I got a question about harm reduction fic recs (because I specifically mentioned harm reduction in this post).

The most directly harm reduction fic I can think of is Ain’t No Grave (Can Keep My Body Down) by spitandvinegar because needle exchange and the dangers of femoral injection are both specifically mentioned. Also One Day at a Time by KeelieThompson1.

Wrt sex, I would love to see Negotiated Safety done really well in a really hot fic. But I’ll just have to keep looking.

I think that any drug fic that rings true to me is going to have to involve some acknowledgement of harm reduction, so I’ll give you my general drug fic recs (warning that all of these involve explicit injection drug use):

Ain’t No Grave (Can Keep My Body Down) by spitandvinegar. Captain America, Stucky, post-CA:WS. Mature. 107K.

Falling, Flying. (All My Love on Paper Planes) by Queertrees. Sherlock BBC, Sherlock/Victor Trevor, Unilock to the present. Teen. 56K.

Can’t Rewind Now We’ve Gone Too Far by Basser. Sherlock BBC, Sherlock/OMC, Unilock. Mature. 112K.

Sherlock Character Studies by Basser. Sherlock BBC, no pairing, missing scenes. Teen. 25K.

The Cold Song by Eldritchhorrors. Sherlock BBC. Johnlock, BDSM. Explicit. 73K.

One Day at a Time by KeelieThompson1. Sherlock BBC. Johnlock, post-Reichenbach. Mature. 35K.

Just aired on WWNO 89.9 FM Reversing Opioid Overdoses Saves Lives But Isn't A Cure-All : Shots - Health News : NPR

This story had some good points – the acknowledgement that drug treatment is over-booked and expensive, and the statement that the point of narcan is first and foremost to keep people alive – but the moralizing over drug users who do not quit after their first overdose was so aggravating and so different from a harm reduction perspective.

I hope that overdose-reversal has not been mis-sold as a drug treatment, because that seemed to be the perspective a lot of people, particularly the police were coming from. I mean, I expect the police to be dicks about drug users, but it makes me mad every time a hear a medical professional implying that drug users are wasting ER resources by not quitting.

I would also have been interested to hear more from the guy who was talking about how narcan sent him into withdrawal, which is a real problem, but seemed to be used as just an example of how out of control he was.

For someone who asked. (Though, “peer” is a very squishy term. At what point after one stops using a particular drug, does one cease to be a peer?)

Here is the original manual on employing active drug users: http://www.opensocietyfoundations.org/sites/default/files/work-harmreduction-20110314.pdf (I read a earlier version, but the main points seem to be the same. The part that I found most helpful was about setting boundaries and not being tempted to use the needle exchange as a way to find new connections.)

There is also a peer-specific manual that I haven’t read yet: http://www.canadianharmreduction.com/sites/default/files/PEERGUIDE2013.pdf (In general, peer workers get screwed, because they often get stuck in low-paying peer positions and not offered reasonable opportunities for advancement.)

Also, an article by Donald Grove on harm reduction organizations looking the other way when their employees need help: http://harmreduction.org/publication-type/newsletter/communication-issue-seventeen/ (Excerpted here by me: http://sometimes-behaves-so-strangely.tumblr.com/post/45019108711/we-work-within-a-philosophy-that-supports-the-idea)

Tits and Sass: PrEP: What It Is and How Sex Workers Can Use It

marginalutilite:

Lindsay Roth and Cassie Warren give us some 101 about PrEP (pre-exposure prophylaxis), and explain how joining the conversation around it and other HIV prevention methods is strategic for sex workers.

“In our opinion, in order for biomedical interventions to successfully impact sex worker communities, they must address two main concerns: The general disparities that sex workers experience in medical settings and the need for expanded access to biomedical interventions like PrEP in clinical settings.”

Also so true for injection drug users.

