Episode 1: Loretta

Welcome to the Gold Standard with Dr. Sue. Thanks for joining us today. My name is Dr. Kim Sue, and I'm the Medical Director of the Harm Reduction Coalition. We at Harm Reduction Coalition are doing a limited series podcast, highlighting people and programs around the country that are making opioid agonist treatment easily available to people who want it. In our current U.S. opioid overdose death crisis, we particularly need to prioritize getting these life-saving medications, like Bipinorphin and methadone, into the hands of people who need them, when they want them, and where they live. Today, I'm joined by my patient, Loretta S., for the first podcast of the series. It's an honor to talk to her today to learn about her experiences accessing low-threshold Bipinorphin in a serene service program in New York City, and to get a perspective on trauma-informed care of women who use drugs, and how to provide stigma-free services. Say hi. Hi. I'm Loretta from the Bronx. So, the goal of this podcast today is basically to talk about what it means to be a low barrier Bipinorphin program. We met first several months ago in March of 2019, where I was prescribing Bipinorphin in one of the serene exchanges, St. Anne's, corner of harm reduction in the Bronx. And so, I was hoping that Loretta could tell me kind of what brought her to the serene exchange, and how she found her way to meet me. Okay, well, I met Loretta at St. Anne's, syringes, st. Anne's in the Bronx. I used to go there to get the syringes, and the things I needed to see from me to use. And that's where I met you, I needed help, I might help. And can you tell us how long you had been going to St. Anne's? I had been in St. Anne's for maybe two more years. And besides syringes, were there other things that you got there when you were that you needed to inject in a safer and more sterile fashion besides syringes? Yes. What else did you get there? They gave us the cookers, the alcohol, the water. Pretty much everything you need to save, you know, to it safely. Yes, yes. And at the time, how much heroin were you using a day, would you guess? About 14 bags a day. Yeah, yeah. So that's quite an opioid dependence there at that point. And would you be able to tell us how many years approximately you've been using heroin this last time? Since 2014. And so what were your goals in finding a doctor that prescribed buprenorphin or why did you decide to come see me that day? Oh, like I said, I was looking, I knew I needed help. And St. Anne's, they told me about you, they were there, and you missed. So it was good time, I was there, I went there every day, and you missed the air. So that's how it worked again. And even if you had wanted a doctor to prescribe you this medication, it would have been difficult for you in many ways to organize yourself to find someone. Yeah. And so the idea behind the prescribing in a syringe access program is that it's a little barrier model, meaning that we meet people where they're at, and we don't ask people to necessarily go to a doctor far away, or that you have to have an appointment, or that you have to have a counselor first, or there's various things that we were able to do. And I think that day we were able to get you medication that very same day. Is that true? Yes. Yes. So let's walk through for the people listening how it worked. So you and I sat down for about an hour or 45 minutes and we just talked about your medical history, some of your medications, your psychiatric history, and I talked you through the process. Part of me talking you through the process was asking if you'd ever taken it before because it actually helps me to know if you've taken it before, whether a friend gave it to you or you bought one on the street or you've been receiving it from another doctor. So can you tell me if you've taken it before? Yes. I did. I was buying it in the street, and how much did it cost on the street for one dose? One dose is $5. And why would you buy that medication? What does it do for you? I won't want to take the medication, I won't have any physical withdrawal, it was, I bought it on the street, like if I had a visit family or stuff, I didn't want them to see me. Yeah. And I mean it was easier for you in many ways because you use intravenously, so it's, that was another problem, because of my veins, I was in successful with getting one of my work, I can use that. And so in addition to heroin, you also use some other substances, which is common, most people use many substances, not just one, and can you just tell me what others you were doing in a typical day? A typical day, my first drug of choice is heroin, then I did cocaine and crack. Right. And can you just walk me through again how much usually you would spend on each of those? Okay. The heroin, 40 Mags a day was, I'm at $100, $140 a day, cocaine and the crack, there was anywhere from $500, $100, I mean, that was a regular day with that. And how did you use the heroin in the crack and the cocaine? You'd use heroin primarily because you were dependent at that point in opioids, but how did you decide to use the cocaine and the crack? What did that make you feel or why did you