Nice to see everyone. We'll get started here. So this is the first training and as part of sort of a two-part workshop, the next one will be next week. I'll show the time and date at the end. But broadly, it's substance use and housing programs offering support with a harm reduction approach. So this is the first part. In a minute, I'll talk about the topics we're going to go over today and then the next part will be next week. So just want to say, you know, with two hours, good to take a break. So sometime, you know, around 11 a.m. or either a little before or after, we'll take a 10-minute break. So that'll give everyone a chance to stretch, refill coffee, whatever. So support for this webinar or training workshop comes from SAMHSA and the Opioid Response Network, which assists communities with evidence-based prevention, treatment, and recovery. You'll see that we're going to talk a lot about harm reduction today, so that's part of the agenda as well. This is just a little bit more information about that and just kind of an overview of what the Opioid Response Network does and kind of what resources are available. Here's their contact information. So just to introduce myself, my name is Susan Stalin. I've spent most of my career working in journalism and teaching media ethics and went back to school to study public health in 2017, so that was before the pandemic. I'm really interested in focusing on substance use and, you know, since getting my degree, I've been working on projects to reduce overdose deaths, educate people about substance use disorders, improve access to treatment and harm reduction services, and support people in recovery. I kind of like to say I support it all. You know, I facilitate training workshops on all of these topics and really try to present a wide range of perspectives. I often collaborate with my husband, Graham McIndoe, who's a photographer who's been open about his history of addiction, incarceration, and recovery. So, you know, I was with him through much of that trajectory and, you know, that has really informed kind of my understanding and approach to these topics. So just a few, you know, try to make this interactive. So please don't be afraid to comment or ask questions. You know, keep the chat box open. You know, if you're in a place where you're comfortable speaking, feel free to raise your hand using the Zoom function. Try to be open-minded about different points of view. You know, there's a lot of people have different perspectives on these topics. I'm really trying to respect everybody's experience, you know, and we'll talk a little bit about that. Just be mindful of time, you know, so everybody who wants to gets a chance to talk. And we'll speak a bit about kind of stigmatizing language and kind of evolving guidance about respectful terms. You know, really also want to reiterate, you know, to avoid generalizations, you know, often people who share some characteristics can have really diverse experiences. And please mute if you haven't done that already. And, you know, some topics may be familiar to some of you, new to others in the group. So, you know, I think there's something in here for people with kind of different levels of familiarity with some of these topics. So we'll start off kind of looking a bit about how we all learn about drugs, substance use, treatment, harm reduction, and recovery. We'll talk about types of substance use and how substance use disorders are diagnosed. A little bit about substance use and people experiencing housing challenges, barriers to care and treatment for people with substance use disorders, drug use trends and strategies to reduce overdose risks, harm reduction principles, practices and services, how stigma impacts people who use drugs, and tips for engaging in conversations about substance use. So those are today's topics. There'll be others that get into more, you know, treatment and other services next week. My first question, and again, you know, we'll use the chat. If you're comfortable speaking, just raise your hand using the Zoom function. What are some of the ways you learned about drug use, addiction, treatment, and recovery? So think broadly about the sources of information that shaped the views you have, people, experiences, popular culture. How did you come to kind of know about this topic? So someone's mentioning in the chat my employment, right? So a lot from work, college, the environment, so family members, so personal experience, previous positions as well. What else? Think about, you know, even growing up. Yeah, so television, school, the work that people do, the community, music, great. Sometimes people overlook that. Social media, great specific programs, you know, people have mentioned here basketball diaries, you know. So, you know, just to kind of show here, you know, a lot of our knowledge is actually shaped by not just our personal experience, but also, you know, the culture and the sources of media and now social media that we're exposed to, right? So this is just kind of some examples, you know, the music, the movies, sometimes memoirs, news coverage, you know, personal stories that people share in different venues. So understanding that, you know, in some senses for most of us or many of us, our understanding of these topics really can be kind of dependent on what you were exposed to and what your personal experience has been, you know, before you get into the workplace. So because I kind of came out of that media experience, one of the things I focused on, you know, in grad school was looking at, you know, research, examining media stereotypes about people using drugs. So this just summarizes kind of some consistent themes. And, you know, one is that, you know, news coverage specifically of people who use drugs has found more negative portrayals than in entertainment media. So probably not a surprise to many of you that, you know, the news coverage can kind of emphasize kind of some negative stuff, the, you know, violence, you know, cartels, that kind of thing. And then entertainment media, you know, not a surprise that there are differences based on the substance used. So kind of more negative coverage of certain substances, whether that's crack or, you know, heroin kind of back in the day. Clearly differences based on race, ethnicity, and class of the individual. Importantly, television and photos are more likely to reinforce negative or inaccurate stereotypes about people who use and sell drugs. So what that means is that the text or, you know, what's being spoken if you're watching a TV segment may not be quite as negative or stigmatizing as the imagery that's being shown to illustrate that story. And by perpetuating stigma, news coverage can contribute to social isolation of people who use drugs, you know, tendency for family members to distance themselves, you know, society accepting more punitive or punishing policies and a reduced likelihood that people would seek treatment. Any questions or comments, feel free to raise your hand or add things to the chat. Definitely monitoring that here. My next question is kind of, again, thinking broadly, what are some of the reasons people use alcohol and other drugs? You know, this is kind of just great mental health, personal issues, grief, trauma, coping, just reading what's here, stress, numbing, self-medicating, good to see to escape. There's positive reasons to recreation, boredom, important one, social events, great fun. So seeing great people are capturing kind of a range, you know, might be loss of a family member because they've become addicted, injuries, right? So I put this slide together kind of based on, you know, different things that have come up in workshops as well as, you know, research, but, you know, you can see that these are, there's a lot of different reasons people use drugs and, you know, important to note that people might use different drugs for different reasons, right? So, you know, someone who might use cannabis, that might be something they pick up or turn to for one reason, different than methamphetamine or crack, you know, so, and it can change over time. So, you know, someone might start using substances because of socializing or to fit in peer pressure, but then it becomes avoiding withdrawal or perhaps there's, you know, loneliness or triggers or grief. So, you know, again, recognizing that drugs can have both positive and negative effects. And when we think about the reasons people use drugs, if you, someone is trying to reduce or quit using drugs, you know, how are they going to deal with these reasons in these situations? You know, if they are stopping or reducing their substance use, you know, what are they putting in place to sometimes deal with these situations or navigate these situations? So just important kind of in a context to talk about, you know, recognize that there's a lot of reasons here and they can kind of be combined in different ways. I like to use a lot of imagery and, you know, I think this is, there's many different ways of illustrating types of substance use. You know, here you see it presented as kind of a continuum and described as a continuum. There's other graphics I've found that, you know, it's more of a circle, you know, that people can kind of move back and forth and, you know, importantly might be in different places for different substances or at different points in their life. But, you know, broadly the range can be from, you know, you see no use on the left here, experimental use, social or occasional use, medication used as required, so maybe someone has been prescribed, you know, prescription painkillers. Then harmful use, you know, someone is starting to experience negative consequences of medications or substance use. And then dependence or what we might know as addiction, you know, we'll talk specifically about the criteria for a substance use disorder. But, you know, you see that these kind of can change over time and, you know, people might move back and forth between harmful use and then deciding, you know, I'm going to dial back and only drink on the weekends, for example, or recognize that maybe they're using cannabis every day and, you know, want to cut back on that. Any questions? So I'm going to show different things, you know, over both sessions from this survey, you know, many of you might be familiar with. It's called the National Survey on Drug Use and Health. It's been offered for every, you know, annually for quite a long time. This graphic comes from the 2022 results. So, you know, still affected a bit by the pandemic, both the data collection and, you know, the responses people gave. But, you know, looking at past year illicit drug use, now that does include, you'll see on the right, marijuana or cannabis, that, you know, for people age 12 or older, just about 25% responded to that survey saying, yes, I've used some type of substance, you know, among these in the past year. So if you look at the right side, you can see with that bar graph that marijuana by far is the most common substance in that category of use. So again, this isn't including alcohol. So these are, you know, what are termed in the survey illicit drugs. So then you have hallucinogens, you know, misusing prescription pain relievers, cocaine, tranquilizers or sedatives, stimulant misuse, methamphetamine, inhalants, and then heroin. So, you know, these aren't mutually exclusive categories. So