So I went looking for data on the health impacts of HIV vs smoking in the LGBT community, and found a whole slew of short news item/ blog pieces:

http://www.medpagetoday.com/HIVAIDS/HIVAIDS/36521

http://thinkprogress.org/health/2012/12/19/1358131/tobacco-deadlier-hiv-virus/

http://thinkprogress.org/health/2013/04/01/1805771/cdc-targets-lgbt-anti-smoking/

http://www.huffingtonpost.com/jimmy-lasalvia-/smoking-lgbt_b_5053140.html

http://sfbaytimes.com/the-new-old-gay-epidemic/

http://vadamagazine.com/09/07/2014/news/us-smoking-bigger-problem-lgbt-people-hiv

http://www.washingtonblade.com/2014/07/09/smoking-now-bigger-gay-health-threat-hiv/

http://www.huffingtonpost.com/2014/07/16/lgbt-wellness-july-16_n_5591815.html

To the degree that these pieces reference any primary research at all, they seem to be talking about this study out of Denmark from 2012: http://www.ncbi.nlm.nih.gov/pubmed/23254417 [contact me if you want the PDF]

What the study says is that in Denmark (which has much better comprehensive health care for HIV than the US) among a group of people mostly in their late 30s through early 50s, the death rate in HIV+ nonsmokers is very similar to the death rate in HIV- smokers. And that if you look at HIV+ smokers the deaths are much higher than you would expect from just adding the deaths in HIV- smokers and the deaths in HIV+ nonsmokers (2.4% per year vs. 0.61% and 0.62%). Also, it’s worth noting that of the HIV+ people who died in the study, three quarters died of something other than AIDS (defined by CD4 count <400).

Which is all super interesting and really emphasizes that, because of HAART, people with HIV are living long enough to start worrying about other health problems, like cardiovascular disease and non-AIDS related cancers.

That being said, the study has some big problems. They did not control for income or education (which would be pretty standard things to control for in a US study). And there is clearly something different about the HIV+ smokers compared to the HIV+ nonsmokers. They found that the HIV+ smokers were twice as likely to be HCV+ as HIV+ nonsmokers and they don’t seem to have any data for HCV in HIV- controls and no HBV data at all.

But the thing that seems really off in the study (and the thing that keeps getting quoted in the press and advocacy infographics) is that HIV only takes 5.1 years off your life expectancy, which would make HIV less dangerous than smoking, Type II diabetes or recurrent depression. Most other studies estimate that (in the HAART era) HIV takes between 20 and 30 years off your life.

And I just don’t think anyone has enough data to make that kind of claim. HAART is amazing, and apparently is responsible for more total years of life saved than any other medical intervention in the last 20 years. But we have no idea what the side effects from being on HAART for 40 or 50 or 60 years will be, because no one has ever been on HAART for more than 20 years. The Danish researchers calculate their life expectancy estimates using Kaplan-Meier analysis which assumes that nothing weird happens to patients after you stop following them (most patients were only in the study for about 3-5 years), so it can not be used to predict long-term side effects from a relatively new drug cocktail.

Another thing is that they found a similar synergistic effect of being HIV+ and having EVER smoked, as seen in the following rates of death (per year):

HIV- never smoker: 0.14%

HIV- previous smoker: 0.28%

HIV+ never smoker: 0.61%

HIV+ previous smoker: 1.31%

Which means either

-HIV+ people who have never smoked are in some way different from HIV+ current and former smokers

-smoking is so dangerous for HIV+ people that smoking cessation programs are only going to have limited usefulness in extending people’s lives

This, of course, isn’t mentioned in any of the advocacy and outreach efforts.

I am all for more support for LGBT people who want to quit smoking, but I think the paper is being overinterpreted, and it is making HIV seem like a less serious health problem than it really is. Also, a lot of the reporting overlooks the differences between HIV care in Denmark (super amazingly good) and HIV care in the US (good if you are affluent and white, otherwise underfunded and catch-as-catch-can) and so underestimates how much more money and attention need to go into HIV care in US before it would make sense to shift the focus to smoking.

Why I Started a Petition to Remove the Head of the AIDS Healthcare Foundation

I have nothing against Weinstein as a person, nor do I mean to devalue his past achievements or the AHF in general. I simply question his role as a leader of an HIV organization and as an influential public figure on HIV issues….

There’s some crazy rhetoric around Truvada. Like people who are using PrEP to prevent HIV are being so irresponsible. Because it’s not a condom.

Of course, the cost is a big issue. But that’s not what Weinstein is complaining about, when he calls it a “party drug”.

Anyone know if there is data on Truvada in injection drug users?

