Makin’ It Happen Podcast: Dean LeMire of the New Hampshire Harm Reduction Coalition
Recorded April 5, 2018
Some content has been edited by interview participants for clarity.
Jenny O’Higgins, Makin’ It Happen: Welcome to this edition of Makin’ It Happen in the Greater Manchester Region. These segments are brought to you through collaborative partnership with Manchester Access Channel and 95.3 FM radio, and Makin’ It Happen, a regional coalition focused on creating a coordinated response among individuals, organizations, businesses, and communities to promote behaviors that measurably improve overall health and well-being of our youth, families, and community. Our work is rooted in the core belief that behavioral health is essential, Prevention works, Treatment is effective, and people recover. The greater Manchester region includes the communities of Auburn, Bedford, Candia, Deerfield, Goffstown, Hooksett, Manchester, and New Boston. I’m Jenny O’Higgins and I’m here today with Dean LeMire.
Thank you so much for joining us, Dean. So the topic of today’s segment is Opioid Overdose Prevention and Response, and we’re going to talk a little bit about your recent presentation at our Community Learning Series.
So we loved seeing your presentation and got great feedback, too. The idea of the podcast is to let people who couldn’t be part of the presentation have an opportunity to hear some of the information, and the Community Learning Series is really about making sure that all of our neighbors understand they can be part of the solution. So that’s what we’re going to focus on today – is learning in general, and feeling empowered, and then learning some ways that we can all help
So you’re from the New Hampshire Harm Reduction Coalition. What does that mean?
Dean LeMire, NHHRC: Sure. The New Hampshire Harm Reduction Coalition is a collective of folks who have direct experience with certain kinds of harm reduction programming throughout the world, down to nurse practitioners, people in recovery, and people with no direct experience with harm reduction services. We all recognize that there is a need to perhaps approach our drug crises differently and insert a lot of compassion and practicality into our approaches. We’re a small band of folks who are looking to grow our membership and our impact. We have a direct services arm called Hand Up Health Services, which is a syringe services program – sometimes called a syringe exchange program – that we operate in the Strafford County and Seacoast areas.
Jenny O. And what are some of the basic principles of harm reduction? Like, when you say ‘harm reduction,’ what does that mean?
Dean L. I’ll just take it straight from the national Harm Reduction Coalition: ‘Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs’.
So generally, ‘harm reduction’ is a really familiar concept. It’s something that everybody practices if we put a seatbelt on. If any of us has ever used a condom, or promoted using a condom for safer sex, we have practiced harm reduction. Harm reduction accepts that there is going to be risky behavior. And that’s OK. Even drug use is not always bad. Drug use has been a part of every society, every culture, since the Dawn of Man. Drug use can be part of religious ceremonies, spiritual awakenings. It can cure boredom for some people. The supermajority of people who use drugs, including alcohol, do not experience the kind of problems that the super-minority does. And often we design our policies on drugs and drug use, and our general approaches, around that super-minority that experiences problems. And what that creates is another set of problems. If we’re trying to create a drug-free society that has never existed in history, our policies are going to be a little strange, and are going to cause harm. So harm reduction has policy implications, but the harm reduction mantra is not necessarily, ‘Let’s accept and condone and decriminalize and legalize all drugs because they’re all OK and never harmful to the majority’ – that’s not it at all. However, harm reduction does have policy implications where a lot of the policies that we have around drug use are actually harmful to the majority that doesn’t experience problems, and especially [harmful] to the minority who do. To simplify it, the harm reduction approach is more like asking, instead of ‘How can I mold you to suit my reality, or my practices’ – whether I am a police department, or an emergency department, or a treatment center, or a drug prescriber – ‘How, instead, can I change my practices to mold to your individual reality and needs?’
Enter a Syringe Services Program, which is offering free syringes, and often naloxone, and cookers, and cottons to draw up the illegal drugs with, as an engagement tool to provide a new connection to a hard-to-reach population – the injection drug using community. So whereas they might really only interact with the local police, or some usually bad interaction with healthcare providers on a totally emergency basis, a Syringe Services Program can enter their lives and say, ‘We support you and we’re going to give you the tools you need to inject more safely,’ without an agenda of ‘You need to stop using drugs right now.’
