The Patron Saint of Harm Reduction

Source : http://www.thefix.com/content/patron-saint-harm-reduction

The Fix Q&A with Dan Bigg of the Chicago Recovery Alliance on exasperation, solutions and everything in between.

Dan Bigg may not be a saint. Perhaps he is more like Socrates—on the fringe of society, answering difficult questions about complex human problems and schooling anyone who will listen. Since the ‘80s, he has been clearing away ideological and moral fog that obfuscates public health policy as it intersects with drugs and HIV. He has opponents on all sides, from other harm reductionists to those in the 12-step community. But that’s never stopped him.

Bigg is co-founder and executive director of the Chicago Recovery Alliance. Their program has set up harm reduction sites that offer clean syringes, safe injection practices, vaccinations, and naloxone distribution and education in the most drug-ridden areas of Chicago, largely known has the Midwest’s heroin mecca. All of this work is done under a simple philosophy: Any positive change as a person defines it for him or herself.

The Fix spoke with Dan about the thirty-year long, up-hill battle he has waged in honor of his friend and co-founder, John Szyler, who died of a heroin overdose many years ago. Ever since the death of Szyler, Bigg has advocated for sensible harm-reduction policy and has distributed naloxone—a life saving opioid overdose antidote—around the world, from users in the street, to caring family members.

Locally, do you butt heads with 12 step and abstinence treatment programs? 

We have a Hazelden in Chicago and they have been wrangling internally. They wanted me to do some HIV education and I told them I’d be happy to do that but I will not talk to people about drug issues and HIV without talking about the range of issues going on right now. That includes hep C, which overtook HIV in terms of death and sickness in 2007, and also overdose prevention with naloxone. I said, if you want someone to talk about all those things, I am your man. If you don’t want me to talk about this stuff, then find someone else. And that has bothered them because they didn’t want to think they were keeping information from anyone but that is exactly what they are doing.

There is another big treatment center in the area, Rosecrance, and they have resisted us for a long time. The Rockford Register Star talked to them and asked what about this naloxone stuff?

So those are the two big name 12-step treatments in Chicago?  

Yes, and let them do that 12-step stuff, that’s fine, because naloxone isn’t an intoxicating drug: it’s garlic to the vampire, not the blood. So Rosecrance, firstly, they don’t even show up to meetings they say they will show up to. One time they had two or three suited people stand up and say they needed more money, and that they needed their money doubled this year and also a 50% increase each year over the next 5 years to do a better job. They never say how that money is connected to overdose.

John Strang’s article, which I had in my testimony, said that completion of abstinence-based treatment is associated with increased death following treatment. Those who fail to complete the treatment have no mortality in the following phases of the study. Of those that do complete the treatment: 7% die. What’s wrong with a program whose successful completion causes death? Is it something to concern you? Doesn’t seem to concern them.

There is this woman from Love Park whose son died from an overdose; her and her husband took mortgages out on their home to pay back their loans. She cleans houses on the side trying to pay these mortgages off. So her son got out, I think from his fourth stint in Rosecrance, and within a week was dead of an overdose. She is an OD educator now. And she cannot believe Rosecrance, how it could—out of all those visits and all that money—never have said a thing about naloxone, an antidote that could have so dramatically kept their son alive.

But if that isn’t enough for them to do it, what is? We stopped by there and asked, we gave them our cards and said we’ll do an in-service, that we’ll do training, they have rejected everything we’ve said.

Purely based on ideology? 

I don’t even know. That would be me guessing. Maybe they just don’t like me.

That would be even worse. 

I may be stinky (sniffs his armpits) but they could put me towards the window.

Maybe addiction treatment is too young. It is such a young discipline that maybe they lack the confidence to innovate, to try new things—even when there is evidence that they are killing people. Now that says something real scary about a discipline. If medicine took the same approach, we’d be in big trouble. But right now, in addiction treatment, some places do accept the evidence.

