When people call the 816-361-5900 crisis hotline at First Call KC, they’re often out of options. The nonprofit, which helps people with substance abuse prevention and recovery, responded to nearly 5,000 calls in 2020.

And throughout the COVID-19 pandemic, callers have become even more desperate. 

“They’ve usually made a lot of calls, and are not getting answers and are not getting support,” said Megan Fowler, the clinical director. “They’re usually pretty exhausted.”

Since the initial lockdown, the crisis center has regularly screened people for suicide risk, and the staff has had difficulty finding resources for people in trouble. Beyond the danger of death by suicide, the risk of death from overdosing on synthetic opioids, especially fentanyl, has soared during the pandemic.

The number of synthetic opioid overdose deaths, including those not yet fully investigated, increased significantly in both Missouri and Kansas between the 12 months ending in February 2020 and those ending in February 2021. In Missouri, the number increased by almost 40%, and in Kansas, it increased by more than 125%.

Kansas City addiction treatment centers moving beyond abstinence

The escalating crisis has left treatment providers scrambling for both resources and policy options.

Some addiction programs are abstinence-based, meaning they encourage those who use substances to abstain entirely from use. But abstinence programs won’t work for everyone, Fowler said.

“When somebody knows that they need to make a change, and they’ve experienced a lot of consequences from their use, they may not be physically ready (to stop using),” Fowler said. “Opioids are really uncomfortable to withdraw from, really painful. And so people get really sick and go back to using if they can’t find the support.”

An alternative is a harm reduction approach, which aims to reduce the risks associated with drug use rather than stop it entirely. These practices include supervised injection sites, where a clinician can monitor patients while they inject substances, and needle exchanges, where clients can trade dirty needles for clean ones. The goal is to reduce infections and overdose deaths.

“There’s a misconception that (substance users) want to die, we don’t care, we’re so reckless or whatever other thing you may have heard,” said Chad Sabora, co-founder of Sana Lake Recovery Center in St. Louis and a recovering user. “We’ll take advantage of these services despite what you think.”

Legal concerns for harm reduction in Missouri and Kansas

Missouri lags behind many states in legalizing harm reduction measures that aim to prevent deaths, infections and other disastrous effects of substance abuse. After Arizona legalized syringe exchange in May, Missouri is one of only 11 states where needle exchange is prohibited by law. Kansas is also in that group.

The ban on needle exchange persists as health care providers raise concerns about risks of hepatitis C and HIV infection. According to the Missouri Department of Health and Senior Services, more than half of people who inject substances develop hepatitis C infections within five years. 

The Centers for Disease Control and Prevention published a study in 2016 that listed 220 counties in the U.S. that were vulnerable to HIV and hepatitis C outbreaks. Thirteen of those counties were in Missouri. Only three states — Kentucky, Tennessee and West Virginia — had higher numbers of vulnerable counties. 

In 2019, the rate of new chronic hepatitis C infections in Missouri was 77.5 per 100,000 people — about 137% the national rate. It’s the ninth highest rate in the U.S.

A bill proposed during the 2021 Missouri legislative session included a provision to permit needle exchanges at locations registered with the Department of Health and Senior Services. Sponsored by state Sen. Holly Thompson Rehder, who represents a district in southeast Missouri, Senate Bill 64 passed both the Senate and the House with bipartisan support, but the session ended before the bills could be reconciled and sent to Gov. Mike Parson.

During a Senate committee hearing, representatives from the Missouri State Medical Association, the Missouri Pharmacy Association and the Missouri Nurses Association, among others, spoke in favor of needle exchanges. No one spoke in opposition. 

A staff member from Rehder’s office and state Sen. Greg Razer, who represents part of Kansas City, both said the needle exchange provision would be proposed again in the 2022 session.

“Twenty — even 10 — years ago, the idea of needle exchange was seen as encouraging drug use, and I think as a society, we have moved beyond that,” Razer said. 

He said needle exchanges are important to stop the spread of infections such as HIV and hepatitis C, and to help substance users find resources for treatment.

In the meantime, alarmed by the threat of outbreaks and frustrated by the absence of legislation, individuals and groups who work on harm reduction sometimes break laws in an effort to save lives. Several needle exchange sites operate quietly in Kansas City, Missouri, a local advocate told The Beacon. They were not willing to identify the sites or operators, for fear of being shut down. (First Call KC does not operate any needle exchanges.)

“Most of the institutions that are running a program like this, it has to be word-of-mouth,” Razer said. “If you can start advertising that this is a place where you can get a clean needle, you’re going to get more people coming in … which means fewer infections.”

Harm reduction is a widespread treatment approach for addiction

Though the concept of harm reduction is often associated with substance use, the approach is used for a variety of medical conditions. It refers to any treatment or prevention method that seeks to minimize risk, rather than eliminate it entirely. 

Dr. Doug Burgess, medical director of addiction services at University Health (formerly Truman Medical Centers), often uses diabetes as an analogy for his students. For example, if a person has severe Type 2 diabetes, doctors prescribe a medication to reduce the patient’s blood sugar levels, even if eliminating sugar entirely would theoretically be more effective. 

“Harm reduction is basically identifying the things that are most likely to cause problems in the person’s life … so that you can minimize the injury to the person,” Burgess said. “Abstinence is what we ultimately strive for with all of our patients, but we know that may not be possible with everybody.”

Burgess said the criminalization of harm reduction practices for substance users in large part comes from a fundamental misunderstanding of addiction.

Substance use disorders exist in the psychiatric diagnosis manual, and many clinicians refer to addiction as a disease. These disorders can be diagnosed and treated, whether through abstinence-based programs such as Narcotics Anonymous or with medication such as Suboxone, which reduces symptoms of withdrawal.

“Addiction’s a disease,” Burgess said. Very rarely, he said, do those with any disease gain control over it overnight. 

Burgess does not engage in illegal harm reduction techniques, but he does train his patients on how to use naloxone, a powerful opioid antidote that can reverse overdose in minutes, as well as how to use a test dose of their substance to gauge how powerful it is.

“While we hope that the people we’re working with will be able to engage in treatment and never use a substance again, we know that the reality is many people are going to have slips or potential relapses along the way,” he said. “It’s different than encouraging their use or supporting their use. It’s just making sure that, if this happens, we want to be able to help you to get back in your recovery plan.”

Shame is one of the biggest barriers to treating addiction

Fowler said needle exchanges and other harm reduction measures can help combat shame, which acts as a barrier that keeps people out of recovery. The stigma, she said, makes them feel as if they don’t deserve to recover from the disease of addiction.

“(Needle exchanges) just provide hope, and it really can provide freedom for people who are wanting to make a change, so that they don’t feel like they’re not worth it, they don’t deserve it, and that there’s no support for them,” Fowler said.

People who use substances, she said, often hurt people close to them and ruin things that are important to them because of their disease.

“All of that stuff carries such a significant amount of shame that keeps the cycle going,” Fowler said. “If you don’t feel like you deserve to feel hopeful or deserve to have your life change, then you’re not going to ask for help, you’re not going to follow through.”