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Harm reduction is shown to help, but rising skepticism threatens life-saving programs • Colorado Newsline [1]

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Date: 2024-06-20  

A few days per week, Richard volunteers at the Harm Reduction Action Center in Denver. He passes out snacks, helps people with the coffee station and gives hygiene products that the clients, many of whom are experiencing homelessness, need to stay healthy.

In many cases, the 36-year-old also offers people sterile syringes, clean pipes and other supplies to consume illicit drugs.

Two years ago, Richard, who requested Colorado Newsline use only his first name to speak frankly about substance use disorder without fear of stigma, walked into the doors of the single-story, nondescript building on the southeast corner of 8th Avenue and Lincoln Street as a client himself, looking for supplies for his methamphetamine addiction and gear to survive on the Denver streets.

“If it wasn’t for a place like this, I probably wouldn’t be here today,” he told Colorado Newsline during an interview at the center. As he spoke, people walked through the center on their way to a Thursday afternoon health education class on hepatitis C in the back of the building.

“There’d be many times where I would come in because I didn’t have anywhere else to turn. And I’d come here and they would help me,” he said. “They’d bring me back to myself so I could get back on my feet.”

HRAC operates one of about 20 syringe access programs in Colorado. The center runs under a harm reduction model by providing clean syringes and other paraphernalia, free opioid overdose reversal medication and information about the safest way to use drugs, all in an effort to prevent overdose deaths and the spread of communicable diseases.

Employees and volunteers meet clients where they’re at — often during the throes of active substance use disorder — and stand patiently ready to offer referrals to addiction counseling and medication-assisted treatment. The goal is to keep people alive and safe until they are ready to seek recovery. In the meantime, HRAC personnel will give them a cup of coffee and educate them about the risk of disease from using dirty needles. They’ll offer them a quiet place to rest and recharge.

​​“The number one substance use treatment admission requirement is that people have to be alive,” said Lisa Raville, HRAC’s executive director.

In a society where people who use drugs are consistently othered or disregarded, her philosophy is one of humanization and measurable progress, even if it’s through baby steps: “I’m just glad you’re here and I’m rooting for you. How can I support you for a healthier and safer you today? What’s something positive that you can do today? Then we all get to win, and then we can build on those successes.”

Harm reduction is an evidence-based approach backed by public health experts, doctors and community leaders. While the method has gained traction over the past decade, with more states allowing syringe access programs and overdose reversal medicine like Narcan becoming widely available, leaders fear a potential policy regression amid rising skepticism over its effectiveness and increased visibility of the effects of substance use disorder in cities across the country.

This year, Nebraska’s Legislature sustained a governor’s veto on a bill to allow local governments to establish needle access programs. Oregon is restoring criminal penalties for drug possession after three years of decriminalization. And Idaho’s Legislature repealed its five-year-old needle exchange law, becoming the first state to reverse course on the issue.

In Colorado, state lawmakers this year for the second time voted down a bill that would have allowed local governments to authorize overdose prevention centers, where people could use illegal drugs under medical supervision in case of an overdose. Pueblo’s city council, an increasingly conservative body, approved an ordinance in May that prohibits needle access programs in the city.

Research consistently shows that syringe access programs, in conjunction with other intervention measures, reduce HIV transmission. Experts warn that closure of such programs could lead to increased disease transmission among that population, more needle litter in cities because there would be fewer safe disposal sites, and fewer people accessing resources for treatment.

The number one substance use treatment admission requirement is that people have to be alive. – Lisa Raville, HRAC’s executive director

“There’s a backslide right now, unfortunately,” said Mary Sylla, the director of overdose prevention policy and strategy at the National Harm Reduction Coalition, referring to the national landscape.

“We’re seeing pushback of these syringe service programs primarily,” she said. “I think what is happening is homelessness and substance use are colliding with this public health intervention. Folks, locally, are thinking that if homelessness and drug abuse exist, and syringe service programs are the place the people experiencing those things are likely to congregate — people would rather not see the problem. So closing the programs is one way to push those programs back underground.”

That analysis is similar to the thinking behind a Pueblo ordinance from May that seeks to ban syringe access programs in the city. Led by Council member Roger Gomez, the ordinance defines the programs as nuisances “detrimental to the health or safety of the inhabitants” of Pueblo.

It specifically calls out improper disposal of needles and puts partial blame on the two syringe access programs that operate in the city, Access Point and the Southern Colorado Harm Reduction Association. The council framed it as a littering issue with an added danger to the public, and members frequently brought up anecdotes of residents getting poked by dirty discarded needles at playgrounds and parks.

