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This article contains the following information:

We cover the following Harm Reduction information/resources:

What is Harm Reduction?

There isn't one standard definition, but I asked Maia Szalavitz, a Harm Reduction expert who wrote the first comprehensive book on the history of Harm Reduction and drugs called Undoing Drugs , how she would define it. She said "It's policy that focuses first on stopping people from getting hurt, not stopping them from getting high or engaging in other risky behavior. Importantly, that definition doesn't exclude abstinence approaches for those who seek them." The concept of Harm Reduction has been used for years in this country.

For example:

  1. Seat belts - We know people will drive carelessly and there will always be car accidents. So, we use seat belts to reduce harm of the accidents.
  2. Condoms - We know people are going to have sex and teaching abstinence only won't prevent unwanted pregnancies and STD's. So, we have things like condoms to try to prevent pregnancies and STD's.
  3. Designated Driver - We know some people will drink when eating dinner out. So, there is the recommendation to have a designated driver who won't drink to prevent driving while intoxicated.

What is Harm Reduction In Relation to Drugs?

 National Harm Reduction Coalition explains it like this: "National Harm Reduction Coalition works for the Harm Reduction movement built on a belief in and respect for the rights of people who use drugs. Our strategies include building leadership among people who use drugs and supporting communities in reducing the negative consequences associated with drug use." So, basically it means instead of telling people to not use drugs (like Nancy Reagan's just say no movement) Harm Reduction acknowledges that people are going to use drugs, so they do what they can to keep them  safe and alive by using different strategies and techniques. In the last year, there have been over 100,000 drug related deaths in the USA, so clearly what we are doing (the war on drugs) isn't working. As Maia mentioned, if people choose abstinence like with a 12 step program, that is included in Harm Reduction. Although Harm Reduction has been accepted in USA in relation to cars or alcohol, Maia explains that "it's a very old idea, but in drug policy it is radical because we've always focused on stopping drugs, not on harm and we cause lots of harm trying to stop drugs." There are many techniques used in Harm Reduction in drug use. I'll list some examples, and then will add content about each one. As we add each category listed below, we will link each one to the information we add. This isn't an exhaustive list.

  1. Illicit Fentanyl testing strips
  2. Never Use Alone Hotline and Information
  3. Naloxone (Narcan)
  4. Kratom
  5. Lock Boxes/Safe for controlled substances
  6. Safe or safer supply
  7. Needle exchange (syringe service programs)
  8. Safe Injection Sites

What does Harm Reduction Have To Do With Pain Patients?

You might be asking how this relates to pain patients and why this information is even on our website. As more and more pain patients are cut off from their medication, many are going to the streets to purchase pain medication out of desperation for pain relief. Since up to half of the supply of medication on the street is actually counterfeit containing illicit fentanyl, we feel it's very important for pain patients to know how to access Harm Reduction techniques so they can test their medication and not die from drug poisoning. I didn't know much about Harm Reduction (HR) until last year. Several prominent CPP advocates have been trying to join the CPP community with the HR community for a few years. Lelena Peacock, Carrie Judy (a researcher with our org), and D. S. Nelson  were the first CPP advocates I saw who understood early on how HR and CPP's need to be working together and not against each other. 

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Help American Kratom Association fight to keep Kratom legal.

"A well-organized, coordinated campaign from the FDA and Big Pharma is threatening access to the supplements you depend on. Using the false premise that supplements are unsafe, the FDA is working to gain more power over the regulation of supplements in order to further solidify Big Pharma’s monopoly over medicine. These efforts must be opposed.

If this passes, the FDA would have the power to ban kratom by denying supplement registrations.

Please write to your Congressional representatives and tell them to oppose efforts to establish a "mandatory filing" for supplements."

We are not doctors and we aren't giving out medical advice. We are patient advocates who are passing along valuable information and we hope it helps you.

We've received many questions about Kratom. Many of you have been cut off of your pain medication or have been tapered to a dose that no longer helps. Kratom can be a good option for some, but we know it can be overwhelming to figure it all out. We've included information and links to help you get started in case Kratom is an option you'd like to explore.

Throughout the article, we will link to several websites about Kratom. Kratom IQ and American Kratom Association are two of the main sources we will cite. 

What Is Kratom?

