 Hi everyone, I'm Ed Baker. Welcome to the Addiction Recovery Channel right here on Town Meeting TV. I am your host producer and I couldn't tell you how how pleased I am to be with you here this evening. The Addiction Recovery Channel is devoted to the elimination of stigma and to the acceptance and inclusion of people with substance use disorder through a deep understanding of what exactly substance use disorder is, what treatment is and what recovery is. I couldn't be more excited to have two esteemed guests with me this evening who are experts in this field. We have Grace Keller who is a program coordinator at Howard Center Safe Recovery. Welcome Grace. Thank you. And we have Sarah George who is the Chittenden County State's Attorney. Sarah was appointed by Governor Scott in 2017 and is now serving her first elected term. Welcome Sarah. Sarah is an advocate for social justice. Thank you for having me Ed. Yeah, it's a pleasure to have you both. You know, the theme of tonight's show or today's show is harm reduction and I do believe that there's quite a bit of confusion actually about what this concept, what harm reduction actually is. So Grace, I thought it would be really helpful to begin with you and Sarah, if you want to join in too, to really kind of define what are the, what is harm reduction, what are the nuts and bolts of it. So harm reduction is a set of strategies, practical strategies aimed at reducing the harms that come along with drug use. So in the practical sense at Safe Recovery we have syringe exchange, we have Narcan which is overdose reversal medication. We have HIV and hepatitis C testing. We have, and those are really the main ways we look at harm reduction at Safe Recovery. It's really looking at giving people who use drugs a practical strategy, a menu of options to keep themselves safer while we're trying to help them get to treatment and recovery. Very nice. Very nice. Thank you. Sarah. It's an interesting question because when I actually became state's attorney, one of my primary goals was to sort of tackle the overdose epidemic that we were having at the time. As a deputy state's attorney it was someone who gets called for every overdose fatality that we have in the county. It was something that I felt like every time I was on call I was getting call after call after call about people dying alone from substance use and nobody was talking about it. And so it really was one of the first things that I did and by trying to figure out how I could help I went to people like Grace and Tom Dalton at the time and other community organizers and advocates that were working in this field to say like, what can I do? What is my office? How can I help? And that's when I really started to learn about harm reduction and ultimately realized that as the top law enforcement in the county and somebody whose job it is to protect the public, public safety is harm reduction. They're one in the same. It is about finding strategies that help keep people safe and reduce harm within communities and in this sense, actual harm to individuals, death, keeping them alive while they use drugs in order to eventually and hopefully get them into treatment but in the meantime meeting them where they're at and making sure they have the safe materials or safe avenues to navigate their addiction. Yeah, well said and also relationships with people and I know Grace said that's part of what you're so good at is having like meeting people with substance use disorder where they are and establishing a meaningful relationship with them. It's almost like it's the direct polar opposite of the war on drugs. Absolutely. Seems to be the polar opposite of it. Grace, do you want to talk to that aspect a little bit about how you meet people where they are and have relationships with them? Sure. So I've been at Safe Recovery for about 13 years and one of the things about harm reduction is it's a non-judgmental approach. It's literally meeting somebody where they are. They come at whatever stage they're in and oftentimes they're struggling with a lot of different things. It can be homelessness, it can be domestic violence, it can be mental health challenges. So really trying to meet somebody where they are and not judge them about where they are and provide them tools to stay safer and provide them housing support, employment support, help with children, those kind of things. So really it's about building that infrastructure around a person or layers of support so that they know that you're a safe person and building that relationship so they have somebody in the community that they can always go to unconditionally no matter what's going on for them. And it's absolutely critical because a lot of our clients don't have anybody else, especially anybody else in the professional world. So they really know our clients are survivors first and foremost. They're scanning the room for who's safe, who will help them, who will be there for them, who they can be authentic with. And that's really what we provide at Safe Recovery. People also sometimes do have natural supports or family supports but those aren't necessarily supports that they can be completely honest about what's going on for them. And to be able to save somebody's life you have to come with a non-judgmental approach so they can really accurately and honestly tell you what's going on for them and have authentic conversations about the risks that they have and ways to mitigate those risks, prevent those risks or support them in their day-to-day lives. Yes, well said. And you're referring to it directly, feel that they're not going to be punished, they're not going to be prosecuted, they're not going to be accused with a crime, they're not going to be looked down upon that whole unconditional kind of response to the person where they are. And with the situation, the way I think I understand it today, with some of the drugs that have contaminated the drug supply available to people with substance use disorder, we're seeing an unprecedented rate of overdose fatality. I want to put a screen up for a minute for the viewing audience. You'll notice this is a graph from the Vermont Department of Health and that orange line really is what we're talking about this evening, it's fentanyl. And you'll see a steady rise from 2010 actually through 2020, which really begins to accelerate in around 2014, that's what Governor Schumlin was referring to in the State of the State Address. From 2014 straight through 2020, there's an unprecedented rise in overdose fatality. Grace had provided me with some statistics before the show and in 2019 there were 114 deaths, overdose deaths. In 2020 there were 157, so it's a rise of 38% in one year. That's what we're dealing with and this is one of the reasons why harm reduction at this point is so much more important to really get out there and save the lives of Vermonters by meeting them where they are. Now, do you both, Grace, what have you seen in your setting as far as overdoses? I think we just need to, it's not a fun topic, but I think the public really needs to hear what it's really like, what is