylazine, Carfentanyl, and cuts that can be harmful long-term like Levamisole and PhenacetinCannot detect less than 5% ranges -Still use FTS

Credit: Bruker (Ti et al., 2020); (Giulini et al., 2023);

• Expensive & requires training $40,000

Gas Chromatography Mass

Spectrometry (GC/MS)

Fancy lab machine that detects chemicals & reports the results in a graph

Really helpful for PWUD & PH

Check out this great video from samples tested at UNC-CH!

Some local results…

Assumed to be heroin/fentanyl- Sample was from a cotton. Purple powder, shiny dope

2 major substances detected: fentanyl and cocaine, but they found lots of contaminants too, with traces of caffeine

+ 4-ANPP + diphenhydramine + methyl ecgonidine (MED) + phenethyl 4- ANPP

Later assessed more & wounds associated weren’t from Xylazine like they feared, but from being forced to reuse syringes, cottons, and cookers

(UNC-CH,

It’s deeper than the drugs

Fentanyl Test Strips and Drug Checking Services help connect with:

• People who use stimulants, party scene*

• People who don’t inject

• Youth who may use on occasions

• People who face higher surveillance & may not access SSPs (BIPOC/unhoused/sex workers and medical professionals)

• People who have been failed by SUD tx & medical systems (Park et al., 2021); (Strike et al., 2016); (Krieger et al., 2018)

Unexpected Impact

• Decreases violence within drug transactions • Improves consumer knowledge and confidence for those who redistribute (low- level sellers)

Increases safety of supply (reduces unsafe cuts, adulterants, more predictability) • Stabilizes market (European & darknet studies) • Liberating tools & resources to PWUD is KEY (Betsos et al., 2021); (Darknet studies); (Bardwell et al., 2019)

Drug Users Liberation Front

After 6 months of operation and over 1kg of substances provided through the compassion club, there have been no deaths resulting from the club. Further, members of the club are reporting less involvement in crime, less overdose risk, higher financial stability and increased control over their lives.

“The drugs provided by DULF’s compassion club are tested via Mass-Spectrometry, Nuclear Magnetic Resonance Spectrometry, and High-Performance Liquid

Chromatography and then clearly labelled with this information to ensure people know the contents, potency and quality of their drugs. Members of the compassion club are then able to come to a physical location and obtain this ‘community-regulated supply’ for up to 80% cheaper than they would on the street.”

(DULF, 2023)

Struggles, Barriers and Solutions

Delayed responses

• CRA’s program was the world’s first naloxone distro program, tracking number of doses distributed, individuals trained, and reversals reported in the 1990’s

• Early 2000’s increase in OD locally, PWUD knew something wasn’t right with the supply

• Officials didn’t want to listen to PWUD • 2012: CDC publishes first report on take home naloxone programs (2010 data) Remedy Alliance, 2023);

Learn from history…

• 2015: Second CDC report published in MMWR. The MMWR reports document an expansion from naloxone distribution at syringe exchange programs to substance use treatment facilities, the VA, primary care clinics, and pharmacies.

• These reports documented that reversals by PWUD, rather than EMTs and law enforcement, make up the vast majority (>80%) of naloxone administrations .

• These delays in responses are still an issue with local paraphernalia and syringe access laws, and the overall issue of substance use being treated as a criminal issue and not a health- focused one.

(Wheeler et al., 2015); (CDC, 2015)

Conundrum

MDHHS SSP initiative- Great more $ more SSPs

• State law not illegal; however, each local municipality has own ordinances (1,700+) for paraphernalia.

Advocacy efforts have been placed on SSP providers, who have been underfunded for decades, if funded at all. After 40 years of evidence, people still deny harm reduction because of their moral comfort.

Real Ticket from a participant $500 after they left with new supplies from a program I worked at.

So what if your patient lives on the wrong side of the street? Do they have to reuse syringes? Can they use fentanyl test strips?

Good Samaritan Laws

Limitations in who the law will help —probation/parole

An unpredictable supply & drug homicide laws do not mix well

If professionals do not know the supply composition, how would low-level suppliers?

Brorphine, Flualprazolam, and Xylazine unknowingly in Michigan’s supply since 2020

Trust-Building w/in Systems

AQS

“Move at the speed of trust, but operate under the realization you are part of a system that can never be fully trusted & causes harm.”

Keep in mind…

• Many ppl who have insecure housing have valid safety concerns and stimulants may help them with alertness for things like robberies, assaults, and sexual violence.

• Encourage patients to eat, drink, and sleep by offering beverages, snacks, and help with finding housing, getting food and making connections to services and resources.

• Drugs have benefits; otherwise, people would not use them. Most PWUD DO NOT HAVE SUD, if you only focus on “treatment”, you harm those with an SUD and miss the opportunity to provide personcentered care to all your patients.

Credit: Peace House

Guess who else got Naloxone from Dan BIGG & gave out FTS before fentanyl took over the supply?

Local hero & mentor

Lemont Gore

Check Out Part 3: Provide strategies to strengthen and build more positive relationships between patients who use drugs & their healthcare providers

Resources

For detailed access to references email Ashley

Shukait (ashleyshukaitconsulting@gmail.com) to be added to her Zotero account with an extensive list of publications and resources.