Drug overdoses (better described as toxic drug mixtures and poisonings) claimed nearly half a million lives in the US between 2000 and 2014. It was around 2014 that federal grants were made available for cities, counties and states, allowing them to organize community-wide initiatives aimed at curbing drug-related harms. One might expect this widespread expansion of community coalitions to correlate with substantially fewer drug fatalities in those areas and nationwide. This is not the case.
I was a member of one such coalition in Burlington, Vermont in 2017. Its partners were politicians, police departments, schools and nonprofit organizations; its members were clinicians, teachers, parents and other community stakeholders. To my dismay, our regular meetings centered around the questions of, “How do we stop people from taking drugs?” and, “What will it take to convince people that they need treatment?”
Note that these questions smuggle in an assumption that cutting drug supply and swaying drug users to seek treatment will solve our problems. It is seemingly subtle assumptions like these that leave us spinning our wheels, limiting our ability to follow strategies that improve and sustain lives—perhaps making matters worse than they were originally.
Take, for example, the recent strategy of deploying “post-overdose response teams” (PORTs) to the homes of people who have overdosed. PORTs have been used in several states, including Pennsylvania, Illinois, Ohio, Vermont and most recently, North Carolina. They sound good and mean well, but are often associated with negative consequences for the people they’re meant to help.
Post-overdose response teams are groups of professionals—typically a social worker, an EMT, a peer-worker, and either a police officer or a firefighter—tasked with visiting overdose survivors at their homes once they’ve returned home from receiving medical care. The hope, according to SAMHSA, is that this group of compassionate professionals will create an “opportunity to direct people to harm reduction services for active drug users and treatment/detox services for drug users looking to reduce or stop using.” It may sound reasonable, but the devil is in the details.
A surprise visit from a team of professionals, however well-intentioned, is not respectful or person-centered.
One problem is that it puts vulnerable overdose survivors further on the back foot. Visiting a patient at home without warning is a system of care unique to drug users. It tacitly suggests that the patient in question isn’t worth notifying ahead of time, that they’re better off being surprised.
Needless to say, surviving an overdose is already plenty to endure, with societal stigma often producing feelings of shame or embarrassment. A surprise visit from a team of professionals, however well-intentioned, is not respectful or person-centered. Many PORT team members I have spoken with admit that they don’t always receive a warm welcome.
Such problems are amplified by the involvement of law-enforcement officers, as harm reductionists and drug policy experts widely note. Maia Szalavitz, an addiction expert and author, told Filter that there is no reason for law enforcement “to be involved or present when people who have overdosed are followed up.” She added that “follow-up by social workers or qualified peer recovery specialists is fine and may help some—but police are not social workers or addiction experts, and people with addiction tend to have long, negative histories with law enforcement.”
This rings true to me. I nearly died after taking a toxic fentanyl/heroin mixture when I was still in my twenties. Luckily, after a 911 call, I was revived with the opioid overdose reversal drug naloxone.
The following day, a local police officer—obviously aware of the incident—called my home and left a message, asking me to visit the police station and speak with her. Then she followed-up with an email version of her request. I wished to decline but I felt vulnerable. Out of fear, I decided that it was in my best interest to speak to the officer.
But this wasn’t a check on my well-being. Instead, the officer lectured me: She told me that my (drug-taking) behavior was dangerous and that I was lucky to still be alive. Then she asked if I would be willing to turn in my drug dealer. I declined.
Diane, a harm reduction advocate from Illinois who asked that her last name not be used, has direct experience with police officers in the context of post-overdose response teams. Unfortunately, she’s had more than one encounter with these teams following her adult son’s drug-related emergencies.
“It felt like an invasion of my privacy. They asked me some questions that made me uncomfortable.”
Diane told Filter that she still remembers the awful feeling she experienced in her latest encounter with a post-overdose response team in 2019. It happened “three days after my son’s last overdose,” she said. “I heard a knock on my door and when I opened it there were two detectives standing there. I almost fell to my knees. In that split second I thought this was the knock I have been dreading for 15 years.”
She waited, painfully, to be told that her son had died.
“The detective realized what I was thinking and said that this was just a follow-up visit,” she continued. “It felt like an invasion of my privacy. They asked me some questions that made me uncomfortable, so I told them that they needed to talk to my son.”
The response team offered Diane’s son a few different options: to be placed in detox and/or to enroll in the nearest methadone clinic and outpatient treatment service; or to be assessed for immediate placement at an inpatient rehab.
But Diane and her son, whose experiences with such services have not always been positive, asked if there was anything more practical and accessible on offer. Diane, for example, asked if the officers could provide them with harm reduction supplies such as naloxone. The officer told her that the county didn’t have the resources to provide such things.
Diane believes that the response team meant well, but that their intervention was not worth the fear and trouble they put her and her son through. She doesn’t see how this process has anything to do with harm reduction.
