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Scott Webb: According to the World Health Organization, there is no generally accepted definition of harm reduction. However, it is known to cover a set of activities that are intended to minimize the negative physical and social impact incurred by the behaviors related to substance use.

In essence, harm reduction strategists recognize that substance use and relapse happen. So when people are not able to stay sober forever, they should implement practices that minimize the likelihood of fatality. And joining me today to discuss harm reduction practices and how Sierra Tucson can help is Dane Binder. He's the Chief Operating Officer at Sierra Tucson.

This is Let's Talk: Mind, Body, Spirit by Sierra Tucson. Sierra Tucson ranked number one best addiction treatment centers 2020 in Arizona by Newsweek. I'm Scott Webb.

Dane, thanks so much for your time today. We're talking about harm reduction. This is a really interesting topic, and I'm glad to have you on. So I just want to have you start by explaining what harm reduction is and who implements it.

Dane Binder: So harm reduction is essentially a set of principles and behaviors that we can teach just about anybody with a substance use disorder or even sometimes mood disorders, who may have suicidal or self-harm tendencies, to reduce the likelihood that they're going to have extreme harm or even death.

So a harm reductionist in principle is someone who recognizes the realities that relapse is part of the recovery experience, and we have a responsibility to teach people how to relapse safely, so that again, they don't inadvertently kill themselves, especially after a period of sobriety, which is a huge risk factor.

Scott Webb: Yeah, that's really interesting and interesting to know that relapse is, as you're sort of saying, you know, inevitable, but we want folks to do it safely. So when we think about alcohol, opioids, substance use in general and that substance use disorder, does that play a role in suicide risk?

Dane Binder: Yeah. As a matter of fact, it does. So substance use is actually a known risk factor for suicidality. So people with long-standing substance use disorders can often feel very hopeless about their future. They can lack future orientation. It can lead to depression most of the time. And all of those things are known risk factors for suicide. And additionally, when you're using substances like alcohol, they diminish your judgment and your impulse control.

So when we're evaluating how high risk someone is for suicide, we're looking at a conglomeration of factors. But some of those bigger ones are what's your ability to exercise good judgment? What does your impulse control look like? Are you acting impulsively? Do you have a history of acting impulsively? And substance use can lead to diminished judgment and diminished impulse control.

Scott Webb: Yeah, I can see how that would happen. And, you know, it almost seems sort of counterintuitive. It almost seems like folks might sort of maybe self-medicate with alcohol, opioids, things like that because they're depressed or because of whatever their mental state is. But, as you say, and of course I'm sort of paraphrasing, but it almost really makes things worse.

Dane Binder: That's exactly right. And so oftentimes what we find is that substance use, I guess you could say the underlying cause is leading to the behavior of consuming substances, right? So like you correctly pointed out, it's not uncommon for people to turn to substances, particularly in times when they're feeling depressed, because it releases some of the chemicals in the brain that are associated with feeling euphoric. So that is in particular why heroin, for example, is such an addictive substance is because of the euphoria that people feel when they use it.

So if I'm feeling depressed, I'm feeling even suicidal, I'm looking for any way out that I can to get rid of the anguish that I'm experiencing. Substances are sometimes very easy to turn to so that you can get away from those feelings and feel a lot better. But again, as you mentioned, it can lead to increased depression and most of the time it does.

Scott Webb: Yeah. And you could see how someone who is depressed would maybe sort of crave that momentary euphoria, you know, that sort of initial momentary feelings. But long-term of course, it can lead to, you know, negative outcomes for folks. And I want to sort of broaden our focus, sort of zoom out if you will a little bit here, and just kind of discuss the trends that you're seeing within the mental health profession.

Dane Binder: Yeah. So it's really interesting and really tragic. Over a rolling 12-month period, the statistics came out from the CDC a couple of months ago, we actually experienced a hundred thousand deaths in a rolling 12-month period due to overdose. So that is a record unfortunately, and a lot of those deaths stem from the use of opioids, in particular fentanyl, morphine, codeine and heroin, but fentanyl being the biggest culprit of all. So we're seeing an alarming spike in overdose, subsequent to use of opioids. And I think that it kind of naturally follows that with this period of isolation that we've all had because of COVID, someone described it to me as a house cat trying to scratch the door trying to get outside for the last several years, because of COVID we're not able to get out, people are getting a little bit stir-crazy. So the use of substances is oftentimes a natural response for people.

