Harm Reduction Approach Vital for Addressing Opioid Crisis, Says Expert

Blue Mountain Heart to Heart

Eastern Washington Health Profile | Community Health and Spatial Epidemiology Lab at Washington State University

“Treating opioid disorder without meds more harmful than no treatment at all” by Mallory Locklear from YaleNews

“We Must Support People Who Use Substances, Not Punish Them. Here’s How.” by Susan E. Collins, PhD for PubliCola

“New Law on Drug Possession, Use Takes Effect July 1, 2023” by Flannary Collins for Municipal Research and Services Center of Washington

Substance Use and Recovery Services Plan | Substance Use and Recovery Services Advisory Committee (SURSAC)

“Finally Addressing Blake Decision, Legislature Passes Punitive Drug Possession Bill” by Andrew Engelson from PubliCola

“Legislators Continue Failed War on Drugs Approach in Blake Fix Bill” by Doug Trumm from The Urbanist

"WA’s new drug law could help needle exchanges — or restrict them" by Andrew Engelson for Crosscut

[00:00:00] Crystal Fincher: Welcome to Hacks & Wonks. I'm Crystal Fincher, and I'm a political consultant and your host. On this show, we talk with policy wonks and political hacks to gather insight into local politics and policy in Washington state through the lens of those doing the work with behind-the-scenes perspectives on what's happening, why it's happening, and what you can do about it. Be sure to subscribe to the podcast to get the full versions of our Friday week-in-review show and our Tuesday topical show delivered to your podcast feed. If you like us, the most helpful thing you can do is leave a review wherever you listen to Hacks & Wonks. Full transcripts and resources referenced in the show are always available at officialhacksandwonks.com and in our episode notes.

Today, I'm very pleased to be welcoming Everett Maroon, who's the Executive Director of Blue Mountain Heart to Heart. Everett supervises the program areas of Blue Mountain Heart to Heart and is also responsible for fundraising, development, and evaluation of the agency. He has overseen a broad expansion of HIV case management services, harm reduction programs to the Tri-Cities and Clarkston areas, and an innovative outpatient opioid recovery program across six counties in Southeast Washington. Everett co-authored the now-completed Greater Columbia Accountable Community of Health's Opioid Resource Network and contributed to the Washington State Opioid Strategy. He serves as a technical assistance provider on the Law Enforcement Assisted Diversion, or LEAD, program in Washington state. Everett is also a co-chair of the Washington state LGBTQ Commission. He's worked on quality improvement projects for various federal and state agencies for more than 28 years. And Everett and I also had the opportunity to both serve on a steering committee for a statewide ballot initiative surrounding decriminalization of substances. Welcome to Hacks & Wonks, Everett.

[00:02:07] Everett Maroon: Thank you so much, Crystal. And it's really great to see you, and I appreciate having some time to talk with you today - so thank you.

[00:02:15] Crystal Fincher: Absolutely. So I just want to start off - what is Blue Mountain Heart to Heart?

[00:02:21] Everett Maroon: Well, it's a 501(c)(3) nonprofit in Southeast Washington state based in Walla Walla. We also have an office in Kennewick and then another one in Clarkston - roughly 30 people on staff. And it was founded in 1985, originally as an HIV concern, where we probably helped about 250 people live and pass away with dignity at the beginning of the AIDS crisis. Then was incorporated in 1991 - the organization moved into longer-term case management as the medications for HIV became more sophisticated and HIV went from being a death sentence to a chronic condition. And at that point, we began getting more involved in prevention of infectious disease, including HIV, hepatitis C, and STIs.

I came along in about 2010, first as a grant writer and then as the executive director. And it really was notable to me - people would come in - if they had HIV, there was so much the state would do for them. And the state's interest was around public health - so if we keep people from being able to transmit this virus to other people, we'll keep the transmission rate low. In public health, we talk a lot about viral load - community viral load. And so you would add up the viral load of all the people living with HIV or AIDS in a community, and then that's the number that you get. And depending on how many people are in your community, you have a risk assessment for how much you should be concerned about HIV transmission in that community. Well, if you didn't have HIV and you came into my office, I had many more limitations on what I could do for you. Even if you were battling basically the same kinds of issues as people living with HIV had - unstable housing, lack of engagement in the workforce, mental health, substance use - all of these things rise up as things that destabilize people in their lives. Certainly systemic racism - the way that we invite so many foreign-born Latino farm workers to Washington state to pick our agricultural crops every year, but then pay them far below what a living wage would be. And we then expect that there's not going to be detrimental effects on those people. I think we all see that the state needs to do something different around supporting people who are here to make the state so profitable and make its agricultural sector so productive.

