Uncle Tim performs YMCA

There's a better way

IN FEBRUARY 2024, I am 21 years old getting my Master of Science at Northwestern University. I have decided to pursue Journalism, largely out of watching my home -- Appalachia -- be portrayed in terms of flat stereotypes, as an impoverished, homogenous and hopeless place. In some ways, my family -- which has lost Uncle Tim to addiction and, in March 2023, my father to cancer; is known to throw back cheap beers and smoke a pack; let the twangs in our voices slip out and entered into many delightfully humorous and ridiculous redneck shenanigans -- is an Appalachian stereotype. In other ways, we -- a family of PhDs and Doctorates, Master's degrees and mindfulness, liberals and social-justice activists, even queers like myself -- are entirely at odds with who the rest of the world seems to think lives in these hollers. I wasn't patient or content enough to be a teacher so I followed the only passion I've ever had: storytelling.

But since September, 2023, I have lived in Chicago, and for nearly a week now I have been in Puerto Rico. Ever-so-strangely, on this tropical island, I have found a mirror of my home as we explore an under-privileged and oppressed, polluted land — full of passionate people.

In some parts of Santurce, flooding regularly destroys the housing, and the people rebuild. We have biked through the narrow streets and are now looking out over a grassy, almost lagoon-like area as bumblebees drift sleepily between clover flowers and the afternoon sun drips down on us like boiled honey. Across from us is a bar, music spilling out of its low walls. Behind us, people are gathered at outdoor tables, chatting as they lounge and drink. A garage-like structure forms an open-air, small bar that also sells a few quick goods like batteries and snacks and has a pay-to-play pool table. As we purchase a dozen water bottles, a friend and I — drenched in sweat, dirty in workout clothes — dance to the music. A woman strolls by us, laughing and smiling at our silliness. Outside, a cat stretches out on the pavement and rests in the shade between the plastic tables. A few friends of mine squat around it and coo over it, and from one of the outdoor tables a woman calls out in Spanish. Our friend translates, “She said if you like it so much, just take it.”

We laugh and head on our way refreshed; days later, we meet with a professor at the University of Puerto Rico, and mention our trip through the neighborhood. “And you got out alive?” he asks dryly. “It’s not a good neighborhood.”

All of us are surprised. Maybe it was the area, the time of day, but we all felt welcomed. Wanted, even. The people were friendly with us, with each other.

The next day, at Intercambios Puerto Rico in Fajardo — a non-governmental organization doing harm reduction work for substance abusers, sex workers, and more — we are greeted by a bearded man, Rafael Torruella, who high-fives each of us. We spend the next few hours watching him and his co-leader, a psychologist, present a slideshow on the organization’s founding, current work, and intentions — and the state of drug use in Puerto Rico. The two men curse regularly and occasionally bicker over a specific point or varying view they have, or how best to translate something from English. Though the room is sterile, frigid and windowless — this is, after all, a clinic — their banter is warm and engaging, their passion infectious. Luis suggests a break and I catch the word fumar. He says, “I know at least one of you smokes, somebody just went outside.”

Six or seven of us gather in the parking lot, warm and shaded, in view of a

perfectly cloudless sky. As another classmate and I pull out cigarettes, he lights

his own and comments on how common smoking was back in his day and how

he never sees students do it nowadays.

“I’m not judging you of course,” he says. “I’m a smoker too.”

My cigarette and two vapes circulate amongst the students, while my classmate

begins asking him about drug policy. Within a few minutes they’re deep in a

good-natured argument, entirely unaware of our presence. When we eventually

head back inside, they don’t follow for another five or ten minutes. In the hallway

outside the presentation room, we see them both pull up their phones and compare notes, still arguing.

The latter half of our time is more discussion-based; we ask questions and the men are willing to take the conversation wherever we’re interested. Sometimes it’s specific and scientific, other times theoretical and psychosocial. They pass around a vial of naloxone for us to look at, then a dose of nasal-administered Narcan and another that works like an epi-pen. They discuss the varying prices and efficacy of doses, and the racist, oppressive, and largely white, Christian roots of the shameful, punitive strategies used against drug abuse. A few of us accompany Rafael to pick up lunch, and we leave with full bellies, stickers that read "No guerra contra las drogas," fentanyl test kits and, if desired, free condoms. We disperse, and Luis takes a few students to see an open-air market that doubles as a beer garden.

There is total openness, total lack of judgment, and a vibrant, personable spirit entirely unconcerned with the false pretenses of “professionalism” and formality. It reminds me of the good ‘ol boys back home — some of the smartest, most activistic people I’ve known. I can’t help thinking how much my uncle, and how well he and these men would have gotten along. How the work they did would have saved his life.