And additionally, some of the protective factors that we've got are connecting with friends and family and those sources of support. So when COVID hit and people were shut out of all of their sources of support, for a lot of people, that was their lifeline. When you're talking about 12-step groups like AA and NA, which is Alcoholics Anonymous and Narcotics Anonymous, that was a lifeline for a lot of people who are really struggling every day to fight the urge to use substances. So I think that that's part of the factors for sure that led to that 12-month rolling high.

And in response, the Biden administration is issuing $10-million grants over the next three years specific to harm reduction through SAMHSA. And that is a really fascinating pivot because historically harm reduction in general has been kind of shunned. It's highly politicized because there's a lot of people who believe that harm reduction strategies will lead people to using substances. So if I can give an example that probably illustrates it the best, syringe exchange programs. So if I am using needles to administer drugs into my body, I come out with a dirty needle. So, a popular harm reduction program is a needle exchange where instead of me turning to using that needle again, which may get rusty and lead to infection, those types of things or I may give it to a friend of mine and run the risk of spreading some sort of illness like HIV or hepatitis C or something to that effect, oftentimes, I can go to this needle exchange program and give them my old needle where it will get properly recycled or destroyed and I'll get a clean needle in return. So the reason why that's a little bit politicized, the reason why some people don't like it is because they're concerned that we're enabling people to use drugs. When in fact, a harm reductionist, like I'd mentioned, recognizes that substance use exists in the world. How can we make sure that we're reducing the number of deaths associated with substance use so that we can keep people safe and alive?

Scott Webb: I'm going to file this one today, Dane, under lots of food for thought. I want to have you talk about Narcan and is this something we should have at home? And if so, where do you find it?

Dane Binder: Narcan is a prescription medication that reverses the effects of opiates, such as fentanyl, oxycodone, heroin, and codeine and those types of opiates. So it's used for treating an opioid overdose and it works by blocking the opioid signals to the brain through receptors. So it's considered medication that's used oftentimes by EMTs, police, first responders in general, as well as hospitals and those types of things. So when people use a bunch of opioids and they start to go into overdose, you know, when their nervous system essentially tells their body to start shutting down, their lungs start shutting down and they become unresponsive, Narcan is administered through the nasal cavity with a syringe, you know, similar to the way that you would take an allergy medication, you know, in a nasal capacity. And it will reverse that overdose and it'll pop the opioids off the opioid receptors and then the person is essentially brought back.

So it's a really effective way of saving people's lives, so if you or someone you know is using opioids, it's something that's really important for you to have access to and it's a very effective harm reduction measure. Narcan is the commercial name for the drug that's made through the nasal spray. There's also the generic form, which is called naloxone. And generally, it comes in a little vial with liquid and oftentimes comes in a kit accompanied with a syringe or two with two vials. And the medication could be drawn into the syringe and put into a muscle, it's an intermuscular medication, and that additionally will help reverse the effects of an opioid overdose.

As far as where you can find it as concerned, oftentimes you can get it prescribed through a doctor. There are some places that sell it over-the-counter. It's not as readily available or affordable for a lot of people. So, what you can do instead is you can turn to a local harm reduction coalition wherever you're located, they're all over the United States. And there's even some national coalitions. One of them is called the National Harm Reduction Coalition, and they'll mail you a naloxone kit in the mail. And it's really easy to get ahold of. It's very safe to have. If you administer it to someone who has not overdosed on opioids, there won't be any sort of adverse effects. And oftentimes, there's not any sort of litigation associated with it because there are Good Samaritan protections built in so that if something were to go wrong inadvertently, that person would not be held liable for that action if they're acting within the Good Samaritan means.

Scott Webb: Yeah, this is really educational. And so in addition to the Narcan, what are some other things maybe we can do or should have at home to reduce the risk of overdose?

Dane Binder: Generally, when we talk about overdose risk factors and life-saving countermeasures, I tend to stick with five that I try and teach people. So these are simple things that just about anybody can understand. It doesn't involve any sort of special skill set or special knowledge base. You just need to know what these big five risk factors are and then the five countermeasures for it.

