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How can we keep our drug using clients safe?

Kendall Knowland & Sophee Poppe

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What is Harm Reduction?

“Harm reduction is a practical and transformative approach that incorporates community-driven public health strategies — including prevention, risk reduction, and health promotion — to empower people who use drugs (and their families) with the choice to live healthy, self-directed, and purpose-filled lives. Harm reduction centers the lived and living experience of people who use drugs, especially those in underserved communities, in these strategies and the practices that flow from them” (SAMHSA)

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A Case Study: Matthew M.

Mathew M was a construction worker in the Twin Cities area. He used Kratom bought legally in MN for his back pain. In 2019, Matthew went on a trip to Wisconsin to look at a boat for purchase. He neglected to take the bottle of kratom out of his truck before crossing over the state border. While in Wisconsin, he was pulled over for an unrelated traffic violation. During this traffic stop, the officer found his bottle of kratom. The officer determined, based on the number of kratom pills seized, that Matthew had intent to distribute. Distributing Kratom carries a felony charge and possession is a misdemeanor charge in Wisconsin. Matthew was arrested and charged with a class H felony.

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What happened to Matthew?

After being charged with a class H felony, Matthew lost his job and his apartment. His legal fees and carceration prevented him from reporting to his job and he was not able to make his rent payments. His truck was also impounded.
Matthew received a suspended sentence, but the felony conviction remained on his record. He was also sent to rehab against his wishes.
Matthew faced discrimination when trying to find housing due to his record.
Matthew was cut off from government aid that he qualified for after losing his job due to the felony on his record
Matthew was denied educational loans three years later when he applied to a community college

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Grounding:

False Assumptions to Address

Harmful False Assumptions

Absolute sobriety is the end goal
Drug use = Addiction
People who use drugs are troubled or are trying to cope with something
If you try certain drugs even once, you will become addicted

Antidotes

The concept of abstinence sets many people up for failure. Research shows that there is a higher failure rate for individuals following the absolute sobriety path rather than a reduce and control or replace perspective. Alcoholics Anonymous.
There are many types of drug users. Recreational, Medicinal, Spiritual and Addicts are just a few. Consult DSM-5 for exact criteria of addiction disorder.
Talk with your client about their drug use habits and their feelings surrounding it.
There are recreational users of every drug. Some people are more susceptible to addiction than others

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Abolition in Treatment Centers

Jennifer Wiseman (MPS, LADC) was interviewed
Bring abolition into case notes
If a UA comes back positive, choose to continue working with the client instead of dropping them
Keep conversations with LADC or PO surrounding client’s wellbeing
Do a cost/benefit analysis of reporting vs. not reporting

UA is a policing tactic
Provide information about what substances stay in one's system for longer
Make yourself present to be an advocate during PO/client meetings
Make space to have conversations with the client about how the system has affected them

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Building Trust: Talking With Clients About Reporting

How Might Social Workers Report?

Mandated reporting to CPS/APS
Casenotes and medical documentation
Court ordered reporting

Confidentiality and HIPPA

Most organization prohibit the disclosure of information gained in a therapeutic setting.
Therapy notes have extra protection under HIPPA, patient authorization required for anyone to access psychotherapy notes

Talk about how each type of reporting might show up. There is diagnostic information, modalities of treatment, clinical test information, summaries of functional status, treatment plans and sympotms in case notes.

Court ordered disclosure is rare and only comes into play if there is a significant crime commited that is relevant to the clients drug use. A fatal accident caused by a DWI/DUI for example.

The best work around for clients who do not wish for their drug using status to be disclosed within case notes is to speak in hypotheticals or in relation to a “friend”. Many clients will already know and accept that there may be records of their drug use in their therapy notes because many of them come in to seek help for their drug use/addiction. For those who are uncomfortable with it, clarify what HIPPA says about how hard it is to get a hold of therapeutic notes. Basically just leave drug stuff out of the non-confidential part of the notes when at all possible.