IT WAS RAFAEL who taught me that, “Even if we do away with the opioid epidemic or overdose crisis, the main root problems will still persist: bad policies regarding drugs, drug users, health management.”

And to find those roots, we start with a simple question: “Why do people use drugs?”

Because, according to Rafael, of the failure of the healthcare system, they’re in pain — physical or mental, as a result of many different afflictions, including enduring unemployment, poverty and living under capitalism.

“This is what happens when you don't have adequate healthcare, which means universal healthcare,” said Rafael. “It’s not about opioids, it’s not about overdose, it’s not about fentanyl; it’s about the failure of the war on drugs.”

And the War on Drugs is a war of race, class and gender. It was a war started for oppression and which continues to perpetuate oppression of non-white, non-traditional and non-wealthy individuals.

Puerto Rico suffers heavily from the fallout of the War on Drugs, with high rates of overdoses and diseases spread through intravenous drug-use. On the island, Intercambios operates independent of the government, and practices something called harm reduction, which mitigates the effects and risks of drug use.

Examples of harm reduction include:

Clean needle programs, where sterile needles are provided for intravenous drug use to prevent the spread of diseases like HIV and Hep-C
Testing kits to show the makeup and potency of a drug
Naloxone or Narcan for overdose prevention and/or reversal
In rarer cases, safe-use centers (i.e. a place overseen by medical professionals and ready with life-saving equipment, where people who can use substances with consequence-free, life-saving supervision)

Harm reduction is a notable alternative to other treatment options in several ways:

It is not abstinence-based, meaning that someone can benefit from harm reduction while still engaging in substance usage
It is usually distributed/conducted by organizers involving current or previous drug users, creating both a sense of community as well as eradicating shame, misunderstanding and judgment

The numbers of harm reduction don’t lie: it reduces deaths, strain on public health infrastructure (e.g. ER visits), the spread of diseases and more. It also often connects people who use substances with programs that help them reduce or cease their usage.

If you’ve used a condom, you’ve benefited from at least one kind of harm reduction.

While Intercambios runs clinics, a mobile bus that brings care and supplies directly to those who need it, and more, one of the most common forms of harm reduction for opioid usage is methadone programs. Methadone programs are a type of Opioid Agonist Therapy, where certain drugs are used to reduce or eradicate opioid usage, largely by mimicking the effects of opioids/preventing withdrawal symptoms.

Rafael sees methadone programs as abstinence- and shame-based, which can make it difficult for people who use drugs to find longterm, maintainable stability.

Methadone programs, according to Rafael, are often reluctant to provide high doses of methadone — which can cause people who use drugs (particularly fentanyl) in high doses, to still suffer extremely severe withdrawal effects that make it difficult to stick with the program. Methadone clinics also often require patients to provide fully clean urine samples (i.e. no drugs in the system, for example marijuana), which is difficult as methadone only helps with opioid addiction.

In Canada, by contrast, “safe supply” — giving out clean drugs, including sometimes even heroin and meth — is not uncommon… And overdoses are staggeringly lower. For example, there were around 45,000 opioid overdose deaths between January 2016 and December 2023 — a seven year span — in Canada. In the US there were 107,000 overdose deaths in 2023 alone — and that was a 3% decrease from 2022.

If you wage a war on drugs, Rafael said, three things happen: drugs become cheaper, more accessible and more potent.

We’ve seen this ourselves with the transition from smokable opium to early opiates to heroin, to fentanyl, and now carfentanil and xylazine.

But, I decided to talk to a methadone doctor myself.

* * *

SHE IS A methadone doctor who had written an article on the opioid epidemic in Appalachia, tying its history with the coal industry. I was surprised to find that she was from New York, not the central Appalachian state where she works, and to instantly hear the defeated, flat tone of her voice — so at odds with Rafael and Luis’ boisterous intonations and passionate tirades.

I knew we’d disagree when she used the word "enabling," followed by, “If these needles weren’t being handed out, would these people still do what they’re doing?”

I wondered if she’d looked into the numbers, or talked to her patients, as the research shows that unequivocally the answer is yes. Providing needles just helps prevent the spread of Hep-C and HIV.

She described present-day incarnations of harm reduction as having capped out at, “Meeting people where they are… and pretty much leaving them there,” something she said in a listless tone was, “Still better than leaving them there dead, but not really ambitious.”

Still better than leaving them there dead, I thought. I imagined my uncle’s body graying on the motel mattress. I thought of the way my mother had wept. I thought of the reverence with which my brother touched his motorcycle, as if it were a delicate bird in his hands.

