A vital exchange

Megan Miklovich knows what it’s like to cheat death.

At 24 years old, she’d been using heroin for eight years. One night, she came to, disoriented. She soon found out her then-boyfriend had given her a vital medication: naloxone hydrochloride. It didn’t take long for her to figure out what had happened. This was her third time overdosing. The naloxone had saved her life.

“I cried each time [I overdosed],” Miklovich told the CN&R during an interview on the patio of Blackbird Cafe between drags of a cigarette. For her, that night was the last straw. She was determined to get clean.

Miklovich had turned to drugs as a teenager. At 15, she left her crowded childhood home, where her family was struggling financially. As she traveled, she met other people who felt they didn’t fit in elsewhere. Her drug use, which had been experimental at that point, escalated during a toxic relationship.

After that third overdose, Miklovich weaned herself off of heroin with buprenorphine—an opioid medication used to treat addiction—and by staying with friends she knew would kick her out if she used.

“It was hard, but, for me personally, once I started feeling physically better, the mental stuff got better,” she said. “I didn’t have as much anxiety, I didn’t want to just go out and get a ‘get-well shot.’”

Others she met over a decade traveling the States would not be as lucky.

“I can’t even tell you how many of my friends over the years have died of overdoses,” she said.

Miklovich, now 29 and nearly six years sober, settled down in Chico last May, moving in with her best friend, Alexx Collins, who introduced her to the volunteers of a passionate group determined to help reduce harm among drug users—the Northern Valley Harm Reduction Coalition (NVHRC).

They were propelled to act by the region’s troubling mortality statistics.

Butte County’s drug-induced death rate, 18.94 per 100,000 residents, was the 13th highest in the state for 2017, the last year of available data, and much higher than the state average (11.58 per 100,000 residents), according to the California Department of Public Health’s California Opioid Overdose Surveillance Dashboard. Its death rate due to opioids paints a similar picture.

The county has made strides in addressing the overprescription of opioid painkillers such as Norco, Oxycontin and fentanyl, but illicit drug users often fall through the cracks. NVHRC is attempting to change that, and save lives. The approach it takes is in its name: Rather than requiring sobriety for services or support, the coalition focuses on meeting people where they are in their addiction, with the goal of reducing harm. That manifests in myriad ways.

A harm-reduction tool is what saved Miklovich’s life. Naloxone, also known by the brand name Narcan, helps halt the potentially fatal effects of opioid overdose, reversing sedation and unconsciousness and restoring breathing. Local use of the drug gained widespread attention in January, when medical personnel and police responded to a fentanyl-related mass overdose that killed one man and sent 14 others to the hospital.

It’s not the only tool that can save lives. Providing clean supplies for drug users can prevent the spread of life-threatening, costly, easily transmitted viruses, like HIV and hepatitis C.

In Miklovich’s home state of Massachusetts, naloxone, clean syringes and other sterile drug supplies, sharps disposal containers, and testing for HIV and hepatitis C were readily available via harm-reduction centers and syringe exchanges.

In other parts of the country? Not so much. There is no central location for some of the most vulnerable populations to access free, potentially life-saving resources. The harm reduction coalition aims to change that in Butte County, and open up such a center this year.

A public health necessity

It was a cold evening in late January, but Blackbird Cafe was toasty, its foyer packed with people nearly as tightly as its walls are packed with books.

NVHRC co-founder Javi Pinedo launched into the night’s scheduled overdose-prevention training with a basic explanation of harm reduction. Think of it this way, Pinedo said: using a condom during sex, or including more vegetables in a diet, are both examples of harm reduction.

For service providers, “harm reduction is that practice of, ‘I’m going to meet you, talk to you, see what resources you need to be healthy,'” Pinedo told the room.

Pinedo was joined by fellow NVHRC co-founders Angel Gomez and Cassie Miracle, and for the rest of the 45-minute presentation, they educated the group about what leads to opioid overdoses, the signs of an overdose, and—the most vital part of the night—how to use naloxone nasal spray to revive people.

The process involves performing rescue breathing and spraying dosages into the nostrils, which will be absorbed even if the person is not breathing. Before the night was over, every person received reference materials and a box of Narcan with two doses (worth more than $100).

NVHRC, an all-volunteer group, has participants from a variety of backgrounds, including public health, homeless services, LGBTQ advocacy, health care and environmental stewardship. In addition to organizing the trainings, they have collected and disposed of more than 1,000 syringes found during weekly street outreach, when they also give out sharps containers and Narcan.

