The Behavioral Corner 
Hi, and welcome. I'm Steve Martorano. And this is the Behavioral Corner, you're invited to hang with us, as we've discussed the ways we live today, the choices we make, the things we do, and how they affect our health and wellbeing. So you're on the corner, the Behavioral Corner, please hang around a while. 

Steve Martorano 
Not that we needed any more bad news about the coronavirus epidemic. But one of the tragic consequences of this worldwide phenomenon that still is ravaging our country is that it sort of swept away the notion that we had an epidemic going on before the virus arrived, and that was the epidemic of substance abuse and overdoses, just as the public was starting to get their head around the size of that problem, and its enormous -- along comes COVID-19 and obviously our attention is diverted. Well, as you can imagine, it hasn't helped the situation of people in dire need of substance abuse. And so we're going to take a look at that, again, it's an important issue because thousands of people are dying, still dying from substance overdose. So we're grateful to have with us a group that we're familiar with in our area here in the Philadelphia, Pennsylvania area, a group called Prevention Point and what they're about is providing services for people who are struggling with addiction. To that end, we welcome to the program here on the corner. Clayton Ruley. Clayton is a social worker, longtime activist, and he is the Director of Community Engagement and volunteer services for as I said, Prevention Point, Clayton, thanks for hanging with us on the corner.

Clayton Ruley 
Thank you very much for having me. Really appreciate it.

Steve Martorano 
Yeah, Clayton. Did I get that right? I mean, just around the time that you know, as a society, we recognize the size of the substance abuse problem and the deaths associated, the virus comes along and sort of, understandably, I guess, pushes it out of the mainstream consciousness, things have not gotten better in your area, I'm certain. I know that you're, we're going to get into a very specific list of the kind of services and the people that you provide them to. But let's begin at the beginning. A lot of people don't understand groups like yours that are dedicated to simply harm prevention. I think they confuse that with a couple of things. So let's begin there. What do you mean when you talk about harm reduction?

Unknown Speaker 
Thanks. harm reduction has many definitions, but one that I use mainly is a set of practical public health strategies -- designed to reduce the negative consequences of risky behaviors. And it's a set of practices that are typically aligned with drug use and sex work, but in general, is part of a risk reduction continuum and can be used and I think should be used by more people, especially those who don't have access to everything and those who aren't living, what many would deem a perfect lifestyle. So, harm reduction is basically understanding that for a host of people a "just say no policy" abstinence-only policy isn't going to work or it has not worked. And that doesn't mean that there are things that they can't do to be safer in their practices and providing those materials resources and supports to make sure that we're doing that not only for the benefit of the individual, or the groups of people that we work with but big picture for the benefit of all of us because we're all affected by, you know, what each other does. 

Steve Martorano 
Let's talk about the community of people you serve, who we talking about. 

Clayton Ruley 
So, typically are, you know, the primary target is people who are using drugs injecting drugs, people who are engaging in sex work, and then I would say, people living in poverty.

Steve Martorano 
Right. So that group that you approach or approach you for your services, correct me if I'm wrong, very often we are caught up in this notion of, well, that person needs immediately to stop doing what they're doing, get treatment, get into a program, whatever is necessary, so that they can come out the other side sober and maintain that sobriety. The step you're talking about, if I understand harm reduction, and you use the word, "greater safety in their practices," is not facilitating that behavior, but making sure that while that behavior is going on, people aren't dying. Is that is that a way to look at this?

Clayton Ruley 
I think that's a great way to look at it. It's keeping people safe at the very baseline of our services, and what we're able to provide for people through the host of services that we have. Allowing folks to have that moment where if they want to have that moment where they can go and you know, get into a program to be abstinent or be sober or to reduce the number of substances or activities that they're doing in a way that it feels right to them. We're big proponents of folks having a motivational moment because when it's on someone else's motivation, the chances that it's going to be a sustained time is you know, very few.

Steve Martorano 
Yeah, if it's on somebody else's timeframe or schedule, it may not match up with the person who needs the help. So coming together and I guess the expression is getting to somebody where they are in the moment is where you begin, you know, begin where the where your manual tells you to begin. It's very misunderstood, Clayton, as I'm sure you're aware, because some people hear that as, "Well, what do you mean? You mean, you, you, you help them get high." You make sure they don't die while doing that. It's way more than that, isn't it?

