Iowa Harm Reduction Coalition

Iowa Harm Reduction Coalition (IHRC) is a community-based and -led harm reduction organization active across the state of Iowa. Its mission is to advance health equity and improve health outcomes for PWUD through advocacy, education, and low-threshold services. IHRC, which at the time of the project had its primary office in Cedar Rapids, sought to use the project to establish a fixed-site location in Des Moines to anchor their existing mobile services. Without dedicated funding or sufficient staff capacity, IHRC’s presence in Des Moines had consisted primarily of health education and supply distribution. A major obstacle to program growth and participant engagement is that SSPs were, and, at the time of writing, still are, not legal in Iowa. In addition to the typical advantages of a fixed-site location—drop-in space, opportunities for co-located programming—the Des Moines office would also, critically, provide services out of public view, reducing the risk of law enforcement interference and enabling deeper relationships with participants. Though IHRC went into the project with thoughtful preparation, clear goals, and a highly skilled patient navigator, structural barriers hampered many of their efforts and illustrated the precarity in which many community-led SSPs, and the people they serve, survive.

There are limited services for PWUD in many parts of the state and SSPs, IHRC included, are often reluctant to make referrals to unfamiliar programs or providers that have negative reputations. One of the project’s key successes was the development of relationships and referral networks with medical and social service providers and programs in Des Moines, particularly for MOUD treatment. Patient navigation included connections to long-term mental health care (299 participants) and MOUD (83 participants) with providers engaged through the PN project. Before developing these relationships, buprenorphine access often required a four-hour-round-trip drive to the University of Iowa Health Care (UIHC) hospital system in Iowa City for supervised induction and check-ins. When the COVID-19 pandemic disrupted services, IHRC worked with the UIHC clinic to adopt revised SAMHSA guidelines allowing telehealth prescribing—a significant advancement in IHRC’s ability to facilitate MOUD that drastically increased the number of participants interested in pursuing treatment. Instead of arranging and making a four-hour drive, the navigator could meet someone on the side of the road and, using just her cellphone, help them receive a prescription later that same day. This access was, unfortunately, short-lived: when UIHC began reopening, the navigator was informed that providers had been told to prioritize in-person appointments over telehealth to maximize insurance reimbursement to the hospital, and that buprenorphine would no longer be offered via telehealth. MOUD navigation stalled until the patient navigator was able to connect with clinics around Des Moines, and coverage parity emerged as an important consideration for telehealth-based services as jurisdictions evaluated the adoption of COVID-era MOUD policies.

In addition to the difficulties faced by all PN sites—COVID and related control measures, negative experiences with local law enforcement, inadequate access to safe and stable housing—IHRC deals with several challenges as an underground program. Not only do staff and participants risk legal consequences from distributing supplies, the lack of public support for harm reduction affects their credibility with other service providers and within healthcare systems. Their legal status also limits eligibility for some funding sources. IHRC experienced organizational turnover and staff attrition during the pandemic, and with it the loss of institutional knowledge and capacity. IHRC also experienced the recurring loss of organizational partners and champions due to fatal overdose. The navigator was often solely responsible for patient navigation project implementation and monitoring, and general SSP operations, including financial oversight and staff management. She also directed programming to respond to the COVID pandemic, including the transition to curbside pick-up and mail-based supply distribution. Following the adoption of social distancing measures, the navigator reported that public busses were refusing to pick up passengers without specific destinations—riding the bus was no longer a way to get out of bad weather, and people who did not want to disclose that they were traveling to the SSP or an MOUD appointment might be denied a trip. In response, the patient navigator used their own car to transport people, following CDC guidance to the best of their ability to reduce the risk of COVID transmission.

During the project period, IHRC shared information about patient navigation with 1,107 people. Outreach about patient navigation provided a layer of legal protection for the navigator and program participant and was often used as a conversation starter to engage new participants. Navigation encounters are represented in the table below.

Iowa Harm Reduction Coalition Patient Navigation Encounters (March 2020 – February 2022)

Despite the challenges presented by COVID, there were also new opportunities for collaboration borne out of efforts to creatively respond to emerging community needs. IHRC partnered with Des Moines Rent Relief and, using the pandemic-era eviction moratorium, was able to help a family stay in their apartment. As a result, a mother was able to maintain custody of her children and continue her MOUD treatment. Through the patient navigator’s participation in local organizing and demonstrations during 2020, IHRC developed and maintained a good working relationship with mutual aid groups active in Des Moines; with support from community donations, IHRC helped supply an encampment community with twelve propane tanks to provide heat during the winter. They also distributed hay bales to create insulated barriers at the encampment and recommended this strategy to other patient navigation sites. Following the termination of the UIHC telehealth program, IHRC was able to collaborate with a Des Moines-area hospital to again offer telehealth appointments for buprenorphine induction and maintenance.

IHRC’s work during the patient navigation project and the pandemic exemplified the value and impact of skilled and resilient SSP staff for the people and communities they serve. This work was centered on a deep commitment to participants and a first-hand understanding of the barriers they face in taking care of themselves and their loved ones. The successes of these programs and interventions hinge almost entirely on the people tasked with extending these services into priority communities; there is no substitute for the experience, perspective, and love people like IHRC’s patient navigator bring to their roles. One goal following the project is to continue expanding and refining their understanding of the pharmacology and best practices of MOUD and effective models for recovery support, to better advocate for communities served. Capacity to expand IHRC’s presence will require more reliable access to resources and support, and especially funding that adds value to existing efforts without creating unnecessary work.