Photo Credit OverdoseDay.com
August 31st is International Overdose Awareness Day. It is an opportunity to mourn the lives lost to drug overdose, raise awareness to aid in overdose prevention, and reduce the stigma surrounding illicit drug use. Drug overdose is the leading cause of injury-related death in the United States of America. In 2014, over 47,000 people died in the country from a drug overdose. In 2013, the number of drug-induced deaths (46,471) was more than the number of people killed by car accidents (33,804) and guns (33,636). That same year 29,000 people were killed by alcohol induced causes including dependent and nondependent use of alcohol, as well as death from alcohol poisoning. Everyone should be aware of overdose prevention strategies and the policies that support them. This is particularly true for case managers working in Housing First programs.
Consider some of the risk factors and populations that are correlated with drug overdose death in our country. Overdose is the leading cause of death among people who are homeless. A study assessing adults receiving care at Boston’s Health Care for the Homeless Program showed that drug overdose was the primary cause of death in the population, ahead of cancer and heart disease. Another study in Washington showed drug overdose is the leading cause of death among formerly incarcerated people. People with chronic health problems, primarily those involving a compromised immune system or respiratory problems, are also at a heightened risk of overdose. People who use drugs and are HIV-positive have a 74% greater risk of overdose compared to people who use drugs but are HIV-negative. These groups directly map onto the vulnerable populations served by Housing First programs, underlying a clear need to be informed about drug overdose and develop strategies to prevent it.
Many drug overdoses occur when people are using multiple substances. Opioids are involved in 60% of all drug overdose deaths. Opioids include drugs like heroin, fentanyl, methadone, and prescription pain relievers like oxycodone (e.g. OxyContin) and hydrocodone (e.g. Vicodin). The number of opioid-involved overdose deaths has nearly quadrupled since 1999 and is driving the increase in drug overdose deaths. While many people associate drug overdose with illicit drugs like heroin, it’s important to note that the majority of opioid drug overdose deaths involve a prescription opioid. Pharmaceutical drugs are involved in the majority of all drug overdose deaths. Medications used to treat mental health conditions are also frequently involved in overdose. Besides opioids, this most commonly involves benzodiazepines (e.g. Klonopin, Valium, Xanax). Therefore, it is crucial that service providers expand the range of participants they talk to about drug overdose.
Addressing overdose begins by learning about risk factors and talking with our participants about it. Helpers should be willing to bring up the topic of drug overdose with participants, find out what they know and what experiences they have had, and offer additional information when appropriate. Overdose often happens after a break in using. Tolerance levels for drugs like opioids can change drastically just a few days after someone stops using. This can occur when people are hospitalized or incarcerated, decide to quit or go to a treatment program, or just run out of money. That means the amount of the drug they need to get high will decrease, which may be a benefit for them, but it also means the amount that could lead to an overdose will decrease as well. Tasting, using a smaller amount than usual to determine the potency of a drug, is one strategy people can use to address this risk.
There are other factors to consider like using alone, mixing drugs, and route of administration. A person is more likely to die from an overdose if they use alone. Combining drugs like alcohol, cocaine or rock cocaine, heroin, and pharmaceutical drugs can all increase the risk of overdose. Use of multiple depressants can slow down breathing or other bodily functions to dangerous levels while mixing stimulants and depressants can overtax a person's body. Although injecting drugs increases the risk of overdose or transmitting diseases, some people prefer injection for a variety of reasons including a more intense high or efficient use of a substance. The Chicago Recovery Alliance provides an excellent resource for better vein care and safer injection techniques. For more information on risk factors, check out this worksheet from the Harm Reduction Coalition. In the spirit of a harm reduction approach, this information should be used to emphasize the individual’s safety rather than focusing on use itself. When people become more aware of the risk factors, they are more capable of making safer decisions about their drug use.
A drug overdose doesn’t have to result in death.
It’s also important to be informed about laws and other resources designed to curb overdose. The two main legal measures to address overdose death are naloxone access and Good Samaritan Laws. A drug overdose doesn’t have to result in death. Naloxone (Narcan) is a medicine traditionally used by first responders to reverse drug overdoses involving an opioid. By blocking opioid receptors in the brain for 15-30 minutes, naloxone can restore breathing and enable a person to survive an overdose. Many states are increasing access to naloxone for anybody who may witness or experience an overdose. In those states, people who use drugs, as well as their family members, friends, or service providers can carry naloxone in case of an opioid overdose. Find naloxone or overdose prevention programs in your area by using the Naloxone Finder.
