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Join us for a discussion on harm reduction and the controversy surrounding the provision of clean drug paraphernalia in harm reduction kits. Our guest, Bonzo Reddick, a family physician, will shed light on the principles of harm reduction, dispel myths, and explore the evidence behind these initiatives. We will delve into the impact of stigma, media portrayal, and political rhetoric on policy decisions while examining the ethical considerations at play.

Bonzo Reddick is a family physician.

He discusses the KevinMD article, “How stigma and online trolls stopped an intervention that could save lives.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome Bonzo Reddick. He’s a family physician. Today’s KevinMD article is “How stigma and online trolls stopped an intervention that could save lives.” Bonzo, welcome to the show.

Bonzo Reddick: Thank you so much for having me. Excited to talk about harm reduction.

Kevin Pho: All right. So let’s start by briefly sharing your story and journey.

Bonzo Reddick: Sure. So my name is Bonzo Reddick, a lot of people just call me Dr. Bonzo, and I’m a family physician down in the Savannah, Georgia area. That’s where I was born and raised, and I’ve spent quite a bit of time here.

But my outpatient clinical work for the past six or seven years or so has been at a federally qualified health center, what a lot of people refer to as an FQHC. But our FQHC is a little bit different, because it’s also a federally designated health care for the homeless site. So for the past six or seven years, my outpatient practice has been primarily with people who are experiencing homelessness.

Kevin Pho: All right. So tell us some typical cases that you see. What would a typical day be like for you?

Bonzo Reddick: Sure. So we rotate. We have sort of a central area downtown that we focus on, it’s our catchment area, and so the mobile clinic rotates each week and goes to different sites. They’re all within walking distance of each other, so that way we’re able to serve the same community and have some continuity as well.

So we do some basic things, chronic disease management, hypertension, diabetes, acute care management for respiratory infections, skin infections, other musculoskeletal complaints. But we also do see high rates of substance abuse as well.

And sort of the background that led to this article was, we had one particular community we served where there were high rates of intravenous drug use, even out in broad daylight. And so we really just saw increasing need for harm reduction techniques to decrease the risk of transmission of viral infections and that sort of thing.

Kevin Pho: All right. So let’s talk more about your article. It’s titled “How stigma and online trolls stopped an intervention that could save lives.” For those who didn’t get a chance to read that article, tell us the story behind it.

Bonzo Reddick: So the way the story came about, the timing was interesting, because one day we were at the mobile homeless clinic and saw a patient in a ditch trying to fish out an old needle. So there’s a really dirty, just kind of green, kind of sewage filled ditch where people just chuck their needles in after they inject, and the patient was trying to retrieve a needle from there to reuse.

And that was the day where it really clicked, that there are some days where there’s not anything you can say or do to stop somebody from using drugs. That’s just the way it is. And so in that situation, you don’t want them to overdose, you don’t want them to acquire HIV or hepatitis C infections, you don’t want them to acquire bacterial endocarditis or heart infection.

And so around the time that that happened, when we started really increasing our use of needle exchange to try to decrease the transmission of infections, and giving out naloxone to prevent overdose, I saw the article that I referenced in your article, which was where people were highly critical of the White House for giving out what they were calling crack pipes in these harm reduction kits.

So, giving out things like clean needles and clean syringes, or clean glass pipes with rubber mouthpieces to smoke. And people just couldn’t believe it. There was uproar from the media, people said, how in the world are you going to enable, you know, drug addicts, they were saying, and they were using a lot of stigmatizing language in the media, using words like addict or junkie, saying that we were fueling addiction, saying that the White House was giving out crack pipes.

And so to the lay person, that sounds probably ridiculous. But again, what I’ve seen in my practice, but also seen in the medical literature, is that there’s actually great evidence for harm reduction. It’s kind of a weird situation where, when you show people that compassion of trying to make sure they don’t acquire infections, make sure they don’t overdose, people are actually more likely to pursue drug rehab, and actually have lower recidivism rates as well.

So giving people substances is a weird paradox, where you give them things that would seemingly enable drug use, but they actually are more likely to get help with their substance abuse and more likely to have successful rehabs.

