FENTANYL, STRYCHNINE, NALOXONE
This past winter, an extraordinarily potent batch of China White heroin took an extended stay on the New Orleans scene. The first alert came on Christmas Eve 2015: twelve EMS transports of heroin overdoses before dinnertime. Over that holiday weekend, two people passed away. Through January, overdoses continued to threaten the lives of many heroin users. By February, having been consumed or diluted, the lethal batch was off the streets of New Orleans.
An EMS worker notified me on Christmas Eve of the overdoses because I am recognized by social service and healthcare workers as someone who has built rapport with people who use drugs. Through the harm reduction collective I cofounded, Trystereo/New Orleans Harm Reduction Network, I engage with people who use drugs on their own terms. Learning about the overdose risks, I advised every person I knew who was in danger. I reached out to current and former users and drug user allies. Many were eager to add information, amplify the warning, and share their personal experience.
The stories that emerged differed from what local media decried as the “rise in heroin abuse.” People who use drugs fought to save their friends’ lives. While strides were made toward drug user representation in legitimate health care spaces, pre-existing policies focused on criminalization forced users underground. Many lives were lost.
As with any illicit drug market, users can never know for sure what has been mixed with their product or how strong it will be. Some people who use drugs intend to mix more than one substance, often in the attempt to enhance the effect of a certain drug. It is also a condition of prohibition that drug choice is not theirs to make because street heroin can be any combination of dope and/or fentanyl, benzodiazepines, methadone, shoe polish, baking soda, milk powder, and feces (among other additives), colloquially referred to as “cut.” In June of last year, a batch of heroin laced with strychnine, an active ingredient in rat poison, hit the New Orleans downtown transient punk scene. It resulted in hospitalizations for uncontrollable muscle spasms and several deaths.
Increased law enforcement on the I-10 corridor between New Orleans and Houston in the last year caused local suppliers to change their sources. The Christmas round of China White, popular in the Northeast, likely entered New Orleans via Baltimore. Drug users said the heroin contained a fentanyl cut, and media statements from the DEA in Jefferson Parish confirmed their suspicions. By mid-March the coroner confirmed that 72% of the people who died from overdose so far in 2016 had fentanyl in their system (compared to 19% in 2015).
Fentanyl, a lab-based synthetic opiate 50 to 100 times more potent than heroin, exploded the heroin economy in a dissimilar event in 2005 and 2006. At that time, opium from Afghanistan was abundant, and the fentanyl-laced heroin was not. Its source was ultimately contained and controlled. Since then, the network of opium growers, clandestine chemists, and traffickers experienced sweeping changes. Due to the geopolitical climate, a shortage of opium cultivation in Afghanistan and Myanmar led to the introduction of synthetic opiates higher up in the supply chain.
People who use drugs report they are not treated with human decency, dignity, or respect—especially at the pharmacy.
In response to uncertainties of the heroin economy, many drug users develop preventative techniques to avoid the worst possible outcomes of their habit. Some drug users avoided the new China White blend, opting for the weaker high they are accustomed to. Among those that had access to it, some took care to inject tester shots, smaller doses than usual, or asked their less experienced friends to snort instead of inject. Most kept naloxone, an opiate antagonist that reverses overdoses, on hand.
Successful delivery of naloxone literally saves the life of someone overdosing, and it does not take advanced medical training to learn how to administer it. It has been used in emergency care for reversing overdoses since 1971 and dispersed among layman responders through underground harm reduction agencies since 1996. Many New Orleans drug users are skilled at administering naloxone and know how to access it through their peer networks. Anecdotes of overdose victims dying because their friends were afraid to dial 911, or because they used secretively and died behind a locked door, have been superseded by overdose reversal stories.
Despite users’ best efforts at overdose reversal, the Christmas round of China White would prove to be disastrous in New Orleans. EMS personnel started noting an extreme uptick in the number of overdoses they were responding to, a jump from two or three a day (per paramedic team) to as many as six. Due to the strength of the drug, some people died before EMS arrived, while many more were hospitalized. At a number of overdose scenes, people tried to revive their friends with naloxone. They reported that the new batch of China White was so strong that the naloxone simply did not work in time.