“I pretty much shut down when they told me they weren’t providing Narcan to people,” she said. “Maybe there are people who appreciate these home visits and take advantage of what they offer, but I am not one of them.”
In fact, the most common reason people don’t seek medical attention for an overdose in the first place is because of fear of law enforcement. If a person associates their ability to access harm-reduction resources with the police, that’s an obvious barrier for many.
Harm Reduction Versus Coercion
It should be noted that although Diane’s response team did not offer harm reduction resources, PORTs in most states do. But showing up at a person’s doorstep, unannounced and often with law enforcement present, is a uniquely intimidating way to deliver such resources.
James, a carpenter from North Carolina who asked that his last name not be used, recalls his own visit from a post-overdose response team, also in 2019. “I remember getting back home after my OD and just feeling utterly embarrassed,” he told Filter. “I was thinking, ‘Damn, I need to rethink what I’m putting in my body’ and I really wanted to do that thinking alone.”
But James’s independent self-reflection the day after his overdose was interrupted by a paramedic and a social worker knocking at his door. Thankfully, there was no police officer. However, “I didn’t want to see anyone really, but the last person I wanted to see was another paramedic,” said James. “They weren’t mean or anything like that, but the whole thing was pretty intrusive. They kept talking about treatment options but I just wanted them to go away. I didn’t need treatment; I needed time alone.”
The resources offered are tied to a set of assumptions about drugs and the people who use them.
“I kinda wonder,” he continued, “if I went to the hospital for any other condition, like a broken leg, would I be getting an unannounced visit to my home to tell me about my physical therapy options?”
The pressure inherent to these visits marks the distinction between harm reduction and coercion.
The stated aims of post-overdose response team programs similarly cross that line. The resources offered by PORTs—however helpful in themselves—are tied to a set of assumptions about drugs and the people who use them: that overdose survivors ought not be left alone; that they will require treatment; that if they won’t admit to needing treatment now, they will hopefully come around. A few examples:
* Vermont’s PORTs are designed “to persuade drug users to get help“
* A PORT in Pittsburgh hoped to “nudge overdose survivors toward treatment”
* PORTs in Ohio want to be sure that they link patients to treatment, “which would prevent them from doing it again”
When NPR reported on PORT efforts in West Virginia, it titled the piece “Knocking on Doors to Get Opioid Overdose Survivors Into Treatment.” One of the PORT nurses reinforced NPR’s narrative when she told the interviewer, “It can take time to convince people who have overdosed that they need help.”
This treatment-driven mentality strips overdose survivors of their agency by failing to center what they want.
Drugs, Addiction and the Disease Model
If a person takes drugs, even if they’ve overdosed, it doesn’t necessarily follow that they are addicted. (Most are not.) If they are addicted, it doesn’t necessarily follow that treatment will be the best course of action. (Most people recover without treatment.)
PORTs—and drug task forces nationwide—are operating under the opposite assumption: that drug users require treatment to better their lives.
The current fentanyl-adulterated illicit drug landscape means that even people who use occasionally are at increased risk. In other words, many people who may be at risk of overdose are not people who will benefit from treatment services; they are people who will benefit from harm reduction services.
I once asked my fellow Filter contributor Stanton Peele, (whose Life Process Program I work for) to define harm reduction. I will forever remember his answer: “Harm reduction is helping people, non-judgmentally, to live their best lives—starting with surviving—no matter where they start, or what hole they’re currently in. Meanwhile, the helper wants to convey his or her confidence, without criticism, that this hole is not their permanent resting place.”
Harm reduction is also not primarily something that can be manufactured by authorities and deployed in a community from the top-down. Harm reduction is a bottom-up, organic process, instigated and primarily driven by impacted people.
Because if someone is suffering from a disease over which they have no control … then surely the compassionate thing to do is to treat them, whether they say they want it or not?
But the disease model of addiction—championed by the National Institute on Drug Abuse in its “brain disease” framing, but related in its implication of powerlessness to the 12-step ideology that has long been embedded in American culture—has led us down a different road altogether.
Our national acceptance of the disease theory directly harms people who use drugs by teaching us that we are powerless over some process in our brains (or souls)—a belief that becomes self-fulfilling.
And at a policy level, it provides the impetus (and funding) for interventions like PORTs that deny drug users agency. Because if someone is suffering from a disease over which they have no control—as opposed to engaging in chaotic drug use as a comprehensible response to their social and/or psychological circumstances—then surely the compassionate thing to do is to treat them, whether they say they want it or not?
As a result, the community-oriented strategies that receive federal funding ultimately serve an ideology rather than human beings.
Could a version of PORTs that truly entails harm reduction be imagined? Probably. But it would depend upon, and only operate according to, the wishes of impacted people. It would rule out law enforcement involvement and surprise visits. And ideally, it would operate within a framework that supports people in using drugs safely (and therefore legally) and addresses the suffering and inequalities that foster chaotic drug use.
Detail of photo by Staff Sgt. Nicholas Rau via US Air Force/Public Domain.