When asked about the policies that left us there dead, she said discussing them was “all very boring,” and that one of the main deterrents of access to care was the fact that people simply do not want it, or want to get off of drugs. (I thought here of my uncle detoxing violently and agonizingly in the VA, because there were no drug treatment centers with availability that were within driving distance.)

Instead, the doctor said, “they could actually enforce local laws [and] restore order… mandate people to drug treatment programs.” She is against housing first policies -- getting unhoused people who use drugs into shelters or affordable housing before demanding they seek treatment -- though I did not ask her how people should get treatment when they can’t get shelter.

When I asked her if she thought that cultural stigmatization of Appalachians and oppression of the region had contributed to the perpetuation of overdoses here, she said that there’s, “Not enough appreciation for the fact that there are educated people there… people who like wine, red wine,” even though many of her patients “look like they walked off a trailer park.”

Since most of my favorite people look like they walked off a trailer park, I decided to go home and see about the work being done there.

* * *

BACK IN TENNESSEE, I searched for people doing the kind of work that Rafael and Intercambios do.

Lesly-Marie Buer, 41, is the founder of Hellbender Harm Reduction in Knoxville, Tennessee, a medical anthropologist, and the author of Prescription Appalachia.

Like the Intercambios organizers, Buer works in both on-the-ground harm reduction — such as Hellbender’s programs that send naloxone and fentanyl test strips straight to people’s houses throughout Tennessee— and explores the sociopolitical

and theoretical side of this epidemic.

“For me, it’s all tied together,” Buer said. “You can’t just think about substance use by itself, you also have to

think about racism, capitalism, neoliberalism, etcetera.”

Hellbender, which was founded in 2022, three years after my uncle's death, works with other harm reduction

organizations to be open after regular business hours in order to provide access for more people — particularly

those with low-wage jobs who can’t afford to take time off.

Hellbender also collaborates with other counties in Tennessee to create harm reduction programs conducted entirely over mail, for counties where there are no accessible in-person programs.

In Tennessee, some policies make it illegal for individuals to overdose more than once -- or for community members, such as harm reduction workers, to save someone from overdose more than once.

“It’s a really sad thing that we’re leaving all this work [of saving lives] to people who are criminalized by our government and unpaid.”

Buer described the impact of “seeing the creation of community among people who have been really marginalized and isolated,” as people who use drugs have come together to help each other solve their own problems, despite having been harmed by the systems of oppression in the U.S., which particularly affect Appalachia and the regional South.

“True harm reduction,” Buer said, “should be staffed by people who do or have used drugs, giving power back to the people.”

While the ultimate goal is decriminalization, Buer described that as a near pipe-dream in Tennessee, where many legal barriers exist. Buer mentioned the illegalization of the TIR machine — which gives the exact makeup of a drug from only a small sample, and is very useful to harm reduction organizations -- as one of the heaviest barriers. Changes to the Good Samaritan law for reversing opioid overdoses — for example, that now in Tennessee a person overdosing is only given immunity for the first time they overdose -- also create problems. Additionally, drug-induced homicide laws make harm reduction providers and users afraid to call for help if someone is overdosing.

And even nationwide, “things are moving in the wrong direction,” said Buer, citing SCOTUS’ decision to allow for homelessness to be criminalized, a particularly important issue in Knoxville, where homelessness has been a longterm, severe issue.

“We’re doing everything we can to hurt the most marginalized people in our society,” Buer said. “It’s villainous.”

Buer’s Hellbender is in the same area of town where I used to work in a coffee shop. Nearby is what we call the bridge, under which there are always dozens of unhoused people.

An older white man with watery eyes and violently trembling hands once came into the coffee shop, most likely from that bridge. He showed me a $10 or $20 bill ripped in half. He asked me for some tape. I handed him some masking tape and watched for just a second before offering to fix it for him.

He agreed, and I taped the bill together.

“Do you think people would accept that?” he asked.

“Yeah,” I said. “I think so.”

He bought a drink with it, and I couldn’t help but smile at the ingenuity.

The bagel shop that shared a wall with us left all their bagels and bread

out at the end of the day. Saran-wrapped in two-packs, in a box out front.

Once, an unhoused woman had come in with nothing but tatters of a

shirt. Her teeth were rotted and her body bone-thin in the way of users.

I had some clothes I’d been meaning to take to Goodwill in my car so

I gave them to her. I didn’t have shoes, though.

Over the winter this year, one of the women I’d see most often died. She froze to death.

A community organization posted about her passing on social media. We all recognized her. It’s so much bigger. It’s all so much bigger.