Though naloxone became available over the counter in 2014, it could not be distributed by local organizations like NVHRC until this past summer, when California’s public health officer issued a standing order. As soon as NVHRC heard the news, it applied to distribute it. So far, the group has received nearly $120,000 worth of the life-saving drug to give to community members.

While NVHRC works on becoming a formal nonprofit, the North American Syringe Exchange Network is serving as its fiscal sponsor, Miracle said. NVHRC also connected with a Chico physician to receive a local standing order to distribute Narcan and develop a medically sound training program.

Butte County Public Health has received state funding to distribute naloxone as well, and has gotten it into the hands of first responders and the county’s Behavioral Health Department, which has been giving it to clients.

Though NVHRC volunteers have plenty to do between outreach and naloxone trainings, the group is pursuing state authorization to set up a syringe-access and -disposal program, also known as a syringe exchange. One of its first tasks: conducting a vulnerability assessment to show that Butte County is at risk for significant increases in hepatitis infections or an HIV outbreak due to injection drug use.

Miracle, who has a background in public health education, doesn’t think that will be hard to prove. Butte County has experienced a 13 percent rise in hepatitis C cases, from 318 reported in 2013 to 359 in 2017 (see “Beneath the surface,” Healthlines, Sept. 6, 2018).

Syringe exchanges, and their related services, are a public health necessity, she added, and the group stepped up because it felt that local leaders were not acting quickly enough. Miracle said such programs often are misunderstood and controversial primarily due to a lack of education.

“I think it’s scary for people, honestly,” she said. “I think they fear harm reduction and they think all sorts of things instead of dealing with the fact that, whether we like it or not, prescription and nonprescription drug use is a part of our world.

“And we are trying to minimize the harmful effects that it has, not just condemn the folks that are affected by it,” Miracle continued. “We, as a community, have to come together and support each other, and support [the health of] these folks that are using drugs.”

Miklovich felt motivated to get involved with NVHRC because of the friends she has lost to overdose.

“I hope to break down stigmas, to just really execute the whole idea of harm reduction, make things safer, make people happier, save lives even,” she said. “A lot of people have the idea [addiction will] just go away if we don’t enable any harm reduction.”

Evidence-supported, but controversial

Harm-reduction practices were first established in California in the 1970s, but became increasingly common in the 1980s and ‘90s, as communities scrambled to react to the deadly AIDS crisis.

These practices, including providing access to sterile syringes and injection supplies, have proven effective in preventing HIV transmission among people who inject drugs, according to Alessandra Ross, an injection drug use specialist with the California Department of Public Health (CDPH). Today, there are 44 syringe-exchange programs in the state.

Miracle said the CDPH has been an incredible partner, helping the local coalition apply for state funding and understand the ins and outs of launching its programs.

“Supporting harm-reduction approaches to drug use is an effective way of stopping overdose deaths,” Ross wrote via email. “In Butte County, organizations like NVHRC have local expertise, which will ultimately save lives and money.”

Ross pointed out that harm-reduction programs are widely supported by major public health organizations, including the CDPH, Centers for Disease Control and Prevention, World Health Organization, Substance Abuse and Mental Health Services Administration, and American Medical Association.

This is because research conducted over decades has found syringe exchanges to be effective in reducing HIV and hepatitis C transmission among injection drug users, as well as promoting entry and retention into drug treatment programs. According to the CDC, such programs do not increase drug use or crime in the areas in which they are located. The programs also decrease needle-stick injuries among first responders.

Another benefit: saving health care dollars by preventing infections. It takes more than $400,000 to treat one person living with HIV over his or her lifetime, according to the CDC. In 2014, $6.5 billion was spent on the hepatitis C medication Sovaldi, making it the top drug in terms of expenditures in the United States that year, according to an article published in the Journal of Health Biomed Law last September. Medicare’s share was reportedly $4.5 billion.

Syringe-exchange programs still face political hurdles, however. In Orange County, a state-authorized program has been temporarily barred from operating after being sued by several of its cities, which cited concerns of increased needle litter.

Studies paint a different picture, however, indicating the opposite to be true. In a 2011 study funded by the San Francisco Department of Public Health and National Institute on Drug Abuse, 80 percent of injection drug users reported disposing of needles via syringe-exchange programs. Of the few found during visual inspections, most were hard to access, found behind fences, in gutters, capped or with tips broken off.