  • From Kratom IQ: "Kratom is a leafy plant native to Southeast Asia, namely Indonesia, Thailand, Malaysia and Bali, that’s actually part of the coffee family. The leaves can be chewed (what Thai workers do to work long hours in the heat) but for the typical end user, the leaves are most commonly crushed and processed to form a fine powder."
  • From American Kratom Association: "Kratom is not a drug. Kratom is not an opiate. Kratom is not a synthetic substance. Naturally occurring Kratom is a safe herbal supplement that behaves as a partial mu-opioid receptor agonist and is used for paiWn management, energy, even depression and anxiety that are common among Americans. Kratom contains no opiates, but it does bind to the same receptor sites in the brain. Chocolate, coffee, and exercise hit these receptor sites in a similar fashion."

What Can Kratom Treat?

Please understand Kratom is not FDA approved, but there have been some studies done. People have claimed Kratom has helped them with the following:

  • Pain
  • Opioid Withdrawal
  • Anxiety/Depression
  • Lack of Energy
  • Insomnia

How Do I Take Kratom?

  • There are three main ways to take Kratom:
    • Steep the powder in tea-this is why you sometimes hear it referred to as "tea."
      • Watch this tutorial by Kratom IQ
      • "You boil up the powder with some water for 30 minutes or so, let it sit, then strain off the liquid. Some people feel this results in better and more consistent effects but it’s obviously more time consuming to produce. The taste isn’t too bad and you can drink it hot or cold. It’s quite nice chilled actually."
    • Take the powder straight, also called "toss and wash."
      •  Some tips on how to do this by Kratom IQ
      • The steps are pretty simple
        • Measure out power (it can be helpful to use a measuring spoon so you know exact amount of dose)
        • Put it in your mouth
        • Swallow it using something to drink.
    • Taking them in capsules

What Do The Different Strains Mean?

  • There are three main strains:
    • Red- This is usually best for pain and relaxation. It's also recommended for those going through opioid withdrawal. It can make some people sleepy. Not everyone is the same and some people actually get energy from red stains.
    • Green- This is usually best for anxiety. Some greens are relaxing and some energizing. Again everyone responds differently to different strains.
    • White- This is usually best for energy. Often people will take a little white with red when they need pain relief but need to counteract the sedating effects of a red. Not everyone is the same and some people get sleepy from whites or even anxious.
  • It is ok to mix the strains, and each strain also has many different varieties. Kratom is a lot of trial and error to find what dose and strain work for you.

What Dose Should I Start With?

This varies from person to person. It does take time to find the right strain and the right dose for your body. Don't give up after trying a few times. Keep at it, and you should be able to find a therapeutic dose for you. This dose is often referred to as the "sweet spot."

Most vendors and Kratom organizations will suggest you weigh your kratom instead of measuring it with a spoon because it's more exact. One teaspoon is approximately 2-2.5 grams of kratom. The following are the steps we suggest you take when beginning Kratom taken from Kratom IQ. Keep in mind a typical beginner dose of Kratom is anywhere from 3 grams (1 tsp) - 10 grams (about 1 tbsp):

  • Step 1: Take 2 or 3 grams (or I suggest 1/2-1tsp). You should start to feel some relief after 20 minutes or so.
  • Step 2: Assess how you feel after 30 – 45 minutes. If you think you need some more, take another 1 to 2 grams.
  • Step 3: Assess how you feel after 15 – 30 minutes. Remember you might have a bit of a higher tolerance if you've taken daily opioids.
  • Step 4: If you still don't feel relief add another 1/2 tsp.
  • Step 5: If you don't feel relief yet, wait another 4-5 hours to try again. 
  • Step 6: After 4 or 5 hours have passed and you want to take more, repeat this process with the SAME strain you used earlier in the day (starting with the dose you ended with).
  • VERY IMPORTANT to remember that just because you found your dose with one strain it doesn't mean it will be the same with all strains. Any time you start a new strain, always repeat this process.

What Happens If I Take Too Much?

  • You'll know if you take too much Kratom because you may feel nauseated or even throw up. This is why we suggest starting small and taking it in increasing small increments until you find your "sweet spot." Many pain patients start out with too large of a dose out of desperation for pain relief, they end up vomiting, and then think they're allergic to it.
  • There is also something Kratom users refer to as "the wobbles."
    • What is it?: You may feel dizzy, have brain fog, feel like you can't focus your eyes.
    • How can I avoid it?:  It's pretty easy to avoid. Don't take huge doses of kratom. Follow the instructions we've listed and you should be fine.
    • How can I treat it?:  There are varying opinions on the internet on how to treat this. Mostly, just know it's not dangerous and it will pass. Drink a lot of water and lie down if you can.