use those on top? Why did you use those on top based on coping? I couldn't deal with my life situations and things that's happened. So like in my past when I got any kind of treatment, like methadone, it would help me with the opiate for a while, but then I would immediately switch addictions to cocaine in the crack. Here at Harmonuction Coalition, we believe that there's lots of different medications that work for different people. So sometimes Bupinorphin works for people and sometimes methadone works for people. And sometimes I am now trexone works for people. So we try to work with people to figure out what works for them now and what helps them achieve their goals. And when Laurence and I first met, I always asked her and I ask all my patients what's your goal in regards to your substance use and what did you say, Laurence? My goal was to stop. And was it just to stop heroin? Was it to stop intravenous drugs? Was it to stop? What? It was to stop heroin and intravenous drugs, but it was also that was the beginning of it. I wanted all the folks to move from my life. Yes. And so during the visit, we went through the substances that you used. We did a quick urine toxicology screen just to inform me of what you had been taking. And then I sent a prescription to the pharmacy and it was for a week of medication for a home induction. And I walked you through when I wanted you to take the first dose. And I told you, usually if you used at night that I'd want you to wait and wake up and feel a little withdrawal and then to take a half a film or a whole film at that point. And how was that for you? Did you have any issues? No, it worked immediately. And how did you feel? How did it make you feel? I felt great, but I only felt good physically, but it also gave me a sense of hope again. And the first time I met you, you actually were crying. I mean, you were, you know, we don't like to use the word mess, but you felt a mess. And I saw you a week later and you just said you were just smiling and laughing and you just said you felt normal. Yeah, I remember. I remember. My life has changed completely. And at the time that I met you, you were sleeping on the train, you were homeless. How long had you been homeless? Almost like two years, I was sleeping on the train. Two years. And where are you sleeping now? No, I got my own apartment and I'm going, wow, thank you God. Yeah. And I hear that you just got a bed. Yeah. We bought a bed. I got curtains, I got a bank account. It's amazing. And the goal of me taking care of Loretta in a low barrier look threshold way is that I got her what she needed immediately, which is the medication. She really needed the medication, buprenorphin, to stabilize her so that she didn't have to hustle every day and her life was very chaotic and it was really marked by trying to get what she needed to take care of herself and not going to withdrawal. Can you walk me through a typical day a year ago, what you would do and what your day felt like? Okay, well, I slept on a train with my husband. When we woke up, we woke up sick, thinking what are we going to do next, where are we going to make money to get that next feeling good bag, you know, that meant either we were shoplift or we would swipe in the trains at this stage of my life, I did some things I'm not proud of also on top of that, you know, which meant to constantly. And really, like at that point when you were using, were you even getting high or were you just staving off withdrawal? Yeah, it was just to get just just to just to feel a little normal, yeah. We're going to take a break now to hear from one of our community partners. Hi, this is Jamie Favaro from Next Harm Reduction. Next is an online and mail based harm reduction program. We run a New York state licensed syringe exchange, which means that if you live in New York and you're in a county where you don't have a needle exchange near you, you can enroll online at nextdistro.org tap supply sent directly to you. Our enrollment is encrypted, which means that your information is always kept safe and private. We also have an online and mail based Naloxon distribution program at Naloxon for all.org. If you have friends or family that you think shouldn't have Naloxon, but they don't have health insurance to access it in the pharmacy, they can go online to take a brief training and have Naloxon sent directly to their door. If you have any questions, go online to the contact form at nextdistro.org. We're back to talk about Loretta's introduction to safer injection practices. Did you learn how to inject in a way that was sterile and clean and safe or how did you initially learn how to inject? No, it was not sterile. I just had someone, anyone use their needle. And we know that people should ideally be using their own set of supplies. In order to prevent sharing, transmitting, commutable infectious diseases like HIV and hepatitis C, did you ever share and can you describe the context in which you would share syringes or cookers? Yes. When you are heroin addict, you can get very physically sick if you don't have it. On one regular day, I might have my drugs, but I don't have a syringole or endocooker. Someone else