Speaker 1: Hi, I'm Ethan Natalman, and this is Psychoactive, a production
Speaker 1: of iHeart Radio and Protozoa Pictures. Psychoactive is the show
Speaker 1: where we talk about all things drugs. But any views
Speaker 1: expressed here do not represent those of iHeart Media, Protozoa Pictures,
Speaker 1: or their executives and employees. Indeed, heed, as an inveterate contrarian,
Speaker 1: I can tell you they may not even represent my own.
Speaker 1: And nothing contained in this show should be used as
Speaker 1: medical advice or encouragement to use any type of drug. Today,
Speaker 1: we're gonna be talking about harm reduction, and specifically harm
Speaker 1: reduction in the context of drug treatment in America, where
Speaker 1: most programs are still abstinence only twelve step programs with
Speaker 1: very little flexibility to meet people where they're at when
Speaker 1: they're struggling with drugs. My definition of harm reduction refers
Speaker 1: really to any policies or interventions that seek to reduce
Speaker 1: the risks, the harms, the negative consequences of drug use,
Speaker 1: or really any other risky or potentially dangerous activity. I mean,
Speaker 1: when it comes to drugs, we think about UH needle
Speaker 1: exchange programs to reduce the spread of HIV and AIDS
Speaker 1: and other infectious diseases, or making sure the lock zone
Speaker 1: is available for people who are using opioids and might overdose.
Speaker 1: Or maybe it's just about getting people to use less
Speaker 1: or to use more responsibly, or to switch from injecting
Speaker 1: drugs to taking them, orally there's all sorts of ways
Speaker 1: of harm reduction. Now in my own life, I've been
Speaker 1: personally engaged in this issue. I mean not just in
Speaker 1: my own life in using drugs in a harm reduction way,
Speaker 1: but also in speaking about this and teaching about it
Speaker 1: and writing about it, and then also beginning in the
Speaker 1: early mid nineties, in helping to fund and support and
Speaker 1: start harm reduction programs all around the United States. Now,
Speaker 1: harm reduction can apply not just to drugs or other activities.
Speaker 1: It can also involve a harm reduction approach to drug enforcement,
Speaker 1: drug policing. It can there can be a harm reduction
Speaker 1: approach to drug markets, harmorduction approach to drug policies. Today
Speaker 1: we're talking with Pat Denning about harm reduction approaches to
Speaker 1: drug treatment. Pat's run a pioneering program with her partner
Speaker 1: Jennie Little in San Francisco for many decades. She's co
Speaker 1: authored books with Jennie she's been a teacher both in
Speaker 1: the US and around the world. So I'm delighted to
Speaker 1: welcome Pat today. I'm really happy to do it, Ethan.
Speaker 1: I I always love talking to you, and this is
Speaker 1: just the best excuse ever. You know, the first thing
Speaker 1: I want to do is just get into the broader
Speaker 1: issue of harm reduction, and keeping in mind that there
Speaker 1: are some people who are into the nitty gritty of
Speaker 1: this subject and there are others are going harm What
Speaker 1: what's harm reduction? And so what's your elevator pitch about
Speaker 1: what's harm reduction to the people who have never heard
Speaker 1: of it? Um, my elevator pitch is that harm reduction
Speaker 1: is what we do every day in our lives, since
Speaker 1: we're human beings. We take risks, we ride in elevators,
Speaker 1: we ride in cars, and we do things to minimize
Speaker 1: the risk. But so when people talk about harm reduction
Speaker 1: in the context of drug treatment, what they usually mean
Speaker 1: our alternatives to treatments that focus only on achieving abstinates. Well,
Speaker 1: you know, I think the other thing, Ethan, is that
Speaker 1: you know, people get confused and talking about harm reduction
Speaker 1: because it's it's not just one thing. There are different
Speaker 1: arms to the harm reduction movement, and the original arm
Speaker 1: was very much grassroots, very much drug user driven. It
Speaker 1: resulted in things like needle exchange programs. But then another
Speaker 1: arm came in, which was the public health arm, which
Speaker 1: really was interested in reducing the spread of disease. And
Speaker 1: then there's policy and advocacy um which is really interesting
Speaker 1: it and ending the war on drug and protecting the
Speaker 1: rights of people who use drugs. And the most recent addition,
Speaker 1: which is not actually recent anymore, is is treatment. And
Speaker 1: while I came in through multiple avenues of all the
Speaker 1: different arms of harm reduction, I think my contribution is
Speaker 1: primarily in the area of harm reduction treatment. I was
Speaker 1: looking around and I saw one of the things you
Speaker 1: wrote in the last year or so. It's for an
Speaker 1: excellent online publication called Filter, and you wrote about your
Speaker 1: dilemma about whether or not to provide alcohol to people
Speaker 1: who were living rough on the streets. You know what
Speaker 1: we call skinro alcoholics who might suffer the d t
Speaker 1: S if they can't get any alcohol. Yeah. It came
Speaker 1: about because for the last two and a half years
Speaker 1: we have been doing a pilot project for the Department
Speaker 1: of Public Health in San Francisco of developing mobile pop
Speaker 1: up dropping centers, and we would come into different neighbor
Speaker 1: hoods with a big the van that was outfitted as
Speaker 1: a therapy office, set up canopies, we cooked hot food
Speaker 1: for people, We had a drop in center, we did therapy,
Speaker 1: and after COVID hit, we had to start shutting down.