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Mandated Reporting: What Does The Law Actually Say?

prenatal exposure to a controlled substance, as defined in section 253B.02, subdivision 2, used by the mother for a non medical purpose, as evidenced by withdrawal symptoms in the child at birth, results of a toxicology test performed on the mother at delivery or the child at birth, medical effects or developmental delays during the child's first year of life that medically indicate prenatal exposure to a controlled substance, or the presence of a fetal alcohol spectrum disorder

If a pregnant person is seeking treatment then they are exempt from prenatal mandated reporting

chronic and severe use of alcohol or a controlled substance by a parent or person responsible for the care of the child that adversely affects the child's basic needs and safety

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Basic harm reduction

Primary Principles

Syringe exchange programs
Overdose prevention and reversal
Drug consumption rooms
Opioid substitution treatment
Testing your drugs
Weighing drugs
Information about how different drugs show up in drug tests

Secondary Services

Low threshold housing
Legal services
Narcan/Naloxone training
Mental health care access
STI, Hepatitis, HIV/AIDS resources

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Drug law nuances

Always check the laws of any state you plan to enter with drugs
Misdemeanor vs felony
Paraphernalia
Laws about searches
Possession vs intent to distribute
Bystander/ good Samaritan laws

https://www.revisor.mn.gov/statutes/cite/152 for specific legal information

As we saw in Matthew M. case study, drug laws are different from state to state and even city to city. I dont know where everyone plans to practice, but always look up the laws directly from the source when conveying legal information. I am going to talk about Minnesota and Minneapolis for the most part.

Minnesota is the most lenient state in the region surrounding drugs. All of our neighbors have cannabis either decriminalized or fully illegal (come on Wisconsin). Additionally, lesser known drugs that are legal for purchase in stores in Minnesota are illegal in neighboring states. Things like kratom. Advise clients against going to another state with drugs, if they can prove that illegal drugs (in the place the person is caught) were moved from state to state, the charges become much worse, usually involving trafficking. Felony.

Before cannabis was legalized in Minnesota, it was a misdemenor to carry less than 1.4 ozs. Anything over 1.4oz was a felony. Many people do not know this and can be charged with a felony and get sucked into the carceral system because they did not know the nuanced difference. All drugs other than cannabis carry a felony charge, but there are degrees. The degrees are determined by the amount that is being carries, how it is being carried and what other items are found on ther person/in the space. Additionally people are more likely to be charged harshly for carrying drugs if they are caught with them in connection with another crime. There are 5 degrees of felony.

Paraphernalia is NOT ILLEGAL in Minnesota. Again, this law is only for Minnesota. Our neighbors dont agree. Possession of drug paraphernalia is a petty misdemeanor in MN, even if it has residual amounts of controlled substances! SYringes and drug test kits are not illegal at all. Scales fall into the paraphinalia category, but the caveat of scales is that they are often used to make the argument that someone is selling. Scales should stay in a secure location and not be brought with anyone anywhere to avoid this accuacation.

In Minneapolis it is not illegal for the police to search a car based on the smell of cannabis. This is Minnespolis ONLY. Whenever confronted with a search, always decline unless the police have a warrant or declare probable cause (which you can fight later in court if so desired)

Large amounts of drugs can be considered having intent to sell. Some key things police look for when trying to prove this charge is multiple bags of controlled substance, scales, and excessive cash. Many times the police will try to make this charge stick, even if it is unfounded.

In Minnesota, and many other states, you will not be held liable in anyway if you call emergency services to assist with a drug induced emergency. This law came out of college kids being too scared to call ambulances when someone was suffering from alcohol poisoning because they were afraid of getting in trouble with the police/school for underage drinking. It is illegal for the police to search and charge anyone aiding in a drug induced medical emergency with possession, paraphernalia or use of controlled substance. Likewise, the person who is the recipient of the medical care is also immune to prosecution for possession or use of a controlled substance. Additionally, this extends to individuals on parole or probation! Again, calling for or seeking medical assistance in a drug induced medical emergency provides immunity for any bystanders and the person experiencing the emergency, even if they are on parole/probation.