So it really bothered me that - in one instance, because there was a transmissible disease associated with the potential client, we were all willing to put money into programs to support them. But then if they didn't, they just had the effects of the destabilizing forces around them and we weren't doing much. I really wanted to change that. I thought that we could get more investment in supporting people and stabilizing their lives and improving their wellness and health. And that that would be a good thing for everybody in the community, not just these people who were facing very serious gaps in resources and support. So we met as a board and a staff and changed our mission, amended a few things to it. And now our mission is really about helping people with a variety of different chronic diseases, including substance use disorder. There are certainly things to say about the limitations around the disease model for substance use, but when I'm thinking about federal and state funding for assistance programs, that model really helps create investment, financial support. So from 2010 to today, the agency has grown from about $150,000 in annual budget to about $4.1 million. We've gone from 2.5 FTEs a year to more than 30, and we have 14 case managers across 3 different case management programs. We have a drug user health equity program. And we still continue to have those prevention programs, but they're more aligned with case management.

So we use a no-wrong-door approach here - no matter what your initial need is when you walk in, we try to see what other resources we can bring to bear to help that individual. So if you're coming in because you're using, or you need syringes for consuming - say, methamphetamine or something like that - you can also get nicotine cessation kits, you can get Plan B, you can get Naloxone because there may still be fentanyl in the substances you're consuming. We have a wound care clinic. We have a contingency management program for people who want to begin abstaining from methamphetamine. So no matter where someone's coming in, we have a variety of programs that we can try to support that person with. The harm reduction philosophy is one of the umbrella guiding value systems or philosophies for our work, even though we're doing some discrete specific activities for people. So that's, in a nutshell, what Heart to Heart is. We have a board of 9 and a staff of 30, and I think 28 of those positions are full-time.

[00:07:47] Crystal Fincher: So who are you typically serving?

[00:07:50] Everett Maroon: We see some diversity across our caseloads - it varies a little bit from program to program. I would say that we have somewhere around 55% are men and 45% are women. We do tend to see white, non-Hispanic people out here more often than not in our caseload, but we have about 12% of folks who are Hispanic and some other race - so white, mixed, African-American, Native. We see a lot of people on the far lower end of the socioeconomic spectrum, I would say - and that varies a little bit from location to location. So when I look at who we've served in Clarkston, about 12% of our prevention clients tell us that they are unhoused and almost 40% of them are temporarily housed - so that could be like couch surfing or at a shelter. The unhoused number is highest for our Kennewick clients at 35.6%, so majority of people that we're serving in Kennewick are unhoused or temporarily housed. In Walla Walla, maybe about 20% of people are unhoused, but the people who are temporarily housed are in truly atrocious conditions. So there are a lot of people in Walla Walla living in someone else's shed or garage - they don't have access to plumbing, they don't have access to heat or air conditioning in the summer when it's 110 degrees out here.

So there're definitely big stressors on the people that we're serving. A lot of the women that we're serving are in very abusive relationships, or they have experience being sex trafficked, or being made to participate in illegal activities in order to have a relationship or to have housing. So there are definitely gender differences in terms of what people are facing among our caseloads. Folks that are in some of the more rural areas that we serve with our mobile clinic - they are very concerned about other people in their small communities knowing what's going on with them. And so they're very reluctant to seek care because they don't want other people to know what they've been engaged in. And that is its own kind of barrier for them.

[00:10:22] Crystal Fincher: Absolutely. And that being tied to the stigma that is causing so much shame, whether it's having HIV, an STI, substance use disorder - a variety of things where the stigma creates this shame cycle, which prevents people from seeking help, prevents people from getting better, and actually encourages the spread because of that and not being treated.

Now, we met each other around the issue of substance use disorder. The landscape about how we deal with substance use disorder has changed over the years. Starting out, particularly with you being so engaged in so many different rural areas in Washington state, what have you seen or how has particularly the opioid epidemic impacted the communities you're working within?

