Protecting our outreach staff

A thought provoking article on drug use among harm reduction outreach staff, below - an issue we should all be thinking about.

Rob

http://online.wsj.com/article/SB123154657089469819.html?mod=googlenews_wsj#printMode

JANUARY 9, 2009, 9:21 P.M. ET Heroin Program's Deadly Toll
Needle Exchanges Save Lives but May Imperil Workers
Article
By JUSTIN SCHECK
SAN FRANCISCO -- Pete Morse devoted his life to saving the lives of heroin users. A dreadlocked community activist with a Ph.D in history, he bore a tattoo that read: "Injury to one is an injury to all."
So his friends and colleagues were shocked when he was found unconscious in 2007 on a bathroom floor with a needle by his side. Doctors pronounced the 36-year-old Mr. Morse dead from an overdose of heroin, alcohol and cocaine.
Mr. Morse spent more than 10 years working in drug-addiction programs that follow the principle of harm reduction. This philosophy argues that the best way to save users' lives isn't to force them off illegal drugs. Instead, its adherents teach safer ways to use drugs -- supplying clean needles to prevent the spread of disease, for example, or teaching how to avoid overdosing. The programs are credited with saving lives in cities across the U.S.

Friends and family say Pete Morse tried heroin after working at exchanges.
But harm-reduction leaders have struggled to address a sometimes-lethal issue: dangerous drug use by the very workers who are supposed to help users. In the circles of New York and San Francisco where Mr. Morse worked, at least five harm-reduction staffers have died of overdoses. These included needle-exchange founders in both cities, as well as psychologist John Watters, a needle-exchange advocate who started a study to track how outreach programs benefited drug users. Mr. Watters died from an opiate overdose in 1995.
Worker drug abuse is "a huge problem," says Jon Zibbell, the founder of a Massachusetts drug users' coalition who is now an assistant professor at Skidmore College. "We prevent [overdoses] among our clients," he says. "So we should try to prevent them among our workers."
Studies suggest that needle exchanges work. In San Francisco, Chicago and New Mexico, heroin-related deaths dropped after users were taught how to administer an anti-overdose medication to each other. In New York City, the rate of new HIV infections among injection-drug users dropped more than 75% between 1995 and 2002 as the number of clean needles distributed doubled, according to a study by epidemiologists there.
How Needle-Exchange Programs Work

