Internet Outreach Ideas for Overdose Awareness and Prevention

You may have noticed the nifty "overdose prevention program locator" on the bottom of each page of this blog. There's also a tab for it at the top of the screen. Its creator, Maya Doe-Simkins, provides info about it, and other ideas for internet outreach, in the post below:

The South Boston Hope and Recovery Coalition has an important physical presence in the neighborhood known as “Southie”- a neighborhood that has long struggled with high rates of overdose and suicide. But because the Coalition members know that some members of the small community might not want to physically visit the Coalition offices due to fear of judgment or reproach from neighbors, the Coalition developed a website that has many different resources for people who would prefer to get information anonymously over the internet. On International Overdose Awareness Day, we added an additional function to the website: a search function for overdose education and naloxone distribution (OEND) programs in the United States. We asked all the OENDs that we know of if they wanted to be listed as a resource and now people can enter their location and get results that show the closest programs.

We realized that we needed to make sure that people who might be interested in OEND programs know about this search function so they can go get signed up, so we began to do some promotion through Facebook and Twitter and also with targeted internet outreach. The two “places” where we’ve had success with internet outreach are posting referrals in the “Comments” section of news articles about overdose or drug use/abuse and posting referrals on drug information forums where people are sharing huge amounts of drug use information. To remain on top of current news about overdose, setting up a Google Alert was useful. Daily, this is what our inbox looks like:










Then I can quickly review what is being said in the news and blogs and choose where is a good article to post a referral, like this one that was in response to the New York Times Small Fixes article about naloxone kits:










This is a good way to raise awareness among people who care about overdose, like loved ones of drug users or professionals who work with substance users.

A good way to talk with people who get their drug use information on the internet is to sign up for an account with a drug forum or a place where people can answer and respond to questions that people post. There are relatively few conversations about naloxone on these sites (though overdose is a common topic). A few examples:





















In the month that we have been doing internet outreach for a few hours a week, we have tripled the number of visitors to the hopeandrecovery.org website (not including paid traffic). We think that we are better serving the visitors, too, because the bounce rate has dropped from 66% to 37% in the month that we have been doing internet outreach. “Bounce rate” is the percent of visitors who come to a page and "bounce" (exit the site) from the same page without diving down into the rest of the site; effectively, this means it wasn’t what they were searching for in terms of content.

The South Boston Hope and Recovery Coalition can pass along a piece of code that can be pasted into any website so that the box with the search function appears on your own website. It will look similar to the image on the right and it shouldn’t take your web administrator more than a few minutes. If interested, please send an email to: info@hopeandrecovery.org.

Finally, if you operate an overdose prevention and naloxone program that isn’t listed, but you would like it to be, please send an email to: info@hopeandrecovery.org. The search function is currently showing results for US-based programs, but we are thinking of expanding to other countries - let us know if you have thoughts!

Message from Thomas Kerr on the Canadian Supreme Court decision

On Friday, September 30th the Supreme Court of Canada ordered the Canadian Health Minister to grant an immediate exemption to allow for the continued operation of Insite - Vancouver's supervised injection facility. This facility has successfully managed over 1500 overdose events, and a recent analysis showed that there had been a 35% decline in overdose deaths in the first two years after Insite opened. In the summary statement of their judgement the Supreme Court justices said the following: "The Minister’s failure to grant [an exemption] to Insite…contravened the principles of fundamental justice…Insite has been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada… Where, as here, a supervised injection site will decrease the risk of death and disease, and there is little or no evidence that it will have a negative impact on public safety, the Minister should generally grant an exemption." This decision establishes the primacy of science over ideology, and in this case ensures that people who inject drugs in Vancouver's Downtown Eastside will continue to have access to a program that has been show to reduce the morbidity and mortality associated with overdose. This is a great victory for both public health and science, and this decision should send a message to policy makers around the world that, despite the ongoing global war on drugs, ALL individuals have an inherent right to life, liberty and security of the person.

News: Canadian Supreme Court keeps Vancouver injection facility open

This is a very exciting endorsement of public health aims in drug laws. And highly relevant to this blog as Insite investigators documented an impressive and convincing association with reduced overdose fatalities.


As you'll read below, the Court not only kept the facility open, but wrote that shutting the facility down under federal drug laws would undermine those very laws.


