Texans seeking help for substance use can call the Substance Abuse and Mental Health Services Administration’s free help line at 800-662-4357. They can also access services available in their region through the Texas Health and Human Services website.

Editor’s note: This story contains explicit language.

HOUSTON — Thirty minutes before a punk show this summer, Claudia Dambra set up a table and taped to it a tablecloth she had hand-painted with broad, white brushstrokes. The banner read, “PUNK NOT DEATH.”

As people flooded into the Houston music venue, Dambra stacked on top of the table several boxes of overdose reversal medication that she was giving away. But underneath, she quietly took stock of a different kind of inventory — clean syringes to help prevent the spread of diseases among drug users.

Dambra knows she has to be discreet about the syringes. Unlike overdose reversal medication, it’s illegal in Texas to carry or exchange drug-using supplies like used syringes and pipes, as well as fentanyl testing strips. Some of the people Dambra meets at venues are afraid to ask for the supplies in public, so she meets them in the bathroom. She tells them to save her number.

“I’m living in a world where organizations are operating very much underground,” Dambra said. “It’s very, very dangerous to be a drug user here. And the fact is, a lot of people are in dire straits right now as a result of the pandemic.”

Through her own experience with substance use disorder, Dambra has tested the effectiveness of a public health strategy known as harm reduction, which includes giving away sterile syringes to reduce the negative health outcomes of addiction. It can help prevent overdoses, minimize the spread of disease and put drug users in a better position to seek out treatment.

Research has shown harm reduction is one of the most effective tools to help people who use drugs, and advocates say such programs are needed more than ever. But state-run harm reduction programs don’t exist in Texas, and the Legislature has previously batted down efforts to decriminalize the possession and distribution of supplies for drug use and drug testing. To steer clear of criminal charges, Texans who use drugs will often avoid getting sterile supplies and reuse the pipes and needles they have.

“The criminalization and the general thought of criminalization is causing people to hurt themselves. It’s causing them to not seek help if they need it. It’s causing them to think that this is what they deserve,” Dambra said. “When you’re living your life in fear of even having a sterile syringe or sterile pipe, your quality of life is just so low.”

Advocates like Dambra aren’t waiting for changes in the law. They operate harm reduction programs across the state in the shadows, regularly giving away these supplies to drug users and risking hefty fines and incarceration.

It’s a matter of life and death, Dambra said.

Harm reduction is a science-based practice that recognizes that people are sometimes unable or unwilling to immediately abstain from drug use. It emerged in the 1980s out of the AIDS epidemic and facilitated early intervention among drug users. Rather than prevent drug use, harm reduction policies ensure people who use drugs stay alive and as healthy as possible until they are ready for treatment.

A way to help 

Dambra had been trying to get sober when she moved back to her home state of Texas from New York in the summer of 2021. But the process of recovering from substance use disorder is not always linear. In her first six months in Houston, between unpacking boxes and helping her family, Dambra used amphetamines, ketamine and synthetic opioids heavily.

Dambra didn’t know where to go for clean syringes, so she reused needles. She couldn’t test her drugs to help her determine the potency of the substances she was using. Without harm reduction tools, Dambra routinely contracted bacterial illnesses like cotton fever, which is derived from injection drug use and characterized by skin lesions, swelling and hives. She overdosed 10 times while the nation was under lockdown due to the coronavirus pandemic. She stopped caring whether she lived or died.

Dambra eventually found the Houston Harm Reduction Alliance online, a local nonprofit that helps drug users, and started routinely accessing clean syringes through them. Her health started to improve, which helped her pull out of what had seemed like a downward spiral: If she stopped getting sick, maybe she could also stop using drugs.

“Through my personal accessibility to harm reduction practices, I was able to slowly regain self worth and slowly regain manageability of my life,” said Dambra, who eventually went to two inpatient programs in the state and has been sober for eight months. “Being able to use harm reduction supplies … you are in a position to gain hope, you are in a position to imagine a better life for yourself.”

Harm reduction includes distributing sterile syringes, pipes and drug-checking tools like fentanyl testing strips and emphasizes prevention and reversal of overdoses. Clean syringes, for instance, lower the transmission of viral diseases like Hepatitis C, according to a study from the Yale University School of Medicine. Drug testing helps users identify the potency of drugs and prevent an accidental overdose.