Needle-exchange programs, like those in San Francisco, can help reduce HIV infections and drug overdoses, WSJ's Bobby White reports. But while federal funding for such programs has grown in recent years, they still face many challenges.
Yet needle-exchange programs can exact a toll on those who operate them. Staffers typically earn little or no money for working on bleak urban front lines with traumatized users. Programs tend to be run on the cheap, often giving little of the training and support that are standard for other social-service workers. Those dealing with other factors -- depression, history of drug use or personal stresses -- may find it particularly hard to cope. Drug abuse is "an occupational hazard," says Alex Kral, a San Francisco epidemiologist who oversees the study Dr. Watters started.
Many exchanges hire workers who are active or former users. Other volunteers, however, have had no exposure to hard drugs before entering the field. Friends and family of Mr. Morse say they believe he learned to shoot heroin years after he first worked in a needle exchange.
Mr. Morse's family members say they don't blame harm-reduction programs for his heroin use. Mr. Morse suffered from depression, they say, and accidentally overdosed shortly after he learned that a family member had been diagnosed with a grave illness.
Some needle-exchange advocates say it would be unfair to pin his and other deaths on an approach that they say saves lives. The fatalities, these people say, represent a small portion of the field's workers. They argue that drug overdoses also occur among the staff members of abstinence programs, the other main branch of drug outreach, which also often hires former users. There are no statistics that compare overdose rates of workers in the two types of programs.
Those who do believe that the needle-exchange deaths are a problem propose two broad solutions. Critics say exchanges that countenance illegal drug use should be reined in. Supporters say that if anything, the programs should receive more funding, in part to better train and support their workers.
State and local government funding for needle exchanges tripled in 2007, to $14 million, compared with 1996. That's minuscule compared with the $1.75 billion that Congress gave states last year for conventional drug-treatment programs. President-elect Barack Obama said in 2007 that he may be willing to lift a ban on federal funding for needle exchanges. A bill now in the House of Representatives would free federal money for exchanges nationwide.
Busy Studying
Pete Morse was raised in Bloomfield Hills, Mich. On an otherwise conservative block of the affluent Detroit suburb, he grew up listening to Peter, Paul & Mary, according to his mother, Patty Morse. He excelled in school.
At DePauw University in Indiana, the lanky, 6'1" Mr. Morse ran on the varsity cross-country team and volunteered with a Red Cross HIV prevention project, his mother said. He seemed too busy running, studying or attending political rallies to drink or smoke much pot, recalls Vince Guimont, a fraternity brother who shared a room with Mr. Morse for three years. "He was always the person who had it together," Mr. Guimont says.
After graduating in 1992, Mr. Morse spent the year hiking in New Mexico, says his father, Pete Morse Sr. He also volunteered for the first time at a needle exchange. But soon he went back to school, beginning work on a doctoral degree, on the history of U.S. labor and social movements, at State University of New York at Binghamton. He joined the Industrial Workers of the World, or Wobblies. His tattoo -- "injury to one is an injury to all" -- is an IWW slogan.
In 1996, his master's degree completed, he moved to New York City.
New York was in the throes of an AIDS crisis, and intravenous drug use was a prime pathway of transmission. AIDS activists believed they wouldn't have much success getting users to quit, but they thought they could slow the disease's spread by allowing users to trade their shared needles for a supply of clean ones.
New York City legalized some needle exchanges in 1992. Public support for the programs grew throughout the decade. "We stepped to the plate," says Jason Farrell, who in the early 1990s co-founded a Manhattan needle exchange where Mr. Morse volunteered.
As exchanges spread, New York's incidence of HIV among injection-drug users dropped. In the three-year period ending in 1995, 44% of New York's intravenous-drug users were HIV-positive. By the four-year period ending in 2002, the infection rate among the population had fallen to 17%, according to a study by Don Des Jarlais, a doctor at New York's Beth Israel Medical Center.
But there were casualties among workers. In 1996, Brian Weil, who founded two New York syringe exchanges, suffered a fatal opiate overdose, according to the New York city medical examiner's office. Three years later, Angela Daigle, who worked at both exchanges with Mr. Morse and started a women's clinic at the Lower East Side exchange, also died from an opiate overdose, according to the medical examiner.
Mr. Farrell says he and many of the other grassroots activists who founded exchanges spent their limited funds on supplies and direct services. Their workers were often encouraged to put in long hours with little professional training. Some volunteers were ill-equipped to deal with the burnout.
"There were a lot of shortcomings in management skills in a lot of folks, including myself," said Mr. Farrell. "A lot of us got into this not to run big organizations, but to address a public-health issue."
Heroin, long considered an outsider drug, was enjoying a mainstream moment. With South American traffickers increasing imports, heroin became cheaper and more widely available. Fashion designers used pale, bony models to popularize "heroin chic." Mr. Farrell says the late 1990s brought an influx of volunteers who were "well-schooled, white, upper-middle-class kids that tend to romanticize and be infatuated with the heroin lifestyle."
'OK to Use Heroin'
Even after seeing overdoses among clients and peers, some volunteers began using hard drugs. Without proper training, Mr. Farrell says, those charged with teaching safer drug use sometimes "misinterpret that to think, 'It's OK to use heroin.'"
It's unclear when Mr. Morse first tried heroin. Writing years later on a blog he kept, Mr. Morse said he had been shooting amphetamines while living in New York.
His younger sister, Carrie Morse, remembers when he told her that he was using heroin. It was in 2000, Ms. Morse says, and her brother was suffering "horrible depression," using the drug to self-medicate. "I was scared that something would happen to him," she says.