---

OK. Answered my own question. Yes Truvada was tested in IDUs in Bangkok, and it had some efficacy (~50% reduction in HIV infection compared to controls). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3266126/

But several groups in Thailand raised concerns about the lack of engagement with community organizations and the way the participants were treated, including, apparently, a lack of access to clean needles: http://www.treatmentactiongroup.org/hiv/Bangkok-prep-statement

Anonymous asked: What do you think of students who take unprescribed Adderall/Ritalin to get through college work/studying?

So, I’ll preface this by saying that I’m old enough to remember when doctors were saying that amphetamines had the opposite effect on people with ADHD than they did on everyone else (i.e. focused vs. manic) and that amphetamines could essentially be used to diagnose ADHD (i.e. if the drugs worked, you had ADHD). I don’t know, maybe doctors are still saying this – they certainly seem to use the same logic with anxiety and depression – but it seems like there is finally starting to be an understanding that ADHD drugs are not pharmacologically different than street amphetamines (see Carl Hart’s work), and that different people having different reactions has to do with the concept of drug, set and setting, as well as preexisting social inequality and the stigma a street drugs.

From a harm reduction perspective, I think that diverted pharmaceuticals are safer than street drugs in terms of consistent dosage and lack of dangerous cuts. Also, swallowing a pill is generally going to be safer than snorting, smoking or injecting a drug. (I should point out, though, that when drug companies start adding anti-tampering compounds to pills to keep people from snorting or injecting them, they may no longer be the safer option.) Since on average, a minority of people who use a drug end up having serious problems with it, more people using a drug may mean more people with problems with that drug, even under the best of circumstances, so honest, non-propaganda-based, drug education and resources for recovery are really important.

But I think that students using ADHD drugs as performance enhancing drugs has a whole other problematic aspect. To the degree that the drugs actually do enhance performance, they create a situation where some students (usually the ones who are already the most privileged) have access to ADHD prescriptions (because they know how to work the system, and are not immediately seen as suspicious and drug seeking) and other students don’t. Apparently some ridiculously high percentage of kids at elite high schools have ADHD diagnoses, presumably because their parents were willing to do anything for them to succeed academically.

UCSF.edu: Six Recommended Measures to Prevent Hepatitis C for Young Injection-Drug Users

Various friends of mine worked for UFO at various points, and it gave me a lot of hope to learn that their preliminary data showed that HCV rates in young injectors were lower than in the older data that was floating around (which said that 90% of injectors would be HCV positive within 1 year).

Also, thinking about this quote:

However, while injectors frequently fail cessation programs, the UFO Study showed that the more injectors try to quit, or “take breaks” from drugs, the more likely they eventually are to succeed. That new data could inform how these and other treatment programs handle relapses in the future.
“Often these programs are very unforgiving and relapses can lead to permanent bans,” Page said. “This is likely not the best tactic for reducing disease exposure risks and also may not be optimal for helping injectors end injection drug use.”

And thinking about how it contradicts what my then therapist told me, that the fact that I’d already quit a few times, for a month or three or six, was a bad sign and meant that I needed to go into a residential program. Which at the time pretty much seemed like bullshit, but I felt really powerless to argue against anything she said. Like arguing against her treatment plan was going to be used as evidence that I couldn’t be trusted to make my own decisions. So I just dragged my feet until she gave up on getting me into a program that I couldn’t afford and that I was sure was going to result in my getting kicked out of graduate school.

"Similarly, the risk-reduction strategy of negotiated safety substitutes the limit of monogamy for that of latex. Given that this strategy rationalized the abandonment of condoms in strictly controlled circumstances, it is not surprising that the doctrine of negotiated safety originated outside the United States. A central element of Australian and European safe-sex education, negotiated safety involved gay men in a committed couple going bareback only when both repeatedly test negative for HIV. As Shernoff correctly observes, “negotiated safety makes AIDS prevention professionals in the Unites States nervous,” because they do not wish to be seen as condoning the abandonment of condoms. Although the doctrine of negotiated safety preceded the emergence of bareback subculture by several years, it should be regarded as a fully rationalized, supremely safe version of barebacking – and therefore, some would say, it hardly qualifies as barebacking at all. Negotiated safety enables unlimited intimacy with a single partner, while simultaneously imposing stringent limits of extramarital liaisons. With this approach – in which condom use remains the norm relative to which a single exception may be carefully elaborated – the investment lies in safety rather than risk.
By contrast, the technique of strategic positioning is employed during bareback sex between discordant partners. Here a high-risk situation may be ameliorated by the HIV-positive man’s taking the role of “bottom,” while his HIV-negative partner takes that of “top.” this configuration reduces (although it certainly does not eliminate) the risk of infection, since viral transmission occurs most readily when a positive man ejaculates inside a negative man’s rectum. As a term, strategic positioning, like negotiated safety, is derived from Australian research’ as a practice, it does not qualify as safer sex (the only sanctioned goal of HIV prevention in the United States) but as a harm-reduction technique."

