Episode 22: Harm Reduction

Sarah Resnick joins the n+1 podcast to talk about her essay in issue 24, “H.

Hosted by Aaron Braun, Malcolm Donaldson, Moira Donegan, and Eric Wen
Audio Engineer: Malcolm Donaldson
Produced by Aaron Braun, Malcolm Donaldson, Moira Donegan, and Eric Wen
Graphics by Eric Wen
Music from Arthur Russell, Yo La Tengo

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Episode Transcript


Malcolm Donaldson: Hi and welcome to the n+1 podcast. In Issue 24, “New Age,” Sarah Resnick weaves together the story of Vancouver safe-injection clinic, Insite, with that of her own efforts to assist her uncle, whose life had come to revolve around heroin. The resulting piece, “H.,” takes an honest look at drug use and drug policy and wonders anew whether addiction can be part of a good life.

SEGMENT: Sarah Resnick and Moira Donegan on Harm Reduction

Moira Donegan: In your piece you talk a lot about this philosophy of drug treatment and drug policy that’s called harm reduction, and you actually went to a center in Vancouver called Insite. Could you tell me a little more about that philosophy and that experience?

Sarah Resnick: Sure, yeah. So, you’re right, I went to Vancouver. I went to this place called Insite, which is a safe injection site, or a “supervised-injection site.” Basically it’s a facility where street-entrenched drug users can come in and inject drugs under the supervision of medical providers. So there’s some nurses on staff, there’s some other regular staff members, who are also around just to supervise. A person can come in and they have access to clean needles, clean syringes, a tourniquet—basically anything you can imagine, anything you would need to perform an injection—including, they even have a pill crusher so you can break down your pills. They have that on-site. And they teach people how to inject in a more safe way. And then there are twelve, or I think actually thirteen injections booths, and so everyone is assigned when you come in. There’s usually a small line, and when you come in you’re assigned to a booth, and you have to tell the receptionist what drug you’re about to take, and then they record that in a database—just in case something happens to you, so they know exactly what you were taking. And then you collect all the supplies that you need, and you go to your booth, and you prepare your injection, and you inject. And if you need help—like, say, if you’re having difficulty finding a vein that’s not scarred or damaged or collapsed—you can seek help from a nurse. They are allowed to really do anything in helping you with your preparation, except that they’re not allowed to push the actual plunger.

So that is what this site does, and it might sound intuitively like, “Oh, how does that work? Why is there this facility that allows people to come in and use drugs? Isn’t that enabling them in some way?” Really it comes out of this philosophy called harm reduction, which is, rather than approaching drug use as something that requires a commitment from the drug user to abstain from the drug altogether in order to offer them help, this philosophy sort of establishes what are the things that actually cause harm in using drugs. A lot of the time, with drugs in general, the environment in which a drug is used and its means of injection are, at least healthwise, the most harmful problems. So, a person, for instance—and just to say that Insite really does focus on people who are street-entrenched, so it’s not for the general public, not anyone can just go in there and sign up—so if you’re living on the street, or in some kind of precarious housing, you might not have access to clean water to prepare your injection. Some people I spoke to there recounted some stories of either they themselves or seeing other people using water from puddles to put into their syringes. My uncle has told me that in the past he has used water from the toilet bowl. So obviously injecting goes right into your bloodstream, it kind of bypasses all the body’s natural filters to filter out bacteria and such. And so if you’re taking water from a toilet bowl and injecting it into your body, into your bloodstream, you can get some very serious infections.

Then, of course, there’s this issue of access to needles. So someone who is street-entrenched probably doesn’t have a lot of money, and needles are not easy to get—I mean, they can be expensive. Oftentimes, at least in the States, they require a prescription, or, if they don’t require a prescription, there’s still some kind of stigma involved if you look a certain way. So they’re not always easy to get. So this facility is really trying to reach people who are otherwise in the shadows of society—people who aren’t necessarily welcome anywhere like at a bank or restaurant, but even in a health clinic or in an emergency room. I have that scene in my piece where I talk about going to the emergency room with my uncle and there’s this person there who is very ill and was vomiting continuously for what seemed like hours, and he was just getting completely ignored by everyone. And when I finally asked someone, “Why are you ignoring this person?” she was like, “Oh, well it’s his fault, he did it to himself.” So the implication was that he had either drunk too much or taken some kind of drug or some combination thereof, and that was the reason why no one was really bothering to help him.

So, this is a facility where they take anyone as they are. The idea is to not formulate a treatment or a service based on an idea of what we want people to be like but how people actually are. In their first ten years they had, I think, more than four thousand overdoses that occurred on-site, but no one died. So you can imagine that’s potentially four thousand lives that were saved. I mean, not every overdose results in a death, but many of them do. So the other thing is that, because these are people that are otherwise sort of forgotten in society, it’s a way to bring them in, and to have contact with other kinds of people. So the organization that runs Insite used to be called the Portland Hotel Society, now it’s called PHS Services, but basically they started as an organization for people who are hard-to-house, they have an array of services available. So if you come in they can connect you to health care, they can connect you to housing, when you’re ready they can connect you to employment. They also have a detox center on-site and it’s on demand, which means that you can basically just come in and say, “I want to go into detox,” and they’ll shepherd you in. You don’t have to—in a lot of other kinds of detox places you either have to call in advance and wait for there to be an available bed or you have to demonstrate your commitment to detoxing and so they make you call every day at, like, 9 AM for a while. [Laughs] It seems really, really crazy, but it’s pretty regular practice, apparently.

