The “opioid crisis” has dominated drug conversations for at least the past decade, while relatively little has been heard about the use of stimulants—a category including illicit drugs like methamphetamine and cocaine, as well as prescription drugs like Adderall and Ritalin. Over the past year, however, researchers, followed by the media, have been drawing public attention back to stimulants, pointing to the soaring rate of stimulant-involved drug overdose deaths. According to the CDC, the number of overdose deaths involving stimulants increased by 33.3 percent from 2015 to 2016, and provisional counts indicate they increased by 39 percent from 2016 to 2017.
But in the rush to bring attention to stimulants, it’s crucial that we don’t simply jump to decrying a new “epidemic.” Instead, let’s make our strategies more inclusive of the reality that most people are polydrug users.
I’ve seen that first hand as Executive Director of the People’s Harm Reduction Alliance (PHRA), the largest needle exchange in the US. The vast majority of people who use our services use more than one drug. Two-thirds use cocaine or methamphetamine (or both). PHRA is a peer-run organization in the Pacific Northwest established in 2007 in response to the government removing all funding for syringe exchanges (they have since resumed funding). We give out about 7.5 million syringes a year. I’m also the founder of the Seattle chapter of the Urban Survivors’ Union (now the National Drug Users Union).
My own drug use, plus over two decades of working with people who use drugs, leads me to believe it’s crucial that we incorporate services for people who use stimulants into our existing infrastructure for opioids. Here are some do’s and don’ts for doing so.
1. Don’t lean on stereotypes.
A common misconception is that all meth users are white men from sparsely populated rural areas, and that all crack users are black men who live in cities. These myths can have dangerous consequences. For example, when the University District needle exchange program, where I worked, started handing out safer crack kits in 2010, the University Chamber of Commerce contacted me and asked why we were giving out crack pipes when so few black people live in the U District. In fact, the vast majority of people who have accessed our safer crack kits have been younger white men who typically go to the University of Washington. If the University District needle exchange had relied on stereotypes, there wouldn’t be a comprehensive pipe program, and we would have neglected a population of people who needed services.
2. Don’t assume method of use.
Another common mistake is to assume that all drug users are injecting, and forget how many people — especially those who use stimulants — smoke or snort their drugs. Smoking and snorting carry their own unique set of benefits and risks, and these type of drug users can’t be left out of programs, whether syringe exchanges or future Safe Consumption Spaces.
3. Don’t pigeonhole people by their drug use.
Remember that there are very few drug users who use only one particular drug; the vast majority of drug users are polydrug users, and they have been throughout the past decade, in spite of the focus on opioids. In addition to those who intentionally use multiple drugs, many people who use illegal drugs may be unintentional polydrug users. Illegal drugs, including stimulants, are often quite adulterated with other substances, including bath salts, PCP, Epson salts, and fentanyl. When a substances is illegal, the FDA has no authority nor ability to regulate the drug supply. By criminalizing drugs, we have chosen cartels not the FDA to look out for the quality and safety of our drug users. In addition to the potentially fatal consequences of using adulterated drugs, we have noticed more and more mental health crises among those who use adulterated stimulants. Regg Thomas, the chapter president of the Seattle chapter of the Urban Survivors Union says, “ I’m seeing more methamphetamine users struggling with psychotic breaks in a way we have never seen before. This has to be the cut of the drugs. This is why I advocate people test their drugs before taking them. You just want to know what you’re taking.”
In addition to drug testing, there are several other concrete strategies we can implement to engage stimulant users in harm reduction services. Some programs do one or two of these services, but it is very rare to find all of them combined.
1. Do offer people food.
This is one of the simplest, yet most helpful things you can do. Miso soup or chicken broth seem to be a favorite of many programs, as they are cheap to make and give the person the opportunity to ingest some nutrients. Stimulate users can be up for days without eating or drinking, and so getting their metabolism working again can be really helpful. Plus, the simple process of sitting down to eat provides them with a break or a breather. This can give them the opportunity to make choices from a calmer, less urgent state.
2. Do provide snorting kits and pipes of various types, in addition to syringes, in order to engage stimulant users.
Providing snorting kits and pipes has several benefits. Using damaged pipes increases the likelihood of cuts to the hands and lips, increasing risk of infection. And sharing pipes has the potential to transmit HIV, Hep C and other illnesses. Providing easily accessible, new pipes reduces those risks. Also, whether we’re talking about opioids or stimulants, you get less of the drug by smoking than injecting, and so transitioning to smoking can be a great way to help reduce use for those who have previously injected. Many active injectors switch to smoking when programs provide pipes. In the eight years that we’ve been providing pipes at PHRA, we’ve been able to give out over 80,000.
3. Do incorporate stimulant users into plans for Safe Consumption Spaces.
As we talk about the possibility of the United States developing safe consumption spaces (SCS), most programs are focused on opioid users. Almost all existing consumption rooms have created “chill out zones,” which are designed to monitor users to prevent overdoses. But stimulant users who have just received a large rush likely have no intention of sitting down and being quiet. We can’t push stimulant users into these rooms among opioid users who likely want to relax. However, if you have thoughtful policies that keep stimulant users in mind, safe consumption rooms can be great at connecting people to comprehensive services like health-care and housing. One idea is for SCS to include smoking rooms. PHPA has designed plexiglass stalls with filters that you can smoke in, while someone on the other side of the door can help you with anything you need to know, as well as monitor you in case of an overdose. SCS can also provide a space where people can move around, even dance if they want to dance. Not a quiet room; more like a “busy” room. Some harm reduction programs already provide spaces like that, and it’s very valuable for their folks — people have a place to be where they don’t get arrested, they don’t get targeted.
4. Do provide safe spaces for stimulant users even while we wait for SCS.
When someone is coming down from a stimulant, they will likely be exhausted after being kept awake for so long by the drugs. The come-down can occur at any hour of the day, and often lead the person to sleep for 12 to 20 hours. They need a safe space to do that. For folks who live on the streets, sleeping is one of the most dangerous acts you can do, as it is time when you’re not alert and not able to defend yourself. Provide space where someone can just sleep, uninterrupted, when they have no place else to go.
5. Do treat people like full human beings.
Rather than thinking about specific “drug treatments,” treating the full person, and their range of physical and mental needs, is the most effective way to prevent needless harms and keep people alive. In my 22 years of working among people who use drugs, I have rarely seen someone change their life in response to being told they’re a bad person. For someone who is in a state of chaotic drug use, it has probably been a long time since they were told they were loved. Providing welcoming services that are inclusive to stimulant users is an important part of combatting the overdose crisis and keeping people alive.
Photo: Safer Snorting Kit via People’s Harm Reduction Alliance