Jenny O: Yeah, so it sounds like…in the last presentation we were talking about building resiliency in young people. And I hear a lot of similar language as you talk about this, because there are a lot of ways that when we work with kids, that adults can say, ‘We brought this program that we’re going to do to you, or for you. And really, youth are more engaged, empowered and learn more when we do something with them. Or if we help to advocate what they want. And we talked a little bit about how community members can help impact the health of their communities, and how that can’t really happen without buy-in. Like, asking residents, ‘What is it that you need.’ Just the idea of meeting people where they are. And so as you talk about the principles of harm reduction, I think it might be harder for some people to hear or understand those because you’re talking about such a heavily stigmatized population of people who inject drugs. And we have a different lens sometimes on thinking about thinking about heavily stigmatized populations. So we’re not always going to think about people who inject drugs in the same way we think about children in a school. But I am hearing that some of the same approaches are present, where people are more likely to access services that they feel a part of, and that they feel are meeting them where they are, and meeting their needs. So where people may not access needed healthcare services, or may feel intimidated, or like there are insurmountable barriers to accessing treatment when they want it or they need it, some of the work you’re doing with harm reduction is having positive interactions with people who often feel like there aren’t positive interactions for them. Is that right?
Dean L: Absolutely. Conditions for people who inject drugs in New Hampshire…this has been studied recently. I was part of an effort to go collect stories from people who at that time were injecting drugs. We spent ninety minutes with each person and tried to get a picture of what conditions were like. Their interactions with law enforcement, how they felt stigma in their lives, their interactions with healthcare providers. And the picture that they painted was really, really grim. And they weren’t coming from a victim stance. They were just telling us about their daily lives, which included what I would consider daily trauma – daily trauma of just being a person who injects drugs in the State of New Hampshire.
I think that people who don’t really have direct connection to the issue, or haven’t seen it, or haven’t experienced the hell that is being somebody who uses against their will – and specifically illicit substances, where you’ve got this criminal element to your daily life – you can kind of burn out on the issue. You can kind of say, ‘Well why can’t they just snap out of it?’ ‘Why can’t they just change?’ And I think a lot of our services in New Hampshire and nationally are set up so that you can only engage in supportive services once you have committed to or actually have stopped using drugs altogether. So a lot of our treatment is like that. We kind of wait for people to crash and burn, and hopefully not die, and come to this magical moment where it occurs to them that, ‘Hey – what I’m doing is totally crazy’, and then we expect them to have this total change in their psyche and their behavior that allows for lifetime abstinence. And that’s not practical, that’s not based in reality, and it’s really not working. And that’s what we’re seeing with the overdose rates, and the death-by-overdose rates, in New Hampshire. Our approach is wrong. The way that we think about addiction is not based in reality and it’s not helping.
So I’ve been part of several efforts to broaden…
Jenny O: Broaden the thinking…
Dean L: Yeah. I think the most effective way to engage healthily on the topic of addiction, and recovery, and really to change the game on whole, is to start thinking of people who use drugs, and people who experience addiction, as people who are just like us, as people who have the same basic needs. In the 1940s we started seeing Mazlow’s Hierarchy of Needs as the fundamental concept about what kinds of psychological needs people have to just not go crazy, to have healthy functioning in their lives. Those are things like air, water, food, shelter, sleep, clothing, and we have sexual needs. How many people can you think of, or that you see on a day-to-day basis, that don’t have those basic needs met? And those overlap pretty significantly with people who are most vulnerable to overdose right now, and people who are most vulnerable to addiction. We need to feel safe where we live, where we work, where we play. We need employment. We need a sense of purpose. We need access to health services. We need positive relationships. We need to be able to share our feelings with people. We need the skills to be able to share our feelings and express ourselves. We need respect. We need self-esteem. We need some sort of status. We need all of these things in order to function, and I think some of us take for granted all the kind of recovery capital that we already have in our lives that might have prevented us from becoming somebody who injects fentanyl. So I think we can check our privilege and not be quick to judge someone who is struggling.