Speaker 1: But in the process of shutting down our mobile sites
Speaker 1: and figuring out how to just do outreach, we started
Speaker 1: coming across people who were clearly in withdrawal from alcohol.
Speaker 1: From alcohol because the shops were closed, people couldn't like
Speaker 1: shoplift alcohol. There were no people on the streets, and
Speaker 1: so people couldn't um ask for spare change or asked
Speaker 1: for money. So people's ability to access alcohol was severely disrupted,
Speaker 1: and it was clear that people were really suffering. And
Speaker 1: I just immediately thought, well, this is crazy. At this point,
Speaker 1: we're handing out syringes, we're handing out crack pipes, people
Speaker 1: are doing methodone take homes, and people are doing same
Speaker 1: day prescriptions. So I'm just thinking, well, my goodness, there
Speaker 1: are all these people who are physically dependent on a
Speaker 1: legal drug that they now can't get access to, and
Speaker 1: the dangers of withdrawal from alcohol are severe, and so
Speaker 1: I thought, well, why don't we just give out alcohol
Speaker 1: just so our listeners understand and correct me if I'm wrong.
Speaker 1: If you withdraw it from something like heroin or cocaine,
Speaker 1: it may be extremely uncomfortable, you know, terrible flu for
Speaker 1: some people, you know, all sorts of things, but it's
Speaker 1: not going to kill you. But if you've become heavily
Speaker 1: dependent on alcohol or for that matter, of benzo diazepines,
Speaker 1: valium like drugs, if you rapidly withdraw from alcohol when
Speaker 1: you are heavily dependent, that can actually be life threatening.
Speaker 1: Rapid withdrawal without some types of help can kill you.
Speaker 1: It's interesting in the history of alcoholics anonymous in the
Speaker 1: old days, they used to always have a bottle of
Speaker 1: booze at the meetings because they knew that the new
Speaker 1: comers who were coming in might actually go into withdrawal,
Speaker 1: and they knew it was dangerous, so they would, you know,
Speaker 1: hand somebody a bottle and have them take a swig
Speaker 1: out of the bottle of booze if they were starting
Speaker 1: to show signs of withdrawal. So we've we've known that
Speaker 1: alcohol withdrawal is very dangerous. So I started calling up
Speaker 1: alcohol distribution places mostly and I will, I'll go ahead
Speaker 1: and use the company name bev Moo and asked them
Speaker 1: if they would make a donation of a little, uh,
Speaker 1: you know, the airplane size bottles of booze. And I
Speaker 1: told them why, and they, of course, we're just like,
Speaker 1: excuse me, but no, I don't think so. So I
Speaker 1: drove down to bev Moo and I bought a few
Speaker 1: cases of basically vodka in little bottles, and I take
Speaker 1: it home and I'm all excited. I tell my staff,
Speaker 1: you know, oh, you know, I've got little bottles of booze.
Speaker 1: We can now hand that out for people. And all
Speaker 1: of a sudden, I'm like, oh wait a minute, pat,
Speaker 1: what hold up? You are a licensed therapist, um, and
Speaker 1: you are going to be handing a drug even though
Speaker 1: it's legal. You go be handing a drug to someone
Speaker 1: in order to help them with a medical problem that
Speaker 1: you're not even qualified to diagnose. So here we are
Speaker 1: with this dilemma of knowing exactly what our clients need.
Speaker 1: And it's like we're not allowed to give clients an aspirin.
Speaker 1: You know, you can't dispense medicine as a therapist, and
Speaker 1: all of a sudden, I'm thinking, yeah, well I'm old
Speaker 1: and I can lose my license and it doesn't bother me.
Speaker 1: Is I'm about ready to give it up anyway. But
Speaker 1: you know that's not true of the agency, and that's
Speaker 1: not true of most of the staff. So it was
Speaker 1: quite a dilemma that I have completely refused to answer
Speaker 1: any question about how we solve that dilemma. So, I mean,
Speaker 1: so pat you found it had been running this remarkable
Speaker 1: army reduction program San Francisco since I guess the nineties.