—

Unlimited Intimacy: Reflections on The Subculture of Barebacking by Tim Dean (2009)

What is the US problem with harm reduction? Trust the US to apply the logic of abstinence-only to safer sex. No wonder it’s not working very well.

Also straight couples use negotiated safety all the time (albeit usually in a watered down form where these is no contingency plan for what happens if one partner strays). How can you have an official policy that expects married gay men to never stop using condoms even within the marriage?

When I’m single, I don’t bareback on purpose usually. I practice safe sex often enough to consider myself “always safe,” even though that’s not quite true. While the overwhelming majority of times that I’ve had casual anal sex, I’ve had the wherewithal and self control to stop and put on the condom I’ve already made sure is within my reach, there have been times when pre-sex teasing has led to penetration. I’ve slipped. There are times when a few condom-free strokes don’t seem like they’d hurt anyone and we were both down so… I’ve given in to requests of full-on bare sex to orgasm on occasion, depending how hot and convincing the invitation was and how turned on I already was. It’s always the exception, though. “That’s not me,” I tell myself during and especially after.

It’s easy enough to sweep this all under the rug if nothing comes of it. If you don’t contract HIV from bareback sex, was it unsafe? What does it even matter? Just do better next time and take solace in the personal rules—somewhat informed, somewhat arbitrary—that you suspect are keeping you protected: I’ve never gotten fucked raw by anyone who wasn’t my monogamous boyfriend—I never need to bottom so badly that I’d ever let a casual acquaintance enter me without a condom.

—

Jim Pickett, the director of advocacy for the AIDS Foundation of Chicago, quoted in “What Is Safe Sex? The Raw and Uncomfortable Truth About Truvada” by Rich Juzwiak, Gawker, March 4, 2014

Just read Unlimited Intimacy, which I found fascinating but also terrifying. I am much more in the category of Jim Pickett (the “That’s not me” problem), with a set of strict rules that sometimes get broken (both in terms of sex and when I used to inject drugs) than the “No limits” men Tim Dean describes. It set off such a deep irrational terror, that I found myself thinking, maybe I should start using condoms again with my husband

On the Passing of Philip Seymour Hoffman - Harm Reduction Coalition

New Harm Reduction Coalition podcast. Talking about how the stigma of relapse can lead people to make dangerous choices (like getting high alone). And also that more treatment programs should offer naloxone, overdose prevention education and opiate substitution therapy (with a brief discussion of the overdose prevention effects of bupenorphine off-label usage and diversion).

Cyd Nova (excerpt): How this plays out at the clinic is a little more nuanced—we are a free health clinic and there is no right or wrong way to be a whore to get services as long as you don’t bring a gun into the clinic or something—but the ways that it plays out in staffing is a little more complicated. Many of our participants are homeless or transiently housed and work in a variety of street economies, while many of our staff could be perceived as people who would have access to doing privileged types of sex work. We aim to be as horizontal in power dynamics and as peer run as possible, but here we are. And it’s complicated—people who have more access to resources are able to gain work experience, volunteer, and be a reliable employee because they aren’t struggling to get their basic needs met all the time—but what it can look like at the end of the day is the people who are providing care and are the voice of the clinic are “one type of sex worker” while the people who receive services are predominantly another. This is something we are actively trying to challenge, but there isn’t an easy answer.

Melissa Gira Grant (excerpt): When sex workers wanted to volunteer there who had never come to clinic themselves, staff would recommend that they come to clinic first before volunteering.