Somebody who experiences childhood trauma is at significantly higher risk of experiencing a range of negative health outcomes leading to an early death. By and large, people who experience addiction…if they haven’t had traumatic experiences early in life, they certainly do just being somebody who’s experiencing addiction in America. We have to take into account that their lens is very different, their experience is very different. And what is very impactful in changing behavior, which is what we’d all like to see, is to meet them compassionately and to ask what their needs and their goals are, and to help them to meet those. That could include, ‘I don’t want to get HIV today’. Or, ‘I don’t want to overdose’, or ‘I don’t want my friends to overdose.’ ‘I don’t want to go to the emergency department today’ – that’s a reasonable goal and that’s something that we can actually help people to meet. Enter naloxone in 2015 in New Hampshire. Suddenly everyone is allowed to carry and administer naloxone. In these last three years, that [policy change] alone has led to huge prevention of overdose deaths. Those death tolls would be much, much higher if the community didn’t have access to naloxone – and specifically the drug-using community, who are using this on each other.
Jenny O: And naloxone is commonly referred to as Narcan…I feel that we should say that for those who don’t know what naloxone is.
Dean L: Yeah, sorry. Narcan is a brand name for one administration device, which is the nasal kind that the state has been buying recently. It’s a one-piece, no-assembly unit and it goes right up the nose. It’s like a Flonase, kind of. We’ve had injectable naloxone forever – that’s what emergency responders usually come supplied with. It’s these little vials of naloxone that they inject into you with a syringe. That’s what our Syringe Services Program is starting to supply people with, and they’re not needle-phobic. It’s second-hand to them to help an overdosing friend out by injecting a needle into them and saving a life that way. Naloxone has been used primarily in the community by injecting drug users, and that administration route, for many years underground, illegally. And we know that it works. When you can supply the people who are using drugs with they tools they need to prevent overdose and to prevent the spread of disease – well, they are the most likely to enforce that prevention effort.
Jenny O: So I’ve heard a lot about ‘why’ harm reduction, and I’ve heard a little bit about what I can do about it, like addressing stigma and burnout on the topic. I also want us to talk about how to recognize an overdose and respond to it, and then after that maybe a couple of other things that community members can do.
So what can we do to recognize and respond to overdose?
Dean L: People can overdose on a variety of things. We most commonly hear about opioid overdose, and specifically fentanyl overdoses. And that’s because fentanyl is many, many more times potent than the heroin that people were using and actually preferred before fentanyl came on the scene. Fentanyl [is used for] late-stage cancer pain. It’s in a patch and transferred transdermally. Then certain suppliers began manufacturing illicit [powder] fentanyl, and it started getting into our drug supply, and now, in the Northeast at least, fentanyl is the primary illicit opioid that is sold and used. We also have an issue with poly-drug-use. We see that in New Hampshire in our toxicology reports, where people are combining use of benzodiazepines like Xanax, like Ativan, or alcohol, with their fentanyl, or other drugs are mixed up in the drug supply. All of these things, without proper education and changing drug use practices, puts people at pretty high risk of overdose.
How to recognize an overdose?
Loss of consciousness. Overdose can take place over a couple of hours, or it could be sudden, but usually by the time you find someone who’s overdosed, they’ve lost consciousness. They won’t be responsive to outside stimuli. So if you shout their name, or ‘Narcan!’, or, ‘Cops!’, and they don’t wake up, that could be a sign of an overdose. Or if you give them physical stimulus – rub your knuckles really hard against their sternum, and they don’t wake up from that, they’re likely overdosed. If they’re awake but unable to talk – we’re talking about depression of the central nervous system, so the ability to talk is compromised. The ability to understand – so if they’re confused, they may be on their way out. If their breathing is shallow…you want to hear about 12-20 breaths per minute. So if you’ve got your ear to their mouth, feeling their breaths with your hand or your ear, you’re looking for 12-20 breaths per minute. Snoring or gurgling. Somebody might just be sleeping, but if you start hearing gurgling sounds, or guttural snoring sounds, that is an indicator of opioid overdose. If they’re light-skinned, they’re a little blue. If they’re dark-skinned, they’re ashen. If they are vomiting, or they have vomited. If their body is excessively limp or excessively rigid. If their pulse is slow, or erratic, or not present. If you lift their eyelids and their pupils are pinned – one effect of an opioid is pinned pupils.
Jenny O: So then what do we do about it?