[00:11:15] Everett Maroon: I think that what you said about stigma is really relevant to answering this question. In large part, we see stigma coming in to sort of silence people and keep them away from seeking help. A 2019 study from Washington State University showed that in general, Eastern Washingtonians have a life expectancy of five fewer years than people living west of the Cascades. Part of the reason why is because of later dates of diagnosis, delayed care - those kinds of things add up for people en masse, and then we see a detriment to the outcomes for them. So if you don't get your cancer diagnosed until you're stage 3, your prognosis is worse than if you'd shown up really early in stage 1. The same kind of thing happens for people who are engaging in substance use. And just to be clear, many people use substances and don't become dependent on them. But when they do, it becomes very difficult very quickly for them to extract themselves on their own. Opioids in particular - because they so mimic this endorphin pathway that we all have as human beings - it's almost impossible for people to just will themselves to stop using because the withdrawal symptoms kick in so overwhelmingly that they just feel terrible. And so to deal with that, they use again. A different way of thinking about how people might seek help is to say it's going to be non-stigmatized for you to come into our office and say - I've been using fentanyl, I've been using meth, I've been using anything in front of me. What can we do today about reducing my use? There are very few places where somebody can walk into a doctor's office and say that and then be taken seriously and aided. When you're talking about rural environments, I think that the stereotype is that people in rural environments don't care about folks that are struggling with these issues. I see directly - I observe - it's that we have such a smaller, thinner resource infrastructure. It's that we have fewer providers. So if there's a problem with one provider, there might not be another one in your health insurance plan that you can go see. So now you got to either work with this person who says something stigmatizing to you, or you just don't do it. And if you return to this place of - Well, I'll just get through this myself. Well, we know that that's really not a good option for most people. It's not a realistic option for most people.

So in my rural environment, what we've tried to do is build a trauma-informed, non-stigmatizing or anti-stigmatizing environment so that people know they can come in, tell us the God's honest truth about what's really going on with them. And we're going to start from whatever space zero is for them. So there're definitely folks who can tell us about a time they were entering treatment and then they relapsed and then they were kicked out of the program. Or due to relapse, they missed two appointments and then they were kicked out of the program. Where they admitted that even though they were getting Suboxone for their opioid dependence, they were still sometimes using meth on the weekends and then they were kicked out of the program. So we just believe in our harm reduction philosophy that - if we're not looking to dispose of people, but we're looking to retain them for future engagement, we're going to see better outcomes for them. Because we're going to walk with them as they stumble, because we acknowledge that that's part of what they're facing - occasional relapses and stumbles. And you can do that in an urban center and you can do it in a rural environment. We just have to have the commitment.

[00:15:08] Crystal Fincher: Absolutely. Now, I've heard a lot of people have different conceptions and misconceptions about harm reduction, and hearing - Well, if you don't require people to be clean before you help them. If you don't use this as a stick to get them to do what is best for them, then we're really just enabling their problem. We're becoming part of the problem. - Why is that not true? And what is harm reduction and why is it important?

[00:15:39] Everett Maroon: That enabling hypothesis is very persistent, almost as persistent as opioid use disorder - it's been around a long time. But when you look at the actual evidence for treatment - in fact, there was a study that just came out that showed that treatment without prescribing a medication is almost worthless. We really need to be thoughtful about what clients need. If somebody had a heart attack after having a heart attack six months ago, the cardiologist would not say to them - Well, you had another heart attack. I refuse to see you anymore. If someone had type 2 diabetes and they walked into the doctor's office and the doctor said - Oh, your blood sugar is really high. You must not be following my treatment plan. I'm just going to cut off all of your insulin and see how you do. We would cite that provider for malpractice. But somehow when we're talking about meeting clients where they are or patients where they are around substance use, people rise up from the woodwork and say - You're enabling them. All we're trying to do is keep people engaged in care so that we don't lose them and we take away opportunities for them to make behavior change. If we're continuing to engage with people and motivating them to come in to see us, then we can provide them with more opportunities to stabilize their lives. If you stop trying to force a particular outcome on a client and you give them room to sort out what their priorities are, you're actually teaching them how to cope with stress the way we want to see people cope with stress - which is in an adaptive, positive way. When we get patronizing with people or we prescribe for people - You must do it this way, you cannot do it that way. Well, I see a lot of people who have overdosed and passed away waiting four weeks or more to get an assessment so they can get into treatment. So I know there has to be more ways for us to reach out to people where they're already at, so that we're not just losing them forever because nobody's going to get better from something if they're not even here anymore.