So I just thought that the people at large need to know, the lay person who may not know about harm reduction needs to know, that it’s actually very effective, that it is actually a good idea.

And the sad part that the article ended on was that the White House administration actually backtracked, and they decided to not include glass pipes or injection drug supplies in these harm reduction kits. So they really let the media outrage and a lot of the online trolls just sort of change their mind about doing something that was actually a good, evidence-based idea.

Kevin Pho: So you talked a little bit about the data and the evidence. Tell us a story or scenario where you personally saw harm reduction move the needle on one of your patients.

Bonzo Reddick: Absolutely. And sometimes, just to clarify, sometimes just for privacy reasons I’ll kind of merge one or two stories, just to protect patients’ privacy.

But I can tell you countless times where I’ve been seeing them in clinic, at the mobile clinic, we’re talking about their substance use, they just kind of cut me off early and say, I’m not really interested, not right now, I just got too much going on, maybe one day, but right now I just want to get help with this medical condition and go about my business.

And I’ll still offer them and say, OK, that’s fine, let us know if you ever change your mind, but in the meantime, I want to make sure you don’t overdose. A lot of the substances, I know in Savannah it’s anywhere from 50 to 80 percent of the street drugs are contaminated with fentanyl. And so I have that conversation with patients, and a lot of them are interested in not overdosing on fentanyl.

So they’re often willing and accepting of receiving naloxone, which is the nasal spray you use to reverse an overdose. And so we’ll give out these two dose boxes to patients, and you keep one, you give one to somebody that you use with, never use alone.

And we’ve also said, what about injections, for people that are injecting drugs, saying, hey, if you get clean needles, you can reduce your risk of HIV acquisition by as much as 80 percent, reduce your risk of hepatitis C infection by as much as 50 percent. People get excited about that and say, well absolutely, give me some of those.

And what I’ve seen numerous times is that when people leave, and they initially said they didn’t want any, they start to step off the mobile unit, turn around and say, actually, who’s that person you told me I could talk to about substance abuse? And I say, he’s right over there sitting at that table, you want to go talk to him?

And I’ve had people, literally the same day that they initially said they did not want help with substances, they accepted clean needles or syringes, accepted the naloxone, that same day people enter rehab. I’ve had it happen more than one time.

Kevin Pho: In terms of the pushback against harm reduction strategies, is this a national issue? Do you see variations locally in different parts of the country? So do you have colleagues out on the west coast, for example, that say that it’s a little more accepted out there?

Bonzo Reddick: So I think there are some areas of the country where it seems to not be as big of an issue. I had a colleague in Colorado say that there’s less pushback there.

And what I’ve seen here is that Georgia is very unique, because we actually have bipartisan support for harm reduction and syringe services programs, which is this process of giving people clean needles and syringes. That bill was signed into law about five years ago now, and it passed by more than 90 percent in the Senate and the House in Georgia.

And a lot of people have an image about Georgia being in the Deep South, not being open to this kind of thing. So when people are actually presented with the evidence and hear it, they actually are pretty receptive to it.

The problem is, though, there’s still that backlash from the lay person about, how could you possibly give somebody using drugs clean needles and syringes, you’re enabling their drug use.

So what I’ve seen is that, even though it’s generally accepted as far as from our legislators, they’re very hesitant to fund the actual supplies. So for example, a lot of times you apply for grants for harm reduction, I’ve actually had two and I’m actually applying for a third one right now, but they very often say, you cannot use this to purchase needles or syringes or crack pipes or anything like that, glass pipes, you cannot use that for anything like that.

And so there’s this sort of fear of, like, we’re going to fund it because we believe in it, but we don’t want to be seen as buying the supplies, because even though we don’t believe it, we know everybody else is going to think we’re enabling drug use. So I see that repeatedly. There’s only one of the grants that I actually had that they actually allowed me to use the grant money to purchase the supplies.

Kevin Pho: So what are some of the strategies from your end? You’re obviously an advocate for harm reduction strategies. How do you change that narrative and convince more of the public about the benefits of harm reduction strategies?

