On the front lines of OVERDOSE PREVENTION
“People aren’t wanting to die. They know that they’re at risk, but they don’t want to die. They have a disease that needs to be addressed, but until we can get them there, we’ve got to keep them alive. — DEBRA CLARK MORGAN, A REGIONAL OVERDOSE PREVENTION SPECIALIST WITH THE HAMILTON COUNTY COALITION”
Like many Chattanoogans, cannabis store owner Elisha Millan doesn’t smoke, use recreational drugs or take any products to “get high.”
When she founded Tennessee’s first hemp dispensary — Grass Roots Health — in 2017, she said it was with a mission to help people experiencing pain by sharing the benefits hemp has had on her own health. Grass Roots sells cannabidiol, or CBD, and other nonintoxicating hemp products derived from cannabis.
But over the years, Millan and staff noticed a concerning trend among customers and passersby outside her storefront on M.L. King Boulevard — a pedestrian thoroughfare between downtown Chattanooga and many of the city’s major health and social service providers.
More and more people were at risk of dying from drug overdoses.
“One customer came in dressed very nicely, and I made the mistake of saying, ‘You look very nice today,’” Millan recalled in a phone interview. “Their response was, ‘Thanks, I was at my cousin’s funeral.’”
Millan said the customer shared that his cousin died from an accidental overdose after buying a product off the street that was tainted with fentanyl, a powerful synthetic opioid in the same family of drugs as morphine and heroin but up to 100 or 50 times more potent, respectively.
The drug is driving the nation’s growing and everevolving opioid epidemic, which has claimed a record number of lives each year since becoming the deadliest drug crisis in American history in 2017.
Drugs killed 226 people in Hamilton County in 2022, according to the Health Department’s Drug Overdose Surveillance Report. That’s up from 176 suspected fatal overdose deaths reported in the county in 2021. The synthetic opioid fentanyl contributed to 73% of those fatalities, according to the report.
Though the statistics are grim, if you use drugs, know someone who does or are just a bystander, there are more tools and policies than ever to help save lives by preventing or reversing an opioid overdose.
Advocates and health care professionals have been working to educate the public but say persistent stigma and misunderstanding surrounding addiction and “harm reduction” — a broad term for approaches that help reduce
certain health and safety risks of drug use — are keeping those life-saving strategies from reaching many of those who desperately need them.
“People aren’t wanting to die. They know that they’re at risk, but they don’t want to die,” said Debra Clark Morgan, a regional overdose prevention specialist with the Hamilton County Coalition. “They have a disease that needs to be addressed, but until we can get them there, we’ve got to keep them alive.”
HARM REDUCTION
As opposed to focusing on preventing substance use, harm reduction is a public health approach that acknowledges some people in life will wind up turning to substances for a variety of reasons, regardless of education and prevention efforts.
For those grappling with addiction, harm reduction is rooted in the understanding that certain people won’t be ready or capable of stopping their substance use at a given time. In those cases, there are evidence-based methods to mitigate the adverse consequences of drugs.
Harm reduction isn’t a new concept or exclusive to illicit drugs. Wearing seat belts while driving or using nicotine patches to wean oneself off tobacco products are forms of harm reduction.
But the opioid epidemic and growing pervasiveness of fentanyl in the drug supply have led to a wave of new laws and policies aimed at widening the reach of certain harm reduction strategies. Some initiatives in the Chattanooga region include distribution of the opioid antidote naloxone, a syringe exchange program for people who inject drugs and fentanyl test strips that can detect the substance in drugs acquired on the street.
“I think one of the biggest things, when it comes to harm reduction, is that people understand it is not enabling,” Morgan said in a phone interview. “It is trying to keep someone healthy and alive because we want to get them in recovery. But until they’re ready, they’re not going to go.”
Because fentanyl is so potent and cheap compared to other drugs, dealers can add it to substances — including nonopioids and counterfeit prescription pills — to cheaply increase a drug’s psychoactive effects and maximize profits.
Cassandra Riddle, a collegiate recovery coordinator at the University of Tennessee at Chattanooga, counsels college students who are struggling with substance use or addiction and conducts educational events for groups across campus. Through that work, she said many of the students she interacts with have confided in her they know someone who has died from a fentanyl overdose.