This is a major victory for all parties - a rare moment when humanity and rationale discourse (and as a scientist I must add - rigorous investigations) have won.


http://www.cbc.ca/news/canada/british-columbia/story/2011/09/29/bc-insite-supreme-court-ruling-advancer.html




CBC News


In a unanimous decision, the court ruled that not allowing the clinic to operate under an exemption from drug laws would be a violation of the Charter of Rights and Freedoms.


The court ordered the federal minister of health to grant an immediate exemption to allow Insite to operate.


"Insite saves lives. Its benefits have been proven. There has been no discernible negative impact on the public safety and health objectives of Canada during its eight years of operation," the ruling said, written by Chief Justice Beverley McLachlin.

Cocaine, Speed, and “Overdose”: What Should We Be Doing? Part 2

By Eliza Wheeler, DOPE Project, Harm Reduction Coalition, San Francisco

This is part 2 of a series about cocaine and stimulant-related deaths and what harm reductionists can start doing about it.  We published the first part last week, which was a collection of thoughts about how to move forward to address stimulant-related deaths. This second part deals specifically with stimulants and “overdose” (not the right word, but we’ll get to that). This is a draft of a manual for speed users created as a result of a meeting with some folks from the Speed Project here in San Francisco. We are looking for suggestions on how to improve this document and welcome any feedback on this draft. We’ve included some great quotes from our discussion.

OVERAMPING!

or speed “overdose”

“When I’m talking about overamping, to me when I’m on speed, right, I’m not happy until the second or third day. I’m trying to get there…the first one is just the preliminaries, the first time you’re not there yet, you’re not in the euphoria or where you wanna be. So I got my sack, the first one I’m snorting, now I’m gonna go look for my rigs, now I take my first shot, ok, now I’m gonna go look for who we’re gonna spend time with. It’s like a whole little adventure, I’m in Alice in Wonderland and all this shit’s happening, and then when you’re into your 3^rd or 4^th day and then you take that one shot, still a lot of dope around, still a lot of people around, whatever, it’s fun, it’s casual, everything’s happening cool, and you take that one shot all of a sudden you go damn, I shouldn’t have done that, you did one too many and you just crossed the line and I’m gonna tell you how that feels. It feels like if you’ve ever had an experience with crack and you’re takin a hit and you’re taking a hit and everything’s fine, and you take that one hit all of a sudden, paranoid, everybody’s looking at you, you’re in a fishbowl, but with crystal it’s different because it lasts 12 fucking hours…and the shadow people are watching, everyone’s just on that side of the door looking at you, the cops have binoculars three stories away…”—R

News: "Drugs, Risk and the Myth of the 'Evil' Addict"

In this New York Times opinion piece, Maia Szalavitz fiercely responds to criticism of her earlier (awesome) piece on OD response with naloxone.

September 27, 2011, 6:15 pm
Drugs, Risk and the Myth of the ‘Evil’ Addict
By MAIA SZALAVITZ

My column on making Naloxone available over-the-counter to reverse overdoses drew many plaudits and two main strands of criticism. One group argued that addicts aren’t worth saving and we need to cut the drug supply; the other said that Naloxone, also known by its brand name, Narcan, is too risky to be available without a prescription.

Let me address the second argument first.

News: Article on naloxone in "Small Fixes" section of the NY Times

There has been a lot of attention to opiate overdose prevention and naloxone in the press lately! Here's the latest piece from the New York Times, which makes mention of the fact that it's not only the U.S. that distributes naloxone to drug users - lots of other countries have programs too.