On January 29th, the New Orleans Health Department issued a public health advisory on opiate related overdoses, warning drug users that their lives were endangered. This first-of-its-kind notice came with a more important directive: a standing order for naloxone to be purchased over-the-counter without a separate prescription. However, the lifesaving drug was only available at two pharmacies in the city.
CRIMINALIZATION AND DENIAL
As the rate of overdose deaths rises nationwide, so does the price of naloxone and the devices to administer it. Naloxone is off patent, but there is only one manufacturer in the U.S. and a total restriction on importing the drug. Devices like intranasal spray and autoinjectors are newly approved by the FDA and patented. Their costs of production are even higher. Thus, intranasal and autoinjectors are far less affordable than the intramuscular injection that emergency services and laypersons have used up until now. The price tag for intranasal at a New Orleans pharmacy was $55 for one person, but costs depend on health insurance.
Recently, someone drove from St. Tammany Parish to New Orleans to purchase naloxone. They reported being probed by the pharmacist for information about crystal meth and heroin, and being asked personal questions in front of other customers and hospital patients. In the end, the pharmacist sold them intranasal naloxone, but did not offer instruction on how to use it. By not providing privacy for such an invasive (and not legally mandated) conversation, this pharmacist perpetuated drug user stigma. During the spike of winter overdoses, the same pharmacy refused to sell naloxone to a couple from the West Bank.
Even when managing to access supportive services at nonprofits, clinics, or other healthcare settings, drug users encounter nasty and dehumanizing discrimination. It is often the prejudicial behavior of workers at such institutions that become storied among communities of drug users, rather than the lifesaving services those institutions may provide.
For some health care professionals who interact with drug users, discomfort with the criminality of drug use overrides the compunction to care for them. People who use drugs report they are not treated with human decency, dignity, or respect—especially at the pharmacy. The New Orleans pharmacist, whose counter is the barrier between the lifesaving tools and the people who have a right to access them, is a prime example of how drug users are forced underground to seek health supplies.
Although it is not legally mandated, pharmacists routinely deny the purchase of sterile syringes to people who are protecting themselves from HIV and hepatitis C. Adults should have no legal problem walking up to the pharmacy counter, stating the size of the syringes that work for them, and purchasing those syringes with the ease of any over-the-counter transaction.
However, users say they are continually barred from purchasing syringes. They message the hotline I help to operate and report: “I have the money to buy them at a pharmacy, but don’t know of any friendly pharmacies,” “pharmacys [sic] deny me,” “the pharmacies won’t sell then [sic] I tried,” and “no pharmacy will sell me rigs.”
Even worse, a drug user ally reported that in their parish, pharmacies that formerly sold syringes abruptly stopped doing so. Those pharmacies collected the identifying information of those who came to buy syringes, and reported it to their family members and local police.
A MIXED BAG
The City of New Orleans Health Department’s notice issued at the beginning of 2016 came after two years of extensive debate in the State legislative branch on how to address the so-called heroin epidemic. Faced with escalating overdose deaths in their constituent districts, politicians decided to push responses oriented toward public health as well as law enforcement.
Taking drugs does not always have dire consequences, but the policies that criminalize drug use do.
Taking drugs does not always have dire consequences, but the policies that criminalize drug use do. Such policies mark certain people—predominantly women, the working class, and people of color—as “criminal.” Communities are recklessly fractured to feed the carceral state. As the War on Drugs finances prosecutors’ offices, prisons, and probation departments, it demands major divestment from schools, recreation centers, housing programs, food security initiatives, medical facilities, and other entities that support public health. Prohibition takes the moral high ground, resulting in widespread drug-related stigma. It isolates drug users from medical, political, social and economic support, and yet expects them to somehow participate meaningfully in mainstream society.
The State’s draconian criminal justice system, aligned with a pervasive drug related stigma and discrimination in Louisiana’s pharmacies and medical industries, nullifies the positive impacts of 911 Good Samaritan laws and naloxone access laws.
Due to capitalism-induced medical exclusion, few people access their human right to health. Yet, when New Orleans drug-using communities called for help during the winter overdose crisis, professionals at varying levels in the healthcare system engaged. Emergency doctors created plans to extend naloxone access to the public. Medical students asked for training on how to give people who use drugs the healthcare they deserve. The City Health Department established a hotline connected to the opiate overdose advisory, and it is run by public health professionals who are committed to hearing feedback on drug users’ experiences with law enforcement and pharmacies. Their unique capacity to hold such institutions accountable lays the foundation for a more just and equitable system of care.