has it. At that time, at point, you're not worried about any kind of sickness or disease. You're just worried about getting better. So that means I have to use that work. Somebody else is poor, even the work that's still down the block. And so at the same time that we were talking about decreasing your risks, you also had told me at one point that you had overdosed a little bit before you met me. And I talked to patients and other people about harm reduction strategies to prevent overdose. So we try to kind of understand why an overdose happened and troubleshoot that. So in your circumstance, could you tell us what was going on when you had an overdose and what happened with the naloxone and medication? Well, I had just come out of a detox and of course I'm out and I was supposed to have an appointment and a methadone maintenance program, but they couldn't take me that day, it was too full. So I panicked because now I have, you know, I need my stuff, I can't deal with no medication, no nothing. We went in, we got a bag, but this bag was, it was fun anymore, I didn't know it was that. And being that I was sick and nervous and everything, I didn't think, and I have very, very thin veins, no veins at that time. So being that I was in detox, you know, I haven't done it for a while, so I was able to get off and I just slammed it. And did you know what's happening? No, no. And so Loretta is talking about a toxic street supply, a poisoned street supply of drugs. We have a poisoning crisis here in the U.S. where people can't access, often can't access heroin anymore. And the harm reduction strategies, we utilize around people using fentanyl or using heroin with fentanyl is to go slow to use with others and do us a test dose, you know, do a little bit. Now, your husband said that you turned blue, so can you tell us what happened after that? Yeah, he said I turned blue, he had a kit with him, he panicked at first and he, when he went to administer it to me, it went off in the air. So there's something like we always say, make sure you got two, just in case, because he nerve, but once he did that, I came back. And when you came back, did you realize you had Odid or did he tell you? He told me. And a lot of people believe that when you come back from an overdose that people are violent, can you dispel that myth? No, what happens is, what happens to me was, I went into a withdrawal immediately. So for me, that can mean having a bowel movement or vomiting, and that's exactly what happened. You know, because I think I was dead and I'm alive again, so that's what you feel, you're more like a shock, like what's going on. Now, I had a Jose also used or were you taking turns? No. So that's another strategy that I tell my patients who are using this to take turns so that you can watch out for each other. So it's really lucky that, you know, Loretta used and Jose was watching her and she would do the same if he was going to use and they could be just watch out for each other. It's important to have multiple moloxone kits and to get moloxone to your patients and people who use drugs because they are the ones who are going to save each other's lives. Like Jose saved Loretta's life and, you know, I'm so glad that he was there because a lot of people use a loan or don't have the medication they need to, and it's a miracle job to save people's life, right? Bring you back from being blue enough breathing? Yes, it really is a miracle. I hadn't experienced, I used it not someone. And I couldn't believe how I saw someone not breathing and you put this thing in the air in his nose and they're back. So let's talk a little bit about, you know, a couple months, a couple months into your treatment with me at the buprenorphine, you know, a lot of things started to come up for you and once the medication stabilized you off the heroin and you stopped using the heroin, what was going on in your life and described what was happening two or three months after you started treatment with me. It was a roller coaster, because a lot of feelings and emotions now are not hiding, I'm not covering them anymore. But with that was a lot of hope. I got, once I started that, my family got back involved in my life. So you were able to see some of your grandchildren, can you tell me about that? My grandson spent a week with me over the summer, I was able to spend time with them, things grandma does with the grandchild, you know. Regular things. Regular things. Like what? We went to Coney Island. I mean, I was able to buy them corn. Yes. And do things. I treated him. Yes. And that's our regular grandma things and even a year ago you were dealing with too much shame and stigma and chaos in your life. You were sleeping on the sixth train to even see him. He made so much progress. Thank you. Yeah. Thank you. And, you know, we, it continues to be a work in progress. We've talked a little bit about how you've sought treatment before. You've had a lot of trauma in your life. You've experienced domestic violence, sexual assault, a lot of death around you. And this is very common for people who use drugs, really to witness and experience a lot of trauma, a lot of abuse. And one time you told me about