Dean L: So I mentioned the first step is you want to evaluate where they’re at. So if they’re unconscious, they may just be sleeping. You want to give that auditory and physical stimulation. If they’re not responsive, you want to call 911, and you want to administer naloxone. In an age of fentanyl, that window is getting shorter between overdose and death. So what’s most important is to get the substance in them.
Just a little background on naloxone…It was invented in 1961 accidentally. They were trying to find a [treatment] for constipation for long-term opioid users. They came across this drug that uniquely reverses overdoses in a way that no other substance can. This is it – this is the miracle drug. What an opioid does is it sits on opioid receptors in your brain. We have those. There are opioids in our system that occur naturally – not enough to address chronic or acute pain, but enough to kind of give us a boost, make us a little happier. We call them endorphins – those are opioids. And if we flood our opioid receptors with an opioid like heroin, fentanyl, oxycodone, Percocet, then we have suppressed our urge to breathe. That’s what an overdose is, is suppressing our urge to breathe. So what’s needed is to kick those opioids off the opioid receptors. And so that’s what naloxone does. And it does so temporarily – it can last between 30-90 minutes before it wears off and the opioids return to the receptors. So it’s super-important to call 911, because guaranteed – [medical emergency responders] have more naloxone than you’ve got and you might need it. It’s also important to just get the substance in them so it can take effect more quickly.
In the case of Narcan, what you probably get from a pharmacy or a state supplier, all you’re going to do is peel off the label, take out the unit, tilt the person’s head back, place the nozzle into the person’s nostril, press the plunger. And then you’re waiting. Naloxone will only take effect after 2-3 minutes, and [usually] not before. You can give someone 50 doses of naloxone and it will still take 2-3 minutes to take any effect.
While you’re waiting, you can be giving rescue breaths. You’re going to tilt the head back, pinch the nose, put your mouth over theirs perpendicularly, and give two long breaths close together. And then one breath every five seconds or so after that. And just monitor the person. Are they coming out of it? Are they not? Check their breathing with you ear. Can you hear or feel 12-20 breaths in a minute?
If so, then great – we’re just waiting for [emergency medical responders] to arrive. If they come out of it, they may vomit. So you want to put them into a rescue position, which is rolling them over onto their side and placing a hand under their face, which puts their elbow out to create a kickstand effect so they’re not rolling onto their face. Drape their outside leg over the other to create another kickstand. This is so that if they vomit, they don’t asphyxiate. Tilt their head backward to maximize airflow.
If they’re not starting to breathe, continue rescue breaths for another 2-3 minutes and give the other dose of naloxone. Every Narcan kit comes with two .4 milligram doses. So you’re just going to peel, place, and press the unit again and continue waiting.
If the person does wake up, then you want to offer some supportive messaging. Let them know that they have overdosed, that you gave them Narcan. You want to let them know that the Narcan may not last, so please don’t use opioids again – don’t use any drugs to complicate the situation and risk another overdose. Let them know that if they feel bad now – naloxone may put the person into withdrawal – that the good thing about naloxone not lasting forever is that the opioids will sit back on the receptors and you will start to feel a little better. Encourage them to seek medical attention or accept the help that’s coming from [emergency medical responders]. Because naloxone is not a replacement for the medical care that they probably need after they’ve overdosed. They need to be monitored and maybe get fluids, etc.
So that’s it! It’s really simple, probably simpler than I’ve made it. Put the naloxone in them.
Jenny O: It’s really simple in [theory], like learning CPR, but not simple in the moment because of the [adrenaline] and fear and anxiety happening at the same time. So it’s one of those things that we try to say, ‘Here are the easy steps you can do’, and try to make it easy because it can be terrifying.
Dean L: Of Course. And you know, if you respond to an overdose, that is super-scary, especially if you’ve never done it before. It can be kind of traumatizing. You were just looking at somebody who was out cold. And if you have Narcan on you, you could be the only thing that stands between life and death. But just try to remain calm. The naloxone will likely work, and even if it doesn’t work and you’ve called 911, you’ve offered this person the best chance to live. And you’re offered immunity from prosecution. If you’ve used naloxone in good faith – you believe a person is overdosed – there is no risk of prosecution. And there is no [medical] risk associated with naloxone use. It will create no effect other than a reversal of an opioid overdose.