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If…. Then…. Plans in regards to encountering carceral authorities

If

If there is a drug induced medical emergency…
If I have a non-medical crisis while under the influence of drugs…
If the police want to speak with me…
If I am confronted with a police search…
If I am arrested…

Then

Then I will call an ambulance or get to a hospital. I will be immune from prosecution.
Then I will call my safety person
Then I will politely decline and invoke my right to silence
Then I will decline the search and ask for a warrant
Then I will request a lawyer and I will invoke my right to remain silent

Sometimes when faced with an emergency people go blank or freeze. Research has shown that formulating and talking about a plan before an emergency happens allows for people to implement their memorized plan, even in the face of great stress. Similar to how the government encourages everyone to make plans for natural disasters. If, then plans are useful to ingrain the information and plan in peoples head so when/if an emergency occurs, the individual can fall back on previously established plans.

Go over these plans and any other relevant ones you can think of with clients. It is best to do this repeatedly so it is fresh in the clients mind and easily accessible to them. We want these to be nearly automatic responses to these situations. SO when the panic sets in when faced with the emergency they don't need to rely on their problem solving faculties to respond to the situation.

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Community training/information

List of wet shelters
Needle exchange resources
Drug consumption rooms
Narcan/Naloxone training
Information on Kratom and Ibogaine

Legal services
Housing services for PWUD
Other harm reduction training
Resources for buying test kits
Opioid substitution treatment

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Resources

A Simple Guide to Court Ordered Rehab: Goal, Criteria, and Types. (n.d.). Mission Harbor Behavioral Health. Retrieved March 26, 2024, from https://sbtreatment.com/resources/court-ordered/

Average Cost of Drug Rehab [2023]: By Type, State & More. (n.d.). NCDAS. Retrieved March 26, 2024, from https://drugabusestatistics.org/cost-of-rehab/

Mandated reporting of maltreatment. Mandated Reporting of Maltreatment - MN Dept. of Health. (n.d.). https://www.health.state.mn.us/facilities/regulation/homecare/providers/maltreatment.html

Initiative, P. P. (n.d.). 1 in 5 incarcerated people is locked up for a drug offense. Retrieved March 26, 2024, from https://www.prisonpolicy.org/graphs/pie2023_drugs.html

Office of the revisor of statutes. Ch. 152 MN Statutes. (n.d.). https://www.revisor.mn.gov/statutes/cite/152

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Rights (OCR), O. for C. (2017, September 12). Does HIPAA provide extra protections for mental health information compared with other health information? [Text]. https://www.hhs.gov/hipaa/for-professionals/faq/2088/does-hipaa-provide-extra-protections-mental-health-information-compared-other-health.html

Every 25 seconds: The human toll of criminalizing drug use in the United States. American Civil Liberties Union. (2024, January 19). https://www.aclu.org/publications/every-25-seconds-human-toll-criminalizing-drug-use-united-states

Fighting 5th degree drug possession MN. Leverson Budke. (2023, May 2). https://www.leversonbudke.com/fighting-5th-degree-drug-possession-mn/

Richert, T., Stallwitz, A., & Nordgren, J. (2023, October 14). Harm reduction social work with people who use drugs: A qualitative interview study with social workers in harm reduction services in Sweden - Harm Reduction Journal. BioMed Central. https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-023-00884-w

Office of the revisor of statutes. Sec. 151.40 MN Statutes. (n.d.). https://www.revisor.mn.gov/statutes/cite/151.40

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Lopez, G. (2015, November 13). Most people in federal prison for drug offenses have no serious criminal history. Vox. https://www.vox.com/policy-and-politics/2015/11/13/9730702/drug-offenders-facts-statistics

Initiative, P. P. (n.d.). Nine-year recidivism rates by offense category. Retrieved March 26, 2024, from https://www.prisonpolicy.org/graphs/sex_offense_recidivism_2019.html

Rehabilitation vs. incarceration: Rehabilitation in the Criminal Justice System. Oxford Treatment Center. (2023, April 19). https://oxfordtreatment.com/rehab-vs-prison/

Keys, 12. (2014, December 15). Relapsing Back to Sobriety: Why People Relapse and How to Get Back to Sober Living. 12 Keys. https://www.12keysrehab.com/relapsing-sobriety-people-relapse-sober-living/

Training Center. (n.d.). National Harm Reduction Coalition. Retrieved March 27, 2024, from https://harmreduction.org/our-work/training-capacity-building/training-center/

What is Harm Reduction? (n.d.). Harm Reduction International. Retrieved March 27, 2024, from https://hri.global/what-is-harm-reduction/