By minimizing overdoses and the spread of infectious diseases, harm reduction can also reduce the financial burden of negative health outcomes on both drug users and health care providers. In 2017, substance use disorder cost emergency departments and inpatient settings across the country more than $13 billion.

Harm reduction programs have helped put people who use drugs on the path to treatment. Those who participate often see harm reduction advocates as their first point of contact for medical referrals when they are ready to seek treatment. Advocates may also identify people experiencing withdrawal symptoms and proactively offer treatment, said Dr. Brian Hurley, the president-elect of American Society of Addiction Medicine.

“It becomes an avenue through which … the addiction treatment sector (becomes) accessible to the community,” said Hurley, an addiction physician based in California. “When somebody indicates that they could use help with opioid withdrawal or when somebody is interested in a referral to medical services … that community-based organization has now a connection to the person who previously would have been disconnected.”

According to a Seattle and King County public health department study, syringe service program participants are five times more likely to start treatment than those who don’t.

Dambra is now trying to set up the first above-ground syringe service program in Houston that provides a consistent source of clean supplies to drug users in the area.

“They can trust that there’s at least one other person … that actually does give a shit even if it’s just in these really basic ways,” she said. “Knowing that there’s somebody who cares about your life and your quality of life gives you the opportunity to care about your own.”

And as overdose deaths in the state reached new heights during the pandemic, advocates and researchers say there has never been more of a need for access to harm reduction supplies.

An overdose crisis

On a Monday in May 2021, Cassandra Saldivar dropped off her 2-year-old son, Ace, with her mother, Patricia Hammad. That evening was supposed to be a short break from the pressures of raising a child during the pandemic.

But it was the last time Ace and Hammad would see Saldivar. Late into the night, Hammad got a call from the local hospital, where she learned Saldivar had died from an accidental overdose. A toxicology test later revealed Saldivar had taken anxiety medication laced with fentanyl, a synthetic opioid that is cheaper but far more potent than morphine.

“I didn’t know they were lacing pills until that telephone call that happened to our family,” Hammad said.

Saldivar had been experiencing anxiety about bills piling up and about finding a job during the pandemic. She had set up an appointment with a mental health counselor, but she missed it. Two weeks later, she tried to self-medicate with anti-anxiety medication that turned out to be counterfeit.

Hammad is now raising Ace. Every day, she points to pictures of Saldivar hung up around the house. “Who’s that?” she’ll ask Ace. She doesn’t want him to forget his mom, though Ace understands that Saldivar won’t come back to pick him up. If you ask, he will tell you his mommy is in the sky, sleeping.

From April 2021 to April 2022, 4,839 Texans died of a drug-related overdose, according to estimates from the U.S. Centers for Disease Control and Prevention. It’s a jump in fatalities by 63.4% over the last three years. The number of drug-related fatalities is likely far higher than reported figures because only the state’s 15 most populated counties regularly conduct toxicology tests to identify the role of drugs in any death; the other 239 counties often forgo them because of financial restraints.

In the face of mental health issues spurred by loneliness, fears and uncertainty, more Texans started or increased substance use during the COVID-19 pandemic — all while access to treatment was disrupted and the supply of drugs in the market became deadlier.

As facilities closed due to the lockdown during the pandemic, substance use treatment became harder to access, including methadone clinics and support groups. Some treatment centers across the state limited their hours or shut down altogether. It exacerbated the existing barriers to mental health care in the state: Texas ranked worst in the country in access to mental health care, according to a Mental Health Care America report based on 2019 data.

The pandemic also disrupted the landscape of drug use. Some people couldn’t get in contact with their regular drug dealers and turned to unfamiliar sources, amplifying the risks. Others started using drugs alone. Many of them couldn’t access sterile supplies or test when they were using drugs.

In addition, the drug supply has been rapidly changing, which has led to more fatal outcomes. Criminal drug networks have flooded the market with fentanyl. In the last decade, distributors and dealers have been cutting heroin, methamphetamine and prescription pills like Xanax with fentanyl to maximize profits.

