On a Saturday morning in July, Pedro Alvarez distributes latex gloves, red sharps containers and gadgets with mechanical claws to six people gathered at Tapestry’s syringe exchange site on Main Street, deep in the flats of Holyoke.
These are the tools needed to safely retrieve used needles. Alvarez, assistant director for urban drug-user health at Tapestry, instructs the crew: Don’t pick up needles with your hands, always use the tool. With the needle gripped in the claw, place it in the sharps container. Do not try to hold the sharps container in one hand while maneuvering the needle with the other, he demonstrates — much too precarious. Set the sharps container on the ground first, open lid, deposit needle, close lid. At the end of the day, lock the container.
With that, two Tapestry board members, workers from other Tapestry sites, and community volunteers, including a woman whose nephew died by overdose, set off. It’s sweltering — not even a breeze rustles the trees — as volunteers walk along the canal near Race Street, turn right on Dwight, cross a bridge and head up the hill towards the city center. They scan curbs and crevices and cracks in the concrete for used needles.
Alvarez, 40, grew up here in Holyoke, where he witnessed a lot of drug use among family, friends and strangers. Wearing black cutoff shorts, running shoes and a white T-shirt with a Tapestry logo, he’s carrying a red backpack stuffed with supplies harm-reduction workers need: condoms, sanitizers and safe-use kits that include water, alcohol pads and naloxone, the overdose-reversal drug often known by its brand name Narcan. These are the tools that help people use more safely.
“I want to help people struggling with addiction,” says Alvarez. The most effective way to do that, he believes, is through the principles of harm reduction, which calls for providing services to drug users without judgment, coercion or punishment. The goal of harm reduction is to build relationships and save lives, not necessarily to halt use.
If the opioid overdose death epidemic is a war, then Alvarez and his team are the troops, and their battle plan is harm reduction.
“Pushing that abstinence-only agenda wasn’t really working,” said Gabriel Quaglia, Tapestry’s post-overdose engagement coordinator. He has experienced many overdose deaths of participants in Tapestry programs. The term participant is used, rather than client, because it suggests a non-hierarchical relationship.
As a person in recovery since 2011, Quaglia has also lost friends and acquaintances to opioid-related deaths. Now 43, Quaglia says he was 19 when he lost his first friend to an overdose death. In the ensuing years, about 10 other friends have died. As for participants who have died drug-related deaths, he wouldn’t even venture a guess. That information is often not available. If participants stop showing up, it could be because they moved away or stopped using. It could also be because they died.
These losses fuel the work, but they also take a toll.
“Being in recovery, there is at times a bit of survivor guilt,” Quaglia said. “I’m a very lucky person: I’m abstinent, I got clean and sober in one try, and I know that’s not the way it usually goes.”
Quaglia believes a harm-reduction approach to the opioid epidemic is imperative for one simple reason: “If people aren’t alive,” he said, “they can’t even get into recovery.”
The whiteboardEvidence of creative attempts to keep people alive abounds at the Tapestry syringe exchange where Quaglia works in Holyoke. On a whiteboard in the waiting room, participants post information about drugs found on the streets. They list names of certain strains — Tick Tick Boom, Superman, Kill, Mortal Kombat, Escobar — with notes about quality: good; better now; good/rare to find; going down/inconsistent. But most messages focus on safety, offering warnings about fentanyl and potency: deadly OD/very strong; actually heroin; fentanyl laced.
While some might see this board and think it condones drug use, harm-reduction workers say that’s not the case. For many reasons, people are using drugs that can be lethal. The whiteboard provides the means to share information that could save lives. That’s harm reduction in a nutshell.
Quaglia explains that people engaged in harm-reduction efforts develop trusting relationships with participants. They believe that lecturing people who use drugs or using punitive methods to get them to stop will not prevent overdoses or promote recovery. He and other harm-reduction workers believe recovery works best when its motivator is internal. His goal is to keep people alive until they get that motivation — and to offer them compassion even if they never do.