it like? The best statistic that I can really demonstrate the effects of fentanyl is that at our office upon intake, we survey people and we ask them what percentage have witnessed an overdose. And for the 16 years prior to it, that number oscillated between 23 and 26% of our clients who had witnessed an overdose. In one short year in 2017, that number jumped up to 81%. So that is what we're dealing with when we're talking about fentanyl. It's an incredibly powerful opioid. It's an incredibly small molecule. It makes the drug supply very inconsistent, so it can be in one bag and not in another. And what can fit on a pinhead can kill somebody with a tolerance. So really what we're up against is this fentanyl epidemic. And when you talk about overdose right now, we talk about the COVID crisis that we're in. Safe Recovery has about 5,000 clients. We've had a few that have been diagnosed with COVID or who have probably had COVID and didn't get medical care, but we have not had a COVID related fatality. But we are seeing overdose and other drug related harms like endocarditis and suicide increase at our office. And it's been very tragic. It's obviously completely devastating. Our clients, the relationship that we were talking about before goes both ways. Our staff is deeply embedded in our relationships with our clients. We know them. We know their children. We often know their goals and their successes. We know a lot about their lives and we know how hard they were often trying to stay alive and to be here for their families and their loved ones. So it's been really devastating to see the effects of overdose deaths. And we've put a lot of emphasis on this and we've done a lot to really prevent overdose and to see those numbers rising in spite of that has also been very, very difficult for I think all of us, especially my staff, but I think all of us that are working together to really try and prevent overdose deaths. Yeah, it's really a situation that's begging for maximum community involvement. Sarah, did you want to add to that? Yeah, just briefly, I wanted to first point out as well that this rise in fentanyl isn't just in heroin. This is now getting into other drugs that people are using, including cocaine, things that people may use somewhat recreationally, for lack of a better term, that it's now in that too. And I think that's driving a lot of these numbers for people that don't really have a long history of substance use but are maybe using once in a while and are dying from it. I also think that because of COVID, we have a lot of people that are staying home and are not interacting with their normal groups or their friends or family. So more people are using by themselves and they have less access to things like, if you come into my office, the state's attorney's office, I have a bowl of fentanyl strips at my door. But my office is closed right now, the courthouse is closed and I'm sure a lot of other places around the county are closed or aren't open in the same way that people can access those tools and strategies that Grace was talking about as easily. People are losing their jobs or are really struggling financially and so the mental health aspects and the basic needs issues of food insecurity and housing insecurity are up and so people might be using more. There's so many, this is already a really complicated substance use in general is always complicated. It almost always has some mental health aspect and trauma aspect that is not being addressed and so when our community in general is sort of limited and shut down in some ways, those can only get worse and so I would just want to kind of highlight that that's a real issue in the community right now and I think that is leading to a lot of the numbers. Yeah, I understood that COVID-19 imposed isolation and then having a drug supply that's available to you that through nothing on the person with addictions part has been contaminated with fentanyl. One of the things that I always like to remember when I think of fentanyl is when an opioid pain reliever, most of us who have had an opioid pain reliever prescribed at one point or other in life, the pharmaceutical opioids are measured in milligrams so a milligram is a thousandth of a gram, so you'll have 10 milligrams, 20 milligrams, 30 milligrams, whatever the dosage is, thousandth of a gram. Fentanyl is such a remarkably potent opioid that it's actually measured in what's called mcg or microgram which is a millionth of a gram. So you have a drug that's so powerful that it has to be measured in millions of a gram and then you have a drug cartel, an international crime organization that is motivated only by profit who is using that drug because it's easier to produce than to harvest morphine and it's easier to smuggle because you can smuggle very small amounts of it and make the same amount of money. So people, the end user, the person who has substance use disorder using that drug is injecting that drug but doesn't really know it or want it or may be afraid of it because of their addiction they're forced to use it and it's like a perfect storm of negativity. The other parts of fentanyl that make it more dangerous too is it's short acting so while it's very very potent it wears off very quickly so that the person goes into withdrawal sooner and has to use again sooner and it builds tolerances, makes the tolerance to opioids much higher so when you use a maintenance medication like methadone or suboxone or buprenorphine they need higher doses sometimes. So it's really, any way you look at fentanyl in the user, from the user's perspective it's very dangerous even in the short term and in the long term. So we have a population in Vermont, a lot of people in Vermont, fellow Vermonters, our neighbors, our sons, our daughters, or partners, you know, we have a population in Vermont with substance use disorder that's dying at an unprecedented rate. So we need now to involve the community as much as possible. It needs to be an all hands on deck effort more so than ever before and I think one of the things that happened that we all know about over this past year is we did it. Vermont is really, we really rallied around COVID-19. We had a health department that was leading the way, we had a lot of information that was disseminated and we had a lot of Vermonters that really cared about each other enough to behave in certain ways. So we can do this with addiction. So I wanted to begin to give you the floor now. There are a couple of techniques that we're going to discuss techniques that people who use drugs can employ to save lives. But there are a couple of actions that people who do not use drugs, community members, all of us can do to save lives. The first one is to call in emergency workers, to call 911. So I'd like you to speak a little bit about that. People hesitate sometimes to do that. Let's talk about that. Why they hesitate and why they shouldn't hesitate. You want me to start Grace or do you want to? Sure. No, you start, please. Okay. So I think that people rightfully have been historically concerned about that because when 911 is called, especially