What Happens If My Dose Is Too Small?

Nothing. You'll get little to no relief. So, keep trying increasing your dose slowly until you find the right dose for you.

Where Should I Buy Kratom?

We highly suggest you don't buy Kratom at a local smoke shop, but instead use a reputable online vendor. Here are some tips on how to pick a vendor:

  • Talk to other CPP's and ask them what they use.
  • Read reviews.
  • Some vendors test their product and list what is in it. This is always a positive thing to look for.
  • American Kratom Association has the following programs:
    • GMP standard program (Good Manufacturing Practice Standards Program). 
    • Truth in labeling program. "The AKA strongly opposes unscrupulous vendors who use illegal health claims to increase sales of kratom products. This new self-regulation program will encourage consumers to report potential marketing violations so that the FDA can investigate and, when appropriate, take needed enforcement actions against kratom vendors who use impermissible health claims to mislead consumers about the actual benefits of using this otherwise safe food product. This new program is a valuable addition to the current AKA vendor GMP program that requires participating vendors to adhere to good manufacturing practices (GMPs) and to submit to an independent 3rd party audit to verify compliance."
    • Here is a list of vendors that qualify for these programs with American Kratom Association

How Does Kratom Help CPP's?

  • Pain- Kratom can help treat pain. It varies from person to person how much it actually helps, but it definitely can help some people manage their pain.
  • Opioid withdrawal - Many CPP's are being abandoned, cut off their opioid medication completely, or quickly tapered causing not only increased pain but also horrific withdrawal. Kratom can definitely help mitigate some of the symptoms of withdrawal.

Will It Help My Pain As Much As Opioids?

For some people it will and for others it won't. It's worth trying to see if you can get some relief using Kratom.

Will My Doctor Test For It At The Pain Management Clinic?

We have heard of some doctors testing for Kratom in their UDT's. Check your pain contract to see if it's listed. Depending on how much you trust your doctor, you may want to discuss it to see what their policy is on Kratom. Since Kratom is considered a supplement and isn't a controlled substance, it shouldn't be against a pain contract unless it's specifically stated. That isn't to say a doctor won't consider it a breach of contract. We've heard of that happening. 

Is Kratom Legal?

Kratom is legal in most states. There are currently 6 states where Kratom is banned, and some others with varying laws.

Other Important Information About Kratom:

  • Since Kratom interacts with receptors in the brain, it's suggested that you put about four hours between taking Kratom and prescription opioids. Some people who don't get enough prescription opioids to treat their pain use Kratom in between doses of medication. It won't be dangerous to take with opioids, but if you don't leave enough time between taking opioids and Kratom, they can cancel each other out.
  • It's important to make sure you stay hydrated by drinking extra water while taking Kratom.
  • You can build a tolerance to Kratom if you take it daily. 
  • Less seems to be more with Kratom. If your dose stops working, instead of taking more, try to cut your dose a little. For some reason this seems to work well.
  • Rotate strains so you don't develop tolerance as quickly.
  • Kratom is considered a Harm Reduction resource since it can prevent patients from purchasing medication illicitly to self-treat their pain or withdrawal.

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What is Naloxone?

From SAMHSA's website (Substance Abuse and Mental Health Services Administration):

  • Naloxone is an FDA approved medication used to rapidly reverse an opioid overdose.
  • "It is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids, such as heroin, morphine, and oxycodone"
  • It should be given to a patient who is showing the signs of an opioid overdose.
  • It can be given by 
    • intranasal spray (into the nose)
    • intramuscular (into the muscle)
    • subcutaneous (under the skin)
    • intravenous injection.

Where can I get Naloxone?

Naloxone is now over the counter and can be purchased at any drug store. 

How does it apply to CPP's?

  • Unfortunately, as many of us know, it's becoming increasingly harder to access prescription opioids for pain. While we would never encourage anyone to go to obtain their medication from someone other than their provider, we are well aware of how common that's becoming.
  • It is important to understand that someone can't use naloxone on themselves to reverse an overdose, so it's essential to teach others how to use naloxone.
  • If someone purchases opioid medication the chance of getting a counterfeit pill laced with illicit fentanyl is quite high. If you know of anyone who obtains their medication this way please give them the following information (in addition to info on naloxone):

When is Naloxone Used?