Clayton Ruley 
Definitely is I mean, I think you, you know, said it best we say meeting people where they are, we deal with people who are, you know, totally absent from using drugs or doing other risky behaviors. We deal with people on the other side of the spectrum who are, you know, have no thoughts of stopping doing their risky behaviors that we're doing, and we have a lot of people in between. And we know that every interaction we have, and every individual that we deal with, is going to be unique in their circumstances, or being unique in their motivation is going to be unique. And no, as I said earlier, it's really about, you know, at the baseline, you know, making sure they have the materials that they need to do whatever they're doing currently as safe as possible. They have the education, they know that they can come in and receive services, keeping the door open always for folks. You know, be safe at what they're doing. And then I think as people request more, and they have the motivation to want more the services can escalate here at Prevention Point. 

Steve Martorano 
Now, that's an important point that we will, that we will get to in a second. It's critically important to, as you say, get them where they are at the moment. Because I think the number now is 70,000 people a year in this country died from substance abuse overdoses. Is that the number?

Clayton Ruley 
Yes, that's, you know, fairly accurate. I know in Philadelphia, we've had the last two or three years, over 3,000 overdose deaths in the city, you know, from 2000, and, you know, 19, a fiscal year down to 2017. So, you know, you don't have to go national to acknowledge that. overdose deaths have hit Philadelphia really hard, especially opioid overdose deaths and something needs to be done to help prevent that. And folks need to always be prepared as best as possible, which is why one of our major programs is our overdose prevention program.

Steve Martorano 
Yeah, I want to talk about all the services you provide in that area. But it's interesting, that number of 70,000 deaths, we used to talk about the slaughter on our nation's highways that we used to be a pretty standard trope that you'd hear the media talk about, particularly during holiday weekends. 70,000 people a year, nationally dying from substance abuse overdoses exceeds the number of automobile fatalities already so we're familiar with losing a lot of people. Isn't it true Clayton, that at the simplest, on the simplest basis, so people understand what harm reduction is all about is people are never going to get sober and lead productive lives. If they're dead.

Clayton Ruley 
Yes. I mean, you know, to answer your question, yeah, absolutely. If you're someone that is, you know, highly charged you see everyone in recovery or everyone abstinent, and abstinence-only is the only thing you think is a success. Well, people can't ever get there if they die due to overdose. Yeah. And the chances that they will likely want to, you know, "come out on the other side" with quotation marks when they have a life-changing or life-threatening disease also makes it a lot tougher to accomplish that. So the safer you can keep people, the more you can keep them engaged with social services and medical services and other services. We provide Prevention Point, the better chance that folks can have that moment to make the change.

Steve Martorano 
How did you get involved in this claim? What's your background?

Clayton Ruley 
I come from a family of social workers, mainly working with children and families actually. I started that Prevention Point in 2008 as an intern, while I was in grad school, and basically 12 years later, I've never been here through a variety of positions and a lot smaller structure of the organization and, you know, organization that was at the threat of closing, but we fought through it with, with great leadership. And fortunately, because we do a great job, but also, unfortunately, because we still have a, you know, major epidemic on our hands, and our services and our organization is needed in the community.

Steve Martorano 
Yeah. Let's talk about the duties of the Director of Community Engagement. I think we understand what volunteer services might involve. That's what your purview is the Director of Community Engagement. And, if I'm not mistaken, there's more than one community that you and prevention point have to engage with. There's the larger community, the people who may, you know, are, are impacted by substance abuse, but maybe you're not active, active users. And then there are active users. In terms of engagement, tell us about dealing with those two different constituencies. How does Prevention Point, engage the larger community who might often go, "Wait a minute? I don't want people like that here in my neighborhood."

Clayton Ruley 
Well, you know, I think it's a work in progress. I mean, Prevention Point for many years didn't have the infrastructure, nor the funding to have a communications department or a community engagement department. So, I think that shows the growth of our organization and the pressing need to make sure that not only our internal community has connections, but also the external community to the work that we're doing. So, it's definitely a negotiation between all sides, you know, working to meet with stakeholders in the local communities in which we serve. It's working with, you know, people that actively use our services. It's working with people in the city on the state and on the federal level, basically being a middle person with all of those groups conveying the messages from all of those groups, mainly for the people that we work with and work for as far as participants or guests go to, you know, a higher, you know, a level of folks that may not hear because they're not on the ground as often as we are. So it kind of floats all different ways -- but certainly, you know, we want the voice of the people that we work with and work for, and I use those terms interchangeably, to be heard when it comes to how services need to be delivered. We want the communities that our participants are living in and living around to know that there's a major reason why the work that we do is important and no, we're not encouraging people to do more activities because we are giving out safe supplies and education and other resources. We're simply trying to keep people safe and keep people alive. So it takes, you know, being very dedicated and, you know, making sure that you know, the message is consistent, but also that reaches different groups in ways that can impact and educate and inform those no particular group. 