Bonzo Reddick: Sure. So some of it is just getting out talking to people. But I did actually write a book earlier that got published early this year, so chapter 13 in the book is an entire chapter on harm reduction and addressing health inequities affecting people who inject drugs. And so I’m trying to just get the word out there.

And that’s probably the chapter I’ve gotten the most feedback about, especially from lay people who read my book, who will say, like, oh my goodness, I had no idea. They’ll tell me, when I started reading the chapter it sounded ridiculous, what you were saying, but the more I read about it, I heard the stories and I saw the evidence, that’s actually pretty remarkable.

So once you actually sit down and tell people this story, kind of the format we’re doing today, people tend to believe it and tend to buy into it. But when they haven’t heard the background, they haven’t heard the evidence, they haven’t heard some of the stories, then it does sound ridiculous to a lot of people, and there’s a lot of backlash.

And until we can get that message out there, that harm reduction is safe, that it works, and that it, in a weird sort of turn of events, encourages people to actually get more help with their substance use, until we get that word out there, we’re going to continue to have a lot of backlash, and there’s going to still be a lot of stigma associated with substance use.

Kevin Pho: So you’re talking to me individually. Are there any national or state level organizations that advocate on behalf of harm reduction?

Bonzo Reddick: Sure, there’s a lot of them. Almost every state that I’ve checked in with colleagues and physicians abroad, they have a state organization typically. In Georgia, the Atlanta Harm Reduction Coalition is really well known. In Texas, I believe it’s the Austin Harm Reduction Coalition. They’re often called harm reduction coalitions, that’s a common name. I know down in Florida, Dr. Tookes, I can’t remember the name of his, but he’s based out of Miami, Florida, they also have a harm reduction coalition.

And so there’s organizations all throughout, it’s just that a lot of times they’re really grassroots organizations on the ground doing the work, and so it may not be something that you just see on your day-to-day basis.

A lot of people see our mobile unit downtown in downtown Savannah, and they know we’re providing medical care to people experiencing homelessness, but they may not know that we’re doing harm reduction, that we’re giving out needles and syringes, or giving out naloxone.

So there’s a lot of organizations, but the word isn’t often out to the lay person. A lot of physicians know about it, but the typical person may not know about this and may not know the great evidence to support it.

Kevin Pho: So tell us your ideal scenario. Let’s say you take politics out of the equation, and if you were to achieve everything that you advocate for, what would be your ideal scenario in terms of implementing your harm reduction strategies?

Bonzo Reddick: In my ideal world, everybody in primary care, people providing emergency care services, they would all be knowledgeable, confident, and supportive of harm reduction techniques, and they would also have the supplies and materials to perform harm reduction.

So for example, my wife’s an OB/GYN, so she has a patient who comes in for prenatal care who is having substance abuse problems, very common. The knee-jerk reaction is, oh my goodness, call Child Protective Services, got to help protect this baby.

But the step further is not only just referring people for substance abuse services and counseling, but providing them the naloxone, providing them clean needles and syringes, and saying, hey, I still want you to get help, but in the meantime, sometimes it takes people a while to kick a habit, I want to make sure you don’t acquire HIV or hepatitis C infection. Here’s some needles and syringes, come back anytime you need them.

Same thing in the emergency room. When people are being discharged from the ER and they have known active substance abuse problems, offering them naloxone, offering them clean needles and syringes, offering them glass pipes on discharge if they’re sharing with other people. So that’s kind of my dream world.

And again, in my dream world, grant funding would be very, very open and accessible for people who aren’t able to afford supplies, so that somebody could just come in and get them whenever needed.

I know there was a pilot down in south Georgia where they were even having these little mailboxes, like little kiosks, that somebody could just come up to and get some naloxone, get some needles or syringes whenever they needed to, and have a sharps disposal container where they could discard their old ones as well.

So that’s kind of my dream world, is where that will be accessible to everyone, and there will be a lot less stigma towards people getting help with substances, and when people aren’t ready, a harm reduction approach to improve their care.