BUT MIKE MEIT, Director of the Center for Rural Health Research at East Tennessee State University, didn’t emphasize those we’ve lost to the crisis, and how hard it’s been to address. He focused on what great work has been and is being done.

I got in touch with Meit through the Appalachian Regional Commission, and quickly realized he’s tired of the worn, tried-and-true narrative of Appalachia as impoverished, dirty, hopeless and sad. Ultimately, it’s this representation of Appalachia that allows for people to brush off and ignore how many of us are dying, under the idea that it’s somehow our fault as a result of backwardness, lack of education, or poor culture.

“We don't know who's using drugs. We know who dies from drugs,” Meit emphasized. “[Overdose] is one of the few causes of death where it is not predicted by poverty. If you look at heart disease, if you look at cancer, if you look at almost any leading cause of death, you'll see this strong association between poverty and health status… Even though Central Appalachia has economic challenges, that's not the case. The Northeast, for example, does not have the same levels of poverty, but has a similar issue with overdose mortality. That, to me, is an indicator of the thumb that was put on the scale by the pharmaceutical industry. They targeted our region.”

And Eastern Kentucky has suffered some of the worst effects of this. According to Meit, it has some of the highest overdose mortality rates nationally. But Kentucky is also one of the states that has made the greatest strides in reducing overdoses.

“We did a study… and what we found is that out of all of the counties in the entire United States, eight of the 10 counties with the steepest decline in overdose mortality were clustered in eastern Kentucky. Fourteen of the top 20 were in eastern Kentucky. That's success, and that is starting to turn the corner.”

Kentucky had accomplished this through both policy changes as well as community work. According to Meit, they expanded Medicaid and added benefits to allow substance abuse treatment to be covered. Because of that, Meit said, they now have treatment accessible at a moment’s notice — rather than like most places, where people seeking treatment generally have to join a waitlist.

Kentucky also has what Meit called “recovery supports,” such as Second Chance employment, housing for those in recovery, and community organizations that both help those recovering as well as raise awareness about the challenges of substance abuse.

The Kentucky criminal justice system is also part of these state-wide changes, and now refers people to treatment after drug charges rather than merely jailing them, Meit said.

Perhaps most surprisingly, Kentucky has also led the Appalachian charge on harm reduction. It is the state with the most needle exchange programs in all of the United States.

“It's not just preventing those secondary illnesses,” Meit said. “It's not just preventing overdose. It's actually creating that connection with individuals. Many of the individuals who ultimately seek treatment, have been engaged through harm reduction programs and the trust that it emanates from that.”

ANOTHER INDIVIDUAL WHO spoke to the success in Kentucky communities as well as some in Ohio and Tennessee, was Bridget Freisthler, a Ph.D. of Social Welfare. She was a contributing member on some research I looked into when formulating this project. Much of her work focuses on families and children exposed to substance abuse — i.e., exploring the generational fallout of struggles like the opioid epidemic, not just the statistics and the science of addiction.

As one of those fallout-children, I was interested in hearing her take.

Dr. Freisthler, unlike many who study the opioid epidemic in Appalachia, focused on where she’s seen success, particularly in Ohio, where she previously worked, and particularly within tight, small communities, or family units.

As far as the Kentucky communities, Dr. Freisthler spoke to the success she’s seen with the implementation of harm reduction vending machines. They’re stocked with naloxone, covid tests, pregnancy tests, wound care kits and more, and allow individuals to access them privately.

In Ohio, Dr. Freisthler saw success in communities where local emergency responders, such as firemen and EMTs, joined campaigns about how carrying naloxone gives them the chance to save a life. When these individuals, as well as sometimes community officials like local politicians or sheriffs, advocate for harm reduction, the stigma — and the fear of being punished somehow under, for example, Good Samaritan laws — is greatly reduced.

Despite my own familial experience with substance use, I hadn't considered how harm reduction also benefits families. One of Dr. Freisthler’s main areas of research is childhood trauma, particularly surrounding substance use. One of the most traumatizing things a child can witness is a trusted adult overdosing. Safe-use centers, for example, reduce not only the chance of that adult dying — but also save their loved ones from seeing it happen.

“The research is pretty clear: it helps,” Dr. Freisthler said. “If you look at things like safe-using, safe-using programs or safe use program sites, they’ve been happening in Australia and Canada for decades. We finally have our first couple here in the U.S., and even those are showing that it's reducing overdoses. It's not bringing more crime or harm to the local communities. It's very clear that there is a need for harm reduction."

Safe-use centers not only help break the cycles of trauma that often end up perpetuating substance abuse, but they’re also often gateways for individuals to access more harm reduction or addiction resources that can help them longterm.