From his vantage point as a harm-reduction counselor, Quaglia sees firsthand how the unrelenting losses impact Tapestry’s participants. When meeting with them, he talks about safer use practices and asks a series of questions, including these three recently added to the script: Have you ever used naloxone? Have you experienced an overdose? Have you witnessed an overdose in the past six months? More than half of participants answer yes to one of those questions.
Quaglia said he was concerned about asking those questions in the beginning, wondering if it was too intrusive. But now he feels differently because he saw that they provoked a range of emotions from the people he asked. He came to see this as a positive, because it gave them a chance to talk rather than carry the burden alone.
“I could see it in their face. I could see that sadness and the grief wash over them,” said Quaglia. Sitting in his office at Tapestry’s Main Street Holyoke location, Quaglia sports a soul patch and a shaved head under a short ponytail. He is somber as he describes interactions he believes are important opportunities for people to talk about traumatic experiences with someone who cares about them.
“They don’t have a therapist, they don’t have a close friend who is worried about their mental state,” he said. “But we are concerned about that.”
He said his goal is not to pressure people into treatment but to build relationships. Still, according to the Centers for Disease Control and Prevention, he notes, participants at syringe-access programs are five times more likely to enter treatment and stop using.
The emotional tollThose who work in the field of treatment and recovery support attend more than their share of funerals.
Debra Flynn-Gonzalez, program director at Hope for Holyoke, a recovery center operating for the past four years out of a storefront on Suffolk Street, estimates that she attends about a dozen memorial services or funerals a year.
“We’re now entering this phase where we’re almost desensitized to it, which is really sad. It’s almost become so common,” she said. “I can’t believe how many people have Narcaned someone back to life.”
There was a time at the center when members made a memorial wall where they would post obituaries to remember people who had died, said Flynn-Gonzalez, until it became too tragic a reminder for people to view every day when they came into the center. They moved the memorial into a book so people could make a choice about whether and when they wanted to see it.
Dr. Ruth Potee described a similar experience in the medical practice she worked in for 20 years as a primary care doctor who developed a specialty in addiction treatment. Staff there began posting obituaries of patients who had died opioid-related deaths on the door of a cabinet in the staff office by way of sharing the information and honoring those who died. So many of them were young people.
“We had to take it down after a few months because it was profoundly depressing,” she said. Their solution was to move the obituary clips to the inside of the cabinet door, so staff could decide if they had the emotional stamina to view the tragic memorial to young people many of them knew.
Peter Babineau, regional manager for Learn to Cope, a statewide family support organization, says in one six-month period in 2015 when he was working for the Hampden County Sheriff’s Department, he went to 26 wakes or funerals for people who died opioid-related deaths.
“There were so many in such a short period of time that I just couldn’t do it anymore,” he said.
Babineau acknowledges there is a certain level of battle fatigue in the field but said he believes that is changing because people are becoming angry and ready to be mobilized in ways similar to when activists took to the streets during the AIDS crisis.
“I hadn’t seen that level of outrage within this crisis until fairly recently,” he said. In December, he attended the memorial service for Eliza Harper, who died at age 26, where Potee spoke and received a standing ovation.
“I’ve never seen a memorial service with a standing ovation,” he said. “Ruth is one of those voices — she’s angry, and she’s loud, and she’s expressing it. We’re starting to see more and more people not wanting to accept the oppression of stigma.”
The changes in the way the community responds to the epidemic is evident in other ways as well. Northampton resident Miguel Rivera, a state-certified recovery coach working at the Northampton Recovery Center who has been in recovery from opioid addiction for 10 years, recalls times when compassion was nowhere in sight.
In an interview at the Interfaith Shelter’s resource center on Center Street in Northampton, where he was working one of several volunteer shifts he does each week, he described how radically responses to opioid use have changed since the days he was actively using.