trying to seek treatment in a place where you specifically requested a female counselor and can you tell me what happened? Well, I didn't get the female counselor and I got a very judgmental male. And you called you a what? Okay, and this is a place that was supposed to be helping people like me, you know. And so, part of the work that we do at Harmonuction Coalition is trying to help other people in the community and people who work with people who use drugs and people who use drugs themselves to learn how not to speak to people and how to speak to people. So the transition to person first language, and I don't refer to people as drug abusers, addicts, junkies, all of these terms become internalized and make people feel really worthless and makes people feel like they don't deserve care. And it really, in many ways, drives people into the shadows. And Loretta has been to the emergency room a lot of times and has experienced some of that language and some of the way that people look at and talk about her. Is that true? Yes. So, recently you came in to see me and you asked for your analysis and can you tell me why you wanted a urine toxicology? Yeah. I don't use. I love urine now. It was the time when I ducked at my head from, you know, and it's not just, it's about, it's a reality. It's like, look, you're, you're really doing this to yourself. Yeah. And it was just the medication she'd be taking in no heroin and no opioids, which is really the goal. And if it had shown, you know, cocaine or other substances, I would never stop Loretta's medication because her medication has been so helpful to her in stabilizing her life. And it's also helped me with the other drugs also. Decreasing the cocaine, the crack, I mean, really, it's like that's all come down. There was no cocaine recently. No cocaine. No alcohol. Wonderful. Yeah. And that was her goal, and so in accordance with her goals, we were able to meet it. Yes. And I've also talked a little bit about, until Loretta a little bit about her experiences with pregnancy and child protective services, which is a big part of what it means to be a woman who uses substances. And she's had a lot of very negative experiences with those systems. I don't know if you wanted to just comment about how that was for your few and your family. It was very traumatic, until today was still struggling with that. This was something that happened in 2001. Yeah. And it just lingers on forever, it really has a very negative impact on your family. It does. Yeah. And let's talk a little bit about, I know you mentioned you had done some sex work, and did you ever feel like there was anyone who was helping you to perform, do sex work more safely, did you have a place where you could talk to anyone openly in any field, that you encountered where you could get the care that you needed for screening and care for things you might have been exposed to? No, not at all. And not at all, and was that because you were too busy using or because no one ever was able to get the trust, to get to that level where you could have those conversations? I think a little of everything, trust, shame, have it all, I think it takes place. And I mean, we're talking about this just because there are so many people out there doing this who don't have access to medication, they can take to prevent getting HIV, called prep, medication that people should have vaccinations, so they don't get hepatitis A or B. People should have flu vaccinations, people should have access to condoms, people should have access to everything that they need for that to do that work more safely. I agree, I agree. This is the first time actually that I learned about any kind of safe drug use or anything. Yeah. You know, you hear, but nobody really says, hey, this is the way, like, the syringe is saying stars, they do teach you that. Can you just tell me some advice that you would give to doctors or nurses or other people that have worked with women who use drugs? Oh, yes, I feel we need more people like you, really, that care, everybody's different. See, they have like this one stand, that's no, I'm different, we all have different, it might be similar that we all use, okay, but it's different. And I think that doctors, everybody loved each person where they were at, you know, because we were not all in the same place without judgment. And without punishment, and I think with some level of curiosity and knowing that you for many years were the expert in your own body and your own life and you are still the expert and you, you have taken care of yourself for many, many years and you have survived a lot. And so I think doctors often, you know, I know what's best or do this, do that. And really, like, I've learned a lot from you and that's why I wanted to have you on this podcast because you have so much to teach, thank you, your story has so much to teach and you've been so strong and so eloquent. Thank you, yay. Thank you again for listening. You can find us on Facebook, Instagram and Twitter at harm reduction. You can find Dr. Sue on Twitter and Instagram at Dr. Kim Sue. Our production team is Dr. Sue, Lizzy Maldonado, and me, Dana Kurser-Yashin. See you next time.