So the first one, the first risk factor is restricting accessibility when using or when someone is using alone. So if they're using opioids behind locked doors, they don't tell anybody about it, they're actually making it very difficult for people to get to where they are through that locked door. Obviously, you got to kick it down and you got to have a key to open it up. And when it comes to overdose, minutes count, seconds count, because when blood stops flowing to the brain, bad things start to happen. So same with when they stop breathing. A good countermeasure is always telling an in-home friend or family member before using. This is much easier said than done. I completely recognize that because opioid use and substance use in general is a really difficult conversation to have with your family and friends, because it oftentimes leads to alienation. But, it's really important that families, again, recognize that if their loved one is struggling with this, they have to prioritize saving their life. So if that means they're not ready to stop using completely, if that's not an option at that point in time, at minimum, we want to make sure that they're doing safe things which involves having open communication when they use and not restricting access to their body.

The second thing that we want to look for in terms of risk factors is combining drugs. So when you combine drugs, particularly benzodiazepines, which is a very popular anxiety medication, along with opiates, you're essentially using two nervous system depressants at the same time. So you're doubling up on these substances that are essentially going to cause your body to shut down if you inadvertently use too much of them.

So when I work with clients in the various capacities I've worked with them over the years and I ask, "How many of you have ever experienced an overdose?" the second most common thing that is said is that they used a benzodiazepine along with opiates within several hours of one another. So it's really important that when using, in terms of harm reduction, if people are going to use, that they do not use two types of nervous system depressants at the same time. Alcohol is another example of that.

The third risk factor that we've got our fentanyl adulterants. So fentanyl started to become kind of a household term when it comes to conversations around substance use in the opioid epidemic. And that's because it's such a strong opioid and using just a little bit of it can often lead to overdose. What people don't know about fentanyl is that oftentimes it's being introduced to other illicit substances like cocaine, methamphetamines, and other sorts of drugs that people are getting in the street. And the reason for that is because according to the DEA, the cartels find it easier to introduce fentanyl, because it will get people more intoxicated, right? So they'll feel a lot more effects of the drug. And a really important countermeasure for that is being able to test your supply. So, as I mentioned, you know, opioids are one of the leading risk factors for overdose, right? They're one of the leading causes of death in terms of drug overdoses. If you have someone who's using methamphetamine, for example, or cocaine, even if just recreationally, they've never used an opioid in their life, if they get a little fentanyl adulterant in there, oftentimes they're immediately going into overdose without even knowing that they've consumed the opiate. So it's a really nasty adulterant that is definitely contributing to the overdose deaths that we've seen increasing over the last 12 months.

So what you can do is you can contact these harm reduction organizations that I had mentioned and ask them for fentanyl test strips. And it's essentially just a test strip that, you know, is very simple to use. And you're able to take a little bit of that substance and they have some sort of ability to essentially dip or place a little bit of their drug onto the test strip and it will tell them if there's fentanyl in it. So that's a really great countermeasure for folks who may be using substances, not necessarily opiates, but in order to make sure that they're not inadvertently taking the opiates, that's a really important countermeasure.

The other thing that is considered a risk factor are pre-existing respiratory illnesses. So, as I had mentioned, opiates are a central nervous system depressant. So part of the central nervous system essentially involves keeping our lungs going. So when we have folks with pre-existing respiratory illnesses, like COVID and COPD are really big risk factors for overdose. You're essentially making it harder for your lungs to work when they're already having a hard time working. So anyone with pre-existing respiratory conditions should avoid central nervous system depressants, and they should have a lot of conversations with their doctor about it because your doctor is generally going to lead you down the right path when it comes to those types of things.

The fifth and final risk factor are tolerance changes. Tolerance changes is generally going to be the leading risk factor for folks that I've interacted with. So what happens is people will go into the hospital, for example, subsequent to whatever, maybe it's an overdose or some other serious issue. And they'll come out of the hospital or they'll come out of rehab or they'll come out of, you know, an inpatient stay for psychiatric reasons and their tolerance will have gone down. So tolerance is essentially when you use enough of a substance over time, you have to start using more and more because your body starts to tolerate its effects. So in order to feel that euphoria, you've got to use more over time. So if you can imagine a graph, when the line starts running up, as soon as you stop using, the tolerance level goes down pretty considerably. And it's usually just a short period of time. So it's really important that people recognize when they've had a period of sobriety and they are going to relapse again, that they remember, "Okay, I need to start slow. I need to use a little bit at a time because if I go use the same amount of opiates I was using previously, it's very likely that I'm going to overdose." So it's very, very important that people with substance use disorders and their family members and friends understand this so that they can coach their loved ones to make sure that they're using in a safe manner that's not going to end there life.