someone may have responded positively that yes, they've used marijuana and they've also used cocaine. But, you know, so that's about one in four people age 12 and older have used one of these substances in the past year. So kind of thinking about when something starts to be considered a substance use disorder, you know, this is the definition from SAMHSA and, you know, they describe it as substance use disorders occur when the recurrent use of alcohol and or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school or home. So there are actually about 11 criteria that are used to diagnose a substance use disorder. And I've got them arranged here, you know, typically they're kind of four broad categories that they fit under. The first one is loss of control. So someone might be using a larger amount of a substance or using it more frequently than intended. They might be trying to stop or cut back and not being able to control their substance use. They're spending a lot of time obtaining or using a substance or recovering from its effects. And they may be experiencing a strong desire or what we talk about as a craving to use a substance. The second category is interpersonal consequences. So that's kind of when your substance use is starting to affect, you know, your life and your relationships with the people around you. So that's failing to fulfill major obligations at work, school or home due to substance use, continuing to use it despite it causing these interpersonal problems, and then perhaps skipping social recreational work activities because of substance use. So those are the first two categories. The next two kind of move into this idea of risky use, you know, so using in physically unsafe situations. That might be, you know, you're using drugs or alcohol and driving, you know, continuing to use despite physical and psychological problems. And then physical dependence is that idea of developing tolerance. So needing more of the substance to achieve the desired effect or experiencing withdrawal symptoms after quitting or reducing use. So that can happen with some substance. You know, the criteria kind of notes that tolerance and withdrawal in the context of appropriate medical treatment don't count as a criteria for a substance use disorder. So if someone is taking opioids to manage pain with cancer, they wouldn't be considered having a substance use disorder. And at the bottom here, you see, you know, sometimes this gets overlooked, but, you know, substance use disorders are actually classified as mild. So if you meet two or three of these criteria, moderate four or five or a severe six or more, you know, so you can see that there's going to be quite a range of, you know, differences between someone who maybe meets two criteria and someone who's up at seven or eight in terms of how this is impacting their life. Any questions? Feel free to add comments or questions to the chat too. I'm monitoring that. My next question is, you know, and again, you can respond in the chat here. What percentage of the U.S. population 12 or older would you estimate had a substance use disorder in 2022? So the first option is 10 percent. The second is 15 percent. The third is 17 and the fourth is 20. Great. So seeing a range of responses, pretty much mostly at the higher end here. Great. So the answer for 2022 is a little over 17 percent. And again, this is people age 12 or older. And important to note that these are not people who've been diagnosed by a clinician. They're people who have answered, you know, the survey. So, you know, kind of looking at those questions. But, you know, that number is higher in that year than it had been previously. And, you know, you can see it does include alcohol. So unlike the previous data I showed that this does include alcohol. So by, you know, certainly people with alcohol use disorder, almost 30 million outnumber, you know, drug use disorder, which is 27 million. And then if you look at specific substances, marijuana use disorder at 19 million is much higher than, you know, people who have a prescription pain reliever, pain reliever use disorder, a little over 5 million, a stimulant use disorder, just close to 2 million. The same with methamphetamine and then cocaine lower at about 1.4 million and heroin just under a million. So similar to the other data presentation, you know, people might fit into more than one of these categories. But, you know, broadly you can see that the number with a substance use disorder, which includes alcohol is kind of higher there. That survey also shows sort of severity levels. So, you know, among people who had a substance use disorder, for about one in five, that was considered a severe substance use disorder. One in five had a moderate substance use disorder. And then more than half, it was a mild substance use disorder. So, you know, you can see that represented graphically, you know, according to the criteria that we just talked about. So, you know, of that 17.3%, about half of those people, it was a mild substance use disorder. So, you know, when we start to talk about treatment or other services, you can kind of see that people probably would benefit from or might be interested in different ranges of services based on whether or not, you know, we're talking about a severe substance use disorder or one that's more mild. Any questions? This is another way of kind of looking at that. That comes from the same survey, but looks at specific substances. So, you know, for alcohol and marijuana specifically, most substance use disorders are considered mild. So you see that represented here, alcohol is the left bar and, you know, the red represents a severe substance use disorder, the lighter blue, moderate, and then the lower part, mild. So that's alcohol and marijuana on the left. But then on the right, when you start looking at cocaine or methamphetamine, there about close to half of people would qualify as having a more severe substance use disorder with those substances, kind of that data pulled out specifically. Any questions? So, you know, another way to represent this too is kind of looking at this, you know, as kind of some circles here that, you know, if you have people who use drugs or at least have used them in the last year, you know, as that outer circle, about a quarter of the population, then moving into risky use, and then in the very center kind of substance use disorders, you know, you can, if you think about who might benefit from harm reduction education and services, you know, arguably that's everybody in any of these circles, you know, particularly with what we're going to talk about with the risks and the drug supply, whereas who might benefit from treatment, you know, may be more likely to be the people in this very center there, you know, doesn't mean that other people might not benefit from some services, particularly if they're, you know, using substances in a risky way, but, you know, broadly, treatment ends up focusing kind of more on that inner circle and then specifically, you know, often people with those moderate or severe substance use disorders. The next session, I'm going to show some more data specifically looking at, you know, people experiencing housing insecurity or homelessness, but just wanted to kind of establish a little context here that, you know, finding accurate numbers on the prevalence of substance use disorders and mental illness among people experiencing homelessness is difficult, starting to be a little more data kind of coming out that tries to capture that in different places, you know, but most statistics do indicate that substance use disorders and mental health challenges are more common among people experiencing homelessness than in the general population. You know, it's important to note that substance misuse can lead to homelessness, but it often arises after people lose their housing, so it's not necessarily just something that kind of goes in one direction or the other, and some people may view drug and alcohol use as necessary to be accepted among their community or difficult to resist if substances are widely available nearby, so that might be in parks or encampments or certain housing situations. So, you know, thinking about that question, why do people use drugs or alcohol, you know, what's in your environment or what's around you or sometimes to fit in or peer pressure, just socializing, you know, that can all play a role. You may have heard kind of talk some discussion of what's kind of referred to as the treatment gap with substance use disorder. So, historically, national surveys report that about 10 percent of people with substance use disorders receive treatment. It's actually a little bit higher in recent years that receive treatment, and we'll be talking about that in the next session, you know, but removing barriers to treatment by offering treatment on demand, helping navigate insurance coverage, transportation, and other hurdles can help improve access. You know, it's important to note that many people need other support beyond treatment in order to recover from a substance use disorder, the same way if you have, you know, surgery for an illness or an injury, you know, you might end up in some kind of rehabilitation program or get physical therapy afterwards. So, you know, that aftercare, those wraparound services are really critical. Some people with drug and alcohol problems achieve long-term stable recovery without formal treatment. You know, sometimes that's referred to as natural recovery, you know, or, you know, other phrases for that. But, you know, not everybody who ends up reducing or quitting using substance necessarily engages with formal treatment services. And it's important to offer services, even if people aren't ready for or interested in treatment, you know, specifically for substance use. So we'll be talking more about that. This slide shows, again, from that same survey, you know, perceptions of need for substance use treatment among adults age, now this is a different age range, 18 or older, with a past substance use disorder who didn't receive treatment for that. And there's a lot on here, but the part in the red is really kind of what I'm trying to highlight here is among those people who, you know, at least according to the survey are perceived to, you know, potentially benefit from treatment, but didn't get it. 95% felt they didn't need treatment. Now, if you're thinking about mild substance use disorders, you know, maybe depending on how they interpret that word treatment, maybe they wouldn't benefit from treatment or don't need the treatment. But, you know, that feeling of I don't need treatment is also, you know, whether you've heard it referred to as denial or just something you've experienced in your own lives with the people you work with or care about, you know, that's not going to be an unfamiliar barrier to helping people kind of access services. Any questions? Great. So my next question for all of you is, what are some reasons to offer services to people who don't want or feel they need treatment for a substance use disorder? You know, why would we offer them services, whether that's health or other services? Great. Seeing, give them information so they have it, education, you know, a lot of times people may not know what's available. Someone's asking, these are references to substance use treatment specifically. Now, these are