Steve Martorano 
Yeah, I know. It's just its tremendous tragedy and heartbreaking to think that there are people who still can't get their heads around a group that is dedicated to harm reduction. They're exactly the kind of people you want in your neighborhood. If your neighborhood is ravaged by drugs, they're lowering the level of desperation. They're probably lowering the level of violence. And, you know, the goal is, of course, to lower the level of substance abuse...

Clayton Ruley 
...and disease and disease.

Steve Martorano 
...and disease. Absolutely. Your neighborhood would be healthier for these organizations. They would not in any way be encouraging this you. So that's why it's important to remember that people can't be...

Clayton Ruley 
You know, I think it's important to note that communities themselves have been in some ways brainwashed with the war on drugs mentality when it comes to how we treat individuals, you know, you don't do something for the better part of 40 or 50 years, where I think the war on drugs specifically was, you know, frame where you want to be more punitive than rehabilitative. And don't think that that rubs off on the same communities that were affected, even if the people that are in those communities have suffered for that. So you definitely have communities that it takes a lot of effort to remind them that the war on drugs was not successful as far as eradicating drugs. It was successful in removing people from the scene, whether it's temporarily or you know, long term but it wasn't its success. So why not try to do something different, that actually honors people is realistic about what people are doing, and not doing and understands. There's a host of reasons why people have gravitated to doing those activities, trauma, and violence, and discrimination, and classism. And if we can't work on, you know, all of that, that surrounds the people using there's always going to be people using it always gonna be people doing risky behavior.

Steve Martorano 
Absolutely. Because you because when you frame it in that context, you are framing it the way it ought to have been framed all along, and not a criminal justice issue alone odor issue, but a medical issue. You don't lock people up because they're sick. 

Clayton Ruley 
Exactly. 

Steve Martorano 
Okay. Let's talk about Prevention Point's services, what exactly are we talking about?

Clayton Ruley 
So we're a nonprofit public health organization. We've been around since 1992, legally. We started doing executive order from the mayor of Philadelphia who was Ed Rendell, and he signed Executive Order in July of 92, due to the fact that the report came out the year before saying of the new cases of HIV, almost 50%. So we say 48 and a half percent of those new cases of HIV the previous year were attributed to people who were injecting drugs. So, folks were actively already doing what we call syringe services or syringe exchange, but they were doing that either facing getting fined or getting locked up for distributing drug paraphernalia. Ed Randell signed the executive order in 92, which we still use to implement legal syringe exchange services in Philadelphia in Philadelphia County, which is synonymous with each other, along with a host of other services that surround that syringe service program, like medical care, HIV specific care, Hep C specific care, prep care, primary care through Stephen Klein Wellness Center, our own medication-assisted treatment or no opiate use recovery program called Step Stabilization Treatment and Engagement Program, acute medical care clinics working with, you know, local universities and medical professionals, nurse practitioners attending Doc's medical students from Drexel, Penn, Jefferson and temple social services. Case management that helps people access benefits, listens to the needs and concerns of participants on a regular basis links them to resources, and hopefully, you know, educates them also on harm reduction and risk reduction, you know, practices. Legal supports, working with the Aids Law Project. Meals to respites. Let me mention the meals. We have a Step It Up to the Plate program that's currently going on with the city. City wise we've given that over, you know, 300,000 meals. Prevention Point has given out 60,000 meals since COVID. Started. We have two respites that have anywhere from 30 to 40 individuals typically, which is basically a gateway between being chronically homeless and on the street and to work with case management in the respite being able to move into a permanent housing diversion program where we work with the police department to get folks who have low-level nonviolent offenses into resources instead of jail and court, no cases and court fines. A entry programs program for folks who are recently released and need help now getting himself back up. An overdose prevention program, which I mentioned, where we give out over 10,000 overdose reversal kits per year or at least the last couple of years and training people how to save a life using Naloxone (Narcan). 

Steve Martorano 
Well, that's a hell of a menu of services. The area is lucky to have people like Prevention Points. How does the community affected or the community in need get to you? Are they -- is it the law enforcement bringing them or can they walk in? Do they need insurance? How does it work?

Clayton Ruley 
We have a drop-in center. While it's limited now doing COVID, typically, pre-COVID, we could see anywhere from 100 to 400 people depending on the day and the services that we're offering, maybe even a little more. We are opening up in a limited capacity currently, with the drop-in space. We're very well known in the community that we work with and work for. So we get a lot of walk-ins and walk-ups. I serve the in-service program that does have mobile sites throughout the city. So folks who are accessing syringes and other harm reduction materials can access us anywhere from Frankfort to West Philly, South Philly, obviously Kensington, North Philadelphia we have mobile sites the same location throughout the week. as well. And then external providers also refer, you know, individuals to us for the host of our programs as well.