for an overdose, police also respond. And so when you're engaging in a behavior that is deemed illegal and stigmatized, you are automatically going to be concerned about calling the police essentially to that scene. Vermont did some really incredible work to pass the Good Samaritan law, which essentially is an immunity law that you cannot be prosecuted for the drug use or drug possession if you are calling because of an overdose. And I think that that has really, really fantastic, it's very well intentioned. And for all of the right reasons, it was passed and supported by law enforcement and our legislature. Unfortunately, like any law, there's sort of, there's loopholes and there's ways that law enforcement over some time have tested those loopholes. And although I don't think, I think ultimately most of that has gotten resolved, it still allows for the community that's using drugs to hear those stories and to internalize those stories and to continue to mistrust that process because they think, well, I know that it's the law, but my friend heard that this happened or this happened to me in the past, they cited me and yeah, they didn't charge me, but they did cite me and the police took all my drugs or whatever the process might be. We still have some work to do, but I can certainly speak on behalf of Chittenden County that that Good Samaritan Law is gold to me. It is more important to me than most of our laws and it is incredibly, I have made it very clear to law enforcement in Chittenden County that that is not to be taken advantage of and that there are no loopholes. So if you are a community member and you are, you see somebody who is overdosing or you are with somebody who overdoses, I mean, my first advice would be to always carry Narcan and to have some sort of tools otherwise, which I think we'll probably get to. But if that is not an option for whatever reason, I do strongly, strongly encourage you to call 911 and every single time that you feel like you cannot handle the situation yourself, so you cannot do it safely, call 911. And if you are in a situation where something has been taken advantage of or law enforcement has taken advantage of a loophole or attempted to or a prosecutor has, please make sure that people know about that and bring that to the attention because there have been times where Grace, for example, has been the one to tell me because of that relationship that you're talking about, Ed, where her clients trust her and so they go to her and then she's able to come to me. That person would never have felt comfortable coming straight to me as a prosecutor or to law enforcement, you know, going straight to the chief about it. So those relationships are really important. So I would strongly encourage people to not only take advantage of the Good Samaritan Law, that's what it's there for, but to also report any times where they feel like that law has been violated, taken advantage of. Really important for the viewing audience to understand that, they do have, they can call, they can get emergency workers in there, first responders, a life can be saved, they're not going to be accused of anything, they're not going to be, oh, no, you have to be a witness and you're going to be, you know, have legal problems that's not going to happen. What should happen is the person should be thanked for making the phone call and perhaps saving a life. Yeah, so thank you. Thank you for your work in that area. And I think wasn't TJ, TJ Donovan was also instrumental in that effort. Was that the case? Yeah. Grace, do you want to, do you want to talk a little bit about that, about that? The Good Samaritan Law, you know, in a state you want your laws to reflect your values. And I think the Good Samaritan Law is an excellent example of that it reflects our values. We want, in any medical situation, we want the first response to be to call 911. And this is where stigma plays a part. If you saw somebody having a heart attack, people would never think twice about calling for help or having a diabetic shock or something like that. The fact is that we've had systems that have been set up, not just in Vermont, but in the United States and other parts of the world where people have been punished or been shamed or had very severe consequences related to calling for help. And I think when we went to the legislature with the Good Samaritan Law and talked about it, they really made it as broad as possible to reflect the values of Vermonters that we would never want somebody who's suffering to not get medical care. And so I think that that's something we should really be reminding all of all Vermonters. And that lot only works if people know about it. So the public, you know, talking about it is really important too. But I think for my clients, especially, you know, their network of survivors, again, I was talking about that before. And messaging gets through, like Sarah was saying, through that network of survival that they've all had to do, especially in light of, you know, what you were talking, the war on drugs, people have had to depend on themselves because they can't depend on systems for many, many years. And what we want is the positive messaging and the accurate messaging to go through those systems rather than what Sarah is talking about when something happens in error or somebody sees a loophole. We want the message to be emergency, call for help, nothing else, no nuance, no running around and making sure that there aren't drugs on the scene. And people aren't doing that to be callous. They're doing that because they're terrified. They're doing that because they're, prior to the Good Samaritan Law, people spent many, many years in jail for well-intentioned calling for help. So we really want to infuse that messaging to everybody. And your show and other ways like that or other public announcements are really, really important. Yeah. And again, it is the polar opposite of the war on drugs, which became a war on people who use drugs, you know, it's got, it has to be over. And thank you for your contributions, both of you in this, you know, most important area. It saves lives. You know, the other part that anyone can do, you know, and Grace, I'd like you to speak to Naloxone or Narcan, you know, what it does, how it works, how people can get it, what the importance of it is. Would you, would you like to do that, please? Sure. Always like to talk about Narcan. So Narcan is a nasal spray. This is Narcan. It reverses the effects of opiate overdose and gets the person breathing again. It's been, it was FDA approved in 1960. It's been safely used in emergency rooms and ambulances ever since then. And in 2013, Vermont passed a law that allowed for community-based Narcan, which means that, that I can give it to Ed and Ed can give it to Sarah and that's legal. It comes from the health department. And so what the law says is that we can give community-based Narcan to anybody who might be president and overdose. And what I want to say is we had a client a couple of years ago walking through the U-Mall parking lot in Burlington, saw somebody they didn't