“If you’re handing out needles and not receiving back the same amount you’re handing out, then that goes against what the community believed was going to be taking place. Now, we have littering and we have needles all over. We have business owners and teachers cleaning up the mess created by the user, who isn’t responsible enough to dispose of their own needles,” Council member Regina Maestri said during a work session about the ordinance ahead of the May 13 vote.

The ordinance passed on a 5-2 vote and briefly went into effect when Mayor Heather Graham signed it. The ACLU of Colorado then sued the city, however, and a judge issued a temporary restraining order on enforcement of the ordinance until the lawsuit’s first hearing in July. The lawsuit alleges that the 2010 state law allowing syringe access programs supersedes any municipal ordinance against them.

That means the two programs can operate for at least another three weeks.

“There’s definitely some concern, across the board statewide, for the state of harm reduction in Colorado,” Christine Charron, prevention services manager for Access Point Pueblo, said in an interview before the lawsuit was filed. “We’re at a weird time where we need to wait and see how (state law) holds up against other things the state has allowed for local decision making. Everyone is feeling a bit of unease.”

Colorado has allowed syringe access programs since 2010. In 2020, the law was amended to allow experienced organizations with certain qualifications to operate a program without board of health approval.

Access Point Pueblo opened in 2014 and offers its syringe access program three days per week. It is the main provider of harm reduction services in southeastern Colorado and one of six Access Point programs operated by the Colorado Health Network across the state. Those other locations are in Denver, Colorado Springs, Fort Collins, Grand Junction and Greeley.

Across all six locations, Access Point distributed over 1.5 million syringes between October 2022 and October 2023, according to CHN data. Pueblo’s location accounts for nearly 570,000 of those syringes. The network recorded about 1.2 million returned syringes over the same time period. It also recorded 1,031 self-reported overdose reversals.

“​​Unlike a lot of businesses or nonprofits, we actually hope that participants graduate out — not that we lose them to overdose, but that they graduate out of engaging with us because they’ve gone through recovery and are no longer using,” said Mike Mansheim, CHN’s chief strategy officer.

Syringe access programs like these are operating during a swell in overdose deaths across the state and country. About 1,800 Coloradans died from a drug overdose in 2022, according to the Colorado Department of Public Health and Environment, compared to 807 in 2012. Those deaths are concentrated in the Denver metro area but also extend to rural parts of the state.

Like HRAC, Access Point also provides overdose reversal medication and education to its clients, and it aims to connect people who use drugs to other behavioral, mental and medical care. That link to care, Charron said, is often possible because people first go to the center for that baseline clean-needle service.

“Our services are part of the cycle of recovery,” said Sarah Money, Access Point Pueblo’s Health Hub manager. “Harm reduction is a method of recovery, and what we provide is a critical piece of the spectrum.”

Charron and Money worry that if the programs in Pueblo are forced to close, more people will contract HIV and hepatitis C from dirty needle usage and the amount of needle litter will increase, since the program is also a spot for safe disposal.

“Closing the Pueblo syringe service program is a fiscally irresponsible move, because people are now going to get more infections that are more costly,” said Dr. Josh Barocas, an infectious diseases physician and addiction researcher at the University of Colorado School of Medicine. “A lot of people either are on state insurance, Medicaid or are uninsured. So where does that cost go? That cost goes directly to the city of Pueblo and its residents.”

Statewide policy landscape

Colorado has a handful of harm reduction policies in place, including the 2010 law to allow syringe access programs. Participants, staff and volunteers at programs are exempt from drug paraphernalia laws, for example, and a 911 Good Samaritan law protects people from certain criminal penalties if they call emergency services to save someone from an overdose. A needle-stick prevention law allows people to avoid drug paraphernalia charges if they inform a law enforcement officer before a search that they have needles on the body, in their car or in their home.

Colorado also has a naloxone bulk purchase fund for eligible entities like school districts, local governments, libraries and religious organizations to have a standing order of the opioid overdose reversal medicine. In the 2022-2023 fiscal year, the fund helped distribute nearly 400,000 doses to over 500 entities.

While the state Legislature did pass a harm reduction bill this year born out of a substance use disorder study committee that clarified some existing law — the “low-hanging fruit,” as Raville characterized it — it also voted against a bill that would allow cities to authorize overdose prevention centers. It passed the House on a 37-18 vote but died in its first Senate committee, a near identical fate of a similar 2023 bill.

“What we’re pushing for and what we know we need is overdose prevention centers. If you don’t like public drug use, then we’ve got a solution for you,” Raville said. “​​People have used drugs forever and ever, and people will use drugs forever and ever. Our value system is that we don’t believe people should have to die of a very preventable overdose.”

