This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

While the COVID-19 crisis has held Michigan's attention for the past year and a half, a different deadly epidemic is taking an increasing number of Michiganders' lives. From 2000 to 2018, opioid overdose deaths have grown tenfold in Michigan. And according to Amy Dolinky, senior advisor of Michigan opioids strategy with the Michigan Department of Health and Human Services (MDHHS), those numbers grew by another 14% in the past year. In November 2019, Michigan Gov. Gretchen Whitmer called the opioid epidemic "the greatest health crisis of our lifetimes" and set a goal to cut opioid overdose deaths by half over the next five years. 

The state has a seven-pillar strategy to combat the opioid epidemic, one of which is sometimes controversial, yet also quickly gaining recognition and acceptance for its effectiveness: harm reduction. Harm reduction involves expanding access to naloxone and sterile syringes, aiming to minimize harmful effects for those who are using opioids. 
Amy Dolinky.
Opioids depress central nervous system activity, slowing or stopping breathing. Naloxone displaces the opioids from the brain's opioid receptors so the person overdosing begins breathing normally again. Sterile syringes prevent the spread of HIV and viral hepatitis. Harm reduction also provides nonjudgmental support and resources that meet people where they are, rather than demand that they make changes they're not ready for.

"Harm reduction has been around for a long time but has been a growing part of the conversation," Dolinky says. "We're recognizing that it's just as important, and sometimes more important."

Decades of experience to draw on

Offering harm reduction services for 21 years, the Grand Rapids Red Project has been distributing free naloxone since 2008. Red Project has extended its reach through a collaboration with NEXT Distro that mails Michiganders life-saving naloxone through an online portal. 

"When Red Project started working in Kent County, 25% of all HIV cases were related to drug injection. Now that's down to 8%," says Steve Alsum, Red Project executive director. "That's a success we see replicated anywhere in the nation with a system of best public health policies that liberally provide sterile syringes for each and every injection. That decreases rates of HIV and hepatitis C, helps people get into treatment, and saves taxpayer dollars."

These days, overdose deaths overshadow the diseases spread by dirty needles. Alsum reports that Kent County has been in the midst of an overdose epidemic for more than 10 years.

"There's lots of people dying. Preventable opioid-related overdoses are occurring right now," he says. "Our communities are getting worse and worse every year and getting more and more dangerous. People have less and less knowledge of what they are purchasing and less control."

As the war on drugs put a stranglehold on the availability of both legal and illegal opioids, drug traffickers turned to the synthetic fentanyl, a synthetic substance produced in a lab that's easier to smuggle. When it comes to street value, a briefcase full of fentanyl equals a tractor-trailer of heroin.

Pam Lynch is the director of Traverse City-based Harm Reduction Michigan, which provides free harm reduction services and professional training and consultation. She reports that coroner's reports in the 13 counties her organization serves show that overdose deaths are up 13% from a year ago. She says 21 different substances are recorded in those toxicology reports, and "three-quarters of them are things I have never seen before."

"Too many people are dying," Lynch says. "... Knowing that these drugs are more and more tainted by these other substances, deaths due to overdose are not going to turn around."
Pam Lynch.
Having naloxone and clean syringes available in public spaces is much the same as having a heart defibrillator mounted on the wall.

"Syringe access and naloxone are very, very important right now. They save lives," Alsum says. "But we are going to continue in this epidemic until we start dealing with some of those bigger overriding social and policy issues."

Harm reduction strategies in other countries include decriminalization of drugs and their abuse, as well as creating safe consumption sites – legally sanctioned facilities where people can consume drugs under the supervision of trained staff with first aid and overdose medication at the ready.

"The reason people typically advocate for these is because of public substance use and people overdosing in public," Alsum says. "A few years ago, a man overdosed and died in the bathroom at Kava House [a popular Grand Rapids coffee house, since closed]. There have been multiple instances in gas stations. It's pretty widespread at this point."

Replacing stigma with policies that work

Harm reduction strategies aren't always popular among communities and their leaders. Alsum shares that while Red Project participants within Grand Rapids are free to dispose of used syringes at Red Project when they pick up clean ones, people in adjacent Wyoming, Mich., can be criminally charged under drug paraphernalia laws. And if Wyoming police respond to an overdose situation, the used syringe can be used as evidence to prosecute for possession.

"We've got to stop criminalizing substance abuse. You can't serve two masters. We can't deal with this epidemic as a public health issue at the same time as we're locking people up," Alsum says. "We've really got to stop operating from such a moralistic standpoint and accept people as who they are and where they are right now — treating them with kindness, love, and compassion instead of slamming the door on them, putting them on the street, and locking them up in jail."

Lynch believes the criminalization of substance use disorder is one factor in the current labor shortage. She shares the story of a young man in recovery who works for her. He is an "animal whisperer" who grew up caring for animals on his family's farm. He has been unable to pursue employment at an animal shelter or veterinarian's office because of his felony drug record. When people with substance abuse disorder have criminal records, they also have difficulty finding housing and owning a car.

"We currently have a system that forces people into treatment when they are not ready or receptive," Lynch says. "Harm reduction is beneficial because it doesn't waste resources by forcing change on people when they are not there yet."

Lynch notes that legal restrictions on prescribing painkillers nudge some people with chronic pain towards street drugs. Limitations on amounts of opiates stocked at pharmacies create barriers to people in medically assisted treatment programs that are more effective than abstinence programs, which only have a 10% success rate. Even naloxone has to be purchased through a pharmacist or acquired from a recognized harm reduction entity. A wiser approach would make it available over the counter.

"As more people access medically assisted treatment, we need to support the pharmacies so they can maintain these medications in stock," Lynch says. "And overdose prevention drugs should be made broadly available through easy-access vending machines."

Michigan jails pioneer naloxone vending machines

With funding from MDHHS, Wayne State University professor Brad Ray has spearheaded efforts to put naloxone vending machines into Michigan's county jails and other accessible sites.

"The struggle is: How do you get to the people who are going to use naloxone? Jails seemed like a really good opportunity to do that," Ray says.

A naloxone vending machine in the lobby of the Monroe County Jail.
Ray notes that vending machines have been highly effective elsewhere in the country. Los Angeles County has distributed over 34,000 naloxone doses since it began installing vending machines in jails in 2020.

So far in Michigan, jails in Monroe, Jackson, Delta, and Kalamazoo counties have the vending machines. Individuals being released can grab a naloxone kit for free, complete with instructions, on their way out. Ray has ordered 10 more of the customized vending machines. Sites in Kent, Oakland, Washtenaw, and Alpena counties are each slated to receive one.

"Just keep that person alive," Ray says. "They can't get clean or in recovery if they're dead. Sometimes it takes time."

Alsum says just about everybody he knows has been impacted by opioid abuse and overdose. He says some people using substances are able to function at work and home. Others experience horrendous negative impacts, like psychotic breaks that push them and their families into chaos.

"We need to rethink how we're providing treatment in the U.S., rethink how we're funding treatment, and how we're talking to people about their substance use. Doctors practice harm reduction in almost every branch of medicine except with substance use," Alsum says. "We want people to stop using drugs completely and totally, right now. Unfortunately, that's not practical."

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Pam Lynch photos by John Russell. Vending machine photo courtesy of the Monroe County Sheriff's Office. All other photos courtesy of the subjects.