Places, like New Age Services have had us in and trained their people. But the rest of the system is so shitty and so backward. If it intentionally tried to do the most lethal, condemning, and inhumane approach, it’s on target.

You have been working closely with people who have HIV and also people who have drug problems for over three decades. Both of these populations have a lot of similarities—what drew you in to being an advocate in these two areas? 

Well, I was working at the Illinois Health Association’s Drug Addiction AIDS Project in 1986 or ’87. And I was hearing from more and more people that, because of HIV, they were alienated from their 12-step group. This was their support system. So myself and a few other people put together an HIV information exchange and support group called HIVIES. I was the special worker of this first group who helped put together a big book for them. It was a way to provide a space for people to get support. All the people that came to it were told by their 12-step groups that this was “an outside issue,” and that the focus was simply to not drink. The people in our support group said no, it isn’t an outside issue, it is in fact a central issue, just like his broken leg or whatever. So there was a strong need for this group.

The group met every Wednesday over the course of the next three years. There, I met a number of people who were both active and so-called recovering drug users—anybody is recovering to me so long as they are making any positive change—and I learned from people about these issues and we formed friendships. Out of those friendships came something beyond self-support, it was something that we wanted to impact the whole community. Self-support was one thing and it was wonderful but it didn’t do enough. It did enough maybe for us, I certainly got something to gain from it despite the fact I don’t have HIV or a habit—I felt great going to those meetings.

So we asked ourselves, is there something needed in regards to the way drugs and HIV come together beyond just a personal thing, but in a community area? And the answer was yes, among all of us. That then became the basis for the Chicago Recovery Alliance.

The name came from the group called the Minnesota Recovery Alliance. I asked them if it would be okay if we called ourselves the Chicago Recovery Alliance and they were honored for us to do that.

“Recovery” in the name has been deliciously ironic for people. I remember this guy Dave Burrows in Australia, he met me in Rotterdam in ‘93 at the International Harm Reduction Conference. He said, I met Dan Bigg “of the rather oddly named Chicago Recovery Alliance,” because for them “recovery” was abstinence-based-hardcore-whatever. And so we were taking the name back to what it really is and how it really applies to our species.

Any positive change—people that really understand that almost always learn the hard way about what addiction is and what recovery is, but people that do get it really see in it a profound shift, a revolution, really. That was what attracted me and that’s what I’ve been thrilled about for so long—how we can unite where otherwise there is division.

CRA’s ideology is strong and at the same time very simple, “any positive change as a person defines it for him or herself.” Other approaches differ in that the institution, a) defines the change the person should desire and…

crams it down their throat, then gets offended when it doesn’t work among the absence of alternatives. We offer a buffet of options. The difference between a more traditional approach and us is that they prescribe; they take your plate and put what they want on it. We give you a clean plate, a utensil, and you decide what you want and how much of it. So this your plate we’re working with and we work respectively and collaboratively with you. We do explain what every dish is and you may find out that this or that isn’t right for you in the long run. Harm reduction recognizes that the most important aspect of its work is respectful collaboration, acceptance, and bonding. Just making a human connection with people because without that you cannot make an improvement.

Harm reduction is a humanism. 

Yes, there was this psychiatrist and researcher who told me that harm reduction is basically all the empirical evidence of behavior change rolled into a single model. But there are other people who take harm reduction and just say, « Well, I’ll just use a blow-torch to clear out all the tables in this place so now no one can trip on anything. » Those people then make preposterous claims.

The same way some say that prohibition was harm reduction because without alcohol there could be no alcohol-related harm, right?

I heard this Australian in 1992 at a drug policy conference say, “Be careful, because the abstentionist may call his or her approach harm reduction, and they might be right.” I said, this is bullshit because we’ve tried it and it clearly isn’t. What prohibition does is maximize harm, in most cases, and that’s because the species we’re working with is an intoxicated species. Simple as that.