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Reuters
Clean needles reduce disease among drug users.
That year, Mr. Morse moved to California, following his longtime girlfriend, who'd moved the year before. He saw a therapist and took antidepressants, and continued working on his doctoral thesis. His family says his heroin use stopped.
In 2000, the San Francisco health department adopted harm reduction as a guiding principle. Mr. Morse continued his work on needle exchanges, sometimes volunteering at one in San Francisco's Tenderloin district, in a fetid alley behind a bar.
Volunteers like Mr. Morse set up tables there once a week to offer syringes, first-aid kits and clean supplies like metal cups for cooking heroin. They showed how to inject safely and instructed people who wanted to quit how to access rehab.
Carrie Morse recalls asking her brother if this tempted him to use. He told her that he needed to keep his head about him to help others, and that his clients' situation reminded him of drug use's negative effects. Mr. Morse said "it was his work in the harm-reduction field that kept him from using heroin," his sister recalls.
Program managers don't take a unified approach to staff drug use. Hilary McQuie, a San Francisco harm-reduction training administrator who was Mr. Morse's last boss, says her organization trains workers to develop a "personalized burnout prevention plan" that includes taking time off work and doing a "self assessment" of whether their own drug use is harmful.
Because harm-reduction programs don't force their clients to quit, making employees do so would be "completely hypocritical," said Ms. McQuie, the West Coast director of the Harm Reduction Coalition, a New York-based nonprofit that trains workers to run needle exchanges and other harm-reduction programs. She and others in the field say drug use also is a problem among workers in abstinence-based organizations, which require workers who use drugs to enter rehab or leave their jobs.
Others believe that workers need more support services, including access to therapy. San Francisco epidemiologist Dr. Kral, who sits on Ms. McQuie's board, has for more than a decade paid a social worker to conduct monthly group therapy for workers on his drug-user study.
Drugs continued to take a toll on Mr. Morse's peers. In 2002, Urban Poole, an ex-convict who provided drug counseling for prisoners and worked for San Francisco's Health Department, died of an overdose. Three months later, Matthew McLeod, a local needle-exchange pioneer and a musician known as Matty Luv, suffered a fatal opiate overdose, according to a report by the San Francisco Medical Examiner. Mr. McLeod had told people, including an interviewer from a punk music publication, that he hadn't used heroin until he started the San Francisco Needle Exchange in 1997.
Mr. McLeod's death shook Mr. Morse. He and a friend, a former heroin user, discussed their own responsibilities and loved ones, and agreed they didn't want to risk a similar fate.
Still, Mr. Morse never stopped identifying as a user. In counseling with clients, the tattooed and dreadlocked Mr. Morse listened silently and, based on his own use and drug knowledge, explained how certain prescription drugs interact with heroin, recalls Kirk Read, who worked with Mr. Morse gathering data for a drug-user study for the University of California. "Your authority with clients is sometimes measured by how much you've lived," Mr. Read says.
Stopping Overdoses
By 2003, needle exchanges had steady funding in San Francisco. Harm-reduction advocates began expanding their scope. Mr. Morse worked on the San Francisco health department's new Drug Overdose Prevention and Education, or DOPE, project, training users to administer naloxone, which cancels out the effects of an opiate overdose.
Participants in the naloxone program reported stopping almost 150 near-fatal overdoses over the next three years, says Josh Bamberger, San Francisco's homeless-outreach coordinator, who ran the program. Opiate-related fatalities in San Francisco dropped almost 50% from 2003 to 2005.
Mr. Morse stayed with DOPE after the Harm Reduction Coalition took it over, with the help of city funding, in 2005. He started working full time for the Harm Reduction Coalition the following year, providing assistance to needle exchanges around the state.
By late 2006, Mr. Morse had also joined San Francisco's HIV Prevention and Planning Council, and the board of San Francisco's Homeless Youth Alliance, which runs a needle exchange. He finished his Ph.D dissertation on the Wobblies.
Though his professional life bloomed in the last years of his life, his depression was sometimes deep, his family says. His paperwork-heavy job left him unsatisfied, his sister said. He was also jarred by the death of his cat, who had nestled on his lap as he wrote his thesis. He had its name, Otter, tattooed on his left biceps.
Then, three days before Christmas in 2006, his sister was diagnosed with cancer. Carrie Morse says her brother was despondent. "Other people's pain was Pete's pain," said Ms. Morse, who works in the public-relations department of The Washington Post. The two spoke daily for the next three weeks, she says.
Shortly before his sister's cancer surgery, late on the night of Jan. 12, 2007, Mr. Morse ended up drunk at a friend's house in San Francisco's Mission District. He went to use the bathroom. The friend discovered Mr. Morse unconscious on the floor, according to the medical examiner's report. He was declared dead at 4:31 the next morning.
An autopsy found scar tissue on Mr. Morse's arm, and a needle puncture in the crook of his elbow. The medical examiner said his death was accidental and attributed it to alcohol, heroin and cocaine in his system.
More than 300 mourners attended the funeral. Many paraded down a palm-lined stretch of San Francisco's Market Street with drums and a five-foot-tall photo of Mr. Morse.
Mr. Morse's parents blame his heroin use that night on his decision to drink too much as he despaired over his sister's illness. They say they're proud of their son's efforts to bring harm reduction into the mainstream.
Since her cancer treatment, Carrie Morse has been volunteering at Prevention Works, a needle exchange in Washington, D.C. Such programs, she says, "save lives."
Mr. Morse's coworker, Mr. Read, learned another lesson from his friend's death. "It punctured the illusion that knowledge can protect you," he says.
Write to Justin Scheck at justin.scheck@wsj.com