As a result, people often do not know what substances they are using, which can turn into “a recipe for accidental overdose,” said Claire Zagorski, the program coordinator for the Pharmacy Addictions Research and Medicine Program at The University of Texas at Austin College of Pharmacy.

“We’re seeing this really broad proliferation of substances in the drug supply,” Zagorski said. “And every time there’s a change and a shift, that’s a learning curve.”

Hammad said she wants the state to intervene to stop the hemorrhage of loss across Texas. If Saldivar had had access to a fentanyl testing strip, it would have helped her identify the drug she overdosed on as counterfeit.

“What I wish [the state] would do is take it more seriously because there’s a lot of kids dying,” Hammad said. “Fentanyl is wiping out a generation.”

But in Texas, not everyone believes that giving away testing kits or sterile supplies is the best way to help drug users.

A skeptical state 

Despite the scientific evidence, critics believe harm reduction tools enable and encourage drug use.

U.S. Sen. Ted Cruz, R-Texas, has openly criticized harm reduction as a practice.

“You want to fight for minority communities? Get the kids off crack. Don’t give them crack pipes,” he said on his podcast, “Verdict,” earlier this year.

Research has shown that people experiencing poverty and marginalization are more vulnerable to substance use disorders and that the distribution of clean pipes is an affordable way to reduce disease transmission among drug users.

Harm reduction supporters in Texas have sought to decriminalize these tools for years and failed. During the 2021 legislative session, a bill sponsored by state Rep. Jasmine Crockett, D-Dallas, aimed to remove criminal penalties for possessing drug paraphernalia in Texas. Though the bill passed out of committee with bipartisan support, it never came up for a vote by the Texas House.

Gov. Greg Abbott has favored bolstering border security as a solution to the overdose crisis over harm reduction initiatives. Citing deadly drugs that are transported across the border, he recently directed the Department of Public Safety to step up its efforts to crack down on Mexican drug cartels. Abbott has also repeatedly blamed overdoses on the Biden administration’s border policies.

In a September letter to the heads of state agencies, Abbott said the “federal government’s unwillingness to take border security seriously” has contributed to overdose deaths. But in a rare moment, he also signaled an openness to policies beyond policing.

“The efforts of DPS are noteworthy and commendable, but law enforcement alone cannot be expected to end this crisis,” Abbott wrote, asking agencies to propose other initiatives to decrease fentanyl deaths in Texas for next year’s legislative session.

Naloxone, an overdose reversal medication, is the only harm reduction tool that Abbott has openly supported, though its supply is dwindling. The federally funded state program for naloxone has previously run out, while the price of the medication is increasing.

Advocates aren’t optimistic that the state’s approach to harm reduction will change. And as long as most harm reduction tools are illegal, they must continue to make careful calculations about what supplies to carry and where to give them away.

A risky undertaking

Kirby Jack spends Friday nights in downtown Dallas bar hopping, leaving plastic baggies they packed by hand next to bathroom sinks. Jack hopes that the kits — which contain fentanyl testing strips, sterile water, cookers used to prepare drugs and foam filters — will make their way to people who use drugs and help them stay healthy and safe.

But Jack won’t stick around to know; they have to move quickly. Carrying drug paraphernalia like fentanyl testing strips is illegal in Texas, so if police are expected to be at a venue, Jack won’t go.

Possession of drug paraphernalia — items used to consume illegal substances that can include fentanyl testing strips, used syringes and pipes and other harm reduction supplies — is codified as a Class C misdemeanor in Texas and is punishable by a maximum fine of $500. If there’s evidence of an intent to sell or distribute drug paraphernalia, a person can be charged with a Class A misdemeanor, which is punishable by up to a year in jail, a fine of up to $4,000 or both.

Law enforcement agencies across the state are inconsistent in how they crack down on possession and distribution of drug paraphernalia. Advocates say officials in rural areas tend to deliver harsher penalties compared to urban areas.

In Williamson County, paramedic Daniel Sledge said he’s seen some police officers arrest residents over drug paraphernalia, with rural areas doling out harsher punishments. Others confiscate supplies and let residents off with a warning, he said. Meanwhile, Houston district attorneys have told local organizers they are not actively trying to prosecute activities that are related to harm reduction.