know overdosed in their car, opened the door and saved their life with Narcan from our office. So when you talk about that, and, and then one of our coworkers reversed an overdose on Church Street, it means that all of us could be president and overdose. If walking through a mall parking lot is where it can happen, it means that all of us can be present. It's a very easy and safe medication to, to have and to administer. And if you give it to somebody who's not overdosing, it won't do anything. So you're not going to hurt somebody. So it's very safe to carry. When we did the testimony for the bill, we talked to poison control about what would happen if a child gets it. And they said you do not have to be concerned, which for poison control to say that about a child is, is, is, is pretty serious. The truth of the matter is we don't want kids to get anything they shouldn't have. And we know that's the best practice. But it is a very, very safe medication. Our office has given out 28 over 28,000 doses. Since the law passed, we really, and we've trained over 2000 providers. So homeless shelters, domestic violence shelters, libraries, schools, a lot of the schools in Chittenden County have been trained and have Narcan on site. So it's really about getting it out to anybody who might be president and overdose. If you are interested in Narcan at the end, there'll be a slide that has our office information. Always feel free. It's an anonymous program. It's free. The other thing is pharmacies do carry Narcan. There is a pay, there's a cost associated with it, but all pharmacies in Vermont have Narcan. And what Sarah was talking about, about calling 911 before this law, not every ambulance in Vermont had Narcan. Now every ambulance has Narcan. And I believe all but one or two police officers or police agencies have it. So when you call 911, the person responding will also have Narcan. So that's a really good thing to know if you don't have it. The other really good thing to know about calling 911 that I always try and tell people is even if you don't have service or a plan on the phone, if a phone can turn on it, can call 911. So always keep, even if you don't have a phone, keeping a phone that doesn't have service is always a safety measure, keeping it charged. Because even if it doesn't have service, it will be able to call for help. That's a really great point to know. And thank you for speaking so enthusiastically about Narcan, about Naloxone. Vermonters, we all put on masks and we put on double masks and we stayed six feet away from each other and we didn't see our family and we did lots of things. So I do think with an all hands on deck kind of approach, getting this kind of information out to Vermonters who care about Vermonters and a person with substance use disorder, you know, I mean literally can be one of your children and you may not know about it. It can be anybody. So having some Narcan around just doesn't seem to be, you know, it seems to be a relatively easy thing to do. And if you need it and don't have it, that's going to be very bad. So it just seems like good old sense to have some Narcan available. It also allows for really good conversations. Like I do not leave home without it. I have it in every one of my purses or bags, my car. And it is, you know, people ask, like when I'm rummaging through my purse for whatever I'm looking for, sometimes I was in an airport once and they're on an airplane and I happened to take the Narcan out of my bag in order to get to something else. And the man next to me said, are you a nurse? So he clearly knew what the Narcan was. And I said, no, I'm a prosecutor. And I think that we had such a great conversation about harm reduction and how that's my job as a prosecutor, but it's also our job as community members. If you really are horrified by these numbers that you're hearing and seeing, which you should be, this is a really easy way to potentially be a part of the solution to potentially save somebody's life and always be ready for it because you saw the size of it because you've got a tiny little nasal spray in your bag. Yeah, to ever be found, I literally will, when I'm just running up to church street from my office, if even if all I grab is my ID badge and Narcan, I never leave without it. And I think that it's so important for people to recognize how easy it is and how important it could be. You may never use it. And that's great. But that is great. But if you need to use it, you don't have it. That's not great. Yeah. Yeah. And I think people would be really upset to know they could have had something and didn't. And we have given out 28,000 doses. So don't people shouldn't feel any shame or embarrassment about getting it. It's really just something that people should have. I had a similar experience to Sarah. I went to a concert in Vermont and had my bag searched and somebody asked what it was. My partner looks like, Oh, here we go. Somebody's getting the training. But the truth of the matter was they before I even said what it was, they saw the label and said, thank you. So I think the community does understand and we should really be talking to the individuals about carrying Narcan. We've also seen an increase in overdose in people that get prescribed medication and also in elderly populations. Because sometimes people take more than they should or accidentally take more than they should. So we have a law in Vermont that makes it so you can have companion prescriptions. So if you get a certain amount of milligrams, as Ed was saying, of opioids, there will be a prescription for Narcan that is there that is paid for by your insurance. So always pick that up. Sometimes you hear people declining it, but it's really good. It's just like anything else. If you have something that can kill somebody, having the antidote for it right there is best practice. And really that's what we would do for any other medication or any other parts of life that could really be dangerous. Yeah. And thank you. And little by little, because of efforts like yours, we're moving forward. And as we reduce stigma, I think these kinds of activities will become more prevalent. The more people understand what this is about, the more we'll find people taking meaningful action. Now, I want to move into the next part of the interview now. So we've covered what the general community can do. And now really it's about people who use drugs. What can people who use drugs do to make using drugs safer for them? And I want to be clear about our team here, the three of us, we're not recommending using drugs. We're not advocating that someone who doesn't use drugs should use drugs. We're saying people who use drugs, whose lives are at risk, need to have information that can help them to stay alive. And so I just want to be clear about that because sometimes it's misunderstanding. So Grace, I'd like you to begin with that. Maybe start with having someone there with you and having Narcan on board for people who are using drugs. Right. And like Ed's saying, the reality is that people use drugs and people do things that can be unsafe in all aspects