As Biden fights drug overdose, harm reduction groups face local opposition

HOUSTON — Casey Malish had just entered a 2nd ward intersection when a woman with tattoos and pink hair jumped unexpectedly into the back seat of his gray Mazda. He does outreach for the Houston Harm Reduction Alliance, a nonprofit organization that helps drug users like her stay alive.

The woman, Desiree Hess, had made an appointment with him, but Malish, as usual, wasn’t quite sure what to expect this afternoon. Hess told Malish to take her to the Value Village thrift store before explaining why she was so furious.

Earlier that day, around 2 a.m., Hess said, a woman — a “very little girl” — had overdosed at the warehouse Hess hung out at. No one there could find naloxone, a drug that reverses an opioid overdose, and the woman’s lips turned blue. Hess said she blew into the woman’s mouth, trying to keep her alive, while others covered her with ice. Finally, someone found some naloxone, often referred to by the brand name Narcan, and injected the drug into her nose. After the woman regained consciousness, Hess made a decision.

“I knew I had to call Casey,” the 39-year-old recalls, “to get more Narcan.”

Malish drives through the city streets, handing out needles, naloxone, cotton balls, and condoms from the trunk of his sedan. But the Houston Harm Reduction Alliance, which works on less than $50,000 a year according to tax records, can only afford Malish a few thousand dollars every now and then. His full-time job is as a research assistant at the University of Texas Health Science Center in Houston.

Malish — a 31-year-old who said he had a problem with alcohol and opioid pills and then heroin before giving them all up nearly 10 years ago — estimated he can only reach about 20 people like Hess a month. Meanwhile, 1,119 people in the city died from drug overdoses last year, according to the Houston Police Department.

President Joe Biden wants to expand harm reduction programs, such as the one Malish works for, as part of a broader strategy to reduce drug overdose deaths, which have risen to more than 107,000 nationwide by 2021. But the $30 million plan faces a complicated reality on the ground. In Houston, as in many parts of the country, harm reduction programs operate on the fringes of legality and on tight budgets. Lawyers like Malish often have to navigate a maze of state and local laws, fierce local opposition and hostile law enforcement.

Regina LaBelle, who was acting director of the Office of National Drug Control Policy until November, credits Biden’s White House as the first presidential administration to openly embrace harm reduction to curb drug overdoses. She said the $30 million tucked into the $1.9 trillion US Rescue Plan Act is just the first step and too many groups rely on an unstable patchwork of subsidies.

“You shouldn’t be holding a bake sale to give people the care they need,” says LaBelle, who now leads an addiction management program at Georgetown University.

Casey Malish hands out syringes from his sedan in Houston on June 3, 2022. Malish estimates that he can only provide resources to about 20 people per month. The Houston Police Department said 1,119 people were killed last year from drug overdoses. (Mark Felix for KHN)

In addition, the government faces restrictions on what it can do when programs are kicked back by state legislators and local leaders. “What you don’t want is for the federal government to come in and impose something on a recalcitrant state,” she said.

Both Republican and Democrat-led states have legalized aspects of harm reduction, but many remain resistant.

By 2017, all states and Washington, DC, had relaxed access to naloxone, according to Temple University’s Center for Public Health Law Research. Still, fentanyl test strips — which help people avoid the potent synthetic opioid or take more precautions when using it — are illegal in about half the states. According to KFF, seven states don’t have a program that provides people with clean needles, which help prevent the spread of HIV and hepatitis C, as well as bacterial infections and emboli that develop from overuse, weak needles break off in a vein. And New York is the only city with injection sites where people can use drugs under supervision, although Rhode Island has legalized them and the Department of Justice has signaled that it is paving the way for more sites to open.

Texas is one of the states that has been slow to embrace interventions — and hasn’t expanded Medicaid eligibility, so low-income Texans have limited access to recovery programs. At the 2021 legislative session, lawmakers scuttled a bill that would have repealed criminal penalties for possession of drug paraphernalia, items such as clean syringes and fentanyl test strips.

That means the Houston Harm Reduction Alliance operates in a “legal gray area,” Malish said. While it has tacit support from the Houston Police Department and other local entities, the nonprofit could be in trouble if they invade a neighboring city.

“Programs that ease addictions by providing people with the tools they need to continue using drugs are not helping our community,” Texas Sen wrote. Ted Cruz, a Republican, in an email to KHN. In February, Cruz criticized Biden’s grant program, saying it “crack blowjobs for everyone” in a retweet of a story on a conservative website. Fact-checkers debunked the story’s claim, but it remains fodder for opponents of harm reduction practices in state and local governments, even in places where overdose deaths are rising rapidly.

Louisiana allows local officials to decide whether to allow syringe exchange programs, but only four of the state’s 64 parishes allow the services. “We know in the public health field how these programs save lives,” said Nell Wilson, project director of Louisiana’s Opioid Surveillance Initiative. “But because it’s a more conservative state, a big part of the problem is fighting widespread misconceptions that aren’t based on fact.”

In Kentucky, local public health departments conduct harm reduction programs, said James Thacker, a program manager at the University of Kentucky harm reduction initiative. In some parts of the state, local law enforcement agencies support programs. In other countries, they enforce laws that consider fentanyl test strips to be illegal drug paraphernalia.

Harm reduction programs also face backlash in progressive places, such as San Francisco, where some residents believe they are promoting drug use.

Still, state and local harm reduction groups say the Biden administration’s $30 million grant isn’t enough money to expand their programs to reach the number of people in need of help.

“We were disappointed by that number,” said Cate Graziani, co-executive director of the Texas Harm Reduction Alliance, which sought the $400,000 maximum in funding but was not among the two dozen organizations receiving grants. Her group planned to distribute the money to local outposts, such as the Houston Harm Reduction Alliance.

“These programs are still running on a little bit,” said Leo Beletsky, a public health law expert at Northeastern University. “That’s not how public health is supposed to be.”

Casey Malish, 31, provides outreach for the Houston Harm Reduction Alliance, a nonprofit organization that helps drug users stay alive. (Mark Felix for KHN)

Harm reduction proponents do not believe that such efforts alone will suddenly halt the number of overdose deaths. Addiction is a complicated, chronic disease. And in 2021, overdose deaths rose 15% from a year earlier, according to the Centers for Disease Control and Prevention. Today, illegal fentanyl and its analogues from Mexico and China have tainted the street supply of counterfeit pills, heroin and even stimulants such as cocaine and methamphetamine, causing overdoses and deaths for casual users as well as those with long-term addiction.

“No one is going to solve the overdose crisis, but this is going to save a lot of people’s lives,” said Dr. Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health, on harm reduction efforts. †

Many of Malish’s clients talk about wanting to quit drugs. According to the CDC, people who use syringe programs are five times more likely to start treatment and three times more likely to stop taking drugs.

When Malish Hess drove past Value Village to the abandoned comic book store where she usually lives, she said she plans to start methadone treatment for heroin addiction as soon as she can get an ID that the town offers to those without housing.

“I’m tired of watching my friends die,” Hess said.

As she got out of Malish’s car, he loaded her arms with boxes of syringes, sterile water, injectable naloxone, tourniquets, and fentanyl test strips that she could share with others.

Hess then asked Malish if she could use two quarters she found in the seat cushions of his car to buy drinking water before walking through the double doors of the mall.

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