So for me, what harm reduction means is - I'm using a respectful position as a professional to support people how ever they initially show up and to continually be there for them so that we can help them move through these stages of change that we know people go through when they're dealing with some behavioral health challenge. So if we allow people to come in and say - I relapsed last weekend - and they know that they can say that because we're not going to throw them out of the program for that. Then we can say - Okay, what do you think was the root cause of why you used again? And then you can sit down and say - Well, they wanted to please somebody, or it was offered to them and they weren't ready for it to be offered to them, or they haven't really broken out of this friend group that's always telling them to use it, or maybe a trauma happened to them. And then we can respond to that root cause and help them find another way to get through that if that ever happens to them again. If we had just said no to them and pulled a hard line on it, they would do no learning, we wouldn't learn as professionals, and we would lose that client. Life isn't perfect and people aren't perfect, so our programs should not demand that of them - in the same way that we don't demand it of other people who are living with conditions that we don't stigmatize like we stigmatize SUD.

So harm reduction is very easily misunderstood, but it is also the most studied public health intervention of the last 30 years, with more than 1,500 different research efforts pointed at it. And what it has continually shown is that it is better at engaging people and retaining people and getting behavior change. So if you want to get concerned about a syringe service program in a particular neighborhood, do know that people that are going to it are five times as likely to get into recovery as people who don't utilize it. So I think that there are many ways that we could have this knee-jerk reaction against harm reduction, but at the end of the day - it gets people into recovery, it helps them reduce their use, it helps them stabilize the things in their life that were very out of control, and it helps keep them safer so that they encounter fewer infections and sequelae associated with having those infections. So we're here to help reduce the traffic on first responders and hospital systems and law enforcement. And I will just always sing the praises of the harm reduction approach because I see it work every single day.

[00:20:42] Crystal Fincher: Yeah, like you, I've seen it work up close. You are certainly doing the work, have so much experience in seeing it work. But to your point, we have so much evidence. We have so much data pointing towards this being the most effective method. And it is largely because of stigma and because these deeply entrenched narratives and beliefs - largely by people who don't know many people who've been in this situation, or who hear an anecdote that is happy and was the case for one person but is not addressing what the majority of people are experiencing and what is shown is helpful. And principally, addiction is not a logical activity - people are not making inherently logical decisions. You can't just say - Well, I've decided that this person is going to be hitting rock bottom. They need to hit rock bottom in order to really get things together, and certainly the logical response to something going bad is to prevent the things that caused it from going bad and changing behavior. - And nothing about the reality of substance use disorder functions like that. And our refusal to come to grips with that from a policy perspective is playing out and seeing worse outcomes on our streets in many situations, worse outcomes in our communities - both people housed and unhoused, with great support without great support - it is just such a challenge. And I appreciate people in your position, organizations like yours, who are engaged in really trying to do that.

Now, in Washington state, we've had a bit of a roller coaster ride over the past few years when it comes to substance use disorder policy, drug policy, and how we've approached it. Which kicked off this roller coaster ride with the Blake decision by our State Supreme Court, which basically decriminalized personal possession of all substances in our state, which kicked off a reaction that said - Oh, but drugs are bad and we have an opioid crisis. So clearly we need to reinstitute these laws, crack down and reinstitute penalties, and make sure we know this is criminal behavior and we can lock people up for engaging in personal use, now use in public places. - What is your opinion of that approach?

[00:23:06] Everett Maroon: Well, the State Supreme Court was not trying to decriminalize drug possession in Washington state. It was saying that the statute as written, which was different from all 49 other states in the United States, was not constitutional. Because there was no other statute that they could turn to to say this is how law enforcement should enforce simple drug possession, we then did not have a statute on the books that was valid for detaining people around that for, I think, eight weeks. You will note that the state of Washington did not completely fall apart in those eight weeks with no drug possession statute. But it is an extremely common statute to cite people on, which is why it's costing the state millions and millions of dollars - I think seven figures, right? Eight figures. It's in the tens of millions of dollars. To re-adjudicate all of these sentences - because when you void the statute, you void all of those convictions that go back to the 1970s. So it was very commonly asserted in courts across the state of Washington - the statute around possession without intent - and so prosecutors did not want to not have something to turn to. When I talk to jailers and corrections staff, when I talk to many sheriff's deputies - the people who are actually on the ground - and many peace officers in city police departments, everybody knows that simply locking people away and arresting them and demanding accountability from them hasn't worked. If it had worked, we would not be here today. So people were really ready when the Blake decision came down, in my opinion, to do something different.