just broadly services. If someone said to you, you were talking to them about, you know, availability of different types of maybe inpatient or outpatient programs, they said they weren't interested, you know, why would we still kind of engage with them and offer them a range of services? Right. To prevent homelessness, you know, so they're informed, plant a seed, maybe they can think about it and decide. Great. Plant a seed to provide stability, necessity, harm reduction. We'll be moving into kind of talking about that. Assisting with, you know, other life skills or activities of daily living, you know, helps them to know that there are options and the availability of care can inspire hope or change. Great. Education and prevention. You know, treatment can be considered broadly. We'll be talking about that. So, you know, maybe treatment for another condition, improving health outcomes, starting the change process. Great. Promoting wellness or order or structure. To let them know there are people who care, really important, or decrease stigma against seeking services. You know, most of us resist change of certain types in our lives. So, you know, this is a process. Letting them know they're not alone might be improving their lifestyle. Great. Lots of responses here. Reducing loneliness. Yeah, letting them know that people, that there are people who care about their well-being. Great. So, these are kind of, you know, we'll be kind of delving into this kind of more specifically, but goals of care for people with substance use disorders, you know, this is adapted from some health department materials, but can be thought of as kind of falling into these three categories. You know, the first is sort of substance related. So, you know, might be about reducing, changing or stopping substance use. We'll be talking more about reducing harms associated with substance use, providing evidence-based treatment options. In the middle, kind of their overall health. So, you know, preventing overdose deaths and deaths from other causes, you know, preventing and treating HIV, hepatitis C and other health conditions, addressing mental health challenges. And then on the right, you have kind of just functioning. So, you know, helping someone meet their own goals, whatever those might be, you know, improving social support. So, those connections that people have been talking about, writing about in the chat, and then connecting to other services. So, those could be legal, housing, employment, or, you know, what that person might need for their situation. And, you know, may be more important for them to address before they tackle anything related to substance use. So, as we move into kind of talking more specifically about harm reduction, you know, just to get a sense of who's here today, how familiar are you with the concept of harm reduction as an approach to substance use? So, number one is very familiar. I could explain what it means. Two is somewhat familiar, heard of it, not sure you're comfortable describing it. And then three is not too familiar. See some responses coming in. So, there's a couple hundred people here. So, I should be able to get seeing a lot of ones, some twos. I see a two and a star, maybe that's two and a half. Great. So, most people kind of in the one to two category. So, that means for my next question, I should be able to see a lot of responses, because a lot of you just said you could explain what it means. So, how would you describe harm reduction to someone who asked what it means? So, say you're in a social situation, or you're mentioning it, or, you know, there's a participant or a colleague who said, well, what does that really mean? How would you describe harm reduction? You know, it doesn't have to be a formal definition, but, you know, how would you describe it to someone who asked you? Great. So, someone writes using lesser, safer methods, using the substance in a safer way. And I appreciate that you're saying safer, not safe. You know, really important to acknowledge that things that have risks, you know, can't guarantee complete safety. You know, potentially helping people decrease their use, reducing the harms associated with drug use, using a space with support, we'll be talking about that, a way to minimize the risks associated with use. Great. Meeting clients where they are, so not necessarily an abstinence model, reduction over abstinence, providing tools and information to make positive change. Great. Yeah, not being non-judgmental, one of the principles, we'll talk about that. Great. Yeah, so, you know, comment here, you know, informing an individual on ways to be safer with addiction. So, it wouldn't necessarily just be addiction, you know, thinking about those concentric circles, especially with things like fentanyl in the drug supply. You might be someone who uses drugs occasionally and not meet the criteria for a substance use disorder and still benefit from harm reduction. Great. Lots of people capturing here, you know, yeah, and reducing the consequences of ailments or diseases and using in a safer way. Yeah, so, a lot of this is kind of capturing some of the things and, you know, specifically naloxone here. These are a couple of different ways of defining it, you know, and within the realm of kind of public health and research and even advocacy, you know, most of these groups would say, you know, there's not just one way to define harm reduction. At the same time, it's good to have kind of a consensus about what it means in terms of, you know, funding and that research I mentioned and kind of understanding what that refers to. So, you know, this top definition comes from the National Harm Reduction Coalition, and they define it in two ways. And the first one is kind of with a lowercase harm reduction as a set of practical strategies and ideas aimed at reducing the negative consequences associated with drug use, you know. So, that's, you know, these practical strategies that we'll be talking about. When they put harm reduction in capital letters, they refer to it as also movement for social justice built on a belief in and respect for the rights of people who use drugs. So, those are kind of different things that they acknowledge, you know. One is the practical strategies. The second one is kind of more this movement. Below that is a definition from SAMHSA, which defines harm reduction as an approach that emphasizes engaging directly with people who use drugs to prevent overdose and infectious disease transmission, improve the physical, mental, and social well-being of those served, and offer low threshold options for accessing substance use disorder treatment and other health services. So, you can see kind of comparing those that they're, you know, the second one is more specific about, you know, what strategies they're talking about or prioritizing and, you know, maybe potentially a broader set of goals than the first one. But, you know, broadly a lot of what, you know, you've posted in the chat is, captures this idea of reducing the negative consequences of substance or drug use. And then the principles, like these come from the National Harm Reduction Coalition as well. Some of them have been mentioned in the chat, you know, that they say, you know, it's an approach. It's not a single intervention, but that harm reduction overall emphasizes respectful, non-judgmental interactions. It empowers people to reduce harmful behavior. So, important that, you know, not just telling people what to do, but kind of giving them the support to, you know, make these choices. Supports participants goals, but while recognizing they may change over time. Recognizes that abstinence from all substance use may or may not be a goal. Prioritizes holistic person-centered care. So, you know, on that last or a recent slide I showed, you know, range of goals of care for people who use drugs in general. Any questions or comments? So, if we step kind of more broadly back, you know, you can see that we all practice harm reduction in some fashion, you know, helmets, sunscreen, seatbelt, condoms. There are many ways to reduce the potential harms of things we do that involve risks. You know, so sometimes kind of talking about this more broadly and kind of connecting it to things that people recognize and, you know, do in their own lives can help people kind of understand what harm reduction means. And then kind of moving into specifically harm reduction related to substance use, you know, what are some examples of harm reduction related to substance use you've heard about or used? You know, some of those have been mentioned earlier in the chat, right? Syringe exchanges, Narcan or Naloxone, great. Medications such as Suboxone, safe injection sites, not using alone, great. Testing kits, fentanyl test strips, great. Medications, support groups, not using in isolation, nicotine patches, great. You know, even thinking about alcohol, you know, what are some harm reduction approaches to alcohol that you have probably done in your own life? Any thoughts on that? Great moderation for alcohol, not drinking and driving. So, designating a driver, you know, if you're going out with friends and, you know, you agree who's going to handle the keys and drive, keeping hydrated while drinking, you know. So, we've all been living with harm reduction in various forms, you know, specifically thinking about, you know, alcohol, which is much more commonly used or even smoking and nicotine. So, you know, this is part of, you know, most of our lives and, you know, moving specifically into illicit substances is, you know, where people maybe it's either new or unfamiliar. We'll talk about some hesitations people have. Yeah, having someone watch your drink in a bar, you know, so not just walking away and using the bathroom and leaving your drink, you know, that's something certainly younger generations are paying attention to more. Great. Yeah, Uber, rideshare services or having a friend drive you home. Great. So, you know, these are examples specifically related to drug use that, you know, we'll talk more in more detail about today, you know, obviously carrying naloxone, the nasal spray known as Narcan, as well as other formulations to reverse an overdose and knowing how to use it, using new syringes and supplies, testing drugs with fentanyl or xylosine test strips, you know, in New York City, you can also take substances to some harm reduction locations and kind of do, you know, more advanced testing and using with someone or calling a hotline. You know, I have here the website and phone number for the Never Use Alone hotline. How many of you have heard of that? Or talked about that with residents? Is that something you've heard about or encountered Never Use Alone as a hotline? Okay, some yes, some no. Great. So, you know, basically, this is a hotline that anybody can call, you know, for different reasons, some people, you know, don't feel comfortable or using with other people. And, you know, for them, this option of being able to call a hotline, you know, it's a national hotline, you know, staffed by volunteers. So, you know, that person will ask your location, you know, in case you become unresponsive. So and, you know, then they would call emergency services, you know, and you don't have to give your name, but they stay on the line with that person to make sure they don't become unresponsive. You know, there's starting