Good Samaritan Laws provide legal immunity or other protections for people who call 911 to report a drug overdose. For instance, if someone calls to report that their friend is overdosing, a Good Samaritan Law can prevent them from being charged with possession of a controlled substance. Some participants are still concerned about the police arriving when they call 911. Telling the dispatcher that their friend has stopped breathing, as opposed to saying they are overdosing, increases the likelihood that only paramedics will come to the scene. To determine the exact laws in your state, check out the Law Atlas pages on Good Samaritan and naloxone.
Finally, make space to mourn and to act. Too often, families and loved ones are denied the ability to grieve when a life is lost to a drug overdose. The stigma associated with drugs contributes to shame about a substance-related passing. We should treat a death from drug overdose like any other death—a tragedy that impacts the lives of family, friends, and communities. Create space in your programs for participants to remember those they have lost to drug overdose. Attend a remembrance event, post something about drug overdose on social media, advocate for naloxone access in your community, or speak about the issue in your social service agency. The situation may seem bleak. But, there are concrete strategies everybody can implement to address drug overdose and reduce its impact on our communities. Too often, programs and service providers don’t consider their agency response to drug overdose until one of their participants has been affected. Make International Overdose Awareness Day the reason that you start or continue this conversation in your own program.
The Housing First Model and harm reduction promote the values of self-determination, connection, and human rights. Many of the people living in housing first programs use drugs or engage in other risky behaviors. The idea of respecting people who use drugs and improving their access to healthcare services is not unique to the Housing First Model. The Harm Reduction Coalition has been at the forefront of the social justice movement to recognize and uphold the rights of drug users for over 20 years. This post highlights this incredible organization and some of their resources which can support the work of housing first case managers.
The Harm Reduction Coalition was founded in 1993 by a group of drug users, needle exchange providers, and community activists. It is a national organization with offices in New York, NY; Oakland, CA; and Washington D.C. They promote harm reduction policies, practices, and programs in an effort to restore dignity and health to the individuals and communities who are impacted by drug use. To pursue this mission they host a bi-annual National Harm Reduction Conference, provide training and technical assistance to community-based organizations, and advocate for policy changes. Through their policy work and organizing, they give people who use drugs a voice in the policies that affect their lives. The core issues they focus on include drug overdose, transmission of HIV and hepatitis C, addiction, and incarceration.
The Harm Reduction Coalition is currently undergoing a leadership transition. Allan Clear decided to resign as Executive Director earlier this year after 20 years of leadership, service, and commitment to the cause. In his time with the Harm Reduction Coalition, Allan touched many lives and has inspired a generation of service providers and advocates. Allan chose to move on so that he could work for the New York State Department of Health AIDS Institute and serve as their Director of Drug User Health. It’s a testament to the work of the Harm Reduction Coalition that harm reduction has gone from being considered a radical idea to a formalized element of governmental agencies’ approach to public health. Recently, the Harm Reduction Coalition appointed Monique Tula as Executive Director. She worked in the HIV field for the past 20 years. Monique’s career is marked by dedication to harm reduction and the inclusion of people living with HIV in the programs and policies that impact them.
When case managers have questions about drugs and drug use, their clients are usually the best resource to consult. The next place to consider looking for information is the Harm Reduction Coalition website. They maintain a number of resources that can help case managers navigate complicated issues that may come up. For instance, they have some great resources related to Hepatitis C including “If You Drink Alcohol and have Hepatitis C or HIV Read This!” For a more general overview of Hepatitis C and some harm reduction tips for people who use drugs, check out this pamphlet. For basic drug information on cocaine, heroin, or speed case managers can consult the Straight Dope Education Series. Sometimes it can be hard to imagine how a person who is injecting drugs can reduce harm. Getting Off Right is a safety manual that provides an in-depth look at strategies to improve the health and safety of people who inject drugs. If you have a client that is required to submit for drug testing but is still actively using, you may have questions about how long drugs can be detected in a person’s system. The Harm Reduction Coalition has a resource for that. The Harm Reduction Coalition also maintains a national database to enable providers to connect locally with harm reduction programs in their area. These are just some of the resources that case managers can find to improve their work with participants who use drugs. Alongside organizations like the Harm Reduction Coalition, housing first programs can recognize and uplift the voices of vulnerable communities and support their ability to pursue an improved quality of life and sense of well-being.