“Coming to clinic” can mean a lot: not just getting an STI or HIV test, but a massage or acupuncture, going through the clothes closet, hanging out and watching a movie, getting hormones, etc. The idea was, we wanted to close the distance even among sex workers between the people who want to help and the people who get help. We could all use services. We could all use care. There’s nothing wrong in asking for that. But it could be tough, because some of us do have this self-image of being the kind of sex workers who don’t “need” anything, that harm reduction or self-care is for some other sex workers. I get not wanting to take what are unfortunately all-too-scarce resources from those who you think might need them more, but there’s something powerful about asking for the help you need. You can call it mutual aid, or community building, or just taking care of each other. It’s so important.

—

“Who Gets Left Out: Respectability Politics Round Table, Part One” Tits and Sass, September 30, 2013

Issues I wish had been talked about more when I was volunteering in needle exchange and harm reduction.

I particularly like the idea of having people who want to volunteer, participate in the services from the other side first.

All the Things: Seriously.... NYC cops should do like Seattle.

This is going to make me sound like an old curmudgeon, but, seriously, Molly (and bath salts and all the other new “designer drugs”) sounds like the worst drugs ever.

When I was young, and you got bad e, it was cut with heroin or speed, which are fine drug in their own right and have been around long enough for people to know what the side effects are and how to manage them. And neither of them will give you a fever of 106 (i.e. “temperature regulation issues”).

These new crappy, extra-dangerous drugs are the direct result of drug prohibition. Both because there is no quality control and because in the current system, these drugs have the advantage of not being illegal.

http://mashable.com/2013/08/17/seattle-tweet-hempfest-doritos

DanceSafe.Org: Drug Information and Harm Reduction Resources

I have certainly had some very bad interactions with HR organizations – like the dick who tried to bully me into quitting heroin when I went in for a HIV test, and pretty much kept me from getting another HIV test for a few years, or when I was volunteering at a needle exchange where NO ONE was out about their history of drug use and it was standard to treat the people who came to get needles like they were sneaky children.

And what starts out as palatable spin for funders (like getting people into treatment) seems to always become the mission over time.

But I have been listening to Alan Clear’s Harm Reduction Coalition podcasts, and I think there is still a passionate group of HR people out there who really care about human rights, and who see that creating a safe, non-stigmatizing space where people can access services that they already want but were too marginalized (and also too justifiably angry and alienated) to access otherwise, can help people manage their use in a way that’s closer to what they want it to be.

I worry that user’s unions are not immune to the issues that corrupted harm reduction, that as you get bigger, you need funding and real estate and managers to make things run. I don’t know as much as I should about VANDU, but it seems that they have a significant number of supporting members (i.e. with no history of drug use). Although their constitution says that supporting members cannot be director, from what I’ve read about Ann Livingston (co-founder and long-term coordinator, or maybe executive director), she came out of social welfare agencies and not personal experience with drugs. And they’ve accomplished some pretty amazing things, but would maybe not fit everyone’s definition of a user’s union, and also seem to be getting sucked into a more formalized, public health role.

Junk TV: Harm Reduction on the Lower East Side: Part I

Lower East Side Harm Reduction Center NYC talks about the principles and benefits of Harm Reduction. circa 1994

Great time capsule from mid-90s LES.

I had no idea there was a drug user’s union (ICARE, the International Coalition for Addicts’ Resources & Enlightenment) in New York in the 90s

Drug User Activism in Seattle - Harm Reduction Coalition

“We exist because drug users are used, in my opinion, drug users are used as a market item. We’re described as defective, powerless, broken, and in need of being saved. All of these things are lies. My experience is, is that drug users are people who decide to pick up a drug, pick up several drugs. They find the drug that works for them and they begin to use it. Unfortunately, there’s no social mechanism for how to use your drug correctly, for how to keep your life in balance. What we’re offered is a system that is flawed and based on myth: the idea that you can go to recovery and that you will be recovered. "Recovery” is to be turned back to the shape you were in before you started….You can’t go to Cincinnati and get a surgery and have it all happen all over again. You are who you are, with the experiences that you have. We are not allowed to talk about our experiences; we’re not allowed to talk about the good times; we’re not allowed to talk about the joy. We are always, in my experience, we are always confined to this narrow little box about who and what we are. The Union hopes to change that.“ – Lee, Urban Survivor’s Union

In the middle of training a group of Russians on the finer points of self-injection, I agreed, by phone, to write this introduction. While I never got quite so far as womyn, not long after I hung up it began to bother me: why junkies and why girls? language is very important to me and I make a big deal about the words I (and people around me) use. In different locations, times, ears, the same word can have entirely different impact, nuance. When I was growing up, for instance, you pictured completely different things when you heard “He’s a professional,” versus, “She’s a professional.” I, if you get my drift, am now the former and was once the latter.