Steve Martorano 
Talking about harm reduction quite simply helping people stay alive safely regardless of their behavior until or at that point when they decide to move beyond the dangerous behavior and get a handle back on their life. We have more hanging on the corner with Clayton Ruley. This is the Behavioral Corner.

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Steve Martorano 
Clayton, let's take a moment and talk about something that's referred to as M.A.T. -- Medicine Assisted Treatment. Tell us what that is.

Clayton Ruley 
Well, maybe people would recognize medication-assisted treatment or medication-assisted treatment, probably one of the primary versions of that would be like methadone. Methadone is a, you know, an opiate that's used by federally qualified health centers. It's administered typically daily with daily dosing and then their surrounding services like behavioral health with drug and alcohol treatment that typically surrounds it. Prevention Point has its own medication-assisted treatment program. The terminology changes regularly so always want to say opioid use recovery medications recovery, medication-assisted treatment. All three of those are around the same sphere. We have a program that we've been doing since 2008 that I think was very novel at the time and continues to be a leader in the city, where we started using buprenorphine, or what many people would call Suboxone to treat people. And we did that in a way that was not daily dosing. But treating people like they had a disease and that like they need to be eyeballed every day. So starting people out on a once a week appointment, asking and requiring through insurance that they do attend behavioral health or some type of therapy. And then as folks continue to do well with therapy, with taking the medication, completing, you know, UDS screens, graduating to coming less often. So, once every week turns into once every two weeks after, you know, a month or two of appointments and then no so forth, and so on. Until a maximum of once a month appointment. Basically trying to dispel the myth that people who use drugs need to be basically verified every step of the way for what they're doing or not doing. And giving people another option. I mean, I think people use methadone because of daily check-ins because of the cost-effectiveness of it. And because for some people, it's highly effective, but that's not going to be everybody the opportunity to bring in other medications like buprenorphine, which we started doing, which was typically a medication that was only doled out to people who had private insurance, and worked with private doctors, primary care doctors or, or others and taking that to a street-level where folks who had street Medicaid or Medicare but mainly Medicaid could get access to it was a really big deal, particularly in 2008. For many years, we were one of the only places that you can get a free doctor's appointment, and have your medication paid for through your insurance. I'm happy to say access to Suboxone -- and moving forward -- we started doing Naltrexone and Vivitrol has increased to a high level in the city where now you have multiple providers, maybe a couple of handfuls worth of providers are doing sometimes methadone maintenance, but also buprenorphine or Vivitrol, or just buprenorphine or Naltrexone slash Vivitrol. So, more options are available to people. And I think it's very important that we give people options because whether it's just the administration, the treatment they're receiving, or it's the fact that the medication itself doesn't take to their body well, it shouldn't be, you know, one choice or no choice at all the type of proposition for folks.

Steve Martorano 
From my experience in following this and interviewing folks, that's been the big sea change when the entire providers when the entire industry of substance abuse and treatment shifted from an almost universal abstinence model, to one where you had to acknowledge that there needed to be some other therapies involved in there before you could even get to abstinence. And that was, you know, medically assisted treatment, there is no doubt now that the best way to handle severe addiction is, as you said, with both models, first, you do no harm you give the people the medicine they need, whether it's Suboxone or Vivitrol to stabilize them. And then, of course, you direct him to long term therapy. That's the model, isn't it?

Clayton Ruley 
 Yeah, I think that's a great model. For many people. I think we should always, you know, try to be as flexible as possible with our options. We do have some individuals that you know, we're going to need, you know, everyday therapy or every week therapy and then you're going to have individuals who need a little bit less. So it should always be catered to the individual -- what they need. But yes, do you but I think that's a great general idea of what know many people would consider a model, you know, especially when you're talking about the fact that even the detractors of medication-assisted treatment or whatever term you want to use to describe getting medication as part of treatment, even as a detractor. If you're someone that says well, oh, you know, what's the point? They're just substituting one drug for the other? Well, no, the difference is that you are going to get a medication that has been prescribed by a medical professional, you're going to have surrounding supports by you and in a world where fentanyl is in most of the drug supply and is much more potent than the heroin that a lot of folks know 20 or 30 years ago grew up on or opioid pain pill. I mean, fentanyl can be anywhere from 20% stronger to 100% stronger and there's like 40 different versions of fentanyl. If you don't allow someone to get some sort of medication-assisted treatment and you say, well just go out on the street, you might as well be using heroin or you know, you know, popping pills still, then if they get "that batch," which is high in potency, they can potentially overdose. If they prescribed something, at least, you know, what you're working with, as the individual and as the provider and there's all that surrounding support. So just another example of keeping people as safe as possible keeping people alive and at least with our program, there is no, you know, that we're trying to accomplish. Do you have some people that eventually want to get off buprenorphine or Suboxone or stop using Naltrexone slash Vivitrol? We sure do. But we also recognize that it's better to be on medication-assisted treatment, for you know the unforeseeable future and continue to be alive and help yourself and be well get back into society and then to like have a one year period of doing this now, then and then we're gonna leave you out to fend for yourself.

