Naloxone is a heath intervention that can’t be effectively provided without the knowledge and social connections of people who inject drugs

Programmes to provide naloxone, a drug that reverses the effects of opiate overdose, are successful because they harness the social contexts of drug use and train drug users to be ‘indigenous public health workers’ capable of intervening in an overdose, according to a qualitative study published in the May issue of Social Science & Medicine.

“Whereas prohibitionist policies seek to isolate users from the spaces and cultures of drug use, in contrast, harm reduction strategies like naloxone see the social networks of drug users as sites and tools for intervention,” writes Rachel Faulkner-Gurstein of the London School of Economics. “As a public health strategy, naloxone depends upon the experience and expertise gained by users in their careers as users.”

Drug overdoses are now the leading cause of accidental death in the United States. Just under 50,000 people died of a drug overdose in 2014, nearly triple the number recorded in 1999. The majority involve an opioid such as heroin or fentanyl.

Glossary

harm reduction

Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use (including safer use, managed use and abstinence). It is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.

stigma

Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

depression

A mental health problem causing long-lasting low mood that interferes with everyday life.

range

The spread of values, from the smallest to the largest. The inter-quartile range (IQR) only includes the middle 50% of values and measures the degree of spread of the most common values.

exclusion criteria

Defines who cannot take part in a research study. Eligibility criteria may include disease type and stage, other medical conditions, previous treatment history, age, and gender. For example, many trials exclude women who are pregnant, to avoid any possible danger to a baby, or people who are taking a drug that might interact with the treatment being studied.

Naloxone is an opiate-blocking drug that reverses the effects of opiate overdose by counteracting the depression of the central nervous and respiratory systems that can cause death. When administered promptly and correctly, naloxone can prevent death. It usually takes effect within a few minutes, is neither addictive nor psychoactive, and is not associated with serious adverse events.

Initially, naloxone was only provided to paramedics, until activists, drug users and healthcare professionals developed the model of peer-administered naloxone. Just as syringes circulate within social networks of drug users, the model uses the social connections between drug users to disseminate naloxone so that it is available when and where overdoses occur. People who inject drugs are provided with naloxone kits and trained in their use, so that they can provide naloxone to a peer if they need to.

Over 80% of people receiving naloxone kits are drug users, dwarfing the 12% provided to friends and family, and 3% provided to health professionals.

The researcher used ethnographic methods to investigate the implementation of harm reduction in the South Bronx, New York City in 2011 and 2012. Fieldwork included participant observation at three harm reduction agencies, including observation of overdose prevention trainings and 40 semi-structured interviews with staff, peer volunteers, advocates and policy officials.

The harm reduction agency focused on in the article provides syringe exchange, case management, primary health care, showers and a social space for its participants, many of whom are homeless. Overdose prevention training was provided every day and there was no limit to the number of times a participant could attend. Some people attended regularly.

The training lasted less than 30 minutes and was adapted to the requirements of each group (typically, around 15 participants). Dialogue and discussion were encouraged, drawing on the expertise and real-life experiences of participants.

Being trained to be a peer provider gave individuals the opportunity to have a new, active role within their social networks. Peers taking part in the training felt respected, which counteracted the stigma they felt in many other situations, as these participants explained:  

 “When I first got here, I didn’t feel out of place. What I did feel was included in the process. Everywhere during the time I was using, that was something that was stigmatized. That I was a drug user, all the behaviours that I went through. I was excluded from many places. So when I got here, and they included me, that was very significant to me.”

“It’s taught me a lot. It’s taught me to be responsible. And the only way I can give back is what I’m doing now... I’m just a participant, peer, whatever, but I take so much pride in coming in to [the agency].”

Peers needed to master a wide range of practical and technical knowledge. Properly administering naloxone requires knowing how to recognise that an overdose is occurring; how to manoeuvre an unresponsive body into the recovery position in order to reduce the risk of choking and to optimise airflow; determining whether or not naloxone is even appropriate given the specific substances that have been taken; how to use syringes and other medical paraphernalia in a highly time-sensitive, life-and-death situation; and how to respond to possibly violent people experiencing drug withdrawal symptoms.

The training builds upon the expertise that peers have already developed in their careers as drug users, including the effects of different drug classes on the body, the differences between opiates and opioids, and knowledge about the strengths of branded batches of heroin.

“Far from treating users as passive objects of policy intervention, then, naloxone draws on the relatively high degree of medical knowledge that exists, in its own distinct forms, within the cultures of drug user networks,” says the author. “Overdose reversal would be impossible without precisely those practices, knowledges, and skills that are stigmatized in prohibitionist drug policies: facility with needles, experience with drug interactions, comfort and familiarity in the social spaces of drug use. Users can act as competent reversers of overdose only because they possess this taboo form of expertise.”

Moreover, delivering naloxone when it is needed relies on peers’ familiarity with and access to the spaces in which people take drugs. The social connections between people who inject drugs are used as a tool to amplify the effectiveness of a public health policy.

Training people who inject drugs to provide naloxone also creates new relationships between drug users and medical authorities. Drug users are not seen as patients or criminals, but as public health workers, tasked with saving the lives of their peers.

But this process raises questions about responsibility, liability and authority, says Faulkner-Gurstein. Drug users are asked to carry out technically advanced work without any financial reward, and with no clear framework should something go wrong. In line with wider neo-liberal trends, the responsibility for protecting and preserving life is transferred from the state and the medical professions to individuals.

References

Faulkner-Gurstein R The social logic of naloxone: Peer administration, harm reduction, and the transformation of social policy. Social Science & Medicine 180: 20-27, 2017. (Abstract).