Speaker 1: What's the essence of that? Well, you know, it was
Speaker 1: kind of a long journey, and as as I I
Speaker 1: said in a staff meeting today, I was a you know, nice, sweet,
Speaker 1: perfect little girl who got really rebellious really fast and
Speaker 1: started questioning everything. And the HIV epidemic came along, and
Speaker 1: that gave me a reason to really start looking at
Speaker 1: UH drug treatment and alcohol treatment because we were throwing
Speaker 1: a lot of young men into programs who were dying
Speaker 1: and treating them not very well. So that I started
Speaker 1: thinking about alternatives. And this was in the in the
Speaker 1: early eighties, and over time just kept developing new ways
Speaker 1: of thinking and eventually met Jeanie Little, and we both
Speaker 1: had this idea of wanting to run a center that
Speaker 1: would take everyone, no matter what the status was of
Speaker 1: their drug use, no matter what if their goals were
Speaker 1: for treatment, And so it was really the two of
Speaker 1: us just being defiantly determined to do it differently. So, Pat,
Speaker 1: when you and Jennie decided to do something new, tell
Speaker 1: me about your approach. The Harm Reduction Therapy Center UM
Speaker 1: provides individual and group therapy. At times, we also have
Speaker 1: medication available. The goal of harm reduction therapy is to
Speaker 1: help a person who is having trouble with drugs and
Speaker 1: alcohol decide how they can better their life, how they
Speaker 1: can reduce their harm in whatever ways that is going
Speaker 1: to be necessary. Are they really going to need to
Speaker 1: take psychiatric medications? Are they going to need to absolutely
Speaker 1: quit drugs? Are they going to need to have family therapy?
Speaker 1: The clients are primarily very low income, often marginally or unhoused,
Speaker 1: often with very significant psychiatric or emotional difficulties as well,
Speaker 1: people whose drug use and emotional and family problems are
Speaker 1: so interwined that you can't separate them. So we provide
Speaker 1: the full range of services. There's no limit to the treatment.
Speaker 1: A lot of our community programs offer therapy on a
Speaker 1: drop in basis because our clients lives are often so
Speaker 1: disorganized that they can't keep appointments. Going back to the
Speaker 1: origins of the phrasing of harm reduction, back to I
Speaker 1: guess the Netherlands in the eighties and such, and then
Speaker 1: coming in around needle exchange, both in Europe and the
Speaker 1: US and elsewhere, there was people in our world debating
Speaker 1: whether harm reduction was the right word. Then our opponents
Speaker 1: were successful in calling harm reduction and legalization were synonymous,
Speaker 1: which in fact they weren't. It was overlapped um. And
Speaker 1: then there was a point where some of our opponents
Speaker 1: that they might try to co opt the term, and
Speaker 1: they said, well, we're doing harm reduction, we're forcing people
Speaker 1: into drug treatment, and it always saying that when other
Speaker 1: core element to the definition of harm reduction is that
Speaker 1: it needs to be non coercive. It's an absolutely fundamental distinction.
Speaker 1: The foundation of harm reduction therapy and harm reduction treatment
Speaker 1: approaches is self determination and a true collaboration between two experts.
Speaker 1: If you will, you know, the client is the expert
Speaker 1: on their life, and often the expert on their drugs,
Speaker 1: and the therapist is an expert in helping people, you know,
Speaker 1: an expert in developing a relationship that allows a person
Speaker 1: to be honest and to find their own power in
Speaker 1: terms of changing. It's like almost anything can be harm reduction.
Speaker 1: Twelve step can be harm reduction. Abstinence based treatment programs
Speaker 1: are harm reduction. If the client has a free choice
Speaker 1: in a menu of options, then what they choose is
Speaker 1: harm reduction, right, and the choice should not be between
Speaker 1: either take this treatment or go to jail. That's right.
Speaker 1: Has to be an element of choice that actually involves
Speaker 1: a real freedom of choice. Yes, if it evolves, especially
Speaker 1: the state involved in coercion, it can't be harm reduction.
Speaker 1: Now when you get to elements of compulsion by family
Speaker 1: or employers, I guess it gets a little cloudier. Then, huh, well,
Speaker 1: it gets cloudier. But the difference is who is the
Speaker 1: therapist loyal to and in a lot of the drug
Speaker 1: treatment programs, especially because the carceral system is so involved.
Speaker 1: Now the funding and drug treatment is coming in enormous
Speaker 1: measure from the criminal justice system, and so now drug
Speaker 1: treatment is very much in bed with this coercive system,
Speaker 1: with all of its racial and oppressive undertones. And so
Speaker 1: now if you're coercing, even if it's family that's coercing,
Speaker 1: the therapist cannot be part of the coercion. The therapist
Speaker 1: has to be free. So you know, I've worked with
Speaker 1: people who have been mandated to treatment before um, mostly
Speaker 1: professional athletes, and the first therapeutic duty is for me
Speaker 1: to say, um, you have to be here, and you
Speaker 1: don't have to talk to me. You know, what goes
Speaker 1: on between you and me in here is confidential, and
Speaker 1: your main decision is are you going to show up?
Speaker 1: And if not, are you prepared to take the consequences.