to be some apps that people can get on their phone and other services. This is probably one of the better known services. But a good thing, you know, and if you go to their website, they have different flyers and, you know, graphics and things to distribute within your communities to let people know that this exists. You know, specifically talking about fentanyl test strips, they're also xylosine test strips, but you know, we've all just been through COVID. And, you know, many of us are familiar with other types of tests. But, you know, just to illustrate, this comes from the CDC, how fentanyl test strips work. So, you know, someone would put a small amount of the drugs to be tested in a clean or dry container, add a little water to the container and mix it together, place the wavy end of the test strip. So in this graphic, you see that's the end on the right into the water and let it absorb for about 15 seconds, taking it out and putting it on a flat surface for two to five minutes and then reading the results. So, you know, here you see one red line is positive for fentanyl, two red lines negative for fentanyl. And they point out here, use caution. You know, it doesn't mean, you know, with fentanyl, and I'm going to show a graphic kind of illustrating how it can be distributed unevenly, particularly if you're kind of testing and crushing up a piece of a pill. So, you know, two red lines doesn't necessarily mean it's not in some other part of the substance, but, you know, it will at least tell you one red line positive for fentanyl. And, you know, someone can make the decision to not use alone, maybe not use at all, maybe use less, maybe use a different mode of administration. But, you know, encouraging people to become familiar with this. Great. Someone posted they've been shown this by a client. So, you know, these are pretty widely available in New York City, certainly. And, you know, I'll talk about, you know, different sources for obtaining these kinds of supplies. You know, kind of also it's important to acknowledge that people have hesitations and concerns about harm reduction. You know, for some people, this is kind of a new concept, or at least some of the strategies associated with harm reduction, you know, perhaps is that kind of more political movement are, you know, things that people don't necessarily fully understand or may have hesitations about. So, you know, what are some hesitations or concerns you've heard? Yeah, so some people believe it promotes drug use, that it perpetuates that or encourages others to use drugs. You know, that term enabling is, you know, something many of you may have heard. Great. Embarrassment, that it's not suitable for the community, that it makes it too easy, that it, you know, not in my backyard. So maybe it's more an objection to having these services in their own community. Yeah, so, you know, these are definitely, you know, can be some polarizing, you know, perceptions about it. And, you know, just to put some out on a slide here, you know, these are concerns that are kind of frequently cited about harm reduction. The first one, you know, encourages or enables risky drug use is a perception that, you know, you'll see in some of that news coverage or social media or comments, or just in the environments maybe you live and work in. You know, there can be a perception that it makes neighborhoods less safe or a concern that by attracting people, buying and selling drugs, people may feel that it spends taxpayer money on people who made bad choices, right? So, you know, we're always comparing expenditures and, you know, particularly in times of budget constraints, you know, so people may not feel that it enables people, but, you know, have that moral or, you know, stigmatizing feeling about the population that these services help. You know, we'll talk more about medications for opioid use disorder, like methadone and suboxone next week, or yeah, next week, but people sometimes feel those just substitute one addiction for another, you know, so misunderstanding that, you know, the benefits that these medications provide. There can be a perception that, you know, harm reduction opposes abstinence or recovery, which, you know, broadly is not the case that, you know, it's just recognizing that the abstinence might not be the goal, and certainly abstinence from all substances for everyone forever, you know, at that moment. You know, only reduces some harms related to substance use disorders, you know, as a public health approach, it is important to kind of recognize that there are certain things that are prioritized, you know, reducing the spread of HIV or hepatitis C, reducing overdose deaths, but, you know, if you broaden out and think about all the harms, particularly of people with kind of more moderate or severe substance use disorders, you know, people might feel, well, you know, clean needles or syringes, you know, that's not addressing the harm to families or communities, that might be something that they're concerned about. And then finally, you know, kind of more recently hearing some, you know, concern that harm reduction can meet people where they're at and then leave them there, you know, and in this next slide, kind of, you know, thinking about harm reduction is not just meeting people where they are, it also means helping them make changes and move toward where they want to be, you know, so usually, you know, particularly with people with severe substance use disorders, you know, I do a lot of work with a local harm reduction organization here in Brooklyn, and people tend to know, you know, or be able to express, you know, what they're dissatisfied with or wish they could change in their lives. So, you know, offering that help, it might not be quitting using, you know, opioids or stimulants in that moment, but, you know, recognizing that they do have goals, and maybe their first priority is getting stable housing. But, you know, harm reduction isn't about encouraging or endorsing drug use, and it's not against abstinence, and it's not helping a person who has quit using drugs start using again, you know, so, you know, just trying to put some context to this discussion, which is certainly, you know, out there, and that if you think about, you know, a continuum of care, that, you know, harm reduction is one part of that continuum that also includes, you know, treatment and recovery support, and, you know, in some communities too, you know, the importance of preventing addiction, or for younger people, preventing initiation of substance use. So, I think this is a good time to take a break. Just, it's 10 50 right now, so, you know, we'll set a little clock here, but if I'm going to pause my video and audio, and we'll reconvene and finish the second session starting at 11. And I, you know, the chat will be left open, so if you have any questions or comments, you know, feel free to add them, but I will see you at 11. All right. Hopefully, everybody is back. And we'll get started here, you know, shifting a little bit to talking about trends in drug use and the drug supply. So, this slide presents kind of just some basic bullet points about that, that will be familiar to kind of themes that some of you have certainly heard in New York City, or just from the work that you've done, but basically, you know, polysubstance use is very common, you know, people tend to use multiple substances, often mixing prescription medications, alcohol, and other drugs, you know, so some people might say that, you know, polysubstance use has always been more the norm than the exception, but certainly now, you know, a range of research and surveys and ways of testing kind of demonstrate that this is kind of much more the norm than someone just using one substance. At the same time, the potency of many drugs has risen, you know, so including for cannabis and methamphetamine. So, you know, there's different ways of kind of representing that but, you know, really shifting in that in terms of the potency here. Plant-based drugs like heroin are being replaced by synthetic drugs made of chemicals that are easier to ship and have higher profit margins for sellers, you know. So even with something like methamphetamine, you know, which used to be made more, you know, with ingredients from the ephedra plant, now, you know, is more likely to be entirely synthetic. So that's really been a big shift in the drug supply, you know. And partly because of these changes, the drug supply is arguably more lethal now, especially due to fentanyl, a powerful opioid that may be mixed in with other substances, including stimulants like cocaine, you know. We'll also be talking about xylosine, sometimes referred to as tranq, an animal tranquilizer that's being combined with other drugs. Sometimes this doesn't get talked about as much but, you know, drugs are more widely accessible, you know, with technology and the internet and cell phones making purchases and delivery easier, you know. At the same time, there are many more prescription medications in people's homes. So, you know, you have this combination of both the illicit drug supply and then prescription drugs that are certainly more ubiquitous than, you know, kind of looking 10 or 20 or 30 years ago. This comes from a New York City Health Department flyer, you know, you may have seen specifically kind of trying to educate people about fentanyl and, you know, that the fact that it's showing up in heroin, cocaine, and pills, you know, sometimes marked as Xanax or other types of medications, you know. Fentanyl is the most powerful opioid routinely used in human medicine. You know, it's about 50 to 100 times the pain-killing power of morphine and it is often used to treat post-surgical and cancer pain. So, you know, it does have medical purposes. It's a short-acting opioid with a rapid onset, you know, so people feel the effects more quickly but they don't last as long, you know. And for at least the past 10 years, illegally manufactured fentanyl has been increasing and often found in heroin, you know, in New York City and many other places. It's pretty much replaced heroin but it can also be in other types of pills. Importantly, you know, naloxone can reverse a fentanyl-related overdose since it is an opioid, you know. Some, in some situations, might need more than one, you know, application of naloxone but it is something that, you know, can address an opioid overdose. Any questions? I see a couple comments of, you know, losing clients or people, people know, you know, to fentanyl which is an experience, unfortunately, that's pretty common to many of us, you know, doing this work if not our personal lives. And I had mentioned that I wanted to show this, you know, in terms of both testing substances but really understanding, you know, some people ask, well why, why would people, you know, who sell substances be mixing this in or, you know, kind of why is it so haphazard? So if you see kind of, you know, this tablet, you know, in the green here and then the substance is considering that to be something fentanyl and then when it's kind of blended, you can see at the bottom that, you know, there might be more of those red dots in one pill and fewer of them or potentially none in other pills that are sold as part of the same thing. So, you know, when you see that this is, you know, it's, it's not put together in the same way that the medications you