Harm Reduction at Sea: Tight-Knit Fishing Communities Navigate Drugs

    The setting sun shines a crown of pink light through the windows of a loud bar on the Massachusetts coast, packed with fishermen. It’s 3:30 pm—the end of a long day that began well before dawn. The weight of wear and tear on exhausted muscles and minds is as palpable as the bursts of deep belly laughter and the smell of sweat. Johnnie*, a salt-and-pepper fisherman in his late 50s, is smiling as he tells me what happened one dark night last year.

    “It was like a movie star, dropping down from the sky off the helicopter to get to my crewmate, pitch of night,” he says. “The Coast Guard—this handsome guy, my wife would’ve loved him, like Rock Hudson—dropped down from the moon. Felt like hours after we had given him all the Narcan we had. The Coast Guard still didn’t carry it back then, did you know that? So they pulled him up into the clouds and we all were left below at sea.”

    “It’s not the first time that’s happened on our boat,” Johnnie says. “If we didn’t have that Narcan on board though, kid probably wouldn’t have made it.”

    I feel my skin chill. But Johnnie smiles even wider as he looks over the overdose prevention and response resource I’ve just handed him. “ODP Ashore & At Sea,” reads the header. “What do you think?” I ask. “You made it for us with the Mayday channel on it and all, that’s real nice,” he says.

    Another member of our local harm reduction program, an outreach worker like me, is down the other end of the bar, near the bathroom door. She’s showing two younger crew members how to administer a 4 mg naloxone dose.

    They tell her they have seen a handful of overdoses in their lives, lately involving both fentanyl in adulterated cocaine and “pressies”—various types of pills that frequently contain fentanyl—and that it’s good to have a kit on hand just in case. They’ll be back out at sunrise tomorrow. One of them, even with his beard, doesn’t look old enough to drive a car.

     

    High Risks and Health Inequities

    It is well known that fishing workers, along with those working in construction, have significantly higher rates of opioid-involved overdose deaths than almost any other industry. Around two in five of the 60,000 fishing workers in the United States have experienced either an opioid-involved overdose or a substance-related accident or injury while on the job.

    Being a fisherperson is tough, more than many of us can really imagine. It’s physically grueling and dangerous, with long, intense hours and the feelings of loneliness that can come with being away at sea. What many of us do not often stop to think about is how fishing workers, who do not receive sick time or paid vacation, face relentless issues maintaining health insurance coverage due to their fluctuating incomes.

    “The vessel does not turn around once they are out at sea—that is not an option. They work through the pain.”

    “Fishing people simply do not have health equity the way things are right now,” said Deb Kelsey, a community health navigator for Fishing Partnership Support Services in New Bedford, Massachusetts. “If someone is in pain or sick, the vessel does not turn around once they are out at sea—that is not an option. They work through the pain.”

    This combination of extraordinarily challenging work conditions and health-care vulnerability creates a need for many people to find their own ways to cope. Drugs are one obvious option. Respiratory depressants such as prescribed and street opioids, benzodiazepines and alcohol are all in the mix. They could be taken to calm the nerves, ease pain or endure bad weather and rough seas. Stimulants are used too, as a way to fight that inevitable fatigue.

    “Sometimes it’s lonely and cold, being down in the fish-hole just tossing fish for hours and hours,” Mike, a young fisherman, told me. “Gives you a lot of time to think, and not always of the good stuff, you know?”

    Combining certain substances significantly increases risks, especially given the prevalence of fentanyl and its analogs in our current drug supply—pointing to the need for more education and resources. But polysubstance use, in commercial fishing and many other industries, serves its purpose to support people in getting the work done.

    While drugs’ benefits to job performance are often overlooked, such publicity as is afforded to drug use in commercial fishing focuses solely on the negative impacts, such as at-sea overdose or overamping. Despite the urgency of reducing harms, this focus can result in the further stigmatization of fishing people who use drugs and their families.

    Members of tight-knit fishing communities have often described to me how finding acceptance for the substance use that’s part of their daily lives feels like a grief-weighted struggle against decades of entrenched cultural stigma and internal shame.

    In many ways, fishing people—with their traditions of solidarity, practicality and mutual aid—are natural harm reductionists already.

    Harm reduction has always held space for people who have been able to navigate their work and lives while using drugs. It acknowledges that drug use is a fact, not something to fight against. It also leaves room to acknowledge the often complex trauma that can build from intergenerational secrecy around drug use, from fear of punitive consequences and from the realities of a hazardous livelihood.

    If fishing workers could have safe spaces to talk about their drug use, injuries and pain, if they could feel less at risk of losing their jobs in risk-reduction conversations with their captains and employers, the sea would be a much safer place.

    What greatly facilitates this work is the fact that in many ways, fishing people—with their traditions of solidarity, practicality and mutual aid—are natural harm reductionists already.

