Illuminating InSights: Aaron Arnold

Welcome to Illuminating InSights, our blog interview series where our team speaks with programs and professionals to learn about their experience in navigating various topic areas related to healthcare training and education. In this post, our team spoke with Aaron Arnold, Executive Director of Prevention Point Pittsburgh, a non-profit organization that provides harm reduction services for people who use drugs and those with substance use disorders. This is part two of our interview with Aaron, where the conversation focuses on misconceptions surrounding substance misuse, and Aaron’s experience working with Lumis. To read part one, click here.

Substance use has been heavily stigmatized by society. We asked Aaron what type of education he thought the general public could benefit from regarding substance use and harm reduction.

Aaron Arnold: Whether it is with drugs or sex, we as a society get really nervous about the realistic strategies people can use to reduce their risks for participating. But when it comes to other social behaviors, we're so ready to say, ‘It's not your fault, here's all these other options that you can do.’ For many years I've talked about how we get asked to buy the ticket for a spaghetti dinner to fundraise for kids sports equipment or something like that. But nobody does a spaghetti dinner for needle exchange--and they should--and it should be just as normalized. I think there's this stigma around it. I've been thinking a lot during quarantine. I haven't sat down in a restaurant to eat or drink since March, and there are so many people that have. I'm trying to come up with a way to equate them, measuring their risk during a pandemic to go out and eat. Why couldn't they just abstain from eating out? Try to apply some of the crappy things that we assume about people who use drugs and the decisions they make and apply it to their [own] behavior during the pandemic. It's like, I don't understand the way that you think, in the same way that you don't understand the way that people who use drugs think. If we all just understood that human behavior is based on a very personal set of weighing risk and reward, then we could be a lot kinder to each other about the decisions that we make.

Aaron elaborated on a few other misconceptions:

I think in a lot of cases, people look at harm reduction and say things like,’Oh, well, it doesn't seem to be working because people are still dying,’ or something like that. A huge misconception is that we're able to reach a significant percentage of the people who need our services. We don't even know how many people are injecting drugs in Pittsburgh, so we can't estimate how many people, or the percentage of the population, that we're helping. Beyond that, it's our mission to help people regardless of what their situation is, and so a lot of people want to tie conditionalities to why we're helping people. [Participants] can come to us [to receive harm reduction services] as many times as they want. [Participants] can go to treatment and come back to us. That's the reality of the situation.

Even though naloxone seems to be a household term these days, when we look at the actual estimates for what naloxone saturation would look like among people who use drugs and are at risk for overdose, we're nowhere near achieving that level of saturation. People see that the state spent four million dollars on Narcan [(brand name for naloxone, the antidote for opioid overdoses)]. That sounds like a big number, but that's like ten thousand kits. We had more than that number of people overdose and die in the last couple of years, so clearly, the need is not currently covered. Just understanding that we're super under-resourced and our impact now is extremely minimal. It's very important for those individuals that come for us. We wouldn't expect to see the larger scale impact unless there's a significant investment in scaling up, making sure that we can reach the people who need our services and take away rules around where we can be located, and who can say yes or no to us operating in a given place.

On the topic of staying informed and educated, Aaron discussed undertraining, or lack of information about opioid overdoses and how to administer naloxone.

For people who use drugs, they typically know a ton about overdose. In fact, most harm reduction came from people who use drugs. Naloxone or pharmaceutical or structural intervention like that didn't necessarily come from people who use drugs; it came from scientists who were creating medicinal compounds for specific uses. But the application of it certainly changed when people who use drugs had their say about how it should be distributed and used. Most of our participants are really knowledgeable about overdose, except for one thing that always surprises me. They don't realize that even if you don't inject drugs, there's still a fairly high likelihood of experiencing an overdose. That's really the only thing that I continually see people not understand. They think, "If I snort it, there's less bioavailability, less likelihood of an overdose." In the fentanyl and fentanyl-analog era and synthetic drug era [which we are currently in], all of that just went out the window. The general public (or people who don't use drugs) are administering naloxone to somebody they anticipate as experiencing an overdose. I'd say maybe thirty five percent of those people are undertrained. That's because they got [naloxone] out of an emotional feeling of being able to help somebody and didn't actually think about this situation: How am I going to feel? How am I going to act? What are the basics for getting through this? They don't practice [administering naloxone], necessarily. They just read stuff, or if they got it from their pharmacist, they'll ask their pharmacist some questions. But almost nobody self-educates to the point that they would, had they [received] an education from a program like us. So we do see a lot of people misusing naloxone in the sense that they give way too much naloxone, way too fast.

Lumis’s collaboration with Aaron and Prevention Point Pittsburgh started during our work supported by a National Institute of Health, National Institute on Drug Abuse (NIH-NIDA) Small Business Innovation Research (SBIR) Grant. We appreciated Aaron and his colleague Alice Bell's participation as subject matter experts throughout the grant work. We asked Aaron to share a few words about his experience while working with us:

It was great. I think there was the openness for messiness, which was good because a lot of what harm reduction does is work within messiness rather than try to overly simplify things or limit options or choice. When Alice and I had our first session, it was probably frustrating to have us say, “except for this and in this situation that.” We didn't want this tool making too many assumptions so that it wouldn't actually teach people appropriately. We also wanted it to basically create a muscle memory for them so that when they are in an emergency situation, it would be something that would come back to them very easily. What we saw with Lumis - Alice and I have talked about this just randomly since - was there were some assumptions in the beginning about the way that people would learn best from the system. We made suggestions about ways that people might learn differently if they don't read as well on a screen, but they respond well to pictures, that sort of thing, like visual cues and keys. That was really interesting to see that get incorporated, going from the original text and narrative based training, to “this is what an overdose actually feels like when you come upon it,” [type of training]. These are the things that you look for, and there's multiple reinforcing stimuli that make that feel pretty realistic, in my sense.

A major goal for Lumis in this grant work is to develop learning modules for clinicians as well as lay people, or non-clinicians, to recognize and respond to drug overdoses. We welcomed Aaron’s thoughts on our goal, as his expertise is centered in this area:

Objectively, though, the kind of crazy thing is we don't have a good sense of how many overdoses never make it into the medical system, and how many are attended to by lay people. Within that, how many are attended to by lay people who don't have naloxone available. Those are huge unknowns that I think are probably larger and more common than anybody could fathom, even for those of us who work in this world and feel like we have a good sense for what goes on. I think if there was a way to capture it all, it would surpass anybody's expectations as to how much nonmedical, reverse thing is happening.

Clinicians are really attuned to looking at somebody's disposition and making a diagnostic judgment, whereas lay people, [they’re] more likely to be socially or physically close to the person that [they’re] responding to. They're the true first responders. We think of doctors, EMS, police as the true first responders. But somebody has to call the police or 911, somebody has to present in a medical facility to be seen by a doctor. Doctors don't just pop up where they're needed. So a lay person, because we have this simple technology, there's no reason for them not to learn about this and to have just as good of an understanding as a medical professional has. That got even more important with the advent of fentanyl and the analogs and other synthetic opioids, and now synthetic stimulants that we're seeing. Even though naloxone doesn't necessarily work on stimulants, it's important for people to understand that administering naloxone when you don't know what somebody is taking is a totally safe response. Seconds matter. We used to say minutes matter back when it was just heroin, but now it's seconds matter. So having lay people know the intricacies of overdose and how to intervene is extremely important, especially if you think about Clairton or Pitcairn or places like that. You can have a twenty or twenty five minute response time for most 911 calls.