of our life. So having honest conversations about safety is something we should always be doing. And people, we see the highest risk for overdose are people who are using a loan. So there's no one there to respond if they overdose. It is very, very rare if unheard of that somebody is able to respond and give themselves Narcan, especially with fentanyl on the market. Fentanyl overdoses happen much quicker. They're much more severe. So making sure that somebody is there with you and or somebody knows that you're using. So if you have to call somebody and make sure they stay on the line, there is a national service called Never Use Alone that you can call and somebody will stay on the line with you. But really trying to make sure that we're taking care of each other in a social distanced way. But you can still be be there for people and make sure that if they overdose that you can respond. Also, if there are two people that are using together, making sure that they don't use at the same time, we have had tragedies in Vermont that have involved simultaneous use simultaneous death. So making sure that one if one person is using the other person is able to respond and waiting some time till the other person uses. And again, we're just talking about practical strategies, making sure that there's a phone available. Like I said before, it doesn't even have to have service making sure that the person has Narcan. The other things that put people at risk is we often see overdose occur when there's poly substance use people using different substances together. And some of the substances that we don't think of as dangerous in acute set ways like alcohol, alcohol and opioids together can be fatal and can cause an overdose. Same with benzodiazepines like Valium and Clonopin. So it's when people are using drugs, multiple drugs at the same time that can cause an overdose also at times when people have periods of abstinence. So they're not using drugs either because they're attempting to not use drugs or they've been in a setting where they aren't able to use drugs like a jail or a treatment center. And unfortunately for some people, even years of abstinence, they're still very much at risk for overdose. And you see that you see that on the national scale with celebrities. But it's something where people's tolerance can change over 24 hours, 48 hours, and they don't have the tolerance that they did before. So we'll talk about medication assisted treatment and how that plays in, I'm sure in a little bit here, but not having drugs in the system can be a risk for fatal overdose and fatal overdose. So having somebody with you, not using a loan, and if both or three people are using doing it in a staggered or a sequential way, so if someone overdoses, someone will be able to administer Narcan and call 911, right? Did you add something to that, Sarah? And the only thing I would add, I don't think you said it, but using fentanyl pest strips, if you can, so that you do know what's in, exactly, it's very, very small, very simple. It's not going to, you know, it's not everything, but it's, and again, just like another little piece or tool that you can have. And it, you know, I've heard a lot of people wonder whether or not people who are using drugs, whether their behavior actually changes from those. And in fact, it does. People do adjust their doses based on what they find on those, when they test their test their drugs. So that's the only thing I would add. Those are, again, very easily found at safe recovery or, you know, eventually, hopefully much broader areas, but having those with you to test your drugs before you use. Chris, I want you to go over the fentanyl test strip in a second, but something Sarah just said. So that would mean that a person would prepare a dose, we would test it with a fentanyl test strip. The test strip would show that there was fentanyl included in the dose. And then they would, would they then administer like a test injection to see what the potency level was, like maybe just a little bit rather than the whole injection and overdose? Is that, is that what they would do? So with fentanyl test strips, we see a variety of people's responses. And to be clear, we also want people to test all drugs that they're using, cocaine, methamphetamine, heroin, for the presence of fentanyl, even if they're going to snort it or take it orally, because we have had overdoses. Fentanyl for somebody who is not, does not have an opiate tolerance, even by swallowing it or snorting it can cause an overdose. So what we do see happen in our office, we've given out thousands and thousands of fentanyl test strips, we don't count them, we don't have data on it, other than we give them out to anybody who wants them. It would be hard to track how many we give out. But we do hear of people disposing of the drug, which I even surprised me, but it does happen, especially somebody who knows that they don't have an opioid tolerance. So somebody who is an occasional cocaine user or only a cocaine user. And other than that, we hear of people using a lot less, like Ed is saying, what we call a test shot, where they take a tiny amount to see how much fentanyl is in there, and whether they are, whether it will overdose them. Fentanyl is such a tiny molecule, like I said, what can fit on a pin head can kill somebody with a tolerance. So we also tell people that it can be very inconsistent, even in their own supply. They could buy five bags of a substance, and one bag could be very, very strong, and the others could be very weak. So you want to test not everything, not only everything you buy, but every time you use it should be tested for the presence of fentanyl, even if it wasn't in something else. So we see people use less, we see people make sure that somebody's there, we see people, you know, talking to the other thing that Sarah was talking about is conversations about fentanyl. And like I said, when fentanyl first came to Vermont, people didn't know enough about it, but people have seen firsthand what, like I said, 81% of our clients have identified witnessing an overdose that was in 2017. So they've seen how scary it is, they know how scary it is, they're wanting the information. I mean, like I said, our clients, one of the things that we all should be talking about too is, I think the misperception about people that use drugs is that they know the risks that they're okay with the risks. And our clients, I think demonstrated by the fact that we've given out 28,000 doses and thousands of fentanyl testing trips want to be alive. They want to survive their use, they want their friends and family to be alive. So they're taking care of themselves and each other. But we do see people mitigate the risks by knowing that fentanyl's in there, taking less, making sure that they're with their friend, making sure they talk to their friend, if their friend doesn't know what fentanyl is, and at times not using it at all. And we aren't just talking about people who use opioids regularly. Everybody in Vermont, if you're using drugs, if it's on a weekend randomly at a college reunion, or