Although the role of the law is in no way minimal, my life (like many others) has been influenced less by those laws I chose to break or respect, than by the labels by which others have defined me. An irony is that the activities and characteristics which -pre-AIDS- I worked hardest to conceal, were precisely the reason I initially became employable. I now· have a good life teaching phlebotomy and fellatio with much the same people as I once had a rough life doing, minus the health insurance and academic credential, precisely the same. Suddenly to say, “I learned to inject from a ‘house doctor’ and when I had the gallery, I worked as one; I managed to keep reasonably clean, well-fed and dry when homeless; and I can sneak condoms on and off with my mouth,” would not be unheard of in an interview. Saying “I worked .. I’ve been getting high for years. my scars are minor, and I’ve got all my teeth,” made me employable, credible, desirable.

Although the word glamour has interesting roots (*), there is no glamour in being an addict; in having, rather than choosing, to routinely break the law; in picking for veins in frosty bathrooms; in living controlled by physiology and the clock. And proud as I am of the teeth I have and the scars I don’t, I make no mistake in the importance in this of having blue eyes, an educated medical family, hospitals and clinics from which I could steal things, and white skin to get me past the guard on the way in.

Despite the novelty of training Russians, or the pleasure of training those new to, and hungry for, the philosophy of Harm Reduction and practicalities of Needle Exchange, the training where the editor found me was pretty much routine. And, as I frequently do when working with Medicos, I told my usual Fred and Ginger joke (*) - namely, injectors do with no professional training everything you were educated to do, only under combat 'conditions, one-handed, and backwards.

Be a dope fiend, or just look like one. Be a straight person, or merely impersonate one on TV. Which’ll get you farther past what door? There’s no reason for injectors to get scarred, scabbed, stigmatized, picked out in a crowd. Or there’s many reasons: laws, fear, access, power, sexism, supplies, status, economics, education, entitlement. There’s power in “sticks and stones” terms to be sure -but only when you have control of who is doing the naming.

(*) Ginger Rodgers did exactly what Fred Astaire did, only backwards, and on high heels.

( *) GLAMOUR = the name for the profuse, shining, vaginal fluid of
horses 'in heat.’ Gypsy lore held that using the glossy pungent
mucous on your hair made one “irresistible” to woman- giving us
both an early ingredient of hair gel (placenta shampoo anyone?)
and a wry twist on the term, “glamour-puss.”

—
L. Synn Stern, Brooklyn, NY, 9 September 1996, introduction to Junkphood: True Stories from Girl Junkies (Heather Edney, ed.)

I’m feeling kind of bad that I had to get the audiobook of Skagboys because I gave up on reading the actual book because I didn’t have any uninterrupted stretches long enough to get into the weird dialect spelling.

Every single heroin scene so far is a harm reduction disaster, which is presumably the point (since it’s set in Edinburgh in the 80s) but it may be a little to bleak and heavy-handed for me right now.

Bathroom Etiquette: Injecting at the Exchange Part 1 - Harm Reduction Coalition
Bathroom Etiquette: Injecting at the Exchange Part 2 - Harm Reduction Coalition

I am really impressed with what these (unnamed) programs are doing to make injecting in their bathrooms safer. Obviously, it is only a clumsy work around for actual legal supervised injection, but still great harm reduction. When I volunteered at an agency that had a bathroom, there was so much fear about the agency being shut down that they put blue filter on the light in the bathroom, thereby making it riskier for people to inject. We also had no policy to check on people for the purpose of administering narcan.

So, yes, I am going to post links to every single Harm Reduction Coalition podcast as it comes out. Because they’re all amazing.

Edith Springer: Goddess of Harm Reduction, Part 1 - Harm Reduction Coalitio
Edith Springer: Goddess of Harm Reduction, Part 2 - Harm Reduction Coalition

How is it that I’d never heard of Edith Springer before last year (when I found the HRC podcasts)? Whoever was responsibile for my harm reduction education was seriously falling down on the job.

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