The following year, a study published in the international journal Drug and Alcohol Dependence compared San Francisco to Miami, which had no needle exchanges. Visual inspectors found 44 syringes per 1,000 census blocks in San Francisco, compared with 371 per 1,000 census blocks in Miami.

In Miklovich’s experience, most drug users don’t want to harm their communities: She came up with her own harm-reduction practices when she didn’t have access to a center or syringe exchange, including disposing her sharps by capping them and stashing them in old water bottles.

Now, when Miklovich does street outreach, she has noticed drug users often feel wary when she brings up harm-reduction resources, like Narcan. They try to justify their interest or even lie, saying things like, “Oh, I don’t need this, but my friend does.”

Miklovich tries to stop them right there: “I’m not one to judge,” she says, and often shares her story.

Gomez said people often express gratitude—and surprise: “When I’m giving out sharps containers, they’re just amazed there’s somebody who actually cares,” she said.

Hope for the future

NVHRC envisions a program not unlike what has been established in Plumas County, Butte’s easterly neighbor with a population of 20,000. The opioid epidemic hit that region particularly hard.

In 2009, Plumas County had the highest rate in the state for overdose deaths from prescription opioids. The public health agency has focused on preventative education, prescribing guidelines for doctors and Narcan distribution, similar to Butte County’s approach. After observing a dramatic drop in prescription-related deaths, James Wilson, health education coordinator for the Plumas County Public Health Agency, and his colleagues realized there was more to be done.

“People inject drugs, and so we had to face that,” Wilson said. His agency, in partnership with the Northern Sierra Opioid Safety Coalition—a group of public health, hospital, law enforcement, criminal justice, nonprofit and community representatives—has “really tried to tackle a whole comprehensive approach” in response to the opioid epidemic.

The county’s syringe exchange, certified by the state, has been operating from three locations—in Quincy, Chester and Portola—two days a month for two hours, since last June. It is entirely funded by the state and federal government through grants and the California Syringe Exchange Supply Clearinghouse.

For everyone involved in the process of setting up the program, it was a “no-brainer public health intervention,” Wilson said. “We didn’t have a big problem with syringe litter when we started. We were, of course, like any other small county in America right now, at risk of an HIV or hepatitis C outbreak.”

This was public health’s chance to take a preventative approach, he continued.

“When you’re presented with the evidence that [harm reduction] works so effectively, there’s not really an argument against it that’s not fear-based,” he said.

The agency conducted a series of focus groups with people who inject drugs to create the best program. In addition to sterile syringes, the Plumas syringe exchange locations offer cotton swabs, water, wound-care kits and fentanyl testing strips. There is HIV and hepatitis C testing, and, for those seeking sobriety, referrals are made to medication-assisted treatment and other social services or behavioral health programs.

Wilson said that over time, as people heard about the program and started to trust that they would not get arrested for accessing its resources, participation grew. The first four months, 1,600 syringes were distributed. In the past four, 19,000 were given away.

Most people use them to inject illicit drugs, he said, though the department has seen a variety of other users, such as underinsured diabetics who need the syringes for insulin shots and transgender individuals seeking them for hormone treatments. In fact, the first person to use the program was a woman who came to dispose of syringes she’d used to vaccinate her horses.

Why isn’t there one already?

This isn’t the first time a syringe exchange has been suggested in Butte County. About a year ago, the Chico City Council tasked its Internal Affairs Committee with looking into needle-exchange and -disposal programs. Mayor Randall Stone, then a councilman and part of the political minority, had brought forward the initiative.

The conversation was then passed to Chico’s Local Government Committee, made up of Butte County supervisors and Chico City Council members.

Dr. Andy Miller, the county’s public health officer, was scheduled to discuss syringe exchanges at the committee’s Nov. 14 meeting. After the Camp Fire broke out, it was canceled. Butte County Assistant Chief Administrative Officer Brian Ring told the CN&R it will “very likely be re-calendared at the next meeting, at a date to be determined.”

Miller said the county supervisors would have to decide if a syringe exchange is something they would like to support. He believes harm reduction is important, and should continue to be pursued, but with buy-in from elected officials and law enforcement. “Their cooperation and their support … is vital” for any harm-reduction program to work.

The county has been tackling the opioid epidemic, but on a different front. Its focus has largely been on the overprescription of opioids and addiction to painkillers.

A medication-assisted treatment clinic was founded in 2015. There, buprenorphine as well as naltrexone (aka Suboxone and Vivitrol, respectively) are used to help patients manage opioid and alcohol dependence. At any given time, the clinic is treating 100 to 120 patients, according to Jennifer Stofa, program manager of substance use treatment and recovery services.

