“All of my friends are dead”: The overdose crisis is taking a toll on harm reduction workers

Stephen Murray’s work in harm reduction doesn’t end when he leaves the office at 5 p.m. As the Harm Reduction Program Manager at Boston Medical Center who runs the SafeSpot Overdose Hotline, he is on call 24/7. Sometimes, his phone rings at 4 a.m. to assist with an overdose.

Still, despite the hours and energy he and others put into keeping people who use drugs safe, he usually doesn't go a month without personally knowing someone who dies from a drug overdose.

“I alternate between feeling numb and feeling overwhelmed by my grief,” Murray told Salon in a phone interview. “You feel like there is no time to rest because it is just constant.”

Overdose deaths seem to have peaked in 2022, with an estimated 112,000 Americans dying from an overdose, reaching yet another annual all-time high. Preliminary data released Wednesday by the Centers for Disease Control and Prevention indicates that, for the first time in five years, deaths from opioids have dropped a mere 4% per year, with 107,000 overdose deaths overall. While this seems like a positive reversal, it's worth noting that drug overdoses dropped between 2018 and 2019, only to shoot back up again during the COVID-19 pandemic, when a lot of people who use drugs were isolating.

The level of carnage, decreasing or not, is still far above historic levels, with an estimated 1 million deaths due to illicit drugs in two decades. And people who use drugs are far from the only individuals affected: federal data released earlier this month found that more than 321,000 American children lost a parent to drug overdose between 2011 and 2021.

This crisis is largely driven by increasingly dangerous drugs being introduced into the supply such as opioids like illicit fentanyl, along with drug combinations like opioids plus stimulants and xylazine. The sheer magnitude of the crisis has outpaced the extraordinary efforts many harm reduction workers undertake to reduce overdose deaths. 

Staff at Prevention Point, a syringe service program in Philadelphia that offers wrap-around medical and community services for people who use drugs, recently experienced five overdoses in a single day, said the organization’s director of Drop-In Services Viviana Oritz.

“Those days are draining,” Ortiz told Salon in a video call. “I remember in 2019, it was like that for about two months.”

Harm reduction efforts have saved thousands of lives, yet the value and legitimacy applied to other first responders often don’t apply to harm reduction, which is still shrouded in stigma and seen by some to be a controversial approach to the drug crisis, said Gillian Kolla, of the MAP Centre for Urban Health Solutions in Toronto. 

A wealth of scientific evidence shows that supervised consumption sites, (where drug use is monitored by medical staff), syringe access programs and naloxone trainings are all helpful tools to combat the overdose crisis. For example, OnPoint in New York, the first legal supervised consumption sites in the U.S., reversed more than 1000 overdoses as of last summer, which otherwise may have been fatal.

In spite of this, a group of harm reduction workers at supervised consumption sites in Canada surveyed in a new study published by Kolla in the International Journal of Drug Policy said the lack of broader crisis support from the government contributes to the emotional toll of this work.

“I regularly have people telling me, ‘All my friends are dead,’’ Kolla told Salon in a phone interview. “These overdose prevention sites and supervised consumption sites were not adapted and developed to deal with this level of overdoses.”

Many in this line of work have experiencing using drugs themselves and employ their lived experiences to help guide others to treatment or safe use. However, this proximity also means that when an overdose happens in the community, it’s more likely a friend or acquaintance. Harm reduction workers who carry the overdose-reversal medicine naloxone on hand have essentially become the first responders, intervening before paramedics arrive at the scene, Murray said.

“Naloxone is in the hands of people who are using drugs and who are the closest to the overdose,” Murray said. “That has shifted the responsibility of overdose response in a lot of ways to people who use drugs and the ones that are supporting them, like harm reduction workers.”

Although the war on drugs pushes an abstinence-only model that discourages “enabling” people who used drugs, evidence suggests those strategies have only made the overdose crisis worse. Other research evaluating 100 supervised injection sites in countries that have implemented them has found they not only reduce overdose deaths but also lower community spread of HIV and hepatitis. They also increase the number of people going into treatment programs. 

If administered in time, naloxone reverses up to 93% of overdoses. In one 2018 study published in the Addictive Behaviors journal, states that enacted laws that improved access to naloxone were associated with a 14% reduction in opioid overdose deaths. But although naloxone is being dispensed at a rate nearly 10-fold since 2016, another study in the Lancet Public Health found Arizona was the only state with an adequate supply of naloxone to meet the need.

Regardless, access to naloxone is one element of harm reduction and doesn’t address the root of the overdose crisis. Without top-down policy changes that address the mental health crisis, the housing crisis and the racial inequities so interconnected with the overdose crisis, people will continue to die.

“Often, we would get people back, and then I would show up one week, one month, or one year later to then pronounce that person back from a subsequent fatal overdose,” Murray said. “That can feel pretty hopeless in a lot of ways.”

So far, New York is the only U.S. state to offer supervised consumption sites while Canada has 39 operational sites. Most of these were opened through grassroots efforts characteristic of the broader harm reduction movement. As a result, many sites rely on grants or donations and face chronic underfunding, which leaves many harm reduction workers doing volunteer work or being inadequately paid without health benefits or paid time off, per Kolla's study. While harm reduction is often focused on “peer” and community support, this label can also sometimes get in the way of harm reduction workers getting adequate benefits and pay, Kolla said.

“The legacy of peer programs means that you often have people who use drugs being brought into organizations to do work either as volunteers — so uncompensated — or they were just given temporary contracts with no benefits and no possibility for advancement,” Kolla said. “They need access to benefits because the benefits are crucial in terms of ensuring people have access to things like counseling and support to help them cope with the grief, loss and stress they’re facing from their jobs.”

To Kolla, this is deeply rooted in stigma against the clients harm reduction workers are serving. In general, the majority of care work is undertaken by underpaid women or marginalized groups, with one 2022 study from the U.S. Department of Labor finding the average care worker was paid $15 an hour. Similarly, many in harm reduction have insufficient wages and no access to benefits.

“Certain forms of care work, because of who's been doing it and because of the population that they care for, are really valued, and we see that reflected in pay,” Kolla said. “The care work for people who use drugs is very devalued because people who use drugs are stigmatized and devalued in our society.”

Many harm reduction organizations do implement supportive measures for staff precisely because they are run by community members who understand the need. In Massachusetts, where Murray is based, harm reduction workers have created an organization specifically designed to support people who have witnessed overdoses called Support After a Death by Overdose. 

At Prevention Point, in Philly, employees get extra days off every three months and the organization contributes to wellness services for staff. After an overdose occurs, the team gathers to debrief and employees are given the time they need to process the accident. Still, every single overdose is trying.

“You can be the person that is the most experienced with overdoses and has reversed the most overdoses, but at the end of the day, you are working with a human being,” Ortiz said. “It can take a toll on you.”