Naloxone should be used when someone is overdosing on opioids. Recognizing the signs of opioid overdose is essential to saving lives.

What are the Symptoms of an Opioid Overdose?

  • Their face is extremely pale and/or feels clammy to the touch
  • Their body goes limp
  • Their fingernails or lips have a purple or blue color
  • They start vomiting or making gurgling noises
  • They cannot be awakened or are unable to speak
  • Their breathing or heartbeat slows or stops

How Do I Use Naloxone?

 

From Harm Reduction expert Amanda Mazur:

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Why Would CPP's Want This Information?

  • I want to be clear that we at The Doctor Patient Forum do not encourage anyone to obtain pills on the street, from a friend, or from anywhere other than your pharmacy.
  • We are aware that some chronic pain patients (CPP's) who have been medically abandoned have been so desperate for pain relief that they've either gone to the street or taken a pill from a friend.
  • Since up to 42% of all pills on the street contain illicit fentanyl, we want to provide Harm Reduction information so if you are getting medication from somewhere other than your pharmacy, you know what to do to try to keep yourself safe.
  • Please understand that when you take a pill that you obtained from someone other than your pharmacy, even if you use illicit fentanyl testing strips, there is no guarantee that the medication is safe for you to take. Even if you test your medication, we highly recommend you have Naloxone available (I will be adding content on this shortly, and I will link the information here) and that you don't ever take the medication when you're alone. In case you don't have anyone who can be there with you, there is a never use alone hotline 1-800-484-3731.  

What is Illicit Fentanyl?

Illicit Fentanyl is not the same as prescription fentanyl. It is often made in labs in China and then smuggled in the the USA through Mexico. Illicit fentanyl is the leading cause of all drug-related deaths in the USA. Many who end up taking illicit fentanyl don't even realize it's in the medication or drugs they ingest. Due to this fact, we prefer to call it a poisoning instead of an overdose. Those who sell it often use pill presses so it looks identical to prescription medication. It is made to look like hydrocodone, oxycodone, Xanax, and other prescription drugs. It has also been found in other illicit substances such as heroin, meth, or cocaine. One reason drug dealers are using illicit fentanyl is due to its potency. A tiny bit goes a long way, but that is also the reason it kills so many people. The last statistic I read was that 42% of all street pills tested has illicit fentanyl in them.

What Are Some Myths About Illict Fentanyl?

  • A very common myth is that prescription grade fentanyl is what's killing so many people. This is absolutely false. Media and even addiction specialists often conflate prescription fentanyl with illicit fentanyl analogues. Illicit fentanyl, not prescription fentanyl, is what's killing so many people.
    • A recent toxicology study showed "Out of 18,393 deaths that were confirmed, probable, or suspected heroin deaths (including 2678 with morphine listed as cause of death on the DC) and 404 as probable pharmaceutical morphine deaths, among deaths with fentanyl detected, 89.3% were defined as probable or suspected IMF (illicitly manufactured) and 1.0% as probable pharmaceutical (prescription) fentanyl."
  • There is a false narrative that's widely spread in media and repeated often that just touching illicit fentanyl or being in the same room as it can cause an overdose/poisoning. You see images of police in hazmat suits. This doesn't happen. It's important to understand this fact because if you by a pill off the street and test it for illicit fentanyl, and it turns out your pill contains illicit fentanyl, merely touching the substance will not cause an overdose/poisoning.

Ryan Marino MD often addresses the myths surrounding illicit fentanyl. He has shared the following image with permission to share it:

Image

What Are Illicit Fentanyl Testing Strips?

Illicit fentanyl testing strips are part of Harm Reduction that assist in overdose prevention. They are actually FDA approved to detect fentanyl in urine, but are also increasingly being used as a Harm Reduction drug-checking strategy.

Are They Legal?

  •  Please check here To find out if they're legal in your state.

Where Can I Get Them?

  • For individual or small orders, you can get them at Dosetest. They cost about $1.00 each. 
  • For larger orders (like if you want to order in bulk for yourself or to hand out) you can get them at BTNX. For more information about how to order them in bulk, please e-mail Michael@btnx.com.They sometimes offer a discount for new customers.