Speaker 1: And if you show up, are you going to try
Speaker 1: and use this to your advantage or you're gonna sit
Speaker 1: here quietly for two years. Any time the therapist or
Speaker 1: counselor has the power to harm a client, it is
Speaker 1: not harm reduction. If you need to have drug testing,
Speaker 1: that's fine, but you have to go somewhere else to
Speaker 1: get your drug testing, and we won't allow the results
Speaker 1: of that drug testing in your chart. We'll be talking
Speaker 1: more after we hear this ad. You and I were
Speaker 1: presenting it some drug treatment conference years ago, and this
Speaker 1: was a real aha moment for me. Somebody was asking you, well,
Speaker 1: I get harm reduction when it comes to opiates. I
Speaker 1: get it when it comes to needle exchange and all
Speaker 1: this sort of stuff. You know, I'm gonna have a
Speaker 1: lot of patients dealing with mitth anthetamine. Well, um, I
Speaker 1: think we're getting into the area of one of my
Speaker 1: favorite topics, which is the adaptive or the self medication
Speaker 1: uses of drugs. And there are people whose functioning is
Speaker 1: actually improved by the use of certain drugs. And this
Speaker 1: one particular guy was very depressed, very disorganized, had all
Speaker 1: sorts of other issues going on, and it was clear
Speaker 1: that when he had had little speed before he came
Speaker 1: into a session, he was much more focused and much
Speaker 1: more able to actually talk. Because usually even within some
Speaker 1: harm reduction treatment programs, they will say just don't show
Speaker 1: up high to treatment. You know, you don't have to
Speaker 1: be absinent, but don't don't use on the day that
Speaker 1: you have a session. And it's like, no, no, no, actually,
Speaker 1: maybe you should use before you come. And and I
Speaker 1: had another woman who was a polly substance user, very
Speaker 1: serious mixed drug use, and she was finally able to
Speaker 1: say to me, I can't come here if I don't
Speaker 1: have a drink. And my office at the time was
Speaker 1: on the third floor of the building and there was
Speaker 1: a bar on the first floor. Sort of handy for
Speaker 1: a harm reduction program, because what happened is that she
Speaker 1: would come to therapy, she would get so overwhelmed talking
Speaker 1: about things that she would go home and be incredibly
Speaker 1: suicidal and would cut on herself or would do all
Speaker 1: sorts of drugs. And she was finally able to say,
Speaker 1: I can't do this, I can't talk about these things.
Speaker 1: And I just said, well, if you had a couple
Speaker 1: of drinks, would it make it better? And she's like, well,
Speaker 1: of horse, it would, but I'm not allowed to do that.
Speaker 1: And I said, well, I'm just trying to help you
Speaker 1: not kill yourself while you're in therapy. And what you're
Speaker 1: dealing with is so painful that if you need some
Speaker 1: alcohol in order to be able to talk about it,
Speaker 1: I just think you ought to go right ahead and
Speaker 1: take care of yourself. I mean, hell, it makes sense.
Speaker 1: And I also remember you're saying that even with that
Speaker 1: person you know who're taking the speed before, and the
Speaker 1: alternative was if he hadn't done that, he'd be sitting
Speaker 1: in that session with you, and all that would be
Speaker 1: on his mind would be getting out of that room
Speaker 1: with you so he could score again and use again.
Speaker 1: So I mean, in a way, it's basically harm reduction
Speaker 1: as this sort of fundamentally pragmatic approach to dealing with
Speaker 1: problematic behavior substance abuse. Who would have you? People use
Speaker 1: drugs for reasons. The reasons are pretty simple. Do you
Speaker 1: use drugs either increased pleasure, decreased pain, or alter your consciousness.
Speaker 1: That's kind of what people use drugs for. And we
Speaker 1: have somehow decided that it's not okay to alter one's
Speaker 1: consciousness for any of those reasons. In America and prohibitionist America,
Speaker 1: we've decided it's basically not okay to get high alcohol,
Speaker 1: well except maybe but not too often. Actually, as a therapist,
Speaker 1: we were trained to be suspicious of anybody who drinks
Speaker 1: every day. So anybody who has a couple of glasses
Speaker 1: of wine with dinner, we're really trained to go, oh,
Speaker 1: you mean you drink every day? And it's like in
Speaker 1: Europe they think we're nuts. But the prohibition mentality in
Speaker 1: America permeates everything, and it's really, of course extreme when
Speaker 1: it comes to illegal drugs because somehow we as a
Speaker 1: society believe that if drugs are illegal, they were made
Speaker 1: illegal because they're bad and they're dangerous. And what we
Speaker 1: don't understand is that certain drugs were made illegal based
Speaker 1: on racial prejudices and attempts at racial control. So I
Speaker 1: picked up the paper the other day and there's this
Speaker 1: report about some of the national health agencies wanting to
Speaker 1: discourage people from drinking every day because they now believe,
Speaker 1: although it may have slight cardiovascular benefits, that it also
Speaker 1: increases the risk of cancer. And we know that when
Speaker 1: it comes to cigarettes, we know smoking cigarettes is not
Speaker 1: good for you, but you see the government getting really
Speaker 1: behind a campaign to ban the consumption of nicotine in
Speaker 1: any form. Conversely, Americans are now saying marijuana should be legal.