But systems don't like system change. Systems are very stubborn and they want to stay in the track that they've been in, which is why reform is so difficult. So in the response that came immediately from Blake, they opened up a bill - even though it was now out of the timeline for the legislative cycle. So they made all these exceptions for themselves so that they could run a bill through. And that was - the engrossed Senate bill 5476 came out in 2021 and stood up a temporary measure. And they said this will sunset June 30th of 2023. And of course, by then, we'll have a new statute. We would never not attend to this. So they gave themselves a two-year window. Well, in 2023, the legislature was not decided on how to respond. Should it be back to a felony? Should it remain just a misdemeanor? Maybe it should be a gross misdemeanor. Maybe we shouldn't make this gross misdemeanor have a sentence of 364 days, but we'll have it make a sentence of 180 days. Maybe that's actually worse. So there was no real throughline in the policy debate around what to do for simple possession. Meanwhile, to the south of us, Oregon had - through ballot initiative - decriminalized all drugs. There's some evidence saying that's been a good thing for them, there's some evidence saying that hasn't been a good thing for them. Oregon is less than half the population of Washington state and has a much smaller revenue base. We've got very large corporations set up in Washington state that Oregon simply doesn't have, including Amazon and Boeing and many other big players, that give us a much bigger budget than Oregon gets.

So I feel like it was maybe foreseeable that the legislative session would end without answering this question. Legislature, in the long year, ends in early May. So now they had less than two months before this statute was going to disappear. And I have heard from several people, why didn't we get there? The progressives ran out of the room and said - We can't vote for this. The GOP had decided they weren't going to vote for the bill as written because it wasn't enough about accountability, which is their new catchphrase for saying the onus is on the individual to pull themselves up by the bootstraps and not have a drug problem anymore. That left only the middle-of-the-road Democrats and they were not enough to carry the day on that vote. Well, then in the intersession between the special session that was called and the end of the regular session, there was a lot of dealmaking and communication. And what we got out of it were some of these middle-of-the-road ideas. So, in fact, it is now a gross misdemeanor with a 180-day sentence. It does still have a line into diversion programming - so instead of arrest, you can put somebody into the Recovery Navigator program that got set up by 5476. And they fixed some problems that were in the paraphernalia statute, so now it is clearly legal again to put out litmus tests to the public so they can test their substances for fentanyl and those things.

The other thing it did was clarify for municipal officials - they can regulate some pieces of harm reduction activities or harm reduction-related activities, most notably around whether organizations or agencies can hand out safer smoking kits. This is an important question because when the pandemic hit, heroin dried up because shipping stopped, which meant smuggling stopped. And the world really got heroin from one notable place - Afghanistan - and when the poppies couldn't be processed anywhere because they couldn't get transported anywhere, China showed up with synthetic fentanyl precursors that Mexican cartels were really happy to turn into fentanyl. And rather than coming all the way from Afghanistan and around to Asia and then the United States, they could just be right next door to the United States. And so they flooded the markets in the U.S. with really cheaply made, very inconsistent fentanyl products. Fentanyl is so much more potent than heroin or any organic opioid. And fentanyl has a much shorter half-life, so people who I saw as participants who were making do with shooting up heroin 3 times a day, now were using fentanyl 30 times a day, and everything fell apart for them. They could not hold a job anymore. They couldn't manage relationships with their family. They couldn't stay housed. Because it was all about that next hit to delay the withdrawal symptoms, which were much worse on fentanyl than they ever felt on heroin. So we had 933 Narcan uses to reverse overdose in 2023, and we had 301 in 2021. So within two years, we saw the crisis hit a threefold increase - that is really astounding. It's horrifying. So King County, I think, has had a 47% increase in overdose fatalities in the last year. There are other places around the state that look more like 28% or 30%. But those are still terrible increases in fatality. It's not really clear where overdose as an event that maybe doesn't lead to a fatality is because many of these events don't ever get captured by first responder systems or hospital systems. But what I see from self-reports from our participants is that it's much, much worse.