Scott Webb: Yeah, I see what you mean. And so when we think about, you know, reducing or harm reduction, as it applies to home for ourselves, our loved ones, let's compare maybe and contrast that with what it's like in a treatment facility, like Sierra Tucson, and the strategies involved there.

Dane Binder: So it's actually really interesting. These are pretty common things that we'll teach our clients, right? The difference is that we've got a captive audience. So whether it's a therapist that's doing one-on-one counseling, whether we've got a captive audience in a residential facility like Sierra Tucson, or what have you, it's really important that we talk about the five risk factors, which again, restricting accessibility when you're using, combining drugs, fentanyl adulterants, pre-existing respiratory illnesses and tolerance changes, if we can educate on those five factors as a treatment facility or as behavioral health providers, we're doing great due diligence with our clients by helping to keep them alive should they relapse.

Scott Webb: Yeah. And you can see that education is so key. And as you say, of course, or you used the analogy earlier, the cat's sort of locked in the house, you know, really wanting to get out in here. If folks come to Sierra Tucson, you have that captive audience and presumably education is perhaps a little easier, a little smoother when, you know, I hate to put it this way, when folks are kind of stuck there for a bit, right?

Dane Binder: Absolutely.

Scott Webb: And they know that you're all there to help and to educate. So, a really excellent information today. And as we wrap up, Dane, you've given us a lot of resources, so maybe you can go through them again. And just maybe what else you want to share? What would be your takeaways when it comes to harm reduction?

Dane Binder: Sure. So I think that harm reduction can sometimes sound scary on the face of it. I've heard people say, you know, "Well, if people have access to Narcan, you're essentially incentivizing them to use up to a certain point where they can use as much as possible putting them on the doorstep of death before bringing them back." And my response to that is generally, "Okay. Let's say that that's true. If you're using with a sober friend, that is harm reduction. We're keeping them alive and it's better than them using too much and accidentally dying." So although it may seem scary, realistically, what we're doing is we're helping to keep people alive by doing that.

Some of the other scary things that people will talk about, that might feel a little awkward for people initially is opening up a space for people to come use under the supervision of a nurse or a doctor or a sober companion. And suppose that they feel that we're inviting people to come in and use drugs, which I suppose that we are, but again, the idea is that it's better there than under a bridge, or it's better there than behind a locked door, because if they're going to use, we want them to use in a way that's safe so that they don't die. When we're talking about overdose deaths, I don't think any option should be off the table. So I encourage people to really stretch their brains and try to understand we don't ever want anyone to use substances, right? But the fact of the matter is that people are out there using, so we want them to stay alive so that eventually they can learn the tools that they need to remain sober for long periods of time or perhaps the rest of their life, because recovery is possible, but people aren't necessarily ready for that change at the moment when a family and friends or behavioral health professionals want them to be ready for it.

But I encourage people to access the National Harm Reduction Coalition. It's a really great resource. You can look them up on the web at harmreduction.org. And I also have to give a shout out to former colleagues of mine at Sonoran Prevention Works. They're the local chapter here in Southern Arizona. And they have distributed tens to hundreds of thousands of doses of naloxone across the entire state of Arizona. And there are dozens, if not hundreds, of other harm reduction programs across the country that are all fighting the same fight and they are definitely worth looking up in your local area.

Scott Webb: Well, Dane, I really appreciate your compassionate expertise today. This has been so educational. As I said, a lot of food for thought. My mind is going to continue working and chewing over what we've discussed today. Thanks so much and you stay well.

Dane Binder: Thanks very much for having me.

Scott Webb: Visit sierratucson.com or call (800) 842-4487. Sierra Tucson, we work with most insurance.

And if you find this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Let's Talk: Mind, Body, Spirit from Sierra Tucson. I'm Scott Webb. Stay well.