School of Nursing pioneers harm reduction in Bexar County

dirty rectangular flat sheet of cardboard plackard with words please help, isolated on white background


Brieanna Flowers-Joseph has experienced the damage of substance use firsthand. Both sides of her family were involved in the drug trade in the Rio Grande Valley and were substance users. As a child, she was traumatized by the violence, deaths, use of alcohol and drugs, and homelessness that can tear families apart.

When Flowers-Joseph was 7 years old, her mother gave her father an ultimatum: Either choose the family or drugs. Fortunately, he chose the family and, at that turning point, put his children on the path to a better future.

Predoctoral research fellow Brieanna Flowers-Joseph, MSN, APRN, CPNP, volunteers through Corazón San Antonio’s harm reduction program. In pursuit of her PhD, Flowers-Joseph is conducting opioid use disorder research with nursing Professor Lisa Cleveland, PhD, APRN, FAAN.

Now a pediatric nurse practitioner in pursuit of a PhD in nursing research at UT Health San Antonio, Flowers-Joseph volunteers to help homeless individuals with substance use disorder (SUD) through the Bexar Area Harm Reduction Coalition (BAHRC) and Corazón San Antonio. Corazón, a nonprofit organization, has a Street Medicine and Nursing program, and an Overdose Prevention Drop-In Center funded by a grant awarded to the School of Nursing that focuses on Bexar County’s homeless population.

Loading her car full of medical supplies, flyers and Narcan, Flowers-Joseph works with the Street Medicine and Nursing teams to meet individuals where they are: under bridges, at pop-up tents along Zarzamora Street or in homeless encampments in downtown San Antonio.

“Unfortunately, sometimes people look at substance use and forget that there’s more (to the person). But these folks need help, services, love, compassion and someone to be their voice and to be out there fighting for them and helping them,” said Flowers-Joseph, a predoctoral research fellow who earned her bachelor’s and master’s degrees in nursing from UT Health San Antonio.

“I’ve realized, through being a nurse and also from my family history, that substance use disorder is usually a result of something deeper, such as childhood trauma, mental health issues, things like that. And I think a lot of times that individuals just get stuck on what they have been led to believe about substance use disorders as opposed to really looking at the whole picture and realizing that there’s some other underlying cause there that needs to be addressed,” she said.

“Harm reduction aims to reduce harm to individuals and communities by building trust, preventing the spread of infectious diseases and providing a pathway to recovery and other needed resources,” said Lisa Cleveland, PhD, APRN, FAAN, professor of nursing at UT Health San Antonio.

Volunteers offer harm reduction kits, which include such supplies as the opioid overdose reversal drug naxolone (Narcan), clean needles and syringes, sharps containers, condoms, wound care supplies, FDA-approved testing kits for hepatitis and HIV, as well as information on how to use these supplies safely.

“Sharing injection needles can lead to HIV and hepatitis, as well as to infections at the injection site. These can become chronic health conditions that are difficult to treat and costly when compared to prevention. Unprotected sex is another risk factor, which can lead to sexually transmitted diseases. These public health issues, while inexpensive to prevent, come at a great human cost with financial consequences for our healthcare system,” Cleveland said.

Cleveland has received $98 million in national, state and local funding over the past eight years for School of Nursing-designed and implemented programs and research focused on harm reduction and SUD recovery. Several of these grants were awarded by Bexar County and the city of San Antonio to support harm reduction programs in San Antonio, such as Corazón, the School of Nursing’s Street Nursing program and the BAHRC.

Harm reduction research

While some still consider harm reduction programs controversial, decades of research in the U.S. and abroad has shown success. The U.S. Centers for Centers for Disease Control and Prevention’s 2018 paper, “Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States,” notes, “Syringe services programs are a key component of overdose prevention strategies” because they facilitate access to health care, social services and recovery programs, improving public health and safety. Participants in harm reduction programs are five times more likely to enter drug treatment and 3.5 times more likely to stop injecting drugs compared to those not involved in the programs, the report states. Harm reduction is now a major part of the White House plan to address addiction and the opioid epidemic.

Even so, Bexar is the only county in Texas that can legally operate a harm reduction program that offers syringe services. And while the legislation authorizing the pilot program in Bexar County was passed by the Texas Legislature in 2007, it didn’t gain momentum until 2018. This was largely due to efforts by Dr. Colleen Bridger, then-director of Metro Health, and the financial support from the county that soon followed, Cleveland said.

According to the Substance Abuse and Mental Health Services Administration, more than 100,000 people in the U.S. died from drug overdose from May 2020 to April 2021 — the highest number ever recorded — and a 29% increase over the previous 12-month period.

The report, “Addressing Substance Use in Texas: Public Health Agency Action Plan,” adds that more than 50% of all drug overdose deaths in Texas are due to opioids.

Students learn compassion and care through Street Nursing

UT Health San Antonio nursing students learn compassionate care with clinical skills education through the school’s Street Nursing Program, said Diana Cavazos, PhD, MHSA, MSN, CMI, RN, which partners with Corazón. Just as in the school’s other clinical education options, students learn to assess patients, treat wounds, take medical histories, document care and refer patients for follow up.

Nursing students learn how to assess and treat wounds through the School of Nursing’s Street Nursing program, under the supervision of faculty member Diana Cavazos, PhD, MHSA, MSN, CMI, RN, assistant professor/clinical.
Photo courtesy of Diana Cavazos

In their orientation, students learn what to expect. “We approach (homeless individuals) with a lot of respect and we announce ourselves, because we need to build that trust,” Cavazos said. “We tell them we are from the School of Nursing and we’re providing medical care…. We also tell them we are from the harm reduction program,” because often they think visitors are law enforcement coming to move them from their space.

“To me it is just like with any other patient. You don’t just walk into a patient’s room and say I’m going to do something without even introducing yourself and your intention,” she explained. “We just provide the service, and the patient has the right to refuse it. If they don’t want our help, then we just move along.”

One student in particular stands out as being uncomfortable with providing care in this setting. It was the only clinical education option that would fit into the student’s schedule, Cavazos said. “She was just terrified…. But as she became more comfortable, she began to enjoy it.”

One patient encounter was the turning point for that student. “A man told her he had been discharged from the hospital with an abscess on his leg and you could just see all the pus draining out of it. She was in shock when he told her that the nurse at the hospital knew he was homeless and just told him to change the dressing and keep it clean. She was furious that he was dismissed like that…. She said that she learned she needs to make sure that her patients have everything they need to comply with the discharge instructions when they leave the hospital. The student ended up continuing to volunteer after the clinical training ended,” Cavazos said.

Turning points like these — when students learn critical lessons or when patients are finally ready to enter recovery — keep Cavazos coming back. “Serving the community is what keeps me going. It gives me almost a spiritual connection to humanity in just doing what’s right. And when they thank you, it is proof that I’m in the right place doing what it needed.”

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