So I think it's good that the state is making these investments in diversion, but we really don't have the treatment bed capacity that the legislature is pointing people to go into. If everybody who wanted to be in treatment today could be in treatment today, there'd be enormous waiting lines. So we have to do a lot more - again, at the system level - and we have to lower the barriers to getting into treatment. So I'm really happy this year to be a part of the Bree Collective that is going to look at treatment reform for OUD. They did look at this in 2017, and this is the first time the Bree Collective has come back to look at the same issue again. But as you said earlier, so much has changed so rapidly that we need to return.

[00:32:09] Crystal Fincher: As I look at that law and what happened with that law - one, I still mourn a little bit the opportunity that was there, but these things happen with policy all over the place. One of the things initially after that decision, the first Blake fix - because there are basically two attempts to fix it through legislation - is everyone seemed to agree, whether it was Republican, Democrat, progressive, conservative, that we don't have adequate detox capacity. We don't have adequate treatment capacity. And that requires a lot of investment and people wonder where they're going to get the money from - there's not universal agreement on that - but that we are lacking there. And part of what I heard from legislators with the intention after the first shot at the fix, where they applied the sunset, and there was - You know, evidence does point to more of a public health-based approach and less of a carceral approach to substance use disorder. But we don't have the infrastructure necessary to responsibly do that, so we need a stopgap in between. So we are providing these carceral solutions to this program with the hope that we take these two years - we really do a lot on adding capacity, making needed investments, and making sure the infrastructure is there so that when we do divert someone, there is treatment there for them to go. Now, the pandemic happened in that interim, which threw a lot of things off - it's not like people simply sat there and said, We plan to do nothing from the outset, this is just a whole red herring. But it didn't happen. And then politics happened and people got afraid of being called soft on crime and soft on drug use, basically. And that motivated some fear-based legislation or provisions.

And so what we wound up with was - in the second fix - was less of a focus on diversion - they basically made that largely subject to prosecutorial discretion. Although they did, like you said, shore up paraphernalia concerns. But they did weaken the ability to reliably stand up harm reduction services and gave cities basically the latitude to say - We don't have to have these in our community - which is harmful because oftentimes, harm reduction services are where people who fall through the cracks of the other programs, people who are rejected from the other programs, people who people say - Well, they won't accept help. Well, they will from harm reduction services that are truly aligned with trying to help them as a person and meet them where they're at. So with this landscape that we have now, what has this done to you as a service provider and your ability to meet the needs of this community?

[00:34:59] Everett Maroon: Let's be clear about what allowances they gave municipalities to affect the work of harm reduction organizations. The State Supreme Court still, very clearly, in 1988 said that giving people clean syringes and the associated other medical supplies is an essential public health program. So there's really nothing that municipalities can do to end actual syringe exchange, be it on a needs-based or a one-to-one-based exchange. There's nothing unlawful about it, and there's nothing that local government can do to stop that work. Where they can come in and say - No, you can't do this - is around the safer smoking kit provision and around litmus tests, because those are the newest things that have been added. Those were clearly not what the State Supreme Court was thinking about back in 1988. So what I've seen happen are harassment campaigns that have been semi-organized, that have made people fearful of going to SSP sites. And I've seen that when public health entities are doing those harm reduction programs, that you can defund those projects. And that stops the work there. But they still don't have the availability to come in and as a county commission or a planning commission for a city council, come in and say - You can't give out syringes to people. So they can't do that.

And let's just note for a moment that the safer smoking kits - they're called things like crack pipes, which elicits this whole racist juggernaut that was put on people in the 1980s, again, because they were talked about in very racialized terms and very racist terms. Whereas people using a different form of cocaine just didn't face the same kinds of penalties and consequences. So it is a reminder to me that local government could have this effect on one kind of harm reduction activity and not another, that we're still operating through a very racist white supremacist lens here with regard to drug policy in Washington state. So for people who are thinking that they're acting agnostic to race and history of racism, I have news for you. You're not. You're still supporting those systems.