She gave the example of a student losing a sibling who took a pill of Adderall — a medication commonly prescribed to treat attention deficit hyperactivity disorder that is also misused among people seeking a stimulant high. The pill turned out to be laced with fentanyl.
“It’s insidious, because with fentanyl, it just doesn’t take a lot for people to overdose and die. Sometimes, this is the first time a person gives them a pill,” Riddle said via phone. “And this is the age where they kind of experiment with things … and that can be lethal.”
Among Hamilton County’s drug overdose deaths in 2022, 16% occurred in people 30 and under.
All illicit drugs have the potential to be laced with fentanyl without the knowledge of the user. But
some people who have developed opioid dependencies seek out fentanyl — typically because their tolerance has become so high that other opioids no longer counteract the feelings of withdrawal that lead to compulsive drug use.
Those people are also at high risk for drug overdoses because the potency of illicit drugs is unpredictable.
LEGAL LEEWAY
To treat opioid overdoses, the U.S. Food and Drug Administration in 1971 approved the drug naloxone — also sometimes referred to as Narcan, which is a device that dispenses the antidote.
Naloxone reverses or blocks the effects of opioids, including heroin, fentanyl and prescription opioid medications, by binding to opioid receptors in the nervous system.
Although it doesn’t work for nonopioid drug overdoses, it can easily and safely be administered by injection or through a nasal spray to someone who appears to be overdosing without causing additional harm. Because a person experiencing an overdose will be unable to administer it themselves, successfully reversing an opioid overdose with naloxone requires another person to be present and capable of giving the drug.
For decades, naloxone was used almost exclusively by paramedics and in hospitals.
But in 2014 — as synthetic opioids, particularly those involving illicitly manufactured fentanyl, began driving a new wave of overdose deaths — Tennessee followed in the footsteps of 17 other states by enacting a “Good Samaritan” civil immunity law for naloxone.
The law gave providers the ability to prescribe naloxone to patients or people who were likely to be in a position of witnessing an opioid overdose and, therefore, able to give the medicine at that critical moment. It also granted civil immunity to the prescriber and person administering the medicine to someone they reasonably believe to be experiencing an opioid overdose.
A 2015 amendment added protection from misdemeanor drug possession and drug paraphernalia charges for people seeking help from emergency services in response to an opioid overdose.
However, naloxone access in the state remained limited because the law required both a prescription and completion of a basic naloxone training in order to obtain the drug.
In 2022, Tennessee again amended its naloxone law by removing the prescription and training
requirements, expanding the definition of naloxone to include any opioid antagonist and providing protection to the individuals who administer the life-saving drug to anyone they in good faith believe is experiencing an overdose, regardless of whether they think the overdose is due to opioids.
There is now no restriction on where naloxone is acquired or how it is distributed in the state, as long as entities authorized to give out naloxone provide it at no cost. The FDA also recently approved the drug to be sold over the counter at retail pharmacies, though cost may be a barrier for some people.
In Southeast Tennessee, the vast majority of free naloxone is distributed by the nonprofit Hamilton County Coalition, which works across 10 counties to prevent overdose deaths, promote addiction recovery and reduce underage drinking and tobacco use.
Morgan said the coalition has handed out 2,808 naloxone units so far this year, including to first responders, high risk individuals and agencies.
Across the state, the Tennessee Department of Mental Health and Substance Abuse Services has distributed 129,098 units of naloxone in the current fiscal year which began July 1, 2022, through regional overdose prevention specialists such as Morgan, according to department spokesman Matthew Parriott.
“That’s resulted in 12,776 reported overdose reversals in the same time period,” Parriott said via email, adding that more than 450,000 naloxone kits have been distributed since the state’s regional overdose prevention specialist program began in October 2017.
The state grant that supplies the drug at no cost requires the coalition to prioritize giving it to high risk people and their family members, Morgan said. But if it was up to her, everyone would carry an opioid reversal drug.
“I’ve had people tell me, ‘Well, I don’t know anybody who does drugs.’ And I said, ‘But do you go to a gas station? Do you go to Walmart?’” she said. “A lot of these officers are going on calls to public restrooms, public places out in the car, or something like that — so you never, never know when you’re going to come across someone that’s overdosing.”
