Western North Carolina has experienced a surge of drug overdose deaths. COVID-19 increases overdose risks for people who use drugs; isolation leads to using alone; pandemics disrupt treatment and support; and PWUD (people who use drugs) suffer determinants of health that compound vulnerabilities. Overdose prevention strategies endorsed by the Centers for Disease Control and Prevention include naloxone distribution and syringe access programs. Harm reduction goes beyond, encompassing practical ideas to reduce negative consequences of drug use through advocacy, social justice and inclusion of PWUD in decision-making — with respect for the rights of PWUD.
Serving populations at increased structural risk for overdose without adequate information is dangerous. When entities without a proven history in community-based harm reduction use the language of harm reduction to describe work not guided by its principles, it threatens people they purport to help. This is seen, for example, when health departments start syringe service programs without involving local stakeholders and thereby divert funds from established community-based programs. Or when political organizations delve into harm reduction without a direct service background. A particular danger accrues from organizations promoting strategies and products not only inconsistent with harm-reduction principles, but scientifically proven to pose direct risks to PWUD.
As a registered nurse working full time in public health with the harm reduction community and an applied medical anthropologist engaged in research with community-based harm reductionists, it is our duty to report behavior detrimental to public health that threatens PWUD. Most recently, a local organization, SeekHealing, whose website describes it as a “nonprofit serving people at risk for overdose” and uses the term harm reduction to describe their work, distributed “herbal first aid kits,” including kratom, as part of a COVID-19 response. SeekHealing advertised the kits for people experiencing pandemic-related withdrawal. Kratom is an unregulated herbal opioid with known overdose risks. High-quality studies demonstrate kratom increases overdose death risks. This distribution violates the tenets of harm reduction.
Harm reduction requires determining, with well-designed research and input from directly affected local stakeholders, what practices keep people safe and empower them to live healthy lives. Evidence backs syringe access programs and drop-in wound care to protect the lives of PWUD. There is no evidence that kratom is effective or safe for opiate withdrawal, as SeekHealing claims. There is mounting evidence to the contrary. Toxicologists determined kratom increased the risk of adverse events, particularly when ingested with other drugs. Overdose deaths have been attributed to a combination of a synthetic opioid and kratom. Naloxone may reverse respiratory distress in kratom-only ingestion. Kratom contributes to respiratory depression, compounding death risk.
Withdrawal increases overdose risks. Offering kratom to people experiencing withdrawal increases vulnerability. Such distribution seems at minimum reckless and at worst predatory, especially when done without honest education and informed consent. SeekHealing introduced “herbal first aid” ostensibly amid concerns COVID-19 would disrupt the local drug supply, causing withdrawal for PWUD. SeekHealing mainly targeted unsheltered folks; partnering with a homeless service organization and an organization offering HIV case management for precariously housed clients and distributing naloxone and safe injecting supplies to PWUD (on a drive-thru basis during the pandemic). Yet kratom distribution began without SeekHealing consulting folks already doing direct service to PWUD. Despite other COVID-19 disruptions, we have not seen it affect local opiate supply or cause pandemic-related withdrawal.
Information distributed with the kratom covers its history but included no overdose warnings. Instead, it falsely claims combining kratom with other opiates “cancel[s] each other out.” Despite efforts to communicate with SeekHealing, discourage kratom distribution and encourage discussion about building trusting relationships when working with PWUD, SeekHealing’s reckless behavior continues. When individualized care and informed consent were suggested, a SeekHealing representative dismissed this as “prescriptive” and not rooted in trust. Those who witness community-based harm reduction know this dismissal is off-base. Individualized care is not only possible; it is imperative during a pandemic. PWUD are too often denied appropriate health and safety resources. Care is often relegated to cookie-cutter, non-evidence-based treatments. Integral to harm reduction is education about safer use and relative risk. Harm reduction isn’t about prescription; it’s about accurate, locally relevant education and supplies that don’t introduce new risks.
SeekHealing’s dangerous actions are in opposition to the harm reduction framework they co-opt. Years of well-designed research and advocacy by PWUD and those in service to them legitimized harm reduction. Reckless behavior under the guise of harm reduction endangers people at risk of overdose and threatens this legitimacy. Harm reduction should not be a buzzword tossed around to gain notoriety and funding. Introducing a new risk into a vulnerable community without education, while blatantly offering misinformation, does not reduce negative consequences of drug use, nor does it show respect for the rights of PWUD. It is not harm reduction. It only harms the efforts of principled harm reductionists, and, by extension, the health of those we serve.
— Vanessa Hixon, RN, co-director of The Steady Collective
and Bayla Ostrach, Ph.D., applied medical anthropologist and community research liaison with The Steady Collective
Editor’s note: The writers note that The Steady Collective is a nonprofit Asheville-based harm reduction organization with a goal of improving overall community health by reducing the rate of drug overdose and the spread of infectious disease with education, advocacy and direct services.
Xpress contacted the nonprofit SeekHealing with a summary of the letter writers’ points and received the following response from the SeekHealing board of directors — Luc Richard, Jennifer Nicolaisen, Dr. Rachel Wurzman, Jennifer Garrett and Joshua Ginsberg: “Unfortunately, this letter is factually incorrect. Not all kits contained kratom — in fact, most did not. SeekHealing did not distribute anything directly: We donated kits to partner organizations that distributed them through peer supports.
“Over two months ago, Steady voiced concerns about the inclusion of kratom. This was confusing because we had reached out to Steady for input on the project prior to launch, without response. Ever since they reached out, we stopped including kratom in kits while we revisited the literature.
“The research around kratom is highly inconclusive. Recent studies show that correlations with fatalities ‘cannot be established in almost all cases because of poly-drug exposure.’ [avl.mx/7rn]
“We offered these kits with compassion to support underresourced people during a pandemic when they were more isolated and unsupported than ever. Participants universally offered gratitude and positive feedback.
“To prevent overdoses as a community, we need more interorganizational cooperation and mutual respect.”