http://www.nytimes.com/2011/09/27/health/27overdose.html?ref=health

Kits Using Naloxone Revive Addicts After Opiate Overdose

By JASCHA HOFFMAN

Next to car crashes, opiate overdoses are the leading cause of accidental death in the United States. In Europe, a lethal overdose occurs every hour. In poorer countries the problem is harder to measure, but in some places it is most likely even worse. When a person overdoses on opiates, his breathing becomes shallow and may eventually stop. Friends may be afraid to call an ambulance for fear of arrest. In remote areas, an ambulance may come too late, after oxygen deprivation has caused brain damage or death. Yet naloxone, a medicine that blocks opiate receptors, can revive even the most catatonic drug users. Used for decades by surgeons and paramedics, the drug has been shown to work when administered by bystanders in American cities. Recently groups in Eastern Europe and Central Asia have been distributing “overdose rescue kits,” which usually contain two doses of naloxone and two syringes. These groups may operate in a legal gray area by training addicts and their families to administer the drug themselves in the event of an overdose. Aside from saving lives, the kits give addicts a reason to return to treatment centers, where they may receive H.I.V. testing or counseling. In China, hot line operators dispatch rescue kits via motorcycle to desperate callers. In Afghanistan, an overdose rescue program relies on the same “skilled injectors” whom addicts pay to shoot them up with heroin. A shot of naloxone runs about $6 in the United States, but in most other countries the cost is below $2 and can be as little as a quarter. Global distribution of the drug as a nasal spray may make the kits even more practical.

Help Us Build a Better Resources Page

You now may notice a new tab in the upper right corner of the site, which offers up a number of resources on overdose prevention and response that we think are helpful. Right now the page includes links to a handful of organizations that are leading the fight against overdose and a selection of training materials, policy documents, and video.


It's a start, but we're missing a lot of good things. So help us build a better resources page by sending your suggestions for content to include and ways to organize the page as a comment to this post or by email to ODPreventionAlliance@gmail.com. Anything and everything is welcome, especially resources in languages other than English.

News: NIH Says Alcohol Poisoning Up in American Youth, Opioids Implicated in 20% of Hospitalizations

The U.S. National Institutes of Health has a new paper out (available here) that reports huge rises in overdose-related hospitalizations among Americans aged 18-24 between 1999-2008, including a 25% increase for alcohol overdose, a 56% increase for drug overdose, a 76% rise for combined alcohol/drug overdose, and a 122% increase in the number of hospitalizations related to prescription opioid overdose. 


Have a look at the press release here. 

News: Naloxone in NYT

For Many, a Life-Saving Drug Out of Reach

By MAIA SZALAVITZ, New York Times, 22 September 2011

An outstanding article on naloxone distribution and a story from Mark Kinzly, a longtime overdose researcher and provider, including a plea for over-the-counter naloxone.

Cocaine, Speed, and “Overdose”: What Should We Be Doing?

By Eliza Wheeler, DOPE Project, Harm Reduction Coalition, San Francisco

This is going to be a two-part post about cocaine and stimulant-related deaths and what harm reductionists can start doing about it. The first part is a rant, the second part is some harm reduction information about stimulants and “overdose” (not the right word, but we’ll get to that), created from a meeting with some folks from the Speed Project here in San Francisco.

The Rant

So, the good news is that we have over 200 places in the U.S. where someone can get naloxone and overdose prevention education, and more are popping up every day. This is a great thing, because we know that opioid-related overdoses (pharmaceuticals and heroin) make up the bulk of overdose deaths in the US. However, according to the CDC’s most recent report, there were 27,658 unintentional drug overdose deaths in the US in 2007 and the second most common drug involved in those deaths, before heroin, was cocaine. According to this report, there were about 12,000 opioid-related deaths and 1,900 heroin deaths—making up the majority. However, there were 5,000 cocaine-related deaths.  I’m sorry, but that’s 5,000 people who died (at least), and I personally think that’s a lot of people.

According to the most recent DAWN report (PDF), here in San Francisco, there were 103 cocaine-related deaths in 2008 and 65 stimulant-related deaths. There were 221 opioid-related deaths. The San Francisco Medical Examiner’s report shows the same thing—the majority of deaths are opioid-related, but following in close second is cocaine. However, cocaine is the most frequently found drug (after alcohol) in people’s system when the Medical Examiner does post-mortem toxicology.  Deaths are not the only issue, however. Stimulants like amphetamine and methamphetamine don’t contribute to a very high number of fatalities on their own, but are mentioned frequently in emergency room admissions and other types of deaths, including homicides, suicides, traumas, vehicular deaths. According to DAWN data, in 2008, cocaine was involved in 482,000 Emergency Department visits—48% of all visits involving illicit drugs. Stimulants, including amphetamines and methamphetamine, were involved in 91,939 ED visits, or 9.3 percent.

My point with the data (and believe me, I know data is flawed and incomplete and never tells the whole story) is that although opioids surely cause the majority of deaths, we have systematically ignored the fact that the second largest number of deaths is attributed to cocaine, not to mention other harms that come from cocaine and stimulant use that land people in the emergency room. By we, I mean harm reduction programs, overdose prevention projects, public health departments—you name it, we’ve done a bad job at addressing cocaine and stimulant-related death and injury.

