What I’ve Come to Understand in the Three Years Since I Lost a Dear Friend to Fatal Overdose

This September marked three years since I lost one of my closest friends to the fentanyl crisis. I think it’s taken me this long to write about it because for the first two years, I was still just trying to figure out what happened. One day I was getting ready to be in her wedding, and what felt like the next I was reading the Prayers of the Faithful at her funeral. Now — after a lot of reflection on the events that led up to that moment — I have identified some things that need to change so we can all do a better job supporting people who are struggling with their substance use.

First, however, I want to tell you a little bit about Jesse.*

I met Jesse when I worked in a harm-reduction-oriented treatment navigation program that primarily served unsheltered people who use drugs. Jesse eventually moved on from her case management role there to become a public health advocate at the syringe service program (SSP), where she really flourished and seemed to have found her calling.

Our programs were attached by a kitchen, and frequently shared assets. For example, my program handed out naloxone and syringes when the SSP was closed, while they helped us link people to services we didn’t offer such as testing, low-barrier medication for opioid use disorder (MOUD), and other health care services.

Among her other contributions, Jesse became a champion for women who used drugs and traded sex for resources. She started the program’s first women’s only drop-in, where people could not only get services but also engage in therapeutic activities that supported their self-esteem, like making art or getting their nails painted. I watched Jesse paint nails week after week, creating a sense of belonging and safety for a group of women who experienced significant and repeated trauma. Jesse also reinvigorated the program's “bad date sheet,” a mutual aid tool for women to report or seek information about predatory behavior in their community. She believed in the strength of these women and in their ability to keep each other safe when reporting such instances to law enforcement wasn't enough.

When Jesse experienced a return to use, she immediately reached out to her friends in the harm reduction space, fearing that her friends in recovery would judge her harshly. They didn’t, though. Without hesitation her inner circle of women came together. We took her to the hospital, found aftercare, helped her negotiate a leave of absence, and even sought out new, less stressful career opportunities for her. One or more of us talked to her every day, from the day we took her to the emergency room to the night before she died, and then supported each other through our loss.

So many people and resources came together around Jesse — who had the added advantage of insight and understanding about her own risk — that some might wonder how it wasn’t enough. From this question, some might even go on to reason that there was simply no way to prevent Jesse’s death, or those of thousands of others who have lost their lives in the same way. But this conclusion would be a mistake. Unfortunately, there are many glaring ways in which our country’s approach to addiction falls short – but each of these gaps also offers an opening for hope that we can do better. Here are some ways that our systems of care can transform longstanding customs and attitudes to more fully support people with substance use disorders, and in turn minimize the loss of life.

Stop the Shame, Stop the Stigma

Ultimately, Jesse died alone — and make no mistake, that was by design. On more than one occasion she had expressed the deep shame she felt for having started to use drugs again. When we brought her to the emergency room, it was because that shame was making her want to end her life. This person who had helped hundreds of people thought that because she used drugs, she didn’t deserve to be alive.

She was not unique in that feeling or experience. In the 15 years of my career, I have listened to countless people in my office question whether they should be alive because they returned to use. Yet returns to use happen to virtually everyone who chooses abstinence as their recovery pathway. Among addiction care professionals, relapses are widely accepted as a normal part of the recovery process. However, outside of the field — and unfortunately, sometimes even within it — such events are framed as failures. We catastrophize, rather than normalize. We withdraw support. The reason people so often die thinking they have failed is that this message has been communicated to them in many ways. Resources like Never Use Alone, SafeSpot, and Brave are necessary precisely because shame drives people to use in isolation — where they are most vulnerable to fatality from overdose.

To stop the shaming, we can educate the public about the normalcy of returns to use; we can embrace people who are struggling, ask them what they need, and then listen; and we can initiate conversations with loved ones who are abstinent about how we can help them stay safe should they use again. Lastly, we can call out stigmatizing narratives, and share information that debunks them. Ending the stigma associated with addiction is probably the biggest challenge we face, but I believe it is the most important; the rest of the steps in this list will not truly be achievable if we don’t get this one right. I encourage you to share widely the life-saving resources linked above.