Note: NH HB270 Good Samaritan Law (2015/2017) gives immunity to overdose callers and victims for small amounts of illicit substances and paraphernalia found on scene. NH HB271 (2015) allows for sale, distribution, possession, and use of naloxone among non-medical personnel.
Jenny O: So we don’t need to be nervous about using it and then finding out that the person is not overdosed, or has not overdosed on an opioid.
Dean L: Exactly. I don’t have any opioids in my system. If I used thirty doses of naloxone right now, it would do zero. Zilch.
Jenny O: That’s good for listeners to know. So I know this was a particularly hard topic to describe over audio only, since when you teach Overdose Prevention and Response, there’s a lot of in-person [learning] like learning rescue breathing, seeing the naloxone, putting someone in the rescue position, etc. So we’ve covered some important things for people to hear, like calling 911 and having Narcan which you can get in the state without prescription so you can have access to these tools…Are there also regular times or ways that people can find out when the live presentations are happening around the state?
Dean L: Traditionally, the state has used the Regional Public Health Networks to provide public naloxone trainings and to dispense the state’s naloxone. It’s a little unclear how the state is going to roll out naloxone now. The state has bought more kits, but the rollout is going to be a little different. But you can pick up Narcan and get some basic training from any [state-funded] Recovery Community Center. You can also get it from any Syringe Services Program in the state (Hand Up Health Services – Southeastern NH; Syringe Services Alliance of the Nashua Area – Greater Nashua). You can also find or request an Overdose Prevention and Response training from the New Hampshire Harm Reduction Coalition at NHHRC.org.
We’ve provided ten tips to prevent our own and each other’s opioid overdoses. If this messaging gets out and starts changing practices of people who use drugs in New Hampshire, we change the game. As we’ve said, people are the captains of their own care. And they’re the most likely to change their own practices and prevent their own harms.
Jenny O: Do you want to read those?
Dean L: Number One is…
1. Don’t Use Alone. This might be counter-intuitive to those who have heard about ‘Narcan parties’ and people who are having them. Well, they don’t exist. And we actually want to encourage people to use together when possible and to have naloxone when they do, and to know how to use it, and to teach each other how to use it. So do not use alone because most people who die from overdose die alone, and because they were alone.
2. Try a Tiny Tester Amount. It may feel counter-intuitive to tell someone to use any amount of a drug. But given that people are using drugs, we want to encourage them to try a little bit first to try to gauge and evaluate the effects. Part of that strategy can be testing the drugs before they use them. I have here a fentanyl testing strip that you can use to test your drugs before you use them. What we know from research is that when people use these, they are ten times more likely to change the way that they use the drug, and to reduce risk of overdose.
3. Go Slow. You can put more in, but you can’t take it out. So don’t ‘slam’, which is when you push the [syringe] plunger quickly. Take your time, make sure you’re not blowing up your vein, make sure you can evaluate the effect of the drug going in as it’s going in, and not hope for the best after you’ve put it all in.
4. Wait to Use until you feel Safe and Calm. Fear causes mistakes. And mistakes are preventable. Try to find a place where you can feel safe to use your drugs.
5. Don’t Mix Drugs. Try to use drugs one at a time.
6. Know the Signs of an Overdose so you can prevent overdose death in real time, and to know when not to use more.
7. Limit Use while Sick. If you’re sick, you’re vulnerable to overdose more so than if you are healthy.
8. Drink Plenty of Water to ward off sickness and to create more blood flow.
9. Change the Way that you Use. If you inject, have you considered smoking or snorting your drug? These administration routes have a lower absorption rate than injection and carry lesser risk of transmitting HIV and HCV than through syringes.
10. If You Want a Change, Insist on your Own Care and Find the Helpers. The best way to reduce risk of overdose is to stop using the drug. If you feel ready to do that, you’ll need help. And there’s help available. Look for those people who can connect you to the services and supports that you’ll need. It’s usually just a person who smiles at you.
Jenny O: Dean, thank you so much for joining us today. And thanks to our listeners throughout the Greater Manchester region. With your support, we’re working to inform, engage, and work together to create healthy, thriving communities. Thanks so much for listening.
The interview podcast can be heard in full at mih4u.org.