MD: It’s like trying to convert to Judaism, you have to ask three times and be told no. [Laughs]

SR: That’s a really funny analogy, but it’s true. [Laughs]

MD: Something that, I think, bugs a lot of people about harm reduction is that, on the hand, it clearly helps, it’s clearly saving lives and connecting people who otherwise wouldn’t get the kind of resources given to them, but on the other hand, I mean, it’s called harm reduction, it’s not called harm elimination, you know? The philosophy does contain an acceptance of a certain degree of suffering on the part of the problematic drug user, and I think part of what is appealing about AA and NA and those abstinence-centered programs is that they really don’t accept any of the bad that the drug does to people. They say, “None of this is OK for your life.” So is there something a little cruel about harm reduction? Is it almost the kind of scenario where they say, you know, to a degree, we’re giving up?

SR: Maybe I might’ve felt that way initially, but I think now, the way I see it is that, actually, it’s the abstinence-only programs that are giving up on people, mainly because they exclude so many individuals from their programs. Again, I don’t think harm reduction and abstinence are—they’re not mutually exclusive ideas. No harm reduction advocate is just, like, “Oh, I just want this drug user to continue using drugs in this dangerous way forever.” Of course they would like to see that person lead a better life. It’s just that it’s saying, it’s a way of accessing other people who are otherwise basically just going to continue to carry on in the ways that they are, and live outside of society, and have access to nothing. I mean, imagine that you are a street-entrenched user and you want to go to detox and like we just talked about, you have to call every morning at 9 AM in order to go into this program. Well, where are you going to find a phone to do that? And we, in the age of cell phones, we don’t even—or pay phones, I don’t know if you’ve tried a pay phone lately on the street, but they tend not to work very often. So that is a really big problem. I think, maybe for middle-class users, some of these distinctions are, I don’t know, less clear, obvious, but for someone who really is living in really precarious ways, some of the demands that these programs require really don’t accommodate their needs. I don’t know, are you giving up on someone if, say you were in the survival sex trade, and you’re street-entrenched, and you’re malnourished, and you’re disconnected socially at every level, but then you start methadone, which is a harm-reduction measure, which maybe doesn’t seem as extreme, or something, like a safe injection site. That’s potentially just because it’s been around for much, much longer, at least in the States, and so, we sort of understand what it is. So, maybe now you’ve started methadone, you no longer need to participate in the survival sex trade. Maybe you’re no longer shoplifting or participating in other kinds of petty crime to support—basically to be able to buy enough drugs to stave off withdrawal. I had a really edifying conversation with this woman who works at BOOM!Health, which is in the South Bronx and—

MD: That’s a similar site to Insite?

SR: Yeah, it’s a harm-reduction services site, so they have all kinds of things. I mean, I wouldn’t say it’s exactly similar; they would like to open the first safe injection site in the United States. That is their intent and their goal, but I think that there’s probably a long way to go. But they’ve set up a kind of model booth, injection booth, that’s based on Insite, and they do a lot of education around supervised injection. But, no, they offer an array of services—they have a syringe exchange, and they have laundry, they have haircuts, they have a health clinic, and it’s all in one place. It’s peer-run, so that means that there’s a lot of people who are drug users themselves, or used to be drug users, who are working there.

So I had this really great conversation with her—she taught me a lot—but one of the things she said was just, like, “I can send someone to detox for twenty-one days, right, and then they come out. Great, so now they’re detoxed. But that person might still not have identification documents, they still don’t have a house, they still live on the street. Maybe they have a criminal record. And then they can’t get a job, despite training. Or they come from a background where they’re poor and they’ve been segregated from education, so what do those twenty-one days do?” she said. Now they’re just back where they started. So, she’s like, “I’d rather just give them clean syringes and work on their housing and work on their psych and basically get them to a healthier place and then see from there. Try to help them stabilize a little bit.” And so sometimes participants would tell her that they used to use ten bags a day, now they use five bags a day, and that’s an improvement. And so, I think that by saying that harm reduction is kind of giving up on people, I think that’s not necessarily true, and I’d like to suggest that we just need other kinds of ways of measuring success, and what that means in the context of problematic drug use. Because we really do just have this notion ingrained in us that no drug use is OK. But for some people maybe less drug use is better than the drug use they’re doing now, but no drug use is not an option on the table, or at least not right away.


MD: Thanks for listening. The n+1 podcast is produced by Eric Wen, Aaron Braun, Malcolm Donaldson and Moira Donegan. Thanks to Dayna Tortorici and, of course, to our guest, Sarah Resnick.

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