Morgan encourages anyone in the Chattanooga region who wants to carry naloxone but can’t afford to buy it to contact the Hamilton County Coalition.
ANOTHER TOOL
Also in 2022, Tennessee decriminalized the possession of fentanyl test strips, which were previously considered illegal drug paraphernalia. The strips allow substance users to test a small sample of drug to see if it contains fentanyl. Since only a sample is tested, a negative result could still mean the batch contains fentanyl, but users are able to make more informed decisions about whether a substance contains the potentiallylethal drug.
As of this time a year ago, fentanyl test strips were still hard to come by in the Chattanooga region. The Hamilton County Coalition began distributing the test strips in October, and Morgan said awareness of their availability is growing. The coalition has handed out roughly 2,100 to date, she said.
Grass Roots owner Millan said her experience with the customer coming from his cousin’s funeral led her to begin stocking fentanyl test strips in her store about two months ago.
“I know lots of people in my life that have overdosed, including friends from high school,” Millan said. “I had been looking into potentially getting them — knowing they were out there — and then once that incident happened, I ordered them that night.”
The strips at Grass Roots are sold individually for $1.49 a piece.
“This literally can save lives,” she said. “It’s a very low-cost method to make sure that you’re safe. It is solely designed for harm reduction.”
Millan said she believes fentanyl test strips remain underutilized because people don’t know they exist, or because they’re afraid to say that they need them. Her hope is that even those who don’t use drugs start spreading the word and distributing those tools, similar to how people learn to use a defibrillator or perform CPR.
“If you’re a person that perhaps goes to Bonnaroo and you see people around you doing drugs, it might be a good idea to have,” she said. “Several of my staff members carry Narcan. They are not heroin users, but because they know they go to places where those people are, they are trained and ready with Narcan so that they can help people.”
ONGOING BATTLE
Though acceptance for harm reduction strategies is growing, Morgan said the concept remains difficult for some people to grasp. One of her primary roles at the coalition is to train groups across the region, including all firefighters and police officers, how to recognize overdoses and administer naloxone.
“Depending on their life experience, you can’t always change how someone thinks,” she said. “I think educating on it does make a difference to a lot of them. But some people, they’re set in their ways — until it touches them personally.”
That was the case with Morgan.
Before she became an overdose prevention specialist, Morgan built a 15-year career working in banking. It was four years ago that she lost her son to an opioid overdose and has since become an advocate.
“I was one of those moms. I didn’t understand what was going on with my kid. I didn’t understand substance use disorder, and that’s not what I used to call it,” she said. “I didn’t understand why he couldn’t quit just hanging out with these same kids.”
Morgan now uses her personal experience to help others understand the science behind addiction and the need to empower more people to employ harm reduction strategies.
“That’s why I try to make it a point to speak out. Because if we don’t speak out, then we’re not helping someone else,” she said. “That’s how I have peace with T.C.’s death — because I know his death meant something, and it’s helping save so many lives.”
Riddle uses a similar tactic at UTC. While she hasn’t abused opioids, she has experienced her own journey to recovery from alcohol misuse, she said. She now uses her personal story to relate to students seeking help.
“We are seeing a rise in students that want help. They recognize they need help,” she said, noting that many students begin using substances — such as marijuana — “innocently” but have come to develop dependencies.
“They’re feeling anxious, they’re feeling stressed, they’re feeling tired, they’re feeling depressed,” she said. “So they’re reaching for something to make them feel better. … They’re not really aware that they might be addicted to it.”
Not only is most marijuana on the market today increasingly more potent, Riddle said, any drug that’s bought off the streets at this point could contain lethal amounts of fentanyl.
“There are just tragic stories of this seemingly innocent, experimental age, resulting in death unintentionally,” she said.
UTC hosts naloxone training throughout the year, and Riddle said she’s able to help those who want to acquire it outside of one of those sessions. Because when it comes to harm reduction in the fentanyl era, Riddle said everyone has a role to play.
“There are students here that are just experimenting, figuring it out,” she said. “I think that’s why we’re all about harm reduction and saying, ‘Hey, we know you’re going to do this, so let’s talk about