something that an anomaly, those are the people that are very much at risk too. So people should be aware if they're using cocaine, even what they think is casual use, and they're not in the drug world. They are at risk. The drug supply is contaminated, as Ed said. So it's just really something to be aware of. Yeah. And thank you. And the more conversations we can have, the more people who can get information like this, we can get this show out to whoever wants it. And the more people who can see it, share it, talk about it, use it as a prompt to have a group with maybe people who are using drugs or people who know people who use drugs, the more education we can do, the better it is. And I do believe that there's a real thirst for science-based information that's characterized by empathy. I don't think that Vermonters really want to see other Vermonters through a lens of stigma. I don't think people want to do that. I think, unfortunately, when we've all referred to it, the war on drugs for decades has taught generations to see people with substance use disorder through a lens of stigma. And it feels so good to finally be talking about it, confronting it, and peeling it away so we can see each of them more clearly. I guess one other thing is sterile syringes and infection prevention. Do you want to speak a little bit about that? Definitely. So at Safe Recovery, my office at Howard Center Safe Recovery, we are a syringe exchange. And syringe exchanges are great for a lot of reasons. They benefit the community in that places, cities and towns that have syringe exchange are much less likely to find syringes on the street. And people who use syringe exchange are sometimes more likely to access treatment than those who don't. So those are CDC statistics. This is very well known as evidence-based. And we distribute syringes for the last, I think we're at 20 years, which I think COVID has changed anniversaries. We'll probably have to do something for 25. But yes, syringe exchange is evidence-based. It prevents the transmission of HIV and hepatitis C. Vermont has very, very, very low rates, almost non-existent rates of HIV in our injection drug use population. And that's because syringe exchange has been robust in Vermont for a long time. But also one of the things that we've lost clients to and recently which involves both syringe exchange and stigma is endocarditis. And endocarditis is an infection of the bloodstream that gathers around the heart and causes damage to the heart and sometimes permanent damage where people need heart valve replacements. When you talk about the cost effectiveness of syringe exchange, which that's what some people want to hear about, one heart valve replacement in a young person costs $600,000, which is way more than our budget, just so everybody knows. So preventing one case of endocarditis is really pays for itself in syringe exchange. But the truth of the matter is what typically happens is that these are otherwise young and healthy people that end up with a lifetime heart condition if they survive it. And where stigma comes in is oftentimes these start as very small infections. Sometimes you can see them on the skin, sometimes you can't, sometimes they're associated with fever. And once they get worse, they have all the other symptoms of an infection. But people who use drugs are afraid to seek medical care in many cases. And so these are the kind of things that syringe exchange and using a new syringe each time and using sterile equipment prevents, but also at times people do get infections. And we really need to be working towards creating positive relationships with medical providers so that people feel safe. Again, just like any other condition we were talking about before, we would never want somebody to not seek medical care for something that they have minor or major. But this is something where it's minor and it's caught early. It's a simple oral course of antibiotics that can be treated in an office setting. And now I'm pretty much on Zoom. But if it gets out of control, people don't survive it and it's a very sad situation. So that's where syringe exchange really shines, but also in the prevention of HIV and hepatitis C and other drug-related harms. Yeah. So again, just to speak a little bit to Stigma, if a person feels that they're going to be understood and they need infection prevention kits and they can go somewhere and not be looked down on, they're likely to go and get that kind of resource and not suffer from some of these grave consequences. And in the process, and I know you've been successful at this, Grace, I want you to speak about this for a little while. In the process of engaging with a person that's, as a non-judgmental attitude toward them and accepts them and is there for them, beginning to trust that person over time, and perhaps then accepting additional help, maybe in the form of a medication for opioid use disorder or another type of therapy, can you talk about that and what your experience at safe recovery has been with that? Sure. So medications or maintenance medications, like people might have heard of buprenorphine suboxone or methadone, are the standard of care for treatment of opioid use disorder. Those medications are also protective from overdose. So any day that somebody takes the medication that we prescribe out of our office, buprenorphine or suboxone, is a day that they're very, very, very unlikely to overdose. It's almost impossible to overdose when you have suboxone on board and you're opiate dependent. And what those medications do is they make the person feel, it prevents the person from going into withdrawal, but it also prevents them from feeling euphoria or getting high. So it gets people to feel normal again. It gets people to be able to go back to work or parent or feel healthy again. And it's really the standard of care for opioid dependence. And what we see in with stigma is oftentimes there are people that are ashamed or afraid to seek those treatments. We also at times in Vermont in this country, those treatments have been scarce or there's been waiting lists. But now we have access to those treatments on demand and at our office and at the hospital and in other hospitals in Vermont. The health departments worked really hard and the hospitals have worked really hard on making sure that if somebody walks into an emergency room, not all, but a lot of the emergency rooms, they'll get treatment for opiate use disorder, three days worth of a medication, and then they'll be connected to treatment outside within three days typically. So usually it's sooner than that, but three days allowing for the weekend. And at our office, we really wanted to capitalize on the moment when somebody's ready for treatment and not have a gap in that time. So we've made it available on demand at our office. Our efforts are really focused on people who've struggled with the traditional system or who've been kicked out of treatment or who have never attempted treatment because of barriers like mental health or stress or their job. But if you come to our office, we will get you into treatment on