I think it's very possible for harm reduction organizations to get legal representation - maybe through entities like the ACLU, but there's certainly other people around the country who are very concerned that harm reduction be able to continue unabated to support people through this deepening overdose crisis, who can help you make arguments like - this is a protected class of patients. So very clearly, people with opioid use disorder and substance use disorder are covered by the Americans with Disabilities Act. And so local government that doesn't have a lot of money should think very carefully about how to restrict - if their goal is to restrict - these operations, because they may very quickly run afoul of the ADA. Also, and I'm not a legal advisor - I just say it as someone who's already come up against these issues - they may also very easily run afoul of the Equal Protections Clause of the United States Constitution. And that is very important for them to think about because damages related to not being in compliance with that are very high, can be very high. And so I really would recommend that people in local government volunteer or at least take a tour of these harm reduction organizations in their midst, have a better understanding of what they're trying to do, and start to ask questions with those harm reductionists about how can we align your work with, say, the work of first responders, the work of law enforcement who are engaged in diversion? How can we help align it with people who are offering treatment in our areas? I would love to see communities around Washington state put together interagency workgroups to try to help respond to the crises that are local to them. Certainly every community has different kinds of resources, different kinds of limitations, different kinds of advantages, things that they've done when working together that have produced great things for their communities. This is one of those times when we really can come together and instead of pointing at each other saying - You're not doing enough or you're doing the wrong thing - we really can say - Wait a minute, these are our kids, our spouses, our neighbors, our co-workers, and we want to show up for them. So how can we do that? And if we all work to have a better understanding of each other, I think we're going to have much better responses on the ground than in simply looking to curtail this activity.

[00:40:10] Crystal Fincher: I think sometimes we get into - we're looking at this from the outside, we're looking at the legislative session, and it is really simple to see - okay, they're entrenched in their interests, and we disagree, and therefore, they cannot be part of what a solution needs to be moving forward, or I can't work with them. Well, what I've seen - numerous examples across policy areas - of when people do sit down together and commit to listening to each other and understand that - Okay, we actually have a number of goals that align here. And how can we work together to make those happen is a really positive thing. Do you see examples of multi-agency responses working well in Washington?

[00:40:55] Everett Maroon: Yeah, we even have one here in Walla Walla, that is run through our public health organization, and it's a behavioral health mapping program. And I think it's doing well to try to help figure out what can we - again, what resources can we wrap around people not necessarily in crisis, but near crisis, who may be in crisis at some point in the near future. I think co-responder programs are doing really well in various places around the state. And I think the world of the Let Everyone Advance with Dignity or Law Enforcement Assisted Diversion programs - I run two of them. And I see prosecutors and corrections officers and population health and case managers and DSHS all showing up to say - Okay, wait, we're going to - here's all the things we know about Sally and how can we help Sally today? And when you turn around and you get a phone call from someone, they say - Hey, I'm calling you from treatment and I'm feeling great. Or they say - Here's a photo of me. I got a photo from someone who was in the woods on the west side and they're holding their kid. And thanks so much, I never thought I'd get my kid back. And they're out in the woods with the mountains behind them - that can and does happen. I would not be such a champion for harm reduction if I didn't see it working all the time to help people reclaim their lives. But sometimes it's no longer appropriate for them to just try and do it themselves and do it just with their families, that they have maybe burned or lied to and all of that. It's better for them to work with professionals and then they can return and re-engage those systems that they thought they were alienated from. But I see it all the time and I know that we can do it and we have to dig in as communities.

[00:42:37] Crystal Fincher: So we're currently in the midst of a legislative session. We have several cities and counties trying to deal with this in various ways. The state is trying to basically incrementally provide more capacity as they find and identify revenue to be able to do that. It's slower than all of us would like, certainly, but they are and have been moving towards that. What would your recommendation to legislators be this session? And what would your recommendation to local elected officials be for what can most meaningfully address this opioid crisis?

[00:43:14] Everett Maroon: I think that local governments are well-suited to looking at their regulations around housing, capacity, zoning, and helping situate things like recovery houses, transition housing, places where people can go to restart. But as long as we are trying to do treatment and therapy and wraparound care for people who are unhoused, we're just fighting - we're fighting the tide with our little sandcastle. So we have to think about what those barriers to the outcomes we want to see really are. We certainly need specific housing for women fleeing abuse. We need specific housing for single men, but also families. We need to be able to help people step back up into more traditional housing over time.