     

    Support Ashore and at Sea

    Fishing Partnership Support Services (FPSS), where Deb Kelsey works, is a nonprofit that serves fishers, shoreside workers, family members and others in the greater fishing community. Its model relies on conducting outreach through a team of trained health workers, or navigators, who are themselves members of local fishing communities.

    The Massachusetts organization has offices in Gloucester, Chatham and Plymouth, as well as New Bedford. Local harm reduction programs—Seven Hills, New Bedford; ONESTOP Harm Reduction Center, Gloucester; Aids Support Group of Cape Cod, Chatham; and BAMSI, Plymouth—work alongside FPSS to improve how harm reduction works at sea and provide new meaning to old community traditions.

    “Fishermen look out for one another—even competing crews. They know they are their own first responders on the water.”

    One simple example is the Ashore & At Sea Overdose Prevention Training program, provided by local harm reductionists during fishing people’s safety and survival training/CPR courses.

    FPSS and their allies have been getting the word out in other important ways. For example, up until a year ago, as Johnnie related, the Coast Guard didn’t carry naloxone on its Mayday rescue calls. Now it does. And in March 2020, the Coast Guard released a Marine Safety Information Bulletin, stating:

    “Consider carrying nasal naloxone on your vessel. If no one on your vessel is experiencing distress, you might be invaluable to nearby vessels that are in distress. Narcan can save lives. If a person is breathing, they are able to live and access support services.”

    When you’re 30 miles from land, it is a reality that other crews are likely to be your first responders. So local trainings encourage each vessel to include naloxone in its first aid kit—spreading the message that an overdose is equivalent to any other medical emergency at sea.

    “Even if you are out in the same area fishing, if something goes wrong on another vessel of a crew you have issues with, you get there if they send out a Mayday call for help, without a thought,” an older, stoic fisherman at one training told me. “Fishermen look out for one another—even competing crews. They know they are their own first responders on the water.”

     

    Policies That Create Dangers

    Naloxone is clearly vital, but it is also a last port of call. A better legal landscape would allow critical conversations to reduce the occurrence of emergency situations. Currently, under federal regulations pertaining to marine investigations, revoking a mariner’s credential or endorsement is mandatory when:

    “(a) A charge of misconduct for wrongful possession, use, sale, or association with dangerous drugs is found proved. In those cases involving marijuana, the Administrative Law Judge may enter an order less than revocation when satisfied that the use, possession or association, was the result of experimentation by the respondent and that the respondent has submitted satisfactory evidence that he or she is cured of such use and that the possession or association will not recur.

    (b) The respondent has been a user of, or addicted to the use of, a dangerous drug, or has been convicted for a violation of the dangerous drug laws, whether or not further court action is pending, and such charge is found proved.”

    The regulations also state:

    “Anyone holding a US Coast Guard captain’s license … will have to wait a least a year after a conviction to renew that license and also complete a drug rehabilitation program, among other requirements (the same holds true for state drug-possession violations)…”

    So a captain will not only lose their boat in such a case—threatening the livelihoods of all crew members—but they will also be mandated to treatment to regain their license and their job.

    These wide-ranging, low-threshold conditions place captains and boat owners under enormous pressure—potentially even over small-scale marijuana possession, and particularly in cases where drugs on board are weighed to determine possession versus “intent to distribute”—to prevent any kind of drug use on board becoming known.

    Stories about boats being “tossed”—by the Coast Guard, the environmental police or sometimes owners, are frequent. And these well founded fears prevent crews from having authentic conversations about safety and overdose risks at sea, even with one another, that could dramatically diminish their risks.

    The need to be silent can be deadly. But every single fishing person I speak with about drug issues mentions, above all, not wanting their captain to lose their boat. Because then, as one person put it, “We are all fucked.”

     

    Cultures of Silence

    Georgia, who helped facilitate a virtual Occupational Services Overdose Prevention & Response training a few months back, was devastated by losing her eldest son to an overdose a little over a year ago.

    He was found in his docked boat, alone, the following morning by crew members who were meeting to head out for their trip. Georgia was full of warmth and sadness as she spoke about her son and how funny and independent he was.

    “I am not sure how to talk to him about it.”

    Her younger son, a fisherman too, sat quietly by her on the screen. During the training, after we discussed the physical symptoms of overdose, he looked up intensely.

    “When you were talking [about that] it was too much,” he said. “It brought back too much of the memory of the details that morning, it’s all true.”

    “I am worried about one of my other crew now too, who I know doesn’t even feel safe enough to tell me he’s using, especially after my brother,” he continued. “I am not sure how to talk to him about it.”

    He became animated later in the training over the zero-tolerance federal regulations he has to contend with on the family’s boat. “Even marijuana, once we are in federal waters, I could go to jail and we could lose the boat over weed on board!”