When it comes to harm reduction and naloxone overdose prevention, you were really blazing a trail. No one else was in this area at the time and no one else was doing what you were doing. How did your peers react to this movement? 

So CRA, we started this program as the result of the death of a friend of mine, co-founder John Szyler, who lived just down the street from here, actually. He died in May of 1996. A couple months later, we were distributing naloxone. Physician friends of mine said that prescribing naloxone is like prescribing sterile water to people. They weren’t that worried, but nevertheless we did everything we could to cover their butts.

In the spring of 1997, I spoke about it publicly for the first time at the International Conference for the Reduction of Drug Related Harm in Paris. They gave me plenty of time to talk about our work. I remember after my talk that the head of the International Harm Reduction Association raised his hand and asked, “What advice would you give to physicians about naloxone for their patients?” And I thought about it for a bit and then said, “Do your fucking job. I am not a physician, no one has empowered me to prescribe, why, after twenty some years of this medicine being available and unquestioned as a pure antidote to opioid overdose, am I the one pushing to get it out there?”

People were very happy with that response. But maybe not Alex Wodak, who is a leading harm reductionist out of Australia. He was opposed to naloxone. He called one of my colleagues, a physician doing this work in New York, the Josef Mengele of harm reduction because naloxone was “untested.”

So from the start you had opponents on both sides of the same coin? There are the obvious arguments from abstainers but also arguments from other harm reductionists? 

Well, you’d think it wouldn’t be so, because one of the tenants of HR, the one I agree with, is that you look at science for what is harm reduction. So I emailed Wodak and that began a months-long discussion and he kept saying “Naloxone is untested.” So I said how is this for a test: Someone you love is using opiates in the street, a bag of heroin versus a tablet of some kind, so the purity is unknown to him or her. Would you want the person next to him to know about naloxone? How it works and how to use it? Have it available, in case of overdose? He wouldn’t answer that question. He hasn’t answered that question for the last 15 years.

One of the worst medical conditions known to man is not breathing, and that is why it’s a good idea to use naloxone.

Your mission from the start has been to get naloxone to those directly impacted, i.e., users on the street and their family members—the people in the line of fire. Do you see this getting derailed anywhere right now? 

Really, what we’re talking about building is a relationship with people so that if I’m using I can be honest with you, so that you can watch my back and that is really what we have to aim for in order for naloxone to have maximum utility.

The vast majority of people who are dying from overdose are those who leave jail. Most die within two weeks of their release. To think the first thing that people will do is go to the outreach site to get naloxone is too much to hope for. We know that from all of our years of work—we just have to make it there and available. All we are trying to do in the jail system is put the kit—a few syringes and a few doses of naloxone—in their belongings so that when they leave they have it.  And at this point we can’t turn that screw. Very frustrating.

You have had a longstanding relationship with Hospira, the only manufacturer of naloxone left. What has it been like to work with a big pharmaceutical company? 

I have been begging Hospira for good pricing for the life of their company. A 10cc vial of naloxone was $1.43 in the late ‘90s when there were 4 or 5 manufacturers. In 2008, all of them dropped out of the marketplace except Hospira, which was created in 2004. The price has dramatically increased, I asked the pharmacist at my Walgreens just two or three days ago how much a 10cc vial of naloxone costs and she said, $331.

A 1 cc vial is now $30. At every level, Hospira has been open to helping us get this at an affordable price to continue our work. Just a year and a half ago they allowed that price-break for our collaborators around the country, and so far 20 or so have gotten this special pricing. But it’s unclear as to whether Hospira will be able to continue to do that.

But injectable naloxone for people who fall outside of our system, is still a problem. Even them offering that special price to us is a problem in itself because let’s say, for instance, a drug re-seller finds out we get a better price than them they will obviously want that price. Hospira may say, « Look, you are not a program who gives this out for free in huge numbers, » so they have been able to shut people up that way. Hospira does not want that recognition as being helpful but from every level they have been incredibly supportive. But it has been a mutually beneficial support.