I think the state has a lot of priorities, and I appreciate that in Washington state, only a small amount of our budget is really actionable through discretionary means. There's so much that we have to spend on by statute or by ruling. And so it's a really difficult question, and I don't envy the legislators trying to tackle it. But when we try to take things little bit by little bit and we're not looking at the whole big picture, then we run into a lot of false starts and failures, and then people start to question if the approach is even right. I swear on all that's holy, the approach is right. But we can't get tens of thousands of people out of this situation very quickly if we don't have attention to housing, if we don't have treatment beds and treatment providers. If it takes three years to get the certification to be an SUDP, you are basically saying we have to wait three years for anything to change in Washington state. So we have to be thinking about workforce resources, housing, programs to help people deal with the trauma that they've picked up either on their way to using substances in a maladaptive way or after they started using them in a maladaptive way. I know people are going to say - Everett, where's the money come from? But I love this idea of health engagement hubs. But boy, the SURSAC committee asked for 10 sites and they got 2. It's just going to take us longer to figure out how to tweak that model to see how to make it work in as many places as possible. And I know also if we get people housed and we get them reengaged in the workforce and we get them back with their families, it's going to generate so much more revenue for the state. We're asking to front-load some programs so that we can get the benefits for a long time after.

[00:46:02] Crystal Fincher: Absolutely. And it is an issue of when and how you pay for it, fundamentally. Dealing with all of the symptoms of substance use disorder, all of the outcomes when you don't treat this in a way that is likely to lead to recovery. Then we see this manifesting in a wide variety of ways and making the other issues that we're dealing with from homelessness to the wealth divide to just everything that we're dealing with - education - so much harder, so much more expensive. We're placing this burden on ourselves, really. So we have to systemically look at getting ourselves out. I appreciate that.

For people in their communities who are listening and just thinking - Okay, I hear this and we need to do something. I see this problem in my community. I know this is a problem. We need to do something. And the low-hanging fruit of something in communities seems to always be - Okay, we'll pass a law, we'll toughen a penalty. What can they look to or help with or get involved with in their communities that is likely to lead to a more positive outcome?

[00:47:11] Everett Maroon: There are all kinds of things people can do based on their own ability, interest, time, and their connections. So if there's a leadership group in your town, join it. If there's a behavioral health committee through public health or city council, go to those meetings. Get a seat at the table. Pester people in your council and commissioner meetings. Ask them how they're working on it. Look at the budgets that are public budgets and ask the funders how do they evaluate the people who are providing services. There are lots of things that you can do to check in on how things are going. You can always write letters to the editor telling people about why they should themselves get involved in this work. You can volunteer at these organizations that are doing the work. And even if you just want to go be a candy striper at your local emergency department, there's a lot that you can do to help people there. Or if you're more into serving at a soup kitchen - consider that a lot of people who are living on the street don't have anybody say anything nice to them all day long. You can be that person. You can be the one who helps build a bridge back to their sense of humanity and connection to the community. So I worked in soup kitchens a lot, and I initially worked there because I had to do community service after shoplifting. So I will say that publicly - I was 22 years old and supremely stupid. But I learned so much from doing my time there. And then I continued to work at that soup kitchen for two or three years after that, because it just was so meaningful to me to be able to commune with people and help them feel okay about this one moment in their day. So I think shoplifting - the best thing I did for myself was get caught.

[00:48:56] Crystal Fincher: Absolutely. Well, thank you, Everett, for your time today, for your wisdom and knowledge. We will continue to pay attention to how things progress through session, through different cities in the state - but really appreciate your experience and perspective here.

[00:49:13] Everett Maroon: Thank you so much, Crystal. I appreciate the opportunity.

[00:49:15] Crystal Fincher: Thank you for listening to Hacks & Wonks, which is produced by Shannon Cheng. You can follow Hacks & Wonks on Twitter @HacksWonks. You can catch Hacks & Wonks on every podcast service and app - just type "Hacks and Wonks" into the search bar. Be sure to subscribe to get the full versions of our Friday week-in-review shows and our Tuesday topical show delivered to your podcast feed. If you like us, leave a review wherever you listen. You can also get a full transcript of this episode and links to the resources referenced in the show at officialhacksandwonks.com and in the podcast episode notes.

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