    These trainings and other collaborative events create safer spaces to overcome a culture of silence. They spark honest conversations that begin to dispel stigma around substance use at sea within the community. They lead many captains who were in the past concerned about perceptions of their boat and crew to see naloxone as a simple safety precaution. That makes a world of difference to people who use drugs at sea—it is an act of love.

    Other times, a frightening experience prompts new priorities. I vividly remember taking a call at the harm reduction center last spring, from one of the local FPSS navigators.

    “Of course, tell them to come down,” I said. “Yeah, right now, before they go back out.”

    A captain and three of his crew members were close by. They had just returned home from their trip unexpectedly, after becoming worried about one of the crew. Their crewmate, they said, “looked like he was in trouble a few minutes after we left shore.”

    They realized they didn’t have any naloxone in the first aid kit. The captain had the good sense to turn the boat around, administer rescue breathing and get him to the local hospital, and he was alright.

    But as the captain said, “That was too close of a call for me.” So before heading back out, they asked to come by, to be trained and given naloxone kits for the boat.

    In federal waters, we still can’t say whether the fishing community is protected when that Mayday call is made.

    There is still a long way to go, however. The Coastguard’s March 2020 Marine Bulletin that recommended naloxone also stated:

    “As always, any vessel casualties which may have resulted from substance abuse is considered a reportable marine casualty and should be reported to Coast Guard command center via VHF channels 16 or 22…”

    “I don’t really get it,” Paul, a willowy young fisherman, said to me once at the harm reduction center. “The Good Samaritan Law, right? If I am on land, I am covered if I rescue someone. If I am at sea and they think they are my drugs and I rescue my crewmate, I am not? That should change.”

    Paul is right. I still haven’t been able to get him a clear answer about whether he’s covered out at sea the way he would be on land in Massachusetts. The question was not addressed in the Marine bulletin. I have asked the Coast Guard, Massachusetts Environmental Police and local police departments, and none of them have provided a definitive answer. Without that assurance, the practical answer for fishing people is no.

    In our ODP trainings, the clearest we can be is to advise people to check their state laws; Massachusetts is covered. In federal waters, we still can’t say whether the fishing community is protected when that Mayday call is made.

    A naloxone kit by the docks

     

    Health Care Out of Reach

    I first met Nick at a small FPSS overdose prevention training. He, another crewmember and a fishing family member there all identified as people who use drugs. The family member’s mother was also there; she didn’t identify as a drug user, but wanted to learn how to use naloxone in case of an emergency with her children.

    During the training, Nick shared that although he had previously overdosed, that risk was not his main concern—it was a lack of insurance coverage for his Suboxone.

    “I will be back at home with lots of connections to dope if I want, but not to a doctor that will get me a Suboxone script.”

    “When I am out for the season,” he said, “I am pulling in $60k a year [and] my insurance and Suboxone script is covered for months, right? I get home, and boom: My insurance gets all glitched up and MassHealth says I made too much this year to cover me, so I am stuck. Without my Suboxone and facing getting sick. Detoxing from Suboxone is worse than coming off dope. I will be back at home with lots of connections to dope if I want, but not to a doctor that will get me a script with no insurance.”

    “I heard there is a monthly shot too,” he added, “but no one has it for us up here. It would help with us being able to work out at sea and not being sick, us fishermen.”

    Nick was talking about Sublocade, which is a monthly injection of buprenorphine—a partial opioid agonist that currently can only be administered by a waivered provider. And he was right: If a person working on the boats for a season had the option of being given the monthly injection, this could make a real difference to their health and safety if they chose.

    I gave Nick the local harm reduction program’s contact info, and arranged with one of the FPSS community health navigators to get him some providers’ numbers and to try to get his insurance back on track.

    Before leaving, he laughed and said, “I have been dealing with this on-and-off for years. There has gotta be a better way!“

    We both shook our heads.

    It is hard for people in the fishing community to maintain health insurance for many reasons, often related to their unpredictable incomes. Large numbers of fishing people do not have a permanent address, and couch-surf with other crew members. Some do not have current IDs, or any at all. This makes care inaccessible, with sky-high out-of-pocket costs no option at all. And longer-term treatment is often simply impractical anyway, when you have to keep going back to sea.

    “There is no time for me to make my physical therapy appointments, like other construction workers or something” one crewmember told me. “We gotta get back out to live.”

    Drugs are simply accessible and practical in a way that health care is not.

     

    Matching the Drug to the Task

    Jack is a fisherman first. But he often tells me how much he believes in the mission of harm reduction. He regularly meets us in the community for quick deliveries, and almost always grabs extra safe, sterile supplies for others who are still hesitant about accessing drug-user health services openly. He is a genuine secondary exchanger at the docks.

    One day, he folded his tough hands over one another as he talked fast and proud about how hard it is to work on a rough sea. His long, lean body moved quickly as he told me about the ways that the fishing community practices harm reduction for itself without using “the language.”