I have many thoughts on why this is. Part of it is because it’s a more complex issue than opioid overdoses, and there’s no magic bullet like naloxone so people avoid talking about it. Also, cocaine and speed are different, and have different effects on the body, so even within the stimulant category, you need different messages. So are we lazy? Do we not care about cocaine and speed users? What’s our excuse? In my decade of harm reduction work, the most I usually hear in an overdose training is “for stimulants and coke, if they’re having a heart attack do CPR if you know how and call 911, sorry.” Is the harm reduction community (with some wonderful exceptions), shamefully heroin-centric? Is there deeply embedded racism, classism and…drugism (I made that up) effecting how much effort we put into certain aspects of harm reduction work? I think so, considering that in 2011, there are still only a handful of programs that even give out crack pipe covers, and inevitably when someone comes to the exchange tweaked on speed at least one person rolls their eyes and pretends to restock the condoms. The amount of shame and stigma still heaped onto coke and stimulant users is incredible—and I’m talking about just in the harm reduction world.

SO ANYWAY, what do we need? What do we do?

1.  First of all, we need a new word. Overdose is not the right word for what happens with cocaine or speed. Even if it was, it has too strong an association with heroin and other downers. I was talking with a group at the Speed Project in SF recently and I asked “what do you consider an overdose?” and they all said, “It’s what happens when you take too much heroin.” The word that group used to describe the uncomfortable or dangerous effects of taking speed was “overamping.” But what is it called if someone who has been smoking crack for 20 years and dies of a heart attack when they’re walking up the stairs at age 40? Is it an overdose? Not really. But there’s certainly a case to be made that a heart attack at age 40 was highly “influenced” by crack use which we know is very hard on the heart. With stimulants, the problem is not even necessarily dose-related at all. You could overamp on speed on your fourth day of a run because you are dehydrated, malnourished, haven’t slept and your body and mind are just telling you to knock it off. So long story short, like I said, overdose is the wrong word. It’s confusing and inaccurate.

2.  We need more data and research. Actually, we need better interventions and resources, but to get those, you need data and research. As Matt said in his post about “Missing Data,” we need more information on how co-morbidities or other behaviors like smoking affect risk of cocaine-related deaths. I’m curious about the speed-related deaths. What happened? I can never actually find any information on that. In the SF Medical Examiner’s report, it said that a few people died from aneurisms caused by speed. Really? I would like to know a bit more about that, thank you. I called the ME one day, and asked if all of the cocaine-related deaths were from cardiac arrest because I wondered if people also died from fatal seizures or strokes. He laughed at me and told me everyone dies from cardiac arrest. Smart ass. I guess it was a dumb question, but I didn’t know how to ask the question. This is where you researchers come in!

3.  We need to invest the same amount of effort into creating realistic messages around cocaine and speed-related harms that we did with heroin/opioid overdose. This means that drug user involvement in creating interventions for coke and speed users is an obvious necessity. We need to redefine overdose, talk to people about the amazing harm reduction strategies they already use (see part 2 of this post), and develop some real prevention strategies, not just “drink water and get some sleep.”  If we do a better job at treating co-morbidities like high blood pressure, COPD, or cardiovascular disease or offering smoking cessation, could cocaine-related heart attacks decrease?  So, is primary care the answer? Do we invest in educating physicians on how to not treat drug users like crap and to address stimulant-related harms by strengthening the rest of the body? Ah, so many questions.

So in the meantime, while you go figure all of this out, be on the lookout for part 2 of this article, which is a strategy we came up with here in SF to talk about overamping on speed. 

News: Overdose Trends in the USA: More Deaths by Overdose than Traffic Accidents?

The Los Angeles Times has a story up that looks at recent data on overdose deaths in the United States and concludes, among other things, that there are now more fatalities from overdose than form traffic accidents. The basic idea - that there are lots and lots of people dying from overdose and that prescription opioids are responsible for a lot of those deaths - is correct.