Advocates say they are always teetering on a thin legal line and at risk of falling on the wrong side of an officer’s judgment. But they say the risk is a necessary one.

“If I get arrested, I’m going to chalk it up to the game,” said Jack, who is known in the Dallas area as the Santa Claus of harm reduction. “Because the people deserve these resources. Because in other states, harm reduction is built into public health programs — we deserve to have that same access. And because I love people who use drugs and I want them to be safe.”

Jack takes a risk when distributing harm reduction supplies like fentanyl testing kits because they are illegal to carry in Texas. “In other states, harm reduction is built into public health — we deserve to have that same access,” they said. Credit: Emil Lippe for The Texas Tribune

Casey Malish, the director of outreach at the Houston Harm Reduction Alliance, understands the risks he takes every time he loads alcohol wipes, syringes, sterile water, cotton balls and tourniquets in his car.

“You can’t always play by the law’s rules when it comes to saving people’s lives,” he said.

Malish compares the $500 fine for possession to an unnecessarily expensive parking ticket. However, he and the alliance do limit their harm reduction operations to avoid the more serious Class A misdemeanor charges. The Houston Harm Reduction Alliance hasn’t launched a syringe access program, Malish noted, because used syringes could serve as evidence for distribution of drug paraphernalia. His voice wavered with uncertainty as he said it — nothing is absolute in the legal gray area where harm reduction advocates operate.

The Houston Harm Reduction Alliance and other similar programs are also limited in the size of the operations they can run. As long as laws around drug paraphernalia stop harm reduction from being integrated into the public health care system, advocates are often scrambling to find funding.

The Houston Harm Reduction Alliance does not have the funds to operate full time or buy a van. Jack works full time as an organizer with the organization North Texas Rural Resilience but struggles to find the funds to import supplies from out of state and pay costly shipping fees.

And yet, the demand is high. At one distribution in downtown Dallas in August, Jack brought hundreds of safe use supplies and ran out in 20 minutes.

“They deserve better”

Advocates say the criminalization of harm reduction tools can also contribute to poorer health outcomes for drug users, who are often hesitant to seek out supplies openly.

“They’re definitely not going to risk persecution to jump through these hoops and just hope to God that a cop is not going to show up on the other end,” Dambra said. “People are hurting themselves in so many ways physically and mentally by using unsafe supplies and dirty supplies. They deserve better.”

And arrests over drug paraphernalia can disrupt treatment because medication for substance use disorders, such as methadone, is difficult to access in prisons, said Sledge, who has been a paramedic specializing in substance use disorder for more than a decade. He works with drug users who survive an overdose to connect them with treatment options, other medical services and social support.

“When an arrest happens and somebody is dependent on opioids, they go to jail and they get very, very sick in jail,” Sledge said, referring to withdrawal symptoms. “Even if that person is on methadone already, it’s extremely hard to access [that medication] in the jail.”

One study in North Carolina found that in the two weeks after their release, recently incarcerated people were about 40 times more likely to die from an overdose than the general population.

The confiscation of supplies for safe drug use can also be problematic, Sledge said, particularly for people who are experiencing withdrawal symptoms and are seeking relief. When safe use supplies are taken away, drug users will reuse or share supplies, increasing the risk of infectious diseases, he said.

When Houston resident Crystal Salinas was using drugs, she would test them as often as she could. People around her have died because they used drugs laced with fentanyl.

But this year, Salinas stopped carrying the fentanyl testing strips in her car. She was starting to get sober, and she was afraid of getting pulled over by a patrol officer.

“They say everything’s bigger in Texas,” Salinas said. “You don’t want to mess with Texas. You don’t want to mess with the Texas law.”

Salinas still keeps the testing strips at home in case other people need them. She said if pharmacies can test the makeup of prescription pills, drug users and their families should be able to get the same resources.

“Why is that resource a bad tool? People are still going to use, and that’s been hard to accept, but it is what it is,” Salinas said. “Texas is so against helping the addict. I don’t know why. I don’t know.”

This article is published as part of the Mental Health Parity Collaborative, a national partnership between The Texas Tribune and The Carter Center’s Rosalynn Carter Fellowships for Mental Health Journalism and other newsrooms throughout the U.S.

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