    “Scallop boats full of Red Bull, caffeine and speed. It’s part of the way we can be good at our jobs and last out there.”

    “We get a bad name, we fishermen,” he said. “But a lot of us are in so much pain, you know? Like, by the time we are 30 years old, we are already feeling it. And it’s what we know that works; we learn it from the old fishermen. We aren’t going to not look out for one another, if one of us has something to help with the pain and we got five more days on a trip.”

    Jack described fishing people’s remarkable ability to match the drug to the work. “You are going out and you know that you are going to have to be shucking scallops for 18 hours straight. The burning of your hands, speed helps with that. Scallop boats full of Red Bull, caffeine and speed. It’s part of the way we can be good at our jobs and last out there.”

    “There is nothing worse than being in withdrawal out in the middle of the sea,” Steve, who identifies as having been in recovery for over three years, shared with me when he stopped into the harm reduction center to get a naloxone kit for a friend’s safety planning.

    “I have been vomiting off the boat before, and all ‘cause I thought I had enough pills to get me through, and then the captain ends up saying we are going to go for another day or two,” he described. “The waves crashing over you as you are heaving, there is nothing worse. But you gotta just push through it, you know? Headphones on, drifting. Sometimes one of the crew or another boat might be able to look out—you know, floating pharmacies.”

    “Other crews are the first ones to show up as first responders with Narcan on their boat if there isn’t any on ours,” he continued. “People don’t talk about that enough—how we look after our own out there. We don’t talk about it, but we do. Most of us are humble, loyal guys, and we just want to work, make our money and go home.”

    “We all know that people use or need to use drugs and we are all ok with it … but we don’t talk about it.”

    Yet Steve acknowledged the culture of silence that persists around drug use in this community—and the role of punitive policies in perpetuating this. “When it comes to drugs on the boats, we all keep to ourselves mostly though … we understand the risks it means for the boat and our captain.”

    “Some fishing people talk about the ‘code of secrecy,’ where we all know that people use or need to use drugs and we are all ok with it, and tell each other to catch sleep if we have been up too many days, but we don’t talk about it,” Steve concluded.

    I could see him thinking about the risky irony of this. “Sounds familiar,” I replied.

     

    Pain and Soldarity

    I met Michelle at another local overdose prevention training. In her late 30s, in her oversized Carhartt sweatshirt, she has a sly smile that lets you know she already has your number before you open your mouth.

    “I started working on the boats for just a few trips a year with my friend, to help her out,” she told me. “We are the only two women on the boat.” She laughed as she described how they always end up being caretakers to the crew and in the community, “not so much at sea though, but when everyone gets back home.”

    “My boyfriend has been using heroin for a few years, and more recently fentanyl, I guess now,” she said. “He is able to cut back out at sea, like on a real schedule, and is safe. But when he gets back ashore, and during the colder months and he is not working, it is really hard. I have had to rescue him a few times with Narcan and it is terrifying.”

    She started to tear up.

    “He just can’t be honest about what is going on, ‘cause our livelihood is tied up in it. He can’t go to treatment. It doesn’t work for us really. I love fishing and helping my friend. But I worry constantly about him, and if he does want to get help for a few months, will he get kicked off of the next trip, and how long is it going to be to get him the help before we need to go out again?”

    “It’s just stuff other people—like, not in the fishing community—don’t get unless you live it,” she said. “Most people don’t die out on the boat from what I know; they die back at home.”

    I thought about what Michelle said for a long time after—about her pain in facing the unknown, and in being the caretaker for someone that she feels is safer when gone for long stretches at a time, and what that must be like.

    I thought about the community’s strength and solidarity. About the daily experiences of fisherpeople, with the push and pull of working a body-punishing job day in and day out, and finding relief in substances—or maybe just enjoying them when they find a break from it all, like most people.

    Drug use isn’t the reason behind overdoses, however many people see it that way. Rather, it’s a society that doesn’t offer security and health care to everyone. And it’s a War on Drugs that extends far beyond the land into the air and waters; it’s wild when you think about its reach.

    If we had a safe supply of drugs, we wouldn’t be sending fishing people out to sea for weeks with drugs they haven’t been able to test. And if we didn’t have punitive drug laws, fishing people wouldn’t be forced to rush their drug use and keep it secret from captain and crew under what feels like an oath—because your job, your liberty, your family, your vessel and the community you love are all at risk.

     


     

    All photographs courtesy of Kristin Doneski.

    *The first-name sources quoted in this article are all pseudonyms, to respect the privacy requested by the people interviewed.

     

    • Kristin Doneski

      Kristin is a program manager of a harm reduction center based in Massachusetts. She is a harm reductionist who has had the honor of learning from, working alongside and being part of communities of people who use drugs in San Francisco, Massachusetts, Maine and the UK.

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