Speaker 1: We're increasingly accepting of people using marijuana up not just medically,
Speaker 1: but to get high in a way. One thing we've
Speaker 1: been fighting for for a long time is to get
Speaker 1: people to change their minds. The problem is that they
Speaker 1: may be changing their minds to the right way when
Speaker 1: it comes to illegal drugs, but maybe heading the wrong
Speaker 1: way when it comes to the legal ones. And there's
Speaker 1: that undercurrent of prohibition that is going it's going to
Speaker 1: raise its ugly head and it's it just depends on
Speaker 1: the times and the culture and who's in charge of
Speaker 1: which drugs are going to get demonized. You know, when
Speaker 1: we had prohibition in this country, you know, for thirteen years,
Speaker 1: the law of the land said alcohol is so dangerous,
Speaker 1: it's so poisonous, that no one should ever be allowed
Speaker 1: to consume it. Thirteen years later, we made it legal again.
Speaker 1: And so what we had to do as a society
Speaker 1: to make that make any sense at all, is that
Speaker 1: we had to adopt this idea that there's this disease
Speaker 1: called alcoholism, and some people have it and some people don't.
Speaker 1: And if you don't have the disease of alcoholism, you
Speaker 1: can drink whenever you want to, because alcohol doesn't cause alcoholism,
Speaker 1: it's only activated by drinking. That's an insane way of
Speaker 1: reintroducing a drug into society is by saying, oh, well,
Speaker 1: ten percent of you can't drink at all, and the
Speaker 1: rest of you can drink as much as you want to.
Speaker 1: I think the important thing is recognizing that it's a
Speaker 1: political ideology, it's not settled science. Behaviors as complex as
Speaker 1: serious drug problems are always a combination of biology, psychology,
Speaker 1: and socio cultural factors, and for each person, the relative
Speaker 1: weight of those factors can be different, and it can
Speaker 1: be different for different drugs. You may have a sort
Speaker 1: of biological propensity to overuse alcohol, but you might have
Speaker 1: a psychosocial propensity to overuse marijuana. You know, drugs are psychoactive.
Speaker 1: They act in the brain. They cause brain changes. Every
Speaker 1: activity that we engage in repetitively causes brain changes. So
Speaker 1: it doesn't necessarily mean it's a disease or it's even damage.
Speaker 1: It's you know, it's a difference. And is it more
Speaker 1: important than a person's psychology. Sometimes often not, But it
Speaker 1: is very much the case that people have the drugs
Speaker 1: they can handle on the ones they can't um you know.
Speaker 1: And I have a friend and colleague. I won't mention
Speaker 1: his name for the purpose of the show, but this
Speaker 1: is somebody who's real problem was um opiates in heroin.
Speaker 1: But when he put that behind him, he found that
Speaker 1: he could be a regular consumer of red wine and marijuana,
Speaker 1: even a daily consumer, and lead a remarkably successful in
Speaker 1: productive life. And and we all have our drugs of choice,
Speaker 1: you know, And whether that be because it's the most
Speaker 1: fun drug, or because it's the one that helps take
Speaker 1: care of us the most. You know, if you could
Speaker 1: only have one drug for the rest of your life,
Speaker 1: what would it be? You know, I'm I'm absolutely clear
Speaker 1: that my Crown Royal is coming with me to the
Speaker 1: desert islands. You know, that's a tricky one from me.
Speaker 1: I wonder let's take a break here and go to
Speaker 1: an ad. You know this issue now right with overdose
Speaker 1: fatalities hitting sixty seventy eighty thousand a year nationwide, getting
Speaker 1: worse in this past year with COVID. I used to
Speaker 1: always explain to people that overdoses was actually the wrong word,
Speaker 1: and the vast majority of cases it wasn't people taking
Speaker 1: too much of one drug. That's the real accurate definition,
Speaker 1: and overdose whose fatal drug combinations, you know, taking opioids
Speaker 1: combining with booze, or with benzodiazepines, valium type drugs. But
Speaker 1: now along comes FENTONYL right, which has got a special
Speaker 1: kick to it, more opponent than heroin. You know, it
Speaker 1: hits my city in New York first, but I can
Speaker 1: see San Francisco is getting hammered by it now, so
Speaker 1: I mean, what are your thoughts about what's going on
Speaker 1: when I see these? I think your rate of overdose
Speaker 1: in San Francisco is much higher now than ours in
Speaker 1: New York, and ours is already incredibly high. What's your
Speaker 1: take on the overdose thing and whether information needs to
Speaker 1: change in light of fentonyl playing a bigger role. Yeah,
Speaker 1: you know, it's it's really complicated, and and I'm not
Speaker 1: really the expert on you know, sort of street level
Speaker 1: drug and drug distribution. Um. You know, what I do know, um,
Speaker 1: is that part of the problem with COVID has been
Speaker 1: that when we have been able to place people who
Speaker 1: have been formerly houseless in the shelter and place hotels
Speaker 1: all of a sudden there alone, and so we started
Speaker 1: seeing a lot more overdoses, partly because people weren't on
Speaker 1: the streets anymore. And the streets of San Francisco, there's
Speaker 1: a lot of narcan out there. There's a lot of
Speaker 1: people who can save your life. Yeah, we should just
