‘We redefined how harm reduction is going to work for us,’ said Jim Duffy, founding director of Smoke Works in Boston, Massachusetts (DDN, June, page 14). Smoke Works had an opportunity to scale up pipe distribution, which was an answer to a lot of local problems – ‘lack of engagement, lack of options. We did something a little different. Rather than filling up backpacks and hitting the streets, which was our day job, we decided to move behind the front lines and work for those who are doing the work.’
Smoke Works was designed as a procurement stream rather than an outreach organisation, he explained. ‘The question was “what if we could take the money being spent on harm reduction, and make it fund more harm reduction?”’ In 2020, when he was working at the AHOPE needle exchange – which is funded by the Boston Public Health Commission – a private grant came through to procure pipes. This also ‘gave us the opportunity to get out and meet more folks, and find out what the effect would be,’ he said. ‘The results were published and they were clear – the impact was awesome.’
In the past there’d been ‘all these folks hanging around outside’ who had no reason to come into a needle exchange, he said. ‘And I realised that was my story too. I didn’t inject. I wasn’t going to walk into an exchange, because I smoked. I thought, “what does that place have for me?” Little did I know it had plenty – HIV testing, people, connection. In hindsight I’m embarrassed to admit that we thought everybody wanted to inject, so we never offered anything more. We were surprised by that.’
UNREACHABLE COMMUNITIES
Around three months into pipe distribution at AHOPE the numbers started to come back. ‘Of those folks coming in solely for pipes, completely new to the programme, no previous engagement – 50 per cent walked out with naloxone. That’s huge, and it helped us get into communities and neighbourhoods that were unreachable prior to that.’ Even when people said they didn’t need naloxone, staff could respond with ‘but I bet you know someone who does,’ he said. ‘It helped us put naloxone into places that we could not saturate before.’
The big question was who does harm reduction serve, he said. ‘Opioid injectors. So who are we excluding? Folks who primarily use stimulants, and people who use more than one drug.’ Syringe access reduced the risk of HIV and hep C, but pipe distribution was also a risk mitigation tool. ‘For safer smoking, pipes replace – and this is my story – drilling a hole in a lightbulb.’ Statistics from the Centers for Disease Control and Prevention, the US national public health agency, showed that people were up to ten times more likely to enter treatment if they engaged with a syringe exchange, he pointed out. ‘Why do we exclude stimulant users and people who don’t inject from that?’
LOGICAL INTERVENTION
Pipes were a very logical intervention, he stressed. ‘It’s safer, it’s more discreet, it’s less time consuming. It reduces overdose risk because it actually means that you pause for a moment to breathe – injection practice doesn’t offer that, especially when it takes ten, 15, 20 minutes to get a shot. If it took me that amount of time to pour a drink at the end of the day, I’m pouring a stiff drink.’
At Smoke Works he and his colleagues began contacting other harm reduction organisations on social media and setting up buyer’s clubs for bulk purchases of pipes – then channelling the profits to those with the fewest resources. Finally he took the decision to leave AHOPE and concentrate on Smoke Works full time. ‘We’re doing this from harm reduction up, not public health down – that’s what’s made the difference,’ he said. ‘We cultivated access to safer use supplies by offering them, only to reveal that the need was there the entire time – we just weren’t asking.’
This meant that it was vital to expand the definition of harm reduction, he said. ‘We have risk mitigation, and then we have the approach we use to make it accessible, and we can widen both. We can meet more people where they’re at, and we can have that impact on more lives.’
KEY PLAYERS
‘Our world has several players,’ harm reduction consultant Mark Gilman told the conference – ‘research, policy and practice, and then commissioners, providers, and the people who use drugs. I’ve been in all of those spaces over the last 40 years, but the one I’ve been in the longest is somebody who’s used drugs.’
From 14 to 19 he’d been ‘insanely drunk most of the time’, he said. ‘Alcohol is a drug, let’s get that out of the way.’ Soon after, taking LSD had changed his life ‘immeasurably for the better, as it meant I could put down the drink for a bit and embrace psychedelics.’ He’d then gone to India and discovered opium. ‘I liked it a lot, and there was a safe supply. I got physically dependent, which had its own problems, but it certainly dealt with my spiritual malady or whatever I had.’
A war on drugs was a war on drug users, he said. ‘And we die, in the thousands. The numbers are terrifying, and are only going to get worse with the polluted opioid supply.’ But the schism between harm reduction and recovery was a ‘false war’, he added. ‘When you’re dead, there’s no more war then.’ Too often people ‘sing to the choir and just get applause from their own people,’ he said. ‘But you don’t get change that way.’
Some of the key people in harm reduction worldwide were personally 12-steppers, he pointed out. ‘It’s usually managers of orthodox services who say “we can’t put people in 12-step abstinence-based recovery in a harm reduction setting – it’ll trigger them”. But what does the ‘Big Book’ say? “We carried alcohol for the new recruits, we went into sordid places”.’
Mutual aid was straightforward, he told delegates. ‘It’s me helping you, you helping me, in community, together, for free, 24/7, 365. What’s not to like?’ In this game we survive together and we die alone. Connection is the opposite of addiction. I’m encouraged by the growth in mutual aid, particularly Cocaine Anonymous.’
UNCONDITIONAL SUPPORT
‘Meet people where they’re at’ was a phrase that was heard all the time, he said. ‘But it has to be unconditional. If we meet people where they’re at and then tell them where we want them to go, that’s conditional. If we genuinely mean meeting people where they’re at, then it has to be unconditional. Imagine being an outreach worker and going out to the 50 per cent of people not in treatment and asking them, yet again, what they want. They say, “what have you got?” And you say “methadone or methadone or methadone or buprenorphine”.’
However, in places like Scandinavia, Switzerland and elsewhere, heroin-assisted treatment was paying dividends. ‘A lot of exciting things are happening in terms of diamorphine. Not just the injectables, but they’ve got the 200mg tablet, a nasal spray for those people with venous sclerosis. It’s a safe opioid supply. And it’s beginning to happen here.’
Watch video footage of the afternoon session here.