Interview with Kyree Klimist
Kyree Klimist is an MST, nurse and family therapist in Ukiah, California. He has also created multiple opioid safety coalitions, including Safe RX Mendocino Coalition. This interview took place on October 1st, 2018.
It would be helpful if you talked a little bit about your background and your current role, and the work that you do that pertains to the opioid crisis.
Sure. I am an MST, nurse and family therapist. I lived in the Bay Area for 30 years before I came up to Mendocino County, and I've only been up here for 4 years. I came up here because I really want to live in the country and I ended up in public health because that's what was kind of available to me and because I knew how to run a unit. I worked in medical halls for years and I was just a supervisor when they hired me to run a unit in public health. I found that I really love it, actually. I run the Health Promotion Unit, prevention work, and run the Safe RX Mendocino Coalition. Because of our demographics, we ended up creating not just the coalition here in Ukiah but we also created a coalition on the coast in Fort Bragg, and that's because people don't come over the mountains very much and we have very different demographics. This past year we started two more coalitions. One we're just starting in the Willits, another we’re starting on the south coast. We're finding that that's really the best way to do it. People like to work within their communities, a little different from the way other people are setting up their coalitions. I have a background in mental health, but I worked with people with diagnoses in mental health and substance disorders, so it's something that I'm very familiar with and most of the patients I work with are people with severe issues from mental health disorders and substance disorders. So, opioid stuff, I know really well. I’ve worked in a methadone clinic for pregnant addicts. I’ve worked in a lot of sort of different situations which made it easy for me to end up working in this position and certainly on this coalition.
Of all the experiences that you've had, what was the most memorable or whether it was something observed or something that you heard someone say that stuck with you?
I would say that probably my most memorable work was when I worked in recovery treatment at the methadone clinic with pregnant addicts. You know there were a lot of memorable things. One was being asked to go to the birth of one of my clients, that was as sweet as can be. Another was a client who had four kids, who came back with a dirty chest, who was pregnant, who came back for like the fourth consecutive time, and we had to call CPS and I knew they were going to her house to take her kids while she was with us, and it was horrific. It was a horrific thing to have to do and it was something I hope I never have to do again, and it was sad and terrible. Another time, I was working with a woman who was HIV-positive and addicted to heroin and also to speed; she had made the decision to have an abortion because she just knew that this baby didn't have a chance and that was her belief, she believed that the baby would probably be born HIV-positive and she wasn't going to be around to take care of that baby anyway. Those are some things that I've dealt with. Hard stuff you know. There has also been some wonderful stuff, like going to somebody's birth, which is a tremendous honor, in my opinion. Seeing this baby being born, and the parents doing well, while the parents are on methadone, just doing well. It's a sweet thing to just see someone doing well while on treatment. Up here we don't have methadone we only have suboxone, which is a similar kind of treatment but different.
The methadone clinic where you worked, where was that located?
That was in San Francisco. That was a long time ago.
What is your experience now, now that they have suboxone as opposed to methadone? What are the similarities and differences between the two from what you have observed?
Well I don't do treatment anymore, I do prevention, so it's a different kind of work. I can't speak directly to it, except for what I have been told from people who do treatment. What I can say about it is that suboxone is easier to deal with in a rural environment. With methadone, you have to come in everyday for a long time to get your dose, so in a rural environment that’s really challenging. People have to travel long distances to get to their dose. With suboxone, it's not that way, they don't have to be dosed every day. Maybe for the first week they do. It's not so much after that and the medication is not as easy to get high from, so it's not as likely to be sold on the street. Its resale value is also not as good as methadone is. As I understand it and as I've been told from people who’ve been on methadone for very lengthy amounts of time, it is very lengthy and very painful to get off of. And with suboxone it's really not as bad as methadone is. So, in both cases and Suboxone particularly, many people just stay on it and are able to function really well without any problems.
Okay great, could you tell us about the work that you're doing with Narcan?
The nice thing about Narcan is that no matter who you give it to, no matter what the circumstances are, it won't hurt them. Even if the person who is down has just had a heart attack and is not overdosing but you don’t know what is going on with them and you think, “oh my gosh, maybe they’ve OD-ed,” and you give them Narcan, it will not hurt them in any way shape or form. That makes it a really wonderful thing. There are some signs where you could actually tell what’s actually going on, but if you're not an expert then it makes it okay to give it to them no matter what and you're not at risk. It’s also a really easy thing to teach to someone. Also, people tend to confuse Narcan and naloxone. Narcan is a spray that goes up your nose, and naloxone is an injectable drug.
The way we've been distributing Narcan is to people in the home of somebody who might overdose. Say a grandma has a prescription and she's been on it for a long time and she might take too much. I know we might want somebody who's in the home with her to have Narcan just in case she forgets and takes too much. That person would not be comfortable with giving Grandma a shot. We wouldn't want naloxone. Let’s say we have a user, an injection drug user, who's using with someone else. They would be fine with naloxone because they don't have a problem with needles. A lot of people have problems with needles and giving other people shots. I don't even want to give my daughter shots if I don't need to. So, we give Narcan to anybody who has anybody in their life who is using, as well as to anybody who has a prescription and is at risk, because you could take more than you think. Part of the problem is that with opioids, you can always just take a little bit and you are always at risk at forgetting how much you took. It's just the nature of the drug.
We have been trying to make sure that we go to fairs and talk to people. We say “Hey, do you have anybody in your home who's using a prescription?” and we make sure they need it because it is expensive so we don't just hand it out to anybody. But if somebody says they want it, we will give it to them. So, it's really just about getting it into the community. We also do this thing where doctors have patients where not all insurance companies pay for Narcan, so if you're on MediCal then your insurance company will pay for it. All the doctor has to do is write a prescription for it when they're writing it for the opioid, or they could just write a prescription for it. In California, all you have to do is ask your doctor, and then when you go to the pharmacist they should give you the Narcan right along with it, and Medical will pay for it for free. But, if you have Medicare, Medicare won't pay for it. I've been giving it to doctors, mid-level medical care providers, like PAs and MPs, who have patients who might need it. Anyone who needs it, we want them to have it. There are programs in our county, substance abuse programs, Street Health Care programs, where they go around and check on people who are homeless and give it to them. We also provide lock bags to all of our users, anyone who wants one can have one. We do that for free so that people can lock their medication up and keep it away from kids. So, all those avenues that I've been talking about, we also give lock bags to all of them. We also give out prescribing guidelines to all of our Narcan providers in the county we send out our co-prescribing guidelines as well.
Do people have to be shown how to administer naloxone or Narcan? Is there any training or lessons you need to see?
You can go online, and you’ll find videos on YouTube that basically explain it, but it’s really easy. There are instructions right on the box. After you flip it open, there's a flip card on the box and then it shows you exactly how to do it, and there's also a thing inside the box. Physically speaking, all they tell you are the signs of an opioid overdose which is decreased respiration and non-responsiveness. So, you try to get the person to respond. You rub the skin underneath their nose and you rub pretty heavy because it's pretty irritating. You can try with your knuckle because if the person experiences pain, they're going to respond and they’re going to be responsive. If you don't get a response, you take this thing and it's like a little nose inhaler: You just stick it up their nose and you spray it, it’s very simple. It's very interesting, there are barriers for various groups of people carrying it. First responders, police, sheriffs, they're supposed to have training. You've now had the training, that's the extent of the training. It's really wild.