Speaker 1: explain to everybody that narcan is the kind of common
Speaker 1: name of a drug called in the lock zone, which
Speaker 1: is essentially a miracle antidote for heroin or other opioid
Speaker 1: overdose that if you administer quickly through the nose or
Speaker 1: a skin prick or whatever it is, that can really
Speaker 1: save people's lives. And so there's been a big effort
Speaker 1: to get that out much more broadly to people. But
Speaker 1: if you're using alone, right, if you're using alone, you
Speaker 1: can't do it. So that's one problem. I think that
Speaker 1: that is contributing to the overdose increases. The other thing,
Speaker 1: of course, is fentyl And you know, I listened to
Speaker 1: a webinar recently on fentyl by Dan Chickarni, who's a
Speaker 1: noted researcher in the area of drugs, and what he
Speaker 1: was saying was fascinating to me that fentanyl is really
Speaker 1: the only drug on the streets that was not created
Speaker 1: to satisfy a demand. It was created to develop a supply,
Speaker 1: So it's a supply driven problem. Dan Chi is probably
Speaker 1: one of the best research in the country writing about
Speaker 1: this stuff. You know, for our listeners who may not
Speaker 1: be aware, federal is something that hundreds of thousands of
Speaker 1: people get legally in the hospital post surgery. It's an
Speaker 1: incredibly effective pain killer, you know, like morphine and things
Speaker 1: like that. Uh, it works really well. It's very potent,
Speaker 1: but in a very tiny dose. And the thing that's
Speaker 1: scary is that they see when you have drug dealers
Speaker 1: and people selling drugs who are mixing fan and other
Speaker 1: drugs are selling it, getting the amount right is really tricky,
Speaker 1: you know, and this stuff is being imported from China,
Speaker 1: China vie in Mexico, are now being made in Mexico
Speaker 1: or whatever. So it's one of these things where law
Speaker 1: enforcement really is sort of helpless because you can send
Speaker 1: through the mails, you know, a small box which is
Speaker 1: enough for tens of thousands of doses, and really there's
Speaker 1: no chance for law enforcement to interceptive stuff, not that
Speaker 1: they could with even the more with marijuana, which was
Speaker 1: much bulking. You know. What happens also because the supply
Speaker 1: is so robust, the dealers often have no idea what's
Speaker 1: in the drugs that they're now selling, which did not
Speaker 1: used to be the case routinely. You know, if you
Speaker 1: had a regular dealer, you could pretty much trust that
Speaker 1: the person would say, hey, this stuff is really good,
Speaker 1: or you know, this stuff isn't as strong as you're
Speaker 1: used to, or you know, this stuff is really potent.
Speaker 1: You might want to, you know, be careful. They can't
Speaker 1: honestly educate their customers now because they often have not
Speaker 1: a clue if there's Fentinel in it, or even how
Speaker 1: much there is, So you don't have that kind of
Speaker 1: community education and support going on, and so people learn
Speaker 1: by their mistakes, and unfortunately, with Fentinel, the mistakes are
Speaker 1: often fatal. So when you have somebody in your program
Speaker 1: and you know they've been playing with vent at all
Speaker 1: or addicted to opioids and using federale, what what's your
Speaker 1: guidance for them? I mean, obviously you're dealing with them
Speaker 1: from a psycho therapeutic dimension, but you're also trying to
Speaker 1: keep them alive so they keep coming back. Just as
Speaker 1: an example, if you don't know any people you have
Speaker 1: in mind or generally that you can think of, the
Speaker 1: first thing that we do is make sure that people
Speaker 1: know that what they say to us will not only
Speaker 1: not go anywhere, but that will take them seriously. So
Speaker 1: communicating that is really important, and being able to say
Speaker 1: to people you don't necessarily even have to tell me
Speaker 1: what you're doing, but can I tell you some things
Speaker 1: that might help? So we don't even necessarily have to
Speaker 1: ask for self disclosure. You know, I can start off
Speaker 1: by saying, I don't know if you're using drugs, but
Speaker 1: here's a few things that I know that are out
Speaker 1: on the streets. Here's some safety precautions. UM, here's a
Speaker 1: list of syringe exchange programs. Oh, by the way, they
Speaker 1: also have safer crack pipes. You know, so I can
Speaker 1: start harm reduction education and support without knowing anything about
Speaker 1: what the person is actually doing. Well, let me ask
Speaker 1: you this. I mean, I'm reading now about you know,
Speaker 1: San Francisco has got this, you know, once again growing problem,
Speaker 1: not just with overdoses, but with homelessness and people building
Speaker 1: tens and what would you be advising the mayor on
Speaker 1: this sort of stuff? Yeah, you know, thank thank god,
Speaker 1: I am not at at that level. I do think, however,
Speaker 1: that there is a fundamental conflict between the haves and
Speaker 1: the have nots. That the economic disparities in San Francisco
Speaker 1: have dramatically changed over the last ten fifteen years. UM,
Speaker 1: that the conflicts between um, you know, neighborhoods that have
Speaker 1: less economic opportunity, the racial disparities, the economic disparities is enormous.