How Do I Use Them?

  • One important point to note is the results are opposite from other tests like pregnancy tests.
    • One tine = positive (+) result (meaning there is illicit fentanyl present).
    • Two Lines = negative (-) result (no illicit fentanyl detected).
    • The following graphic explains how to read results:

Screenshot 31

  • Remember, a negative test result is not a guarantee that illicit fentanyl is not in your pill.

  • Most how to videos and information are geared toward PWID (people who inject drugs). We know that most CPP's who go to the streets won't inject the medication. When testing a pill that you are not intending to inject you have two options -both are explained in the following video:
    1. Dissolve the entire pill in water and test it (this is the most reliable method). Once it tests negative for illicit fentanyl, you can still swallow the liquid, or you can put it in a capsule to avoid tasting the dissolved pill.
      • Here are two websites to purchase gel caps which are specifically made for liquid such as essential oils: 
      • How to fill a gel cap with liquid according to these websites:
        • Pull apart the capsule. One side is larger than the other, allowing the smaller end to fit inside the larger one
        • Draw your liquid supplements into a medicine dropper. Place the end of the dropper over the smaller side of the gel capsule.
        • Carefully squeeze the dropper to fill the capsule. Slide the larger end on to enclose the liquid inside the capsule.
        • Store in an airtight container in a cool, dry place. 
    2. You can scrape off part of the pill as Amanda shows in the following video. Just know there is no guarantee that the composition of a counterfeit pill is uniform throughout. So, it's possible that the small sample you test will be negative for illicit fentanyl, but other parts of the pill will be positive.

  • If you bought more than one pill, testing one of the pills does not guarantee that the other pills will have the same composition.

Here is a how to video by an amazing Harm Reduction advocate, Amanda Mazur. Check out her Tik Tok videos for more information about Harm Reduction. In addition to teaching about Harm Reduction, Amanda also fights for the rights of CPP's to have access to prescription opioids.

As always, if you have any questions feel free to contact us through our contact page. 

This content was written by Bev Schechtman and Carrie Judy for The Doctor Patient Forum. Updated March 3, 2022

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What Does This Mean?

If someone is going to take a substance that wasn't obtained from a pharmacy, it is important to not be alone when the substance is ingested. Although we never encourage CPP's to obtain their medication from someone other than a doctor, we are aware it is happening. We are working on adding information about Naloxone (Narcan), which can be used to reverse an opioid overdose. We greatly encourage if anyone knows of someone who is getting medication from somewhere other than a pharmacy, please pass along this information and we also ask you to pass along our information about illicit fentanyl testing strips.

What if I Don't Have Someone Who Can Be With Me?

  • There is a Never Use Alone hotline 1-800-484-3731
  • This website says "If you are going to use by yourself, call us! You will be asked for your first name, location, and the number you are calling from. An operator will stay on the line with you while you use. If you stop responding after using, the operator will notify emergency services of an \"unresponsive person\" at your location."

Amanda Mazur, a Harm Reduction advocate and expert created these cards. Please reach out to her via email amandamazurholly@icloud.com if you'd like to have one of these cards. You can also follow her on TikTok.

Never use alone

What are Good Samaritan Laws?

According to The Network of Public Health Law: Although the majority of drug overdose/poisonings are due to (illicit) opioids, many witness are too scared to call for help due to the following reasons:

  • "People who witness an overdose are often afraid to call for help because emergency medical services responders (EMS) are often accompanied by law enforcement officers, and many aspects of the use of controlled substances in the United States remain illegal. Many individuals therefore fear that alerting EMS to an overdose might result in themselves, the person overdosing, or both being arrested or prosecuted for possession of illegal drugs, drug paraphernalia, violation of probation, or other crimes."
  • "They may also fear non-criminal consequences such as loss of housing or the involvement of child welfare authorities." 

"To encourage bystanders to summon emergency medical assistance in an overdose, most states have enacted overdose Good Samaritan legislation that provides limited immunity to individuals who do so. As of December 31, 2020, 47 states and the District of Columbia have enacted these laws, which are associated with an approximate 15% reduction in overdose deaths. Recent research suggests that overdose Good Samaritan laws that provide protection from arrest are much more effective than those that provide protection only from charge or prosecution."

What States Have Good Samaritan Laws?

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