demand. And if people stabilize, then we help them transition to either their primary care or another setting in Vermont. But if they are still struggling or for many reasons, they can just stay at our office. And low barrier services is what we call it. Low barrier really means that we're meeting the person where they're at. If they come late, they're still seen. If they come two days late, they're still seen. What's strange is sometimes people come early, which is rare. We didn't expect that. And we work with people if they're using other drugs, counseling is encouraged but not required. So people are really prescribing that for themselves. And when you're working with a trauma, a population of people that have really struggled with trauma, it's trauma informed to allow them to decide what level they want to have and who they want as their counselor, which is not just trauma informed, it's stigma informed. Because in the general population, if you wanted to get counseling and somebody said to you, well, you have to go to this person and you have to go on Fridays and you can't be late and you can't change your appointment for any reason, you wouldn't do it. And so we want to really treat people like agents of their own recovery. And what we see is people coming to counseling and coming to case management. So it's really about trying to meet people where they are. And like I said, any day that somebody takes the medication that we prescribe, which is typically suboxone or buprenorphine, is a day they're not going to die of overdose. So it's really important to get people into treatment and keep them there. Thank you, Grace. And for the viewing audience, we'll have a slide at the end of the show with some resources and we'll let it linger. So if you can have a pencil and a paper around, you can copy down some of the numbers or the websites and you can get in touch with people or you can provide the information to someone you know and love who may need to reach out for help. Sarah, I think that could you talk just for a little while. Weren't you instrumental in some forward-moving activity around prosecuting people for possession of buprenorphine? Yeah. And I say instrumental, you know, because I was the elected that kind of started talking about it, but this is a conversation that Grace and previous to her, Tom Dalt, and have been having for years around the importance of this Medicaid, this MAT, Suboxone and buprenorphine and how important it is for people to be, to have low barrier access to it and to be comfortable with it, to possess it, to want to possess it, to divert it in any way that they feel safe doing. So I listened to them and coupled with the, the, at the time, the Burlington Police Chief, Brandon Del Pozo announced that I would not prosecute people who were in possession of this drug. It is still a illegal to possess it without a prescription. And I made the decision to implement a policy. It was the first in the country to implement the policy that we would not prosecute people for possessing it even if they did not have a prescription. And so it was therefore technically an illegal possession. The conversation was really fantastic in leading efforts to get the hospital, to get more doctors able to prescribe it and getting more of it into the community and in getting police to stop arresting for it. And, you know, I think the biggest, from my perspective, the most important aspect of it, we really didn't prosecute a lot of these cases. I think we'd only had a few come through our office in the year or so before that. But the important aspect was that conversation was the de-stigmatization of it. And for people in the community that use drugs to hear from a prosecutor and from a cop that we want you to have this, that this is safe for you, this is a better option for you. And if you have the choice between that and heroin, please take this and you will not get in trouble for it. We encourage it. And that's a really big shift when you're talking about stigma. And for people to feel accepted, that was really the more important message there. It was just for, you know, this community talks. They talk to each other. They listen to each other and they help each other. So if they start talking about, did you see this or did you hear this? Do you know where I can get this or this? Those conversations are the ones we want to be happening and we want them to feel heard and seen by elected officials and people that are in public safety roles. So it was a really great announcement. It was a great policy. It was a really great conversation. It led to, in my opinion, phenomenal results. We still had way too many people that passed away that year. But in the year that we implemented that policy and got more buprenorphine into the system, our overdose fatalities dropped by over half. So I don't think there's any question that those two things weren't related. And I think had COVID not hit, we would probably be in a much different situation because of it. I agree with you. I remember that year and what a great year that was, because it seemed like the whole effect of everything that everyone was doing so much, so many people doing so much that it finally had begun to take some effect. And we're going to get back on that again. So thank you for your effort. And that message from you, Grace, and from you, Sarah, is so important that there are people in, I mean, Grace is a person in the field, but to hear this kind of message from a prosecutor, that is so powerful. Again, it's the polar opposite of the war on drugs. And I want to thank you both for being on the show and for the lives that your efforts have saved over the years. Grace, how does that feel when you, I know you must run into someone that came in a number of years ago who now is doing great and not suffering all those symptoms that they used to suffer from. And how does that feel to see someone like that who's really doing well today? Well, and I can talk about that, but I do want to step back a little bit to talking about how, especially during that time, we had a group of people, the police, the prosecutors, the hospital, the Department of Health, a whole bunch of people get together and really look at science and compassion. And we did not look at anything else. It was like, we need to solve this. People are dying. What is going to save people's lives? And it was very, very compelling. I think it even surprised all of us how much it worked to have a 50% reduction. Sounds casual here, but no other county, I think in the country had a reduction like that. It's a very big deal. And then, and to have, I mean, for me, it's very emotional and compelling to have law enforcement officers that are, especially prosecutors, prosecutors, people don't talk about the power prosecutors have. They have a tremendous amount of power. They drive the whole system. And so to have a prosecutor talking like that, and I don't want it to go missed, the Department of Corrections also began to prescribe buprenorphine. It was in statute. But for our clients, that was, that was massive. We had people dying coming