Speaker 1: It's like the San Francisco earthquake. And and that's a
Speaker 1: fundamental problem that I don't know how it is going
Speaker 1: to get addressed. I mean, the the hate Ashbury is
Speaker 1: a good example. Um, you know, Hate Ashbury has been
Speaker 1: a haven for runaway youth since the sixties. It still is,
Speaker 1: but now there are people who are paying millions of
Speaker 1: dollars for houses in that neighborhood and they don't want
Speaker 1: any homeless kids there anymore. They don't want their trash,
Speaker 1: they don't want whatever. It's the standard issues around gentrification
Speaker 1: and clashes in community. Yeah, you don't pay you all
Speaker 1: the supersomn issue because you're talking about class in this context,
Speaker 1: you alas struck me. Though then in a way, when
Speaker 1: it comes to dealing with clients patients in a harmonuction perspective,
Speaker 1: there's the same kind of class issue because if you
Speaker 1: have enough money or insurance to a for private psychotherapy,
Speaker 1: the odds are very good that you and your therapist,
Speaker 1: if you're struggling with some type of addictionary dependence, you
Speaker 1: know it's gonna be in a somewhat non judgmental setting
Speaker 1: unless the psychiatry, what ever, is very judgmental. You're sitting
Speaker 1: in that office and the state's not part of the picture,
Speaker 1: whereas if you don't have money right and you're looking
Speaker 1: for some type of treatment or at help, in much
Speaker 1: of the country, the only way you're ever going to
Speaker 1: be able to get that help, you know, or meet
Speaker 1: with counselors is going to be in something that's offered
Speaker 1: through the criminal justice system. That in fact, there is
Speaker 1: a very strong class dimensioned to this as well. I
Speaker 1: absolutely agree that there are major differences in class and
Speaker 1: what kind of treatment you get. However, for the most part,
Speaker 1: the expensive rehabs in this country use exactly the same
Speaker 1: treatment models as the public rehabs and the criminal justice
Speaker 1: based rehabs, because there's only one model that's allowed in
Speaker 1: this country, and that's the Minnesota model, which is twelve
Speaker 1: step and disease model and total abstinence. That's changing in
Speaker 1: some but probably still of drug treatment programs use that model,
Speaker 1: And what you're saying about therapists is also changing, but
Speaker 1: it's not as rosy as you think. I was trained
Speaker 1: that if somebody comes to me and I discover that
Speaker 1: they have a drinking or a drug problem, I'm supposed
Speaker 1: to immediately refer them to a drug treatment program and
Speaker 1: refuse to see them if they don't agree to be
Speaker 1: abstinent and go to treatment. That's how we're all trained
Speaker 1: as therapists. Yeah, no, no, I get your point. I
Speaker 1: really think the major distinction is that if you're poor,
Speaker 1: a lot of this treatment of any sort is going
Speaker 1: to come with the role of the criminal justice system involved.
Speaker 1: But you have the same kind of ideology and pickheadedness
Speaker 1: really at all levels of this thing you know going on,
Speaker 1: you know, right, and and then you've got you know,
Speaker 1: because the criminal justice system is, you know, disproportionately made
Speaker 1: up of people of color, and you know, the other
Speaker 1: thing that happens is that we forget that everybody who
Speaker 1: uses drugs doesn't need drug treatment. And a lot of
Speaker 1: the people who end up being arrested they don't need
Speaker 1: drug treatment. They've been dealing drugs and not particularly using them,
Speaker 1: or they're using them and they don't have a big
Speaker 1: problem with them. But they are sometimes given the choice
Speaker 1: to go to treatment or jail. Most people who eventually
Speaker 1: put a drug addiction behind them did so while they
Speaker 1: were not in drug treatment. People may go through drug
Speaker 1: treatment programs five six, seven times, and basically what happens
Speaker 1: is they hit a point in life when they're maturing
Speaker 1: out or they're ready or change in life when they're
Speaker 1: able to put it behind them, and that typically happens
Speaker 1: not when they're in treatment, but some other time for
Speaker 1: some unrelated reason. Right, the treatment industry has this belief
Speaker 1: that our treatment is perfect, our clients are not, and
Speaker 1: so if the treatment doesn't work, it's the client's fault,
Speaker 1: which is exactly the opposite of the approach we take
Speaker 1: in most medical care, which is, if my intervention is
Speaker 1: not working, I better try something else, because we can't
Speaker 1: blame the patient for this sickness. We have to figure
Speaker 1: out what the right intervention is. You're right, so it's
Speaker 1: a perfect area or ideology just getting ready. People need
Speaker 1: to understand also, it's not as if it's abstinence versus
Speaker 1: harm reduction, because attaining abstinence or sobriety is a perfectly
Speaker 1: legitimate objective of any type of harm reduction and ambition
Speaker 1: or training in intervention. But it's the reaction against abstinence
Speaker 1: as the only way, the my way, or the highway.