Some other aspects of the piece deserve to be read with with a few grains of salt. It's a little unclear how the Times used "preliminary data" from the U.S. Centers for Disease Control and Prevention (CDC) to come up with a purported 37% increase in overdose deaths between 2007 (the year for which CDC most recently reported, at 27,658 deaths) and 2010 (for which the Times estimates 37,485 deaths). Yes the trend has been upward, but I'm going to go out on a limb and say that the figure produced in the article sounds a little wrong.  The article also tends to lean too heavily on scary quotes from law enforcement warning of dire consequences from our "insatiable appetite" for Vicodin and so on, and misses some very interesting data showing major regional differences in overdose mortality. Still, not a terrible article and there's some important information in there.


For a more dispassionate take on recent trends in U.S. drug overdose, it's worth looking at CDC's 2010 issue briefing on "Unintentional Drug Poisoning in the United States." The whole thing is worth reading (and it's only 4 pages), but there are a couple nuggets that strike me as especially interesting. 


One is that while prescription drugs (largely opioids and benzodiazepines, but also other medications used in psychiatry) are now involved in about half of deaths, among illegal drugs cocaine was involved in more than twice as many deaths as heroin, and cocaine deaths have trended upward for the last 10 years. So where's the media attention to cocaine? More importantly, where are good cocaine overdose prevention programs?  Stay tuned, because we'll be looking more into that issue in an upcoming two-part series from the Harm Reduction Coalition's Eliza Wheeler, who runs the DOPE Project in San Francisco. 


Second, there's wide variation among the states. Part of that is due to some big differences in prescribing, but one of the most interesting things is where we see the lowest overdose mortality. For example, in New York and California we see about half the death rate of the states with the highest rates. These also happen to be places that have invested in harm reduction programming, including overdose prevention programs and drug treatment with methadone and buprenorphine. Coincidence? It's probably related to a lot of things, but there sure are a lot of these kinds of coincidences around overdose prevention. 

Embarking on a Cost Analysis of Opioid Overdose Morbidity and Mortality in the U.S.

By Leo Beletsky and Andrea Sorensen

Much attention has been devoted in recent years to the alarming increase in morbidity and mortality related to opioid overdose.  Between 2004 and 2007 there was a nearly fourfold increase in the use of prescription opioids in the US, and in at least five states this is now the leading cause of unintentional injury death.[1]  Data such as the number of emergency room visits and deaths attributable to opioid overdose have raised awareness among states and the federal government that there is much work needed in preventing and addressing this epidemic.

A growing body of research and reports addressing this issue have focused on, for example, the severity of this problem in particular states, the trends of a particular opiate such as methadone[2], or the societal cost of drug addiction more broadly.  Lacking from this literature is an assessment of the overall costs that result from the increased overdose morbidity and mortality.  Thus, we intend to perform a cost-of-illness analysis by assessing the costs associated with emergency room visits, lost productivity due to hospitalization, and costs to society resulting from premature deaths.  Data permitting, we will focus on the annual cost in 2008—the most recent year for which healthcare cost data are available. 

We are currently working to collect data and information from a wide variety of sources in order to provide a national cost estimate and range.  Our costs will include healthcare costs/medical expenses; the economic impact from days of work lost due to hospitalization; and the costs associated with lives lost and premature death.  Thus, we will take into account both direct (medical) and indirect (lost productivity and lost lives) to estimate this annual cost burden.

We are relying on DAWN statistics for Emergency room visit data, which provides a breakdown of the annual number of ER visits attributable to opioid/opiate abuse.  DAWN also provides data for the cost of an average hospital stay for accidental poisoning and substance abuse stays, as well as the average length of stay by condition.  This will allow us to calculate the cost per episode that we can use to determine the entire direct health care cost component.  The average length of hospital stay data will also be used to determine lost productivity due to hospitalization.

Prevalence of premature death will be determined using the National Vital Statistics System data.  We will calculate the premature death costs based on previously established methods used in similar cost analysis research:  we will rely on the value of statistical life (VSL) determined by Aldy and Viscusi (2003)—a value that has been used widely in other similar cost studies.  In addition, we will calculate projected lost earnings based on the number of deaths attributable to opioid overdose in each age group, using life expectancy data and estimated earnings data (for each age group).  International Classification of Diseases (ICD) 10th Revision, T-40.0—T40.6 are of interest for this analysis. The overall category ICD -10 T40 includes Poisoning by narcotics and psychodysleptics (hallucinogens).  We have yet to locate this mortality data.  While there are many summary reports published by the CDC, finding specific breakdowns of mortality causes has proven challenging to pinpoint.  It looks as though the Healthcare Cost and Utilization Project (HCUP) offers databases available for purchase that might contain this information (http://www.hcup-us.ahrq.gov/tech_assist/centdist.jsp).  