Perhaps most remarkable is the advance in trust-building between emergency medical service workers and people who use drugs. Calling 911 can be crucial to overdose prevention. People who use drugs deserve legitimate health care and are entitled to receive it from trained professionals. In New Orleans, when 911 is called for a drug overdose, police are supposed to arrive and secure the scene for the paramedics. Ideally, their interaction with the overdose would end there. However, in reality, they may make immediate arrests for drug possession, or issue warrants afterward. In neighboring parishes like St. Tammany and Jefferson, people report that cops arrive first and begin investigating with drug-sniffing dogs even before tending to the victim who overdosed. In spite of these risks, a New Orleans EMS worker said that as of late, in the event of an overdose, more people are calling for help, staying on the scene, and offering the responders information about the patient.
REGULATE THE MARKET
The ongoing threat of fentanyl-cut heroin and the lack of resources to use it safely makes a case for a legal and regulated drug market. The United States’ skill set in regulation, as with gambling, alcohol, tobacco, and marijuana (in some states and the Capitol)—while flawed—is much stronger than the nation’s deeply harmful system of criminalization. The violence, criminality, and overdose that constitute our “heroin epidemic” are a result of prohibition, while drug addiction accounts for a minor population. Relatively few people who use drugs develop drug addiction, so when the federal government pours billions of dollars into opioid treatment in New Orleans area health centers, the effect is limited. To treat drug use as a public health issue may help to address those with drug addiction, but it does not solve the deeply damaging effects of drug prohibition.
In a regulated drug market, people who use drugs would access medical grade heroin in therapeutic settings that encourage informed drug use. Legitimate suppliers of the drugs would be governed by a quality assurance department that eliminates the risks of unknown, dangerous additives. Researchers would have the ability and funding to develop evidence-based practices. The New Orleans health centers that offer opioid treatment would then have a better chance to engage people with addiction and improve their health outcomes.
For thousands of years people have used drugs to both cope with and highlight human experience: for enjoyment, for connecting to spirits, for getting by when grief is too overwhelming. Scholars assert that our primate ancestors cultivated spoken language through their experiences with hallucinogenic drugs, and ancient Greeks developed direct democracy through the use of narcotics. Considering the history and scope of human cultivation of plants for narcotic and psychedelic effects, prohibition of drug use is relatively new. Yet, its failures are obvious and alarming.
Frustrated by the dire human consequences of the United Nations’ utopian “drug free world” strategy, a group of heads of state from Mexico, Guatemala, and Colombia called on the United Nations to convene a special session on global drug policy.
This April, the U.N. General Assembly and Special Session (UNGASS) will hold a meeting to talk about the problem of the War on Drugs. Human rights groups hope UNGASS will be an important opportunity to push the envelope, amending the United Nations Drug Treaties to safely regulate drugs, and to acknowledge and make visible the social and economic consequences of the War on Drugs. Such hopes were dashed at the annual narcotics meeting of the UN Commission on Narcotic Drugs in Vienna in March. In its secretive process, delegates created an outcome document that the General Assembly is expected to endorse at UNGASS this April. Excluded from the document are the words “harm reduction” and any reference to naloxone. What is included is retention of the same old international drug war tactics.
While drug warriors and pro-legalization delegates from all over the world butt heads at the United Nations in New York City, let the dialogue take place here in New Orleans, among you and your neighbors, friends, and families. Continuing to affirm the dignity and humanity of all people, including those who use drugs, is life saving. Consider: What are the ways I am hurt by drug prohibition? What are the ways that my privilege protects me? What are the stereotypes that change how I see people? How do I treat myself if I use drugs? How do I treat others who use or sell drugs? Relevant institutions that could make a big impact by recognizing and undoing drug-related stigma are populated by us. It’s up to us to act collectively toward ending drug policy’s endangerment of our communities and ourselves.
Nora Maria Fuller is cofounder of Trystereo/New Orleans Harm Reduction Network, where she also serves as a hotline volunteer. To learn more, visit nolaharmreduction.tumblr.com