Steve Martorano 
Brings into very sharp focus something the general public must get their heads around finally, and that is that when you're talking about substance abuse, you're not talking about something that just goes away. This is a chronic disease that needs to be treated and handled all along. It just doesn't go away. Alright, let's talk about in the final couple of minutes with Clayton Ruley of Prevention Point, how all of what you've just said has been altered or evolved because those services are now being provided during this COVID-19 epidemic. What has changed regarding what you guys do?

Clayton Ruley 
We certainly had to limit our services to what we call our "essential services." So, for instance, our drop-in space that I mentioned earlier, could have anywhere from 100 To 500 people in the building, depending on the day and the services we provided, we had to shut down, we're just getting to the point where we probably have about 10 to 15% capacity. But for the better part of March through mid-July, that was closed in a large majority. We kept our mail service because we do have a mail service that has exploded during COVID, from about 1500 people to over 3000 people. So that's an evolution. But now it's one of the things that we kept for...

Steve Martorano 
Before you go any further, what do you mean by mail service? You mean people receiving their medicine through the mail?

Clayton Ruley 
Yes, we mean medicine and more. I mean, to be someone who lives in Philadelphia or the state of Pennsylvania and to be homeless means that if you don't have a mailing address, you can receive public benefits. And so over a decade ago, recognizing that that would be a major barrier to growth receiving the help that we want them to get insurance, access to food stamps, and food sustenance, as well as for those who it's applicable to cash assistance -- folks need to address -- a mailing address where folks can sign up and we receive mail at Prevention Point. We're one of only two agencies that do this. The other is Broad Street Ministry, which is in Center City, which allows folks to actually use the address and folks can come in regularly check for their address. That's one service that we get 

Steve Martorano 
I'm glad you brought it up because, gee, that would be another good reason not to let the Postal Service collapse. 

Clayton Ruley 
Exactly. 

Steve Martorano 
Lack of funding. It's not just about voting people. It's the United States Post Office. It's important Anyway, you know, this podcast, hopefully, is heard lots of different places. Prevention Point is exclusively a Delaware Valley or Pennsylvania organization. Is that right? Or is it a national organization?

Clayton Ruley 
Now Prevention Point, Philadelphia is the Philadelphia county -- Philadelphia only organization. There is a Prevention Point Pittsburgh that has the same initials as us. And we do work with them on statewide issues. But we're not wholly affiliated with. There are obviously, ever-growing harm reduction organizations that do very similar work to us. But we are the largest syringe service program in the country as far as the volume of syringes. And I think one of if not, and I'll say with bias, the most comprehensive harm reduction, public health organization with all the services we provide. Let me quickly say that, along with the mail service, we have continued to do in COVID-19 syringe services. We've continued to do our medical services, especially through telemedicine and our overdose prevention services because it's really important as we don't have folks coming in and folks are more spread out that you make sure that folks are With Narcan and make sure that although the interactions are limited folks don't ever feel like they have to pick up dirty syringes and reuse or share with other people because that defeats the purpose of what we're open for, which is to stop the spread disease and prevent overdose. 

Steve Martorano 
Yeah. An enormous job and you guys have been doing a great job all along. The virus didn't make it any easier. But juggling right ahead. Clayton Ruley is the Director of Community Engagement and Volunteer Services for Prevention Point. If you are listening to this and want more information in as I said, the Philadelphia Pennsylvania area, Clayton, that you have your website what is that? How do people reach you that way?

Clayton Ruley 
Our website is www.ppponline.org. And we also have a strong presence on social media so you can find us on Facebook, Twitter, and Instagram. I think everyone you know, should take a look and see what we do. And you can certainly reach me at clayton@ppponline.org. 

Steve Martorano 
Clayton, thanks so much for hanging with us on the corner. We appreciate it. Maybe we'll come back sometime real soon. 

Thank you. I appreciate your time and thank you for the spotlight around harm reduction and prevention.

The Behavioral Corner 
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