Over the course of his addiction, he was arrested numerous times for crimes including larceny and possession of drugs or hypodermic needles. There were times when he went into withdrawal while incarcerated, receiving no medical intervention, which meant suffering extreme discomfort, pain, shaking, vomiting and diarrhea in a jail cell.
“You’re in the cell on the floor asking for help, and nobody comes to help,” he said. “I remember being punished for having a hypodermic needle. I was being punished for exhibiting symptoms of my addiction.”
He said it is heartening to see improvements, such as widespread syringe-access programs and medication-assisted treatment provided in jails.
“For me to see this new era of recovery today and to see this movement, a community coming together, it gives me hope — but I know there’s much work to do,” said Rivera. “I want to be part of the solution. Yes, we made mistakes in the past, but what are we doing for it now?”
Taking better care of workers Jill Shanahan, who has worked in harm reduction at Tapestry for 11 years, is now in a new position as harm-reduction training coordinator. This post was created out of a need to provide better support and increased training for frontline workers, many of whom were experiencing emotional trauma and burnout.
Shanahan believes concerted attention paid to the impact of losses on the frontline staff will help strengthen the resilience of the workforce. She’s developing staff trainings on self-care and stress management with plans to launch peer-led grief groups for staff.
“If we start to normalize conversations about death, that can help in the grieving process,” said Shanahan.
She and Quaglia have been collaborating with consultant Franklin Cook on initiatives to better respond to situations in which staff experience traumas, such as an overdose death on their watch.
The daily impact of the work done by people working on the frontlines of the opioid epidemic is comparable to that of first responders for mass casualties, Cook said: “What they are facing is similar to a disaster response. Being inside that stress can be very damaging and even debilitating in the short term. This is a normal reaction to being in a situation where you are responding to casualties.”
His work with Tapestry, now wrapped up, had two main goals, Cook said.
“It was to find out what it was really like to be on the frontlines of this crisis,” he explained. It was also an effort to answer the question of whether peer support would help these frontline workers. “Certainly, the answer was yes,” Cook said.
The Tapestry project was a pilot program of the state’s Bureau of Substance Abuse Services specifically to assess the impact on people engaged in harm-reduction work who see high numbers of overdose fatalities. That pilot has become a statewide initiative known as SADOD (Support After Death by Overdose) that is focused on peer support.
Quaglia says Tapestry’s focus on the coping skills of the harm-reduction staff is a good idea given what they do every day.
“We do experience a great deal, and we’re just told to take a yoga class or something,” he said. “We didn’t feel that was sufficient. We also hope always that what we do internally helps us provide for the participants and do our job better.”
On the streetsAs draining as working in the field of harm reduction can be, Alvarez finds it energizing because he believes it saves lives. On the streets of Holyoke, he sees the regular needle pickups as harm reduction in multiple ways.
By the time volunteers signed off for the July session, they had removed 145 needles from the streets in about three hours. Alvarez had engaged in a lengthy discussion with a business owner who was angry that the alley behind his enterprise was a spot for drug use, a conversation that ended with a handshake and a wave. Alvarez hoped he clarified misconceptions and began building a bridge.
He also stopped to talk with several participants, greeting each person warmly, asking about their health and exchanging syringes. One of these conversations took place not far from City Hall with a woman sitting next to an abandoned building in an alleyway, grass grown tall through cracks in the concrete.
“How you doing?” he said, scooching down to where she was sitting as he pulled out a bag containing wound-care supplies, a bleach kit. “You staying hydrated? You being safe?”
He gave her clean needles. She deposited her used ones in his sharps container. As he departed, he called out one last message: “Stay safe.”
Laurie Loisel, a former reporter and editor for the Daily Hampshire Gazette, is director of outreach and education for the office of Northwestern District Attorney David E. Sullivan. Loisel wrote these stories for the Gazette in her capacity as an employee of the district attorney’s office.