out of jail. They'd have no tolerance like I talked about before. And the people going through withdrawal in jail that had impacts outside of jail, trying to get people back into treatment when they've been through withdrawal was a very hard thing. People have been through really inhumane, and I don't want to blame the Department of Corrections in Vermont. It is across the board. And this was a new thing. They've come, they've prescribing buprenorphine to anybody who needs it. And we're seeing tremendous results of people coming out with treatment to treatment. We're seeing people that are exiting the Department of Corrections that have been involved for 20 years. I'm not kidding. These statistics show up very quickly in Sarah and my offices. And so while we talk about the negative statistics, these horrible deaths, we also know when we watch the positive ones, we need to do more of that. So I can talk about our clients coming back. But that's really, really what I want to talk about is these things are anomalies. Sarah is an anomaly, and I'm not just saying that because she's here. I would say it if she wasn't. Syringe exchanges in police departments and Department of Corrections and prosecutors all sitting at the same table with the same goal is probably a byproduct of fentanyl, but it was real. And it really did make a big difference. But yes, our clients, like I said, what we see in our office too is generational impacts. People who have gotten their kids back from DCF. People who have caught addiction very early. People who have survived so many things getting into recovery. But also I want to talk about the resiliency of people that are not ready for recovery. We have a lot of people that are living on the streets of Vermont that have for many, many years. I have clients that have lived in tents for many, many years. I have clients that I hadn't seen for a while. And they were like, oh, we're in the clinic. We're doing really well. And I was like, well, did you get housed? And they're like, no, I mean, these clients are getting up out of a tent. This was prior to COVID at 5.30 in the morning to walk over a mile to the clinic to get their dose to come back to the tent to get ready to go for work. That is resiliency that we don't have that I don't have. I don't know about you guys, but I don't have that. So to be talking about people in recovery, we also should talk about people that are surviving every day and get up and survive, do a lot more surviving before I've even gotten out of bed. So I think we really should be giving the dignity and respect to all of our clients. And it is always wonderful when people come back and say that they're using. But what's wonderful for us is that people come back at all. It shows that they feel valued and are treated with dignity. So that's really important. Yeah, thank you. Thank you. And thank you for, I mean, your emotional commitment is so obvious. And that I think is what resonates with your clients, Grace, is, you know, you're the real deal. And that's unmistakable. And I just want to thank you from the bottom of my heart for what amounts to, you know, a lifetime of dedication and many lives saved. And some I know lost and I know how painful that is. So I want to thank you both. Sarah, do you have anything? I'll give you, Sarah, you want to close? You want a closing comment? My closing comment would be that I agree that Grace is the best thing to happen to Chittman County. And you know, I think you're talking about like that passion that she has is definitely what resonates with her clients. It's also what resonates with, you know, people like me in these really, like she said, really powerful positions that have a lot of influence on the system and how it works. And you need people that have so much compassion that they are willing to advocate for their clients no matter what, without any judgment or stigma to really get things done. And I think it's, we need more, we need more Grace colors in the world. It's super easy for me to come out and say some of the things that I say when I know that there are folks like Grace and her team that are seeing this suffering and the successes and the struggles every single day. So my closing other than that would be just to take care of each other to really look out for one another, especially now where our eyes really aren't on each other in the same way or anything that we do is either on phone or Zoom and to check in with people and just make sure that people are doing okay and try to have eyes on in any way that you can, especially as the weather gets nicer, try to get people out of their houses so you can really see how they're doing and to gauge what help they might need. And that's not just with substance use, it's really for anything or as Grace said, our suicides are not good right now either. They're really horrifying. And so any way that you can just check on your neighbors, check on your friends, get people out of their houses and be kind to one another. I think that would be my closing request. That's beautiful. I was at a webinar with Nora Valkov, the director of the National Institute of Drug Addiction and you just reflected her sentiments exactly. One of the things that she talked about was the after COVID reality and what we're going to see that people, and I think Grace is like very much in touch with this, people who use substances, it really has been a year of loss. They've lost so many friends, they've lost access to treatment, they've lost access to recovery centers, and there's been a toll that's been taken. So as we move out of COVID-19, we do need to check in with each other, reach out to each other and give each other the support that we need. So we're going to close the show now and again, I want to just thank you both from the bottom of my heart. It's such a wonderful thing to have you on and I would extend publicly an invitation, but I know Grace is going to swear and I'll come back on the show for two years, but I'm going to say it's three years. I'm going to explain publicly an invitation for you to come back on the show at a time that you choose to talk about other topics that I know are on your agenda. So to the viewing audience, take this show and give it away, get as many people as you love, people who use drugs, people who don't, to really take advantage of the information that's been given to you. So thank you. And I want to thank you Ed, it's always a pleasure as much as I buck it, but I really do think it can't go without saying about how much you addressing stigma in the way that you have is having a huge impact. And I think when we talk about what we all can do, it's really educating ourselves and being human to each other and really looking at stigma and how even I catch myself times, there's times we have to check ourselves constantly and Ed, we need people like you that are calling it out and in a compassionate way, but consistently because it needs to be addressed, it's also it underlies all of what we're talking about here. So thank you. Thank you, Grace. Thank you, Sam. Thank you. Thank you so much, you guys. Thanks.