Kevin Pho: You mentioned some pushback in the public against harm reduction. What are you seeing within the physician community? Are you seeing any type of pushback from the physician community at all?

Bonzo Reddick: Absolutely. So interestingly, the same thing I described with a lay person, how often there’s this really strong pushback and really strong language about, I can’t believe you’re doing that, you’re enabling drug use, that same thing happens to physicians who have not experienced it.

So very often you might hear of a medical thing, you’re a doctor, you know how it is, sometimes you hear a new evidence-based guideline and you say, really? Think about beta blocker use for heart failure. That sounded ridiculous when it first came out, but once you saw the evidence you kind of understood it.

I’ve seen the same thing with harm reduction, where when you first bring it up to physicians who haven’t really explored the evidence and haven’t really seen it in real life, they give me the same kind of pushback that a lay person does.

I got into an exchange on social media with a colleague, a surgeon colleague of mine, one day, where he just didn’t believe it, he kind of kept firing back. And he hadn’t read any articles on it, hadn’t seen it in real life, hadn’t seen any patients that had been exposed to harm reduction techniques, but he was just arguing with me that he didn’t buy the evidence, that there was no way. And then over time he actually got a chance to read about it and sort of backtracked later on.

But the same initial reaction we get is not only with physicians but also with health care organizations and hospital systems as well.

Kevin Pho: So obviously, if you zoom out, we live in a pretty politically polarized community. Do you see this as another politically charged topic, that despite the amount of studies and evidence that you present, you’re just not going to convince some people of the benefits of harm reduction?

Bonzo Reddick: So, yes and no. So yes, it’s definitely politically charged. Maybe I’m silly, but I’m an optimist that there is a way nationally to get bipartisan support.

So in the article that I referenced, on your page, I mentioned about how the political opponents of the White House administration came out speaking against these harm reduction techniques, they were mocking it, and they caused the White House to backtrack. And so that definitely happens, where people use it for political gain. They know that the lay person is going to think it sounds ridiculous, and they’re going to say, OK, great, I’m going to seize on this and mock somebody who’s trying to implement harm reduction from a legislative standpoint.

But again, in Georgia we did it. I’m not sure exactly how it happened, I kind of know the story, but 98 percent passage in the House, 92 percent passage in the Senate, for House Bill 2117, which made harm reduction legal in Georgia. And so there’s been widespread support for it. So there’s a way to reproduce that nationally.

Georgia has just as much bipartisan bickering as everybody else, but I know the story they started with in Georgia was getting a small coalition of people from both sides of the aisle. I think there were six legislators in general, I believe there were four Republicans, two Democrats, but they all had a personal story, or either had studied it or knew somebody that was affected by substance use. And so they actually bought into it, and their colleagues were more likely to listen when they had bipartisan support.

I believe one of the authors is married to an anesthesiologist who’s done some anesthesia pain management, and they obviously see a lot of the effects of opioid abuse and misuse. And so they kind of had personal stories they could bring to the table.

So I think the more we can have bipartisan supportive people sitting down, listening to hear the stories, and coming to the table together to present it, I think we’re more likely to get passage at a national level.

Kevin Pho: We’re talking to Bonzo Reddick. He’s a family physician. Today’s KevinMD article is “How stigma and online trolls stopped an intervention that could save lives.” Bonzo, as always, we’ll end with some of your take-home messages to the KevinMD audience.

Bonzo Reddick: Sure. So my big take-home message, number one, is that harm reduction works. It improves outcomes, it decreases transmission and acquisition of HIV infection, hepatitis C infection, and also bacterial infections that can affect the heart, that we call endocarditis.

And the paradox is that, if you give people injection supplies, supplies to smoke, who are using substances, who seemingly are not ready to get help with their substance use, they actually are more likely to pursue substance abuse counseling and actually have lower recidivism rates. So they’re actually more likely to seek rehab and more likely to have successful rehab if we offer them supplies.

It’s very interesting what will happen when you show people compassion and show them that you’re interested in improving their health outcomes.

Kevin Pho: Bonzo, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Bonzo Reddick: Thank you so much.