“It addresses lots of things,” said Dr. Freisthler. “You know, not just they're not going to die, but they're going to have more access to resources. They're going to have more access to other types of support. You're not going to be alone, you're not going to be in danger of dying.

With the research clear that harm reduction resources help everyone involved in communities with high rates of substance abuse, the question then becomes how we make them more accessible. According to Dr. Freisthler, people are inhibited from accessing those resources both by federal policies as well as stigma amongst communities.

Like Meit, she emphasized the value of expanding

Medicare and Medicaid, which allows for healthcare

funding to be allocated to areas where it generally

doesn’t apply — in other words, for substance use

treatment.

But federal law surrounding Medicare and Medicaid

also often inhibits the success of harm reduction in

afflicted areas. For example, Medicaid reimbursement

rates are nearly the same as they were 30 years ago,

according to Dr. Freisthler. With the significant inflation that has occurred in those three decades, this serves as a massive deterrent to workers who might otherwise provide that care, but can’t afford to do it pro bono.

Policies like those against the TIR machine in Tennessee are also inhibiting factors. What is needed is a multi-pronged approach that deals with stigma and raising awareness, as well as breaking down systemic barriers.

* * *

NORAH LAUGHTER, 20, is one of the impassioned young people working to break down those systemic barriers -- and a member of those Kentucky communities making such immense impacts. She spends half her time at home in Russellville, Kentucky, and the other half nearly 1000 miles away, pursuing her undergraduate at Yale.

Laughter wrote an article about harm reduction in Teen Vogue, and after reading it, I wanted to hear about how a young Yale student practices harm reduction on-the-ground and what brought her to it. Selfishly, I also wanted to hear her experience of leaving Kentucky for the Ivy Leagues -- not unlike my own journey from Tennessee to Northwestern.

Laughter lives with her grandparents and has been aware since a young age that addiction runs in her family. As she got older, she confirmed that opioids were a big part of it. Harm reduction, she said, was always an unspoken, unnamed presence.

“I knew generally what was happening and I knew harm reduction was a thing for a long time, I just didn’t have a term for it,” Laughter said.

For example, Laughter said, her grandma used to always have something non-alcoholic to sip on or chew on and satisfy that sense of oral fixation.

“My family would kind of intellectualize it,” Laughter said, explaining that it wasn’t until she took a class on the science and politics of HIV and AIDs that she learned about harm reduction for diseases contracted through intravenous drug use, and connected that to the opioids, meth and more that have ravaged so many populations where she’s from, including her own family.

From there, Laughter got involved with labor organization and stakeholder organizing — i.e., the “power to the people” concept that Buer spoke about.

“My whole life I understood the principle and the necessity without knowing why,” Laughter said. “I went to Yale, and there it finally got intellectualized. Though, I’d rather hang out in Kentucky with people who actually get it.”

After a beat, she laughed and said, “I miss Kentucky so much when I’m at school. So much.”

There was a passion and a longing in her voice that I knew often wavered in my own.

Previously having worked with Vocal Kentucky, and now involved with Kentucky Harm Reduction Coalition, Pro-Palestinian movements, labor organizing and more, Laughter is passionate about telling stories from her region and of real-life experiences with these issues. She sees TikTok and the internet as a common way young people get educated about harm reduction and one of the platforms through which harm reduction is becoming truly multi- generational.

In the Kentucky Harm Reduction Coalition, for example, Laughter said there are many older activists. “Gen X, who lived through or were born during AIDs epidemic, and that informed a lot of their praxis and the ways they’ve approached harm reduction," she said. "Whereas a lot of young people are experiencing particularly the opioid crisis. That creates a very intergenerational balance where there’s a lot of history."

None of those involved, Laughter said, are content with the policies or the fact that wealthy white people are still going to be the ones who benefit. Most of them are, like her, involved in many movements simultaneously — whether it’s racial justice, labor rights or something else entirely. Without putting it in the exact words that Rafael used, our generation — which Laughter described as “ready to hop on the van” and get to work — has realized that overdose isn’t about drugs. It’s about injustice.

“The Venn diagram is often a circle, and it should be, because the real power is concentrated in the systems that we aim to destroy,” Laughter said.

So simply, in one sentence, Laughter encapsulated what the Intercambios workers and Buer had also said: It's not about the opioid epidemic. It's not about fentanyl. It's not even about harm reduction, though that's proven one of the most effective ways we can take care of ourselves and each other.

It's about a system that is not built to support us, not built to foster community, not built to keep us healthy, and is ultimately indifferent to our deaths.