Disturbing to me how something like naloxone, that saves lives and is important to public health and public safety, cannot get out of the grip of capital networks. 

Don’t let it surprise you anymore. I’ve been dealing with it for years and it’s been driving me crazy. I can tell you it’s not a healthy way to live. Most of this stuff is beyond your control. I’m working with Hospira now to allow this to continue to be available at an affordable price for the programs that make it available to the people who need it for free. So far it has been going pretty well and there are some really good people at Hospira. The hope is that we are able to re-stabilize that program and continue making it available.

Ultimately, if Hospira did not allow us to continue our work they know they’d be facing a barrage of criticism. Right now the New York Attorney General is criticizing the intra-nasal naloxone people for doubling their price. It used to be $20 for a single, now it’s $40. For a kit it used to be $42, now it’s $100. Just like that, overnight, they doubled the price. When lives are on the line they call it “price gouging.” What that means is, raising the price for a product that saves lives in a dramatic way is the worst business practice. It’s actually illegal.

Not only is the business side of things twisted, but policy makers in this area seem way out of touch with the « who » and « what » of being a human being really is, especially a human being who may have health and mental health issues. 

The U.S. government set up a system for researching addiction called the Lexington Narcotic Farm. It was this idyllic setting where people came to get help from the government, but they rejected the results for moralistic reasons. It isn’t that we don’t know what to do, but it is that we are impeded by our moralistic stance and our magical expectations. It isn’t enough that naloxone revives people and restores them to life? Shit, for Christianity, it was enough that Jesus woke the fuck up and walked around for a little bit but it isn’t enough that a human today can wake up from death and live? It scares the fuck out of me that that can propel a whole religion but not the everyday actions of humans.

We have fucked up helpful things for drug problems in two specific ways for decades, 1) we have so bureaucratically ladened and ghettoized it to make efforts useless (methadone) and, 2) we have priced it out of utility (buprenorphine). We didn’t have to do either of those things. Neither of those actions was necessary. There is not a reason on Earth we couldn’t have empowered physicians to use this stuff—like other countries do—without destroying themselves. We didn’t even need to add an antagonist to a drug that was already an antagonist (buprenorphine/naloxone).

How do you do it? How do you stay in a game that is so stacked against you? 

I can’t dwell in the negative because it really fucks me up. I used to run triathlons and marathons and be a soccer player and stuff like that. I still do some of that. But since I have started doing naloxone work I’ve gained upwards of 100 pounds by not taking care of myself. Part of that is pulling my hair out, some it fell out on its known, but taking the weight of what is so obvious, and to take that burden from somebody else is really inappropriate. And I try not to do it. I am trying to self-care, and my diabetes, of course, is pushing me in that direction. I am getting healthier but it will be a slow process. I got to the point with HIV advocacy that I had to say things like, “I do not care if the entire city of Chicago dies of AIDS, I will not go to another worthless meeting where people talk and talk and nothing gets done.” I have to draw that same line, which I have not done yet, with overdose advocacy. But with the help of others I am moving in a healthier direction personally.

I would like to think that the power of overdose prevention via naloxone speaks for itself. So, like me turning over to a high power, the Chicago Police Department, is not so difficult for me because I know it is beyond my control. I could do something like go to the Sherriff’s Office, so yeah, there are things I can do. We have tried working through medical channels and we’ve tried other things to get Chicago P.D. on board with carrying naloxone, but sitting in his office and asking him just to allow his staff to put this in certain people’s boxes who’ve gone through training—whatever he needs—we can train all the people who do that so they are covered under our program and the law. At this point, he is not willing to talk about it, at least through the people we’ve been able to see.

What I’m trying to say is, any positive change, applying it to myself, is something real hard, especially with regards to my own personal health. I practice any positive change as far as the work I do, but to my personal health, I often don’t.

Hard to practice what we preach, sometimes. 

It is. And I should do it more so I can be healthier.

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