Questions that have emerged during our initial stage of gathering data and defining costs include selecting proper ICD categories and determining the accuracy of deaths attributable to prescription opioid overdose, as earlier research has found that death certificates might fail to specify this as the reason of death, thus underestimating the actual number.[3]

Our goal is for this cost analysis to inform policymaking and funding decisions.  Our findings can help state and Federal government agencies and other funders quantify the costs of opioid overdose morbidity and loss of life.  Cost estimation is important for setting priorities in prevention programming, surveillance, and research particularly at a time of particularly scarce public health resources. Quantifying this piece can also provide an important component in future benefit-cost preventative treatment studies. 

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[1] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5842a1.htm

[2] http://www.cdc.gov/nchs/data/hestat/poisoning/poisoning.htm

[3] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5842a1.htm

Pubmed September 2011 Update

Three notable papers this week

Characteristics of drug users who witness many overdoses: Implications for overdose prevention.

Bohnert AS, Tracy M, Galea S. Drug Alcohol Depend. 2011 Aug 10.

Comment: Another analysis from a non-fatal overdose survey in Harlem and the South Bronx. There have been some concerning results in terms of witness management of overdose from this study. We know that those who have overdosed are at higher risk of overdose and from a 2005 analysis also know that they are less likely to contact emergency medical services when they witness an overdose. Now we know that these findings apply to those who witness multiple overdoses as well (they appear to be almost the same population). Authors propose that prior negative experiences with medical service might dissuade contact at future overdoses, although perhaps successful prior lay resuscitation efforts also discourage calling for help.

Drug-Related Death Following Release from Prison: A Brief Review of the Literature with Recommendations for Practice.

Leach D, Oliver P. Curr Drug Abuse Rev. 2011 Aug 12. [Epub ahead of print]

Comment: I don’t have access to the full article and hope that naloxone distribution is discussed as one of the options.

Mortality among Substance-using Mothers in California: A 10-year Prospective Study.

Hser Y, Kagihara J, Huang D, Evans E, Messina N. Addiction. 2011 Aug 10

Comment: Mortality among pregnant or parenting women seeking substance abuse treatment (including heroin, cocaine, alcohol, marijuana, and methamphetamine) over ten years was 8.4x higher than the general population, the largest portion of which was from overdose (29%). The authors do not breakdown overdose by primary drug problem (i.e. can’t tell if most of the overdoses were among heroin users or if they were more evenly distributed).

Missing Data

By Matt Curtis

Looking back to the situation five or ten years ago, we’ve made major progress in building an evidence base around overdose, both in terms of the prevalence of overdose in different kinds of drug using communities and the efficacy of prevention and response programs. More research is happening now than ever before, at a bigger scale and in more places.

A random graph not actually associated with this article

As with any new area that epidemiology sticks its nose into the first wave of research is often all about counting: how big is the problem, what kind of people is it affecting, where and in what way? Although there’s work to be done still on these kinds of most basic questions, we have a pretty good idea of the scale of the overdose problem in many parts of the world and enough solid information to take action at a public health level without fearing we may be wildly off base. (Some people would disagree with that statement, which may deserve a fuller discussion on OPA; for now I’ll only note that doubters of overdose prevention programming are nowadays mostly confined to the wing of public health usually referred to as “Wrong.”)

So what should come next? Here, thinking out loud, are eight areas that I think researchers could fruitfully investigate:

(1) Smoking and cardiovascular and lung disease: How much is tobacco smoking-related cardiovascular disease related to cocaine (and other stimulant) overdose?  Similarly, how much is smoking, COPD, chronic bronchitis and other chronic lung disease related to opioid overdose?  My gut tells me the answer in both cases is ‘probably a lot, especially in combination with other health problems,’ but there’s very little published information on these subjects. And I don’t know a single harm reduction organization that has a serious tobacco harm reduction or smoking cessation program (though that may be just because I need to get out more). Are we failing people on this because everyone’s just thinking that smoking is pretty punk rock and part of the scene and all I need is nic-fitting crack users running around my drop-in center?