Support Direct Care Addiction Staff

Jesse’s job was by no means the sole reason she struggled, but addiction service organizations should do everything they can to support the wellness of their frontline staff — who regularly experience direct (not just vicarious) trauma in the course of their work. In the programs where Jesse and I worked, I watched several staff in recovery return to use, and saw other coworkers develop substance use challenges who did not come in with them. Many of us (myself included) had to take leaves of absence or even pursue other employment because our mental health had deteriorated. People who do this work love this work and experience immense guilt when thinking about stepping away even to care for themselves. It is already so hard to ask for help; we need to make sure the right resources are available when someone is ready to take that step.

There are many improvements that service-providing organizations can make — starting with paying a living wage. The stress of having to hold multiple jobs or falling behind on bills, on top of the pressures experienced at work, is unmanageable. Frontline SUD staff are doing lifesaving (literally! Reversing overdoses!) work every day, and should be compensated at a rate consistent with the importance and difficulty of their role.

Another important step is to take a closer look at our mental health first aid or responder programs that provide trauma support to direct care staff after a loss or crisis; are often staffed by outside employees far removed from the environment of direct service provision. For this reason, staff members who are struggling often lean on their teams rather than using the responder programs. To increase utilization of these resources, ensure that the person responding is a peer or has done frontline work in the not-too-distant past. Peer-led organizations such as the Massachusetts based SADOD.org can be an effective resource.

Lastly, make sure that after traumatic events staff are able to process their experience and care for themselves. Supervisors should always lead a debriefing session after such incidents, and should provide support by offering extra breaks, accommodating time for therapy during work hours, or giving staff periods of time away from work altogether. Yes, such practices are challenging for understaffed organizations, but there are potential solutions. For example, leaders can fill in so staff can take time away, or the program (in some cases) can close for a day for a retreat or admin day. A healthy staff and workplace are worth the challenge of overcoming obstacles.

Bring the Field Together

From Jesse’s life, her work, and our work together, I have gained insight into the ways our field is fragmented and fighting right now, with harm reduction and recovery staff sometimes seeming to be at an impasse. Together, we must reckon with past harms and have some difficult conversations. Not too long ago, some loud voices in the recovery space devalued harm reduction; one pathway to recovery was seen as the sole solution, while others were criticized. Such responses hurt many people, contributed to the stigma and shame they experienced.

But, from my experience working with a large number of communities, I can report that this attitude is changing. I have heard more talk about valuing all pathways, including those that do not center on abstinence, than I ever used to encounter. I believe that if we can have those hard conversations and value each other’s approaches, we will be stronger and more effective in supporting the people we all care about.

Working with Jesse solidified my belief that this endeavor is possible and worthwhile. While the program I worked in was deeply rooted in harm reduction, it was nevertheless true that people generally walked through our door because they wanted to reduce or end their use of one or more substances (though many other folks just came to get support). Our two programs — one focused on treatment, the other on harm reduction — worked with the same people in different ways. When someone left treatment or didn’t want to pursue it, I could introduce them to Jesse and services that kept them safe and well while they were still using drugs. When someone did want to enter treatment, Jesse could bring them through that kitchen to my door for access that was as close to on-demand as you could get. The value of working together in our different roles was clear, and offers a glimpse of what comprehensive care could look like if the whole field made the same commitment.

Listen to People who Use Drugs

Lastly, whenever we design programs and interventions, we need to listen to the people these projects are intended to serve — or we risk making serious missteps. For example, when she was in the hospital, Jesse had to undergo an assessment to determine next steps. She was asked, while in crisis, about traumatic events from her past. This information was not actually necessary to determine whether she was experiencing suicidal ideation, but the physician became a little flustered when Jesse showed justifiable anger and declined to answer.

The health care provider in this incident was doing what he was trained to do and used an approach that is overwhelmingly common in hospital emergency departments, but that is neither trauma-informed nor person-centered. The process was very obviously designed without feedback from the people it was intended to help; in fact, what it ends up doing is retraumatizing the person in crisis and deterring them from seeking help in such settings the next time they need it. The way to avoid this problem is to involve people who use drugs in the conceptualization, design, and implementation of the systems, services, and interventions that affect them (and to pay them for their expertise). I have been encouraged to see this practice growing throughout the country, though more progress is needed on meaningfully integrating the feedback we receive. Much of this information challenges our old ways of thinking — but since those ways are what got us to where we are, the challenge is a good thing.

*Name changed to protect privacy