Speaker 1: The eye can't help you unless you're willing to be
Speaker 1: sober and and drug free before you even come to
Speaker 1: see me. But for the people who can't cut it
Speaker 1: according to your abstinence only program. What's your fallback? Are
Speaker 1: you at least gonna have you know, Pat Denning and
Speaker 1: g Little's phone number available so that you can send
Speaker 1: them to their program. What has been your relationship with
Speaker 1: the people running the the abstinence only programs? Do they
Speaker 1: see you, do they call you? Do they say you
Speaker 1: may be able to help this person? For the most part, No,
Speaker 1: I've done a lot of training, especially locally in drug
Speaker 1: treatment programs, and um, they're very slow to change. Even
Speaker 1: though San Francisco had a harm reduction policy, is its
Speaker 1: public health policy. We've had it for twenty some years now. Um,
Speaker 1: most of the drug treatment programs are still very much
Speaker 1: old school in terms of their approach. So I'm feeling,
Speaker 1: you know, a little discouraged at the end of my
Speaker 1: career that, um, there's so much that is still the same. Um.
Speaker 1: And every time I say that, people around me go, oh, no, Pat,
Speaker 1: all sorts of things have changed. It's like, okay, yeah,
Speaker 1: I know all sorts of things have changed, but you're right,
Speaker 1: it is. It is frustrating. So Pat, I gotta ask
Speaker 1: you one last question. I don't have to, but you know,
Speaker 1: and I hope I'm not crossing online, but I'm curious.
Speaker 1: You know, a few years ago I heard that you
Speaker 1: were dealing with leukemia, and you know, I hope you've
Speaker 1: come through that cleanly down and it's all good. But
Speaker 1: I just wonder, in reflecting on your work and reflecting
Speaker 1: on harm reduction, where there any interesting insight specific to
Speaker 1: the work and thinking you've been doing all these decades
Speaker 1: where anything came out of that. It was really nice
Speaker 1: to be treated in a medical system that wasn't crazy
Speaker 1: about drugs. I was hospitalized for five weeks at a time,
Speaker 1: four different times for the intensive chemo, and every time
Speaker 1: a nurse came in the first thing they would say
Speaker 1: is are you having any pain? Which I thought, thank you,
Speaker 1: that's really nice. And and I remember one time I said, um,
Speaker 1: you know, I'm a headache and I'm not a person
Speaker 1: who tends to get headaches, and she immediately said would
Speaker 1: you like some morphine for that? And I was like,
Speaker 1: uh no, I think a thailand all will do, but
Speaker 1: thanks for asking. But you know, it was really nice
Speaker 1: to be in a setting where, um that when I
Speaker 1: was in pain at different points, it was freely given.
Speaker 1: As we're benzos for sleep that there was no hysteria
Speaker 1: about oh you know, we can't get you addicted to
Speaker 1: all of this stuff, so it was incredibly passionate. So
Speaker 1: I really loved that. Well, listen on that note, I
Speaker 1: want to thank you so much for joining me on this.
Speaker 1: I really look forward to seeing you before long. I
Speaker 1: wish you all the best, not just for your program,
Speaker 1: but for uh, you know, your forthcoming retirement, and and
Speaker 1: notwithstanding our mutual frustrations that harm reduction has not become
Speaker 1: common wisdom and the dominant ideology, the fact remains that
Speaker 1: you've done some extraordinary work and helped a huge number
Speaker 1: of people throughout your life. So thank you so very
Speaker 1: very much. This was really fun. This really was Say
Speaker 1: hi to GENI okay, and look forward to seeing you.
Speaker 1: Psychoactive is a production of I Heart Radio and Protozoa Pictures.
Speaker 1: It's hosted by me Ethan Edelman. It's produced by Kacha
Speaker 1: Kumkova and Ben Cabrick. The executive producers are Dylan Golden,
Speaker 1: Ari Handel, Elizabeth Geesus and Darren Aronovski for Protozoa Pictures,
Speaker 1: Alex Williams and That Frederick for iHeart Radio and me
Speaker 1: Ethan natal Man. Our music is by Ari Blusian and
Speaker 1: a special thanks to a Vivit Brio, Sef Bianca Grimshaw
Speaker 1: and Robert Beatty. If you'd like to share your own stories,
Speaker 1: comments or ideas, please leave us a message at eight
Speaker 1: three three seven seven nine sixty. That's one eight three
Speaker 1: three psycho zero. You can also email us as Psychoactive
Speaker 1: at protozoa dot com or find me on Twitter at
Speaker 1: Ethan natal Man. And if you couldn't keep track of
Speaker 1: all this, find the information in the show notes. Next
Speaker 1: week we'll have the world's leading expert on Afghanistan and drugs,
Speaker 1: David Bansfield. In one profit sneers the Taliban was earning
Speaker 1: something like five million from drugs. It's a minor form
Speaker 1: of income for them, but absolutely critical rural constituency. Subscribe
Speaker 1: to Psychoactive now see it, don't miss it.