When it comes to prescription use, the county has helped reduce the amount of morphine milligram equivalents prescribed per resident per year nearly in half since 2010, from 2,521 to 1,302. However, “we still prescribe at a rate significantly higher than the state or national average,” Miller said, so that remains a focus of the department.

Dr. James Moore, an Enloe Medical Center emergency room physician, said though there are regular instances in which intravenous drug users have been “Narcan-ed” in the field and end up in the emergency room, it’s much more common that he sees chronic pain patients who’ve taken too many prescription pills. Most of the time, patients require observation to make sure the drugs wear off before the naloxone does. Sometimes, they must be treated with additional doses to keep them alive.

Since there has been a lot of progress made in clamping down on the prescription side of the opioid epidemic, Moore anticipates the problem “is going get worse before it gets better,” with more people turning to heroin because they cannot access painkillers.

‘Game-changer’

Chico Police Officer John Barker first used Narcan this past December. As he arrived at the Regency Inn one afternoon, a woman frantically ran toward him. Her friend had overdosed, she said. Upon entering the motel room, Barker found a man doing CPR on a woman. Other people scrambled about, grabbing stuff (likely drugs, Barker said) and clearing out, now that a police officer had arrived.

“She looked pretty bad,” Barker recalled. “Her skin was gray and mottled … usually it means they’ve been deprived of oxygen for a while.” He used the Narcan while the man continued CPR, with Barker coaching him through it. After about five minutes, she started to slowly regain consciousness.

When first responders from the Chico Fire Department and Butte County Emergency Medical Services arrived, they told Barker the Narcan he’d used “most definitely saved her life.”

Since August (after going through training earlier that year), Chico police officers have used Narcan on 12 people, according to Commander Billy Aldridge. Six of those were used during the mass overdose in January, Police Chief Mike O’Brien confirmed.

“It was a huge game-changer” for the police department, Barker said.

When police arrived at a home in a quiet suburban neighborhood just after 9 a.m. on Jan. 12, several people were found unconscious. Officers soon were joined by fire department and Butte County EMS first responders. They worked together to revive people, performing CPR and giving naloxone to six of the victims.

Aris Turner, a 34-year-old Chicoan and father of four, died. Fourteen others were sent to the hospital. Several were admitted for a few days.

Chico Police announced at a press conference two weeks later that the partygoers had ingested a combination of cocaine, methamphetamine and fentanyl.

If police hadn’t been carrying naloxone, the outcome would have been much different, O’Brien said.

“From my perspective, there’s no doubt that … naloxone saves lives,” he said. “We think this is something we can’t back away from.”

Members of the NVHRC agree. Like Miklovich, Collins had a rough young adulthood, and was homeless for 12 years (see “The long road home,” Cover story, Aug. 31, 2017). She was kicked out of her home at 14 and became a regular user of hard drugs in her late teens. Alcohol and methamphetamine were her drugs of choice, but she also used cocaine and heroin.

When Collins was seven months pregnant, she was diagnosed with hepatitis C. Several of her drug-injecting friends have died of liver failure after contracting the disease. During a recent interview, she noted that she rarely had access to clean syringes. “I probably used 20 to 25 clean needles in the years I used,” Collins said.

A syringe exchange in Butte County would make a huge difference, she continued, “not just for the reason of not transmitting diseases, but not getting infections” related to use, like abscesses, which can get infected.

Gomez said NVHRC is pleased with the progress it has made so far, and wants to encourage more service providers to incorporate harm-reduction methods into their practices, and provide a wide range of services for people beyond the abstinence-only model.

“We’ve had abstinence treatment centers for a long time, and yet the problem keeps getting worse,” Gomez said. “Those work for some people. It doesn’t work for everybody, and that’s a big [aspect] of harm reduction, figuring out what that person needs, and not deciding for yourself what that person needs.

“Having a syringe-access and -disposal program for the people who use drugs, it shows somebody cares, and someone sees them as worthy of having a healthy life, and their drug use doesn’t make them less worthy as a person.”

The way Collins sees it, harm-reduction services help people survive long enough to make a change in their lives. She’s now four years sober, a working single mom with a healthy 3-year-old. She shared excitement at receiving her first tax return this year.

“There’s always room for someone to change,” Collins said. “You can’t change if you don’t get out of your habit. … You can’t get over an addiction if you can’t survive.”