There are currently three OPCs in the country: two in New York City and one in Minneapolis. The first state-regulated OPC is set to open in Providence, Rhode Island soon.

Democratic Rep. Elisabeth Epps of Denver, who ran both OPC bills in Colorado, said during a recent primary election forum that she would bring the legislation back if she is reelected. The other prime sponsor of this year’s bill, Democratic Sen. Kevin Priola, is term-limited and will not be in the Legislature next year.

Opponents of the centers, including law enforcement groups, Republicans and some moderate Democrats, argue that OPCs — and on some level syringe access programs as well — increase crime and enable people who use drugs and create a culture of permissiveness, not treatment, around substance use disorder.

“Here in Colorado, we’ve seen over the last decade or so an increasingly more permissive viewpoint on drug usage. As a result, the city I grew up in now has tent cities in the parks and alleys we used to walk through safely. These more and more permissive steps towards normalizing deviant behavior have not improved our communities,” Greg Sader, deputy chief of police in Commerce City, told a panel of lawmakers in March.

Republican Rep. Ryan Armagost, who sat on the substance use disorder study committee, said that his experience in law enforcement showed that forced intervention can be a successful path to recovery. People arrested for drug crimes and mandated into treatment as a deferral, he said, would often tell the involved officer afterwards that the interaction was life saving.

“I had a lot of resistance in trying and being able to get on board with the harm reduction side of things,” he said. “My focus was always more on the treatment and recovery aspect.”

He said he recognizes the evidence in efforts like syringe access programs but that they are missing an emphasis on treatment.

“It’s not necessarily a detriment to society, but I don’t see it doing more good than it does harm, with the enabling,” he said. “With any disorder, you’re going to have a success and failure rate. There are different ways of addressing that — and I don’t disagree with the fact that there are those different ways of addressing it — but we can’t push one aside to lift others up.”

A bill this year from Republican Rep. Mike Lynch would have let a court order treatment for someone with substance use disorder as a bond condition, but it died in its first committee.

That is an approach harm reduction experts disagree with.

“There’s no evidence whatsoever at a population level to suggest that compulsory treatment works,” Barocas said. “Many lawmakers hear the emotional anecdote about rock bottom and about being thrown into jail. Everybody has heard that story. But anecdotes should not be driving policy. Data should be driving policy.”

He said he hopes lawmakers have informed conversations next year about evidence-based policy.

“One thing that I’m optimistic about is that we’re having a conversation,” he said. “Would I like to see policy move fast? Absolutely. But across the state, slowly, we are convincing people with evidence. It’s not a matter of whether we’re ‘winning,’ but we’re losing if we’re not doing things that are saving people’s lives.”

A mug shot from years ago

Samantha Messer said a heart attack in January 2023 is what forced her into sobriety.

“I was not given a choice. It was like ‘You need to get sober and figure out your life, or you’re going to die,” she told Colorado Newsline.

She went to live in a sober-living house and came to HRAC during the day to volunteer, which led to her current role as a client services manager. She came as a participant between 2018 and 2019 to get clean supplies for her methamphetamine addiction, including needles and pipes, and she credits the center’s work for sparing her from an HIV or hepatitis C infection.

She wanted to use her experience to help people in which she sees shadows of her former self, she said.

“I was at the place they still are,” she said. “I let people know where I came from.” That includes showing clients her mug shot from years ago, something she can now laugh at and use to bring levity to hard situations.

That familiarity becomes important during a client intake, when some people are hesitant to be honest about their drug use. HRAC and other syringe access programs are one of the few places people who use drugs are not judged or penalized for their behavior.

“It’s something people make an effort to hide because they have to,” she said. “It’s a weight off their shoulders that they can come here and they don’t have to do that. You don’t have to keep up the charade. They can be honest about everything here and get genuine help.”

Michael, who also requested Colorado Newsline use only his first name to speak frankly about substance use disorder without fear of stigma, started volunteering at HRAC earlier this year after seeing Richard behind the table helping out. He came to the center on a normal basis, he said, to get supplies for his drug consumption but also to survive the night as he experienced homelessness. He is no longer using drugs and is in transitional housing.

Both Richard and Michael emphasized that the consistent effort HRAC and similar programs undergo to humanize their clients can make the difference.

“I don’t get judged for anything that society would judge you for, and that’s a really big plus when you’re trying to make your life better,” Richard said. “We’re trying to make it a safer place, so people don’t spread disease, don’t share needles, and so it doesn’t put people in a worse position for when they have the opportunity to get better.”

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[1] Url: https://coloradonewsline.com/2024/06/20/harm-reduction-skepticism-life-saving-programs/

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