pick up at the pharmacy, you know, are. So that's why, you know, you might hear of someone who has died from a fentanyl overdose, you know, or those campaigns, you know, one pill can kill because, you know, of what you see on the right here of these little tablets at the bottom. So, you know, counterfeit pills sold as prescription medications like oxycodone, Percocet, or Vicodin can contain other substances in unpredictable amounts depending on how drugs are cut. Someone's mentioning here in the chat that the series painkiller really opened my eyes to how dangerous fentanyl is, you know, and part of that, again, is this unpredictability. Yeah, someone's asking, do the ads over on the subway and on TV help? There is research that's, you know, tries to look at that of, you know, the effectiveness of different publication campaigns, but I don't know how to answer specifically for that campaign. I think there has been research in the past that things like the DARE program weren't so effective if you were old enough like me to have been, you know, exposed to that, but I do think the public education is really important, again, because of this idea that, you know, someone might be someone who uses substances occasionally or, you know, and versus someone who uses them more regularly and not really have as much awareness about what's in the drug supply or what the risks are. Yes, someone mentions the show Nurse Jaxi, and it is true that a lot of us learn about, you know, whether it is those sources like music or television shows or films or books or, you know, what we see on social media. So, you know, another substance that's really appearing more really prevalent in this drug supply in Philadelphia, you know, is definitely present in New York City as well, is what I mentioned Xylose, you know, sometimes that's called Trank or Trank Dope. It's a sedative used in veterinary medicine that's increasingly been showing up in the drug supply. Why it's being used is that it's used with opioids like fentanyl to extend the effects of the opioid. So I mentioned that fentanyl is a short-acting opioid, so meaning someone would need to use again pretty quickly to have that effect or to avoid withdrawal. So xylosine extends that effect. It isn't an opioid itself, but it can cause drowsiness and lower breathing, blood pressure, and heart rate, so it can contribute to an overdose. It also can cause blood clots and circulation problems leading to painful skin lesions, tissue damage, and possibly loss of limbs. So, you know, you might have seen either in the work that you do or news coverage some examples of that. You know, so really important to treat skin wounds early to help prevent bacterial infections. You know, small bumps with a white or purple center and dark red fluid indicate a need for wound or medical care. So that's starting to become more common, you know, part of some harm reduction organizations or outreach programs or street medicine teams, you know, to addressing this kind of basic wound care and teaching people how to take care of and seek help for these types of wounds. Yeah, someone mentions they've heard of this drug Trank. So, you know, having mentioned or seen in the chat here, you know, people who have had residents or clients, you know, who've died, you know, this is a report that the city puts out every year. This is kind of the most recent results. So it goes from July 2021 through June 2022. You know, there were 684 deaths among people experiencing homelessness in New York City. You know, close to 80% of those deaths were among males, and more than half were people age 45 to 64. A quarter were non sheltered individuals and about 75% were sheltered in some fashion. And, you know, one of the main reasons I'm including this here is, you know, the among the top five leading causes of death, you know, the number one was drug related. So 77%, you know, after that heart disease at about 9%, accidents, not including drug overdose 8%. And then alcohol misuse or dependence about 3%. So if you combine alcohol and drug related reasons, you know, that's about 80% of contributing causes to those deaths among people experiencing homelessness. So you know, that's part of why there's such a focus on this and kind of more education and training about this topic. Any questions or comments? So moving into kind of talking about overdoses, you know, during 2022, which is the most recent data, you know, someone died of a drug overdose in New York City about every three hours. You know, that's why there is so much emphasis on, you know, educating people about overdose risks and how to respond to an overdose and trying to prevent those deaths. So, you know, an overdose broadly happens when a toxic amount of a drug or combination of drugs overwhelms the body. And there are actually two types of overdoses, you know, you hear more about opioid overdoses, which is when a large amount of opioids sometimes with other drugs cause breathing to slow or stop. So opioids fit into receptors that also affect the drive to breathe, you know, so oxygen levels in the blood decrease, eventually stopping other organs like the heart and brain, it can lead to unconsciousness, coma, or even death. Stimulant overdoses, which are sometimes referred to as over amping, you know, that's when drugs like speed, cocaine and ecstasy raise the heart rate, blood pressure and body temperature and speed up breathing, you know, that can lead to a seizure, stroke, heart attack or death. And, you know, increasingly finding that, you know, people who, you know, if you look at overdoses and kind of what was in people's bodies when they died, it's a combination of opioids and stimulants often or increasingly. There's a question here. Yeah, what are the statistics for nonfatal overdoses in New York City? And, you know, the answer, I haven't seen that data specifically for New York City, you know, tends the federal government is making more of an effort to collect that on a national level. Among states, Maine is one of the states that, you know, publishes that data every month, both fatal and nonfatal overdoses. So, you know, from what I've seen, it's fair to say, you know, if you look at, think about an iceberg that fatal overdoses are sort of the tip of the iceberg, and that some estimates, you know, think that nonfatal overdoses may outnumber fatal overdoses by 10 or more, you know, so for every 10 overdoses, are there 100 nonfatal, you know, or potentially higher? Have fatal overdoses reduced with the increase of Narcan? So on a federal level, the most recent statistics that were released, overdose deaths had gone down a little bit. It's hard to look at cause and effect in terms of, you know, providing more naloxone, because when you have these trends happening at the same time, increasing, you know, fentanyl, even other substances, there's another class of opioids called nitazines, sometimes pronounced nitazines that are even more potent than fentanyl. So, you know, it's hard to say what impact that has had, you know, certainly providing more naloxone prevents some overdose deaths, but kind of having a specific number is challenging to gather that, you know, because sometimes those overdose reversals aren't actually reported by people. Fentanyl, when is it safe to be prescribed? So, you know, if anybody has had a relative or friend or loved one, you know, receiving cancer treatment, you know, you might have, they've probably, not probably, but may have been prescribed fentanyl. Often that's a patch, you know, in palliative care. So, you know, that's, that's the primary medical use is for kind of those, you know, late stage cancer, the pain associated with that. But there are other situations where someone might be prescribed fentanyl. You know, someone's asking what do they do to avoid dependency? Again, since it's part of sort of end stage cancer care, it's really palliative at that point. So trying to make someone comfortable at the end of life. So at that point, you wouldn't be concerned as much about dependency as making sure that they're not an excruciating pain, you know, for something like one cancer has really spread. Yeah. And it can be applied in different ways, you know, not just through the patches. Thinking about, you know, some of you, and I'll ask this question shortly, but, you know, may have had training in kind of overdose prevention, but thinking of what are some risk factors for an overdose? So what are some things that might make an overdose more likely for someone? You know, things that put them at risk or increase their risk. Yeah. So relapse, someone who returns to using after, you know, maybe having stopped or reduced their use for a while. Some of the things that people are mentioning aren't necessarily, I mean, they can be part of the context of using, you know, things like grief or depression, but, you know, specifically, these are kind of physical things that might increase. So mixing drugs, those kinds of things may increase your risk of an overdose. I'm not sure that there's been kind of research about, you know, in the environment or people you're around specifically related to overdose, but certainly kind of prevalence of overdose. But I'm not sure that there's been kind of but certainly kind of prevalence of drugs in the community or a living situation. Yeah. Thinking you can use as much as you did when you stopped. Great. So, you know, again, these kind of focus a little bit more on physical things than some of the things that have come up in the chat here, you know, that particularly things can be measured and comparing different populations or people over time that, you know, what are the things that, you know, we can intervene on that increase the risk for an overdose. So mixing drugs, right? So many overdoses occur when people mix heroin or prescription opioids with alcohol and or benzodiazepines like Klonopin, Valium, or Xanax, right? This could mention fentanyl as well. So mixing drugs is really a big risk factor for an overdose because, you know, even alcohol is what's known as a central nervous system depression, it lowers your breathing rate, that kind of thing. So when you have a lot of these substances that are all having that same effect, that increases your risk for an overdose. People have mentioned, you know, change in tolerance. So your body's ability to process a certain amount of a drug can decrease rapidly after a break from using. So for example, if you were in treatment, if you were incarcerated, or if you had just stopped using for a while. So sometimes when people if they start using again, you know, don't realize how much their ability to tolerate a certain amount of drug has changed, that can increase overdose risk. The strength and content of drugs. So street dogs often contain other drugs or materials that can be dangerous, including fentanyl. So, you know, that increases the risk, you know, compared to, you know, maybe 20 years ago, when you were talking about, you know, plant based heroin that was didn't have these other more powerful opioids mixed in. Using alone, so that can increase the chance of fatally overdosing because there's no one there to help administer naloxone or call 911. So that's why, you know, something like the never use alone hotline can be really important to kind of reducing that risk. And a previous non fatal overdose. So people have overdosed before are at risk for another overdose. And then mode of administration. So IV injection and smoking deliver the drug more quickly to the brain increasing overdose risk. So those are just kind of some examples are, which are linked to kind of increasing risk factors. There's a question here, are amphetamine withdrawals linked to mixing drug, might have to rephrase that. So I can, I'm not quite sure which part of that is the question. But if you rewrite that, I can try to answer it. So, you know, just to reiterate what these strategies are to reduce overdose risks, you know, using one drug at a time or less of each drug, you know, avoiding mixing alcohol with heroin or pills, you know, this is one that maybe people aren't as aware of, like what risks alcohol kind of added to the mess mix can present. If using after a period of abstinence using less and going slow, you know, doing a tester shot or using fentanyl test strips, using a different method. So maybe snorting instead of injecting, using with someone else and taking turns, making an overdose safety plan and carrying naloxone. And again, kind of using, taking advantage of services like the never use alone hotline, you know, can really reduce your overdose risk. So a few questions here in the chat. Why are people who have overdosed previously at higher risk for a fatal overdose? You know, some of that, I think it's been maybe under discussed that even a non-fatal overdose can have an impact on, you know, your cognitive functioning and even just physically your body. So, you know, as people have kind of overdosed multiple times, you know, it could be a factor that they're just people who are, you know, have a pattern of mixing substances more often or more potent substances, but also just that the body's ability to kind of keep handling that same amount or more drugs, you know, can change as you've had the impacts of non-fatal overdoses. Yes. Is it safe to say that some overdoses were never intended by the user? Absolutely. You know, this is, you know, definitely a reflection of kind of changing drug supply. And, you know, sometimes people never intended to use opioids at all who might experience an overdose. So these are, you know, just some signs of an overdose that might be familiar to many of you. You know, if someone is loss of consciousness or unresponsive to outside stimulus, you know, they might be awake, but unable to talk, you know, their breathing can be very shallow or slower has stopped. For lighter skin people, the skin tone turns kind of blue or purple for darker skin people. It's kind of gray or ashen. They may be making choking sounds, a gurgling noise or vomiting. Their body is very limp. You know, their fingernails can turn blue or purplish black and their pulse or heartbeat may be slow, erratic, or not there at all. So curious to hear kind of, or see how many of you have had naloxone training on how to use naloxone, sometimes referred to as Narcan. Great. So many people here have had that, you know, always good to have a review. And this will be new for some people in the group here. Or it might be, you know, something that you've trained on. It's kind of like CPR. If you do it once, you know, it doesn't necessarily all stick with you. So these are just adapted from other So these are just adapted from a city health department flyer that kind of give a pretty good graphic representation of kind of how to use naloxone. You know, important that it's a, note that it's a safe medication that can reverse the effects of an opioid overdose. It only works on opioids such as heroin, fentanyl, and prescription painkillers, but it is safe to use even if opioids aren't present. So you won't be presenting a risk to the person, you know, if you're not sure. So you first want to check for responsiveness before giving naloxone. So, you know, shouting in someone's ear, if you're not getting a response, you know, doing what's called a sternal rub, which is kind of grinding your knuckles into their breastbone, like you see in this graphic, you know, and if there is no response, then you know, it's an emergency. Important to call 911 for medical help, you know, we'll talk about why. And then to administer naloxone, if you have it, you know, I recently, you know, was in touch with someone who didn't have it, but shouted out, does anyone have naloxone, you know, and someone did nearby. And he was able to, you know, get that and revive the person, you know, so it's like many nasal sprays. This is the one that's being showed here. There's also injections, but you know, you're just peeling back the covering, placing it in their nostril, and then pressing the plunger at the bottom. So if there's no response in two minutes, you'd want to give a second dose. Yes, someone has mentioning, you know, where there's free training and we'll send you naloxone in the chat. So after that, you know, you'd want to give rescue breaths or CPR, if you know how, you know, some of the kits in New York City distributed have a face shield, but this just kind of illustrates what those rescue breaths look like, you know, tilting someone's head back and pinching their nose, giving two breaths and watching for the chest to rise, and then continuing to give one breath every five seconds. You know, when not giving naloxone a rescue baths, you really, it's really important to put someone in the recovery position. So on their side, as you see here, you know, to prevent them from choking. And then you'd want to stay with a person until medical help arrives, you know, so, you know, naloxone works for 30 to 90 minutes, this can really vary depending on someone, you know, what they've taken, you know, characteristics about them, and it can cause withdrawal symptoms until it wears off. So, you know, people have commented here, you may have seen or experienced or heard, you know, that people can respond that, you know, with discomfort or there's experiencing this withdrawal symptoms after being revived with naloxone. Using more drugs is unlikely to reduce withdrawal, but may increase risk for another overdose. So, you know, that's why the point of calling medical help, especially with these combinations of kind of more powerful drugs that someone could, you know, precipitate another overdose, or just to be able to offer help and connection to services for that person. And then, you know, New York City always asked people to report use of naloxone to the program where you received it from, or use their Stop ODNYC app, but, you know, you can go to this website to see more about kind of where to get naloxone. I'll also be showing kind of another source too. It's asking here, you know, someone will use, despite consequences, would harm reduction be the best method? Should a task focus therapy be beneficial? You know, in the second part of the training, we're going to be talking about a little bit more about that linkage to treatment. So, you know, my answer would be, you know, educating people about harm reduction and providing those services always has benefits. You know, it's not the same as treatment services or recovery support, but, you know, again, part of that continuum of care that, you know, keeping someone engaged, whether it's with a local organization, increases the chance that maybe today they're not interested in hearing about or considering treatment or other services, but maybe they will be next week or next month. So, staying kind of connected to that person and continuing to offer help keeps that door open, but it is true that, you know, connecting people to treatment, educating them about services, making treatment more widely accessible and removing some of those barriers, whether that's insurance coverage, accessibility, et cetera, are also really important. Yeah, do people who've had naloxone used remember that it was administered to them? Yeah, I would say in most cases, certainly people, you know, recognize that experience. I've interviewed and spoken with people, know people who can tell you how many times they've been revived with naloxone and, you know, and in many cases gone on to connect with treatment and recovery, you know, so keeping that person alive, you know, thinking about all the people who care about that person or who their future self might be and what they might accomplish, you know, really critical and not just defining someone by, you know, their substance use disorder or where they're at in that moment. So, you know, moving into talking about kind of some of the specific programs that offer harm reduction services, and again, you know, these programs and services are just kind of part of what you can think of as a broader harm reduction approach, like, you know, we can all be part of engaging in harm reduction, you know, educating young people about risks, that's a form of harm reduction, you know, the things that we talked about earlier, but, you know, for these specific programs, you know, you may have heard of or just want to ask, you know, if you visited a syringe service program or know of one that's near where you live or work. Have any of you visited one or at least know the location of one near you? While you're thinking about that, great, interesting to see someone considering pharmacies, those can be part of harm reduction, you know, distributing naloxone or even syringes, but thinking specifically about syringe service programs, I'll talk about them and show you a list of where they're located in New York City, but basically they're community-based organizations that provide access to sterile needles and syringes for free, you know, they collect and safely dispose of used syringes and other drug equipment. Really important to note, they provide a range of services, so not just syringes, you know, overdose education and naloxone distribution, HIV and hepatitis C testing and counseling, drug treatment counseling, support groups and drop-in counseling, so my husband and I facilitate an R.I.P. program counseling, so my husband and I facilitate an art and storytelling group in a drop-in center here, that drop-in center, you know, also offers laundry services and snacks and sometimes meals to people, connect people to addiction treatment for opioids, you know, with buprenorphine or methadone, and, you know, also referrals to physical and mental health care, drug treatment, meals and showers, so, you know, despite the name that kind of focuses on syringes, you know, kind of thinking about them more as harm reduction hubs or drop-in centers is a way to kind of really capture the range of services they provide. Great, I see some comments here. Great, so I'm going to show you this list here, and again, you'll get these slides, so these are all the syringe service programs in New York City, you know, I'd advocate for calling them maybe more harm reduction hubs or, you know, sometimes I've heard drug user health hubs, but, you know, these are kind of in all the different boroughs and some of them have been around a long time, you know, certainly many started kind of during the HIV-AIDS era, you know, of activism and really kind of trying to prevent the spread of HIV and, you know, provide services and, again, that connection and support to people, but you can see this list and the websites, and, you know, I'd encourage you to stop by or at least go to the website and check one out and kind of see the range of services they offer. Great, I'm just looking at the chat here. So, you know, something that's a little bit newer, and at least for now, New York City is unique in the U.S. of having what are now being referred to as overdose prevention centers, so, you know, these are hygienic facilities where people can use drugs. They offer education, equipment, and oversight of drug consumption, and then, importantly, intervene if someone overdoses. They also provide or connect people with health and social services, including treatment, and, you know, this number here has probably, you know, increased since then, but, you know, thinking about about 150 of them in 16 countries, and New York City was the first in the U.S. to officially open two overdose prevention centers in November 2021. You know, importantly, these were open within existing harm reduction locations, so the two are the Washington Heights Corner Project and New York Harm Reduction Educators in East Harlem, both under the umbrella of the name On Point NYC. They regularly update data about the participants they've served, so more than 5,000 people since opening, and they've intervened in more than 1,500 overdose situations, so, you know, there's a lot of different places where, you know, there's a couple links here, but they've, you know, there's different organizations and research institutes and universities are studying kind of the outcomes of these two centers and their impact, not just on the individuals and participants, but also the neighborhood, kind of looking at, you know, syringes, litter, you know, and how much that has decreased around the areas where these operate, and, yes, so someone asks, insurance status for these sites or immigration status doesn't matter. That is correct, you know, so, you know, they're asked some questions, you know, within public health, always trying to balance. It's important to collect data to understand, you know, who's participating and what some of the outcomes are, but at the same time make it so that people don't feel, you know, that they have to disclose personal information that might put them at risk. Thanks for that question. So, you know, this comes from On Point site, but really just, you know, want to illustrate, too, because some of the graphics that come out, I think they're focusing as well on kind of presenting kind of a broader range of services that they do. So, you know, this is just a few of the things that they offer, so that their drop-in centers, which are, you know, safe, no barrier spaces with free services like hot meals, hygiene facilities, syringe services, digital connectivity, you know, I've seen in the place where I volunteer, you know, people sometimes are just coming so they can check email on their phones or get their, recharge their devices, you know, peer support, you know, really aimed at fostering community health and dignity. On Point has mental health services, so, you know, individual and group therapy, social workers, psychiatric nurse practitioners, and peer-led counseling groups there, you know, they offer case management, some of that wound care I've mentioned, as well as HIV and hep C testing, buprenorphine for substance use, people with substance use disorders who are interested in that, and then kind of connection working with clinical care teams, so, you know, people might have other health needs that they want to address, as well as kind of outreach and public safety teams, so, you know, these teams kind of go out in the community, cleaning up hazardous waste, educating people on harm reduction, and, you know, people in the neighborhood can call their hotline to request this kind of syringe cleanup if they need that. Great people, someone's mentioning On Point also offers acupuncture groups, food, pain management, so, you know, this is just sort of a selection, but if you go to their website, you can kind of learn more there. So this is another site I like to mention, you know, particularly if you know people in other states or even if you just want to look up what's available in New York, and I'll pop this link into the chat here. It's an organization and service called NextGistro. So, you know, they offer a tool listing resources in all 50 states, including information about where to get naloxone, find treatment, and connect with harm reduction groups. So, you know, you can plug in Iowa or New York or Arizona or whatever state and kind of see what's available. So, you know, good resource to share with people in your network. And for people in locations where it's difficult to get naloxone, you know, they also offer a program mailing that to people and links to where people can get online training if they can't get it in person. So a good resource to know about and share with people in your community. And they're partnered with, you know, many harm reduction organizations as well. So a couple more topics here. And, you know, one is stigma, you know, which has come up in the chat. And, you know, we all have a sense of what stigma is, but it can be tough to explain. So this is one way it's been defined, you know, as a social process that can reinforce relations of power and control and lead to status loss and discrimination for the person or group that's stigmatized. So there's actually different types of stigma. So interpersonal stigma is the assumptions and attitudes of other people. So those might be friends, family, co-workers, healthcare or other service providers or even strangers on the street. So that kind of happens between people. Institutional or sometimes called structural stigma is systemless level discrimination that can result in excluding a stigmatized population from participating in services. You know, so for example, drug convictions, making someone ineligible for housing. Internalized stigma, also sometimes called self stigma is when someone adopts negative beliefs about themselves, you know, so it can cause shame, stress, and low self-esteem, making someone feel like they don't deserve help or respect. And then finally, stigma by association is a negative assumptions and stereotypes about people associated with stigmatized individuals. So that can impact family members of people with addictions or even providers who work with people who use drugs. So, you know, different ways that stigma kind of is manifest in different situations in people's lives. You know, just some examples of drug-related stigma might be, you know, believing addiction is a moral failing or due to a lack of willpower. Assuming that people who use drugs are aggressive or dangerous. Using stigmatizing language when referring to people who use drugs. Denying them access to financial aid or public housing. Expecting they'll always be high or always seeking drugs. And assuming they're not able to maintain housing or being good neighbors. And some of the consequences of drug-related stigma are increased social exclusion and isolation. You know, increased risky behaviors like using drugs alone or sharing needles rather than accessing services. You know, avoiding interactions with providers who might make judgments. You know, being reluctant to disclose substance use to health care and service providers. And even family members who feel ashamed, you know, or feel the stigma might avoid seeking help. And it can also contribute to greater public support for punitive policies. So kind of those drug war criminalization of addiction policies that have been so prevalent in recent decades. And drug-related stigma certainly overlaps with other types of discrimination. So, you know, with racism, people of color may not be offered the same treatments as white patients and face greater barriers to accessing services. You know, women face stigma for using drugs due to perceptions of violating gender role expectations. And people who are pregnant and mothers face greater stigma. You know, even older patients might be less willing to seek treatment because of feeling stigmatized for their years of substance use by staff and other patients. Homophobia and transphobia. So LGBTQ plus individuals face challenges accessing care that's sensitive to their needs. And certainly familiar to you all will be, you know, housing instability and kind of the stigma of homelessness, you know, that's so public often and associated with substance use. That's so public often and associated with the stigma of poverty. So, you know, even some people using drugs, you know, there's different stigmas with different types of drugs, you know, it's not all the same for every individual depending on, you know, some of these overlapping situations or identities. So my next question is, you know, what strategies have you used to help residents feel they're treated respectfully to kind of overcome or decrease these feelings of stigma? Empathy, someone writes in the chat here. And if you're comfortable speaking, feel free to raise your hand. Yeah, providing a safe space to, you know, engage in conversations. Not judging. Showing respect and providing resources. Great. Yeah, being careful about the language that you use. Active listening. Yeah, someone says escorting them to the facility. So, you know, sometimes that's referred as a warm handoff rather than just giving someone a phone number or website or an address, kind of helping them get there or accompanying them. Listening, so important. See that repeated here. And explaining resources. So kind of not just saying here's the list, but here's what they offer. Here's some of the services and maybe differences between them. Yeah, motivational interviewing, you know, a conversational technique to help encourage people to consider and identify their motivations for making changes. Right. Yeah, being mindful of body language. You know, our reactions sometimes, especially if we're tired, you know, not necessarily having the awareness of what's showing up in our posture, or what that might be in communicating, even if we don't mean to send that message. Great. Advocating, listening. Yeah, that you're working collaboratively. Not just, we'll be talking kind of more about that person-centered care in the second session. Empowering. So, you know, that's sometimes talked about as a strength-based approach, you know, to show them they are more than their struggle. So critical, you know, people have to be really resourceful to deal with the situations of, you know, housing insecurity, and, you know, struggling with substance use disorders and other challenges. Great. Explaining some of the benefits of making changes, you know, showing that hope, you know, part of, you know, helping people understand that, you know, they don't, that it's not impossible, you know, having those role models, getting to know them as a person. Great. So, just kind of on this, you know, you'll see a lot of different flyers or articles or, you know, things posted on social media about avoiding stigmatizing terms. And some of these are, you know, kind of go without saying that we know what some of the more, you know, judgmental and negative terms are that are out there. And, you know, thinking about alternatives to that, you know, when we talk about person first or person centered language, you know, talking about someone who's struggling with addiction rather than the noun addict, you know, abuse is one that I always kind of try to reiterate that that's a really easy one to replace, you know, abuse in the context of, you know, physical abuse, child abuse, it has such negative contexts when it comes to, you know, when it comes to, you know, it has such negative contexts when it refers to, you know, the harm that's done to a person, you know, as opposed to substance, you know, we don't talk about food abuse, you know, so drug abuse, you know, replacing that with substance misuse or substance use is one that's not too challenging to kind of swap out at the same time, recognizing that some of the federal agencies that deal with this topic do still have the word abuse in their name. They're trying to change that as well. You know, we'll talk more next session about medications for opioid use disorder, you know, moving away from clean or dirty, particularly referring to urine tests or drug testing and talking about negative or positive. Instead, you know, some people in recovery will use the word clean. So I have at the bottom here, people with lived experience with substance use might use some of these terms to identify themselves. So it is important to respect different perspectives, you know, but in terms of kind of working in the field, you know, talking about in recovery or sober, or if someone has chosen to be abstinence as an alternative. And then, you know, kind of thinking about participants or patients or clients, as opposed to drug seeker, you know, those aren't ones I think that come up as often. And there's some kind of movement to kind of shift from relapse to return to use. But again, you'll kind of hear people with lived experience, you know, or even, you know, using terms sometimes and certainly like within some 12 step or self health groups, you know, some of these terms kind of come up as people describe their own situations. Yeah, someone's asked when the next session is. And so I'm going to show that and also show a link at the end. So just, you know, kind of some thoughts on stigma is, you know, examining our attitudes and how they can contribute to stigma is not about never having an opinion or making a judgment. We all have feelings and reactions. You know, it's about managing and recognizing those to try to avoid perpetuating stigma and trying to separate the behaviors from the people we're trying to help, you know, even thinking about how one interacts with children as, you know, that trying to reinforce that something they just did is not acceptable, or it wasn't the best choice as opposed to, you know, labeling them, or a certain thing is good or bad. I'm challenging ourselves to clearly examine our own attitudes and beliefs, which may be shaped by our personal experiences with substance use. You know, that's where we started at the beginning of today's sessions, you know, we come into this with personal experiences and a range of kind of sources that have kind of shaped how we think about these topics. And, you know, really just being open to changing our understanding of substance use disorders and how to treat them in a way that respects different pathways to healing and health. So, you know, just some thoughts there that, you know, sometimes I think when people talk about stigma, it is also important to recognize, you know, the challenging situation that many of us live with or work in, and kind of just trying to manage and navigate some of those challenges. So the last topic for today, you know, we'll be kind of developing another training, you know, starting in the fall that's going to get into this a little bit more, you know, conversational strategies. But to just to cover it here, how comfortable are you talking Great, so one is very comfortable, two is somewhat comfortable, and three is not too comfortable. Depends on the client. Great. Right, so a range there, but you know, more ones and twos. What experiences have you had talking about substance use with residents? You know, for anyone who wants to share in the chat, you know, anything, you know, strategies or experiences, you know, this is a topic kind of for more time, I'm going to go over some kind of basic strategies. Yeah, so one here, hearing from someone that they don't feel they have a problem, very common. Yeah, aren't ready to talk about getting help. Yeah, why do I care if they use or not? Interesting. You know, part of that probably comes from stigma and feeling, you know, that they're not worthy of help. Yeah, kind of similar to that, you know, I'm not going to talk about getting help. I'm not going to talk about, you know, I'm not worthy of help. Yeah, kind of set in there, they're used to using drugs set in their mind, set in their ways, or don't want to discuss it with staff. Denial or rationalization. Yeah, kind of, you know, when someone writes uncomfortable talking with a client, but oftentimes the client is uncomfortable sharing truthfully about their usage because they fear judgment. Also, great to hear someone talking about how proud they are to be in recovery. Making promises about how they are going to change. Yeah, whether someone is currently using or under the influence of substances or high, you know, may impact kind of what they want in that conversation. Feeling uncomfortable depends usually the state. Yeah, great. Great, so I'm, there's a lot here. I'm going to save the chat here and spend more time with, you know, before the next session. But, you know, these are just some very basic tips for conversations about drug use and options for care. And this is a hard topic, you know, particularly for any of you who've had this even in your personal lives, you know, to bring up and to think about how to discuss with people. But, you know, for these conversations, particularly in a work setting is, you know, for the initial conversations, respecting the life experience of people who use drugs. Be humble about what you don't know. Encouraging honesty about the positive and negative aspects of their drug use. Asking about both. So, right, when we started off talking about why do people use drugs, you know, this is also kind of part of that motivational interviewing technique someone mentioned in the chat. Listening carefully to where someone is at. What do they want? Is there a desire for change? And is there something motivating change? You know, sometimes a pregnancy, a housing situation, a relationship with a child or partner, or a recent overdose might be that thing that is motivating change. Kind of moving on to services and resources, you know, asking what they know about harm reduction or treatment options and what experiences they've had with services. Chances are someone will have had some experiences with either or both of those. And, you know, it's important to validate any concerns they might express. So, you know, I'm sorry you couldn't get treatment because you didn't have insurance. Or I can see why you had a negative experience with that program. You know, I've certainly heard from people who, you know, were resistant to treatment because they had been kicked out of a program for some type of infraction. So, you know, having to kind of work through that can be part of these conversations. You know, for harm reduction, you know, and treatment options, discussing what they are and ways to get help. You know, maybe it's meeting with a provider through your organization, as well as managing expectations about what's available. Allowing informed choice, giving accurate information about all options, including no treatment, you know, and what that might mean. You know, navigating uncertainty and celebrating progress. You know, being honest and transparent. If you don't know the answer to every question, being able to say, that's a good question. I don't know, but I'll ask around. I'll let you know what I find out. You know, really trying to avoid that word should, you know, not imposing your beliefs, you know, offering options they could consider or try. You know, important to kind of recognize that change takes time and being patient, you know, which can be really difficult when you see someone in a situation where, you know, they're not satisfied where they're at with life and, you know, express, you know, that one step forward, two steps back kind of process. You know, but also acknowledging and celebrating small achievements. You know, that's great. You've cut back on how much you're using. How has that made you feel? And I think that also kind of encapsulates, you know, what one of these goals is with harm reduction is understanding that, you know, achieving abstinence from everything forever for everyone can be a huge thing, you know, when you think about the range of substances and the range of reasons. And I think, you know, as a field, things are starting to shift in terms of recognizing that, you know, maybe the first priority is getting someone to consider medications for opioid use disorder as an alternative to using street drugs and not making prescribing those medications contingent on them quitting everything, you know, maybe they're still going to drink, maybe they're still going to smoke weed, you know, and understanding that, hey, we're starting with this as kind of more of a sequential approach. So, you know, we'll be talking about that. Yeah, someone's kind of mentioning difference between how the opioid crisis is treated versus the crack epidemic. Also important to in that distinction too, is that, you know, because the opioid crisis kind of was the healthcare system, the medical system, pharmaceutical companies, you know, contributed to that, that's also a difference, you know, compared to illicit drugs. So kind of opening up, you know, making it a different response. And finally, just wanted to show some resources before we wrap up here, there'll be a little link to a survey that I'll leave a couple minutes for you to fill out. But if you haven't heard of the 988 Suicide and Crisis Lifeline, you know, hopefully by now you have and, you know, maybe have flyers around your workplace or have seen these maybe in the subway, but, you know, it's not just for a suicide crisis anymore and really is for any behavioral health crisis that does not need an immediate in-person response, you know, encouraging people to be aware that you can call or text 988. There's a link here specific to New York City and if you're not sure if 911 or 988 is appropriate, you can contact 988 and the trained counselor will help you assess next steps, you know, if they say, hey, this is an emergency, we're going to contact 911, you know, you can kind of start with that. You know, important that this is a 24-7, 365 day a year, services available in many languages and, you know, really trying to promote that as a resource to help people connect with services. And finally, you know, these are links for the New York Office of Addiction Supports and Services that can connect people with help. And then the bottom link, New York is kind of unique in having this called CHAMP Ombudsman Program, which helps patients and providers address insurance issues, you know, those barriers specifically related to accessing substance use and mental health services. So, you know, that can help people who've had an insurance denial or just need to know or perhaps need to actually get insured before they can get access to care.

substance use

housing programs

harm reduction

SAMHSA

Opioid Response Network

overdose prevention

recovery support

fentanyl

xylosine

